Nursing Fundamentals II Pediatric Exams, Blood Transfusions

olanjones's version from 2016-08-08 13:57


Question Answer
Exam differences btwn child/adultsDifferent normal VS range, Growth & development considerations, Assessment not always head-to-toe, Communicate with patient & parent, Focus on health promotion/maintenance, Play is a big part of exam
Up to age 6 mth children can be assessed on an exam table, why should they be held by the caregiver after 6 mths?Separation anxiety begins around 6 months. Approach parent first, reads social cues; Calm mom=calm baby
Child exams should progress from least invasive to most invasive, how can this be done?Observe as much as you can from the door (activity, interactiveness, color, work of breathing, tone) Before hands on - RR; then obtain VS (BP & temperature last)
Guidelines for communication during examPrior to age 2 yrs interview/discussion is primarily with caregiver; After age 2 yrs child can be involved in interviewed with help from the caregiver (Establishing trust is PARAMOUNT)
Health Promotion topicsGrowth and Development, Safety, Immunizations, Sleep, Discipline
Medical play, allow child to handle medical equipmentAllow “warm-up” time, Provide reasonable choices when able (don’t give them the option to say no, because they will), Imagination can lead to fear - explain procedure simply

Physical Exam

Question Answer
What should head/chest circumference ratio be at 9-10 months?Equal (if head is < 5% concern for microencephaly; if head increases rapidly concern for increase ICP)
What should head/chest circumference ratio be at 1 year?Chest circumference greater than head
How should pinna be manipulated to exam ear canal?Pull back and down
Why are children more prone to ear infections?Eustachian tube is shorter and straighter (more difficult for fluid to drain); Child's immune system is still developing and is not as effective at fighting infection
When should the fontanels close?Posterior- closed by 2-3 months after birth; Anterior- begins closing at 6 months, closed by 9-18 months
What is the Denver Developmental Screening test (DDST-II)?A test that estimates the abilities of a child compared to those of an average group of children of the same age
What areas are screened by the DDST-II?Personal-social, Fine motor adaptive, Language, Gross motor

Milestones (Growth follows a predictable pattern)

Question Answer
NewbornTurns head from side to side when prone
4 monthsRolls over, sits with support (holds head steady when sitting)
6 monthsLifts chest and shoulders when prone, weight on hands
9 monthsCreeps/crawls, uses pincer grasp
12 monthsWalks alone with help, uses spoon to feed self
Infancy growth rateRapid growth, head grows the fastest
Toddler-Preschool growth rateSlower growth period, trunk grows the fastest
School Age-Puberty growth rateSlowing growth, limbs grow the fastest
Adolescence growth ratePuberty, Rapid growth
Monitor growth curveChildren should progress in growth chart along same approximate line - watch for Falling off the curve or Rising above the curve

Pain Assