peds exam 1

admin of oral meds

- most used

- assess gag reflex & ability to swallow, how child takes med at home

- liquid meds will be ordered mg not mL

- mix bad taste meds with applesauce

- check if meds compatible with food used.

- don't mix with formula/milk

- med cup/oral syringe

- IF CHILD VOMITS NOTIFY MD

Admin of med to infants

Can give on empty nipple or oral syringe along side of cheek, holding baby upright or semi upright; do no mix with formula or milk

Admin of med to toddlers/prek

Oral syringe or medcup; applesauce, followed by juice, soda or snack

Admin of med to school age

Chewable tablets, give food or fluid

Toddler/preschoolers

- Toddlers prone to magical thinking & may view med admin as punishment; allow to examine when possible, allow parent to help

- preK continue w/ magical thinking, fear unknown, painful procedures; may benefit from therapeutic play & offer much control as possible

School age

Fear loss of control, pain, injury; can understand more complex explanations such as why they need med to get better; allow as much choice as possible

injections

- one-time dose

- prepare child with play therapy

- may need to restrain

- oral sucrose for infants

- EMLA-one hour prior

- document amount, site, how tolerated, lot number, reactions

- don't premedicate with tylenol (⬇️ immune response)

IM injections

more solution=larger muscle

no dorsogluteal

needle 22-25G 1/2-1 1/2 long

0.5 mL- infants

2 mL- young kids

3 mL- teens- 1ml deltoid for older children/teens

vastis lateralis

ventral gluteal

otic medications

let warm to room temp

remove drainage

2y and below-pinna down and back

3y and up- pinna up and back

try to keep on side for 2 minutes

inhalation medication

nebulizer/metered dose inhaler

metered dose more effective with spacer

nebulized med can be delivered with supplemental 02

to unconscience/ intubated child

can be delivered through a face-mask/plastic mouthpiece

IV medication

- EMLA cream can prep IV site

- checked hourly

- IV set every two hours to prevent FVO

- IVF bags changed Q24H

- IV tubing Q96H

daily maintenance fluid requirements

Calculate the child's weight in kilograms

Allow 100 mL/kg for the first 10 kg of body weight

Allow 50 mL/kg for the second 10 kg of body weight

Allow 20 mL/kg for the remaining kilograms of body weight

divide by 24 to get mL/Hr

Admin of blood products

confirmation and monitor

5mL/KG/Hr

4 hours

s/s reaction: fever, chills, SOB, HA

stop transfusion, notify MD, follow policy

restraints

last resort

MD order or order within 1 hour

Hand mitts/elbow restraints

type,limit,time

least restrictive

removed Q2H for ROM and neuro check

usually Q15M for 1 hour

infection control

- hand hygiene

- Alcohol based hand rubs

- body fluids=soap and water

- before and after touching pt/ surfaces

- hand sanitizer must completely air dry 30 sec

Standard Precautions

A strict form of infection control that is based on the assumption that all blood and other body fluids are infectious; all patients; use goggles/face shield for risk of splash exposure

transmission-based precautions

CDC precautions used in patients known or suspected to be infected with pathogens that can be transmitted by airborne, droplet, or contact routes; used in addition to standard precautions

Airborne diseases

N95 - worn for all TB cases

measles

chicken pox

varicella zoster

TB

Droplet diseases

influenza

meningitis

pertussis

mumps

Adenovirus

contact precautions

practices used to prevent spread of disease by direct or indirect contact

C-diff

RSV

influenza

wound infection

pink eye

foods that are choking hazards to children under 3

hot dogs

popcorn

peanuts

grapes

mealtime

never prop bottles

colorful plates

limit to 15-20 min

record I/O

temperature

report temps over 100.4 or below 96.8

-recommend axillary over rectal to parents

-start oral temps at 5-6yrs

pulse

apical pulse under 2

For every 1*C temp elevation, BMR increases

10-13%

This increases insensible fluid loss & stress on CV system

management of fever

remove clothing

increase fluid intake, antipyretics

tepid bath (lukewarm)

call MD

- under 2 months with fever of 100.4

-acts very ill

-inconsolable

-hard to wake

-stiff neck

-purple spots

-trouble breathing

-siezure

- unable to swallow/drooling

voided specimens

AAP recommends suprapubic aspiration who has fever of unknown source

urinary catheterization

can develope latex sensitivity

capillary blood sampling

third finger

lateral aspect of heel

know steps

cerebral spinal specimen

requires informed consent!!

number one way to confirm NG tube placement

X ray

When do you confirm NG tube placement

- anytime feeding is interrupted

- prior to each feeding/med

- every 4-8hrs during continuous feeding

assessing tube placement at bedside

- aspirate (grass-green)

- test pH should be 5 or less***

- signs of resp distress

- change in length

if NG tube becomes dislodged

notify surgeon immediately

enteral feedings

aspirate residual from last feeding, return contents

o2 therapy

always use humidifier

Nasal cannula

Delivers 40% or 1-5 LPM

venturi mask/simple face mask

minimum flow rate of 4-6 LPM

Can deliver 6-10LPM

partial nonrebreather mask

supplies 50-60% o2

rate 10-12 LPM

Full nonrebreather mask

100% o2

rate of 10-15 LPM

arterial samples

radial site

can use brachial

PLACE ON ICE IMMEDIATELY

suctioning assessments before

breath sounds

RR

character of respirations

quantity and quality of secretions

Use face shield/goggles

pressures for suctioning neonates

60-80 mmHg

pressures for suctioning children

80-100 mmHg

pressures for suctioning adolescents

80-120mmHG

before suctioning

check level of suction by holding thumb over suction control port

put on face shield/goggles

snoring

Obstruction of upper airways, can be heard with dec LOC

stridor

high pitched

heard on inspiration= laryngeal obstruction

both inspiration and expiration=mid-tracheal obstruction

wheezing

high pitched

musical

expiration

obstruction in lower airway

crackles

fine popping noises

inspiration

fluid in airway CHF/pnuemonia

*can be cleared by 3 deep breaths & coughing

Anxiety or decreased LOC responsiveness indicates

Hypoxia

Rapid RR with shallow resp effort indicates

Resp distress

Very slow RR in a child is often an ominous sign of

Resp failure

Increased resp effort with decreased breath sounds can indicate

No air movement into the lungs; remember that all infants/young children are abd breathers, so observe for rise & fall

respiratory distress s/s

Restlessness, tachypnea, tachycardia, diaphoresis, nasal flaring, grunting, dyspnea, wheezing, accessory muscle use

Grunting

Sound of expiration against partially closed vocal chords; sign of hypoxemia; body's efforts to improve oxygenation by producing positive end expiratory pressure

tripod position

An upright position in which the patient leans forward onto two arms stretched forward and thrusts the head and chin forward.

CPR of child

- chest compressions only not recommended (common cause of arrest is respiratory)

- rolled towel under shoulders to open airway

- enough air for visable chest rise

- ventilate at rate of 20-30/min

- 1 breath every 2-3 sec

Obstructed Airway Management

- if pt is conscious use the Heimlich maneuver. For infants, flip face down and provide 5 back throws.

- If pt is unconscious help to the floor, tilt pt head and lift chin immediately.

- do not do blind finger sweep

- Put infant face down & alternate 5 back blows followed by 5 chest compressions

- begin chest compressions if no pulse noted within 10 seconds or less or pulse

Epinephrine

first line drug for cadiac arrest, arrythmias, and hemodynamic instability

allergic reaction

Atropine

vagal stimulated bradycardia

NaHCO3 based on ABG results

Dextrose

based on glucose results in patients not responding to other efforts

early hypovolemic shock

tachycardia

increase resp. effort

weak pulses sluggish cap refill

pallor cold extremities

decrease U/O

dry mucus membranes

poor skin turgor

late hypovolemic shock

lethargic

decrease BP

met/resp. acidosis

anuria

cold cyanotic skin

weak/absent pulses

dysrythmias

Hyperdynamic (warm) Phase- Septic Shock

brisk cap refill

bounding pulses

extremities warm/dry

older children and adults

Hypodynamic (cold shock) Phase

mottled

cold extremities

weak pulses

infants and young kids

⬇️ CO

late septic shock

tachycardia

tachypnea

cyanosis

perechial purpuric skin lesions

decrease/no U/O

Neurologic assessment/disability assessment

Alert

Voice

Pain

Unconscience

injury

obtain hx of injury

how they sustained injury

presenting complaint

trauma score

Poison control

ALWAYS CALL IF POISONED

name

location

amount

time

submersion injury 1st step of management

removal of water from lungs

-turn to side

-suction

prompt CPR

EMS

2nd leading COD in teens 15-24; 3rd leading in children 5-14

Suicide

suicide

- girls 2x more likely

- LGTBQ 2x more than peers

- linked to social stigma and bullying

- never ignore verbalized threat

- know signs

- ask directly if they have plan to harm

- assess for risk factors

Goal for suicidal patients

Keep child free of injury even after they've left your care

Suicide precautions

ADHD

most common childhood disorder

age of onset is 3-4 years

s/s must be present for 6 months

occur before 12 years

be present in 2 or more settings

significantly appear at least one level of functioning

ADHD stimulant medications

-Dextroamphetamine

- amphetamine

- methylphenidate (Ritalin)

Mgmt of adhd meds

- administer early in the morning

- do not abruptly discontinue

- admin before meals!!!

- give 2nd dose no more than 5hrs after 1st dose

- bloodwork Q3months

- psychotherapy, family therapy, parenting skills training

S/e of adhd meds

- weight loss

- difficulty sleeping

- decreased appetite

- emergence of motor disorders (tics)

- possibility of sudden cardiac events

- monitor q3mo

anorexia

lanugo

dry flaky skin

dull brittle hair

fatigue

muscle wasting

excessive dieting and compulsive exercise

Amenorrhea

How do boys demonstrate weight loss?

Excessive dieting, compulsive exercising, & purging

Refeeding syndrome

metabolic alterations that may occur during nutritional repletion of starved patients

bulimia s/s

- Eating until point of discomfort or pain;

- forced vomiting after eating;

- misuse of laxative diuretics, or enemas;

- going to the bathroom immediately after eating or during meals

- russels sign

- normal weight

- tooth erosion

Abusive head trauma

- trigger is a crying baby

- retinal hemorrhage

- skull fx

- altered neuro status

- head or neck bruises

- subdural hematoma

- seizures

child heath care

-includes health promotion, illness mngmnt, health restoration

-absence of disease does NOT equal healthy

*technology allows children to be treated at home or other settings

standards of care

legal requirements for nursing practice that describe minimum acceptable care set by professional organizations such as CDC, FDA, OSHA, etc

nurse practice act

states what a nurse can or can't do varying by state

negligence

failure to take proper care in doing something

*honest mistake!!

malpractice

Failure by a health professional to meet accepted standards

*knowing it's wrong but still doing it!!

informed consent

pt competence of fully disclosed information

-cannot be given legally by child unless EMANCIPATED

- able to understand @14 include in discussions

-explain procedures in appropriate terms for age

Refusal of care

When parents refuse to consent for what is deemed necessary tx of child, state may be petitioned to intervene

- make sure all parties understand what they are refusing, inform the provider, & document

- keep in mind religious factors may prevent use of blood products, immunizations, etc

traditional family

headed by 2 parents

less poverty, illness, & substance abuse

mostly have dual incomes

non-traditional family

-single parent household

-blended families (step parents/siblings)

-multigenerational or extended families

-adoptive parents

-same sex parents

-communal families

High risk families

- those experiencing

- those with teen parents

- family violence or drug/alcohol abuse

- those with developmentally challenged or chronically I'll children

healthy families

are able to ADAPT TO CHANGE

authoritarian

parents have rules & expect them to be followed without question

"because I said so"

-children can by shy & withdrawn, lack self-confidence

may be sensitive, submissive, honest & dependable

-unaffectionate parents = Rebellion

authoritative

parents show respect for opinions of children & allow discussion of rules, negotiation & compromise occur

-children have high self-esteem, are independent, inquisitive, happy, assertive, & highly interactive

permissive

parents have little to no control over behavior, if rules exist they're inconsistent & unclear, no limits on discipline; role reversal may develop

-children are disrespectful, disobedient, aggressive, irresponsible & defiant

-insecure r/t lack of guidance, creative & spontaneous looking for true limits

redirection

remove problem & distract child w/ another activity or object

reasoning

explaining why behavior is not allowed, used w/ older children

behavior is the focus, not the child

time-out

placing child in non-stimulating environment where parent can observe

-should be 1 min per year of age, timer doesn't start until still & quiet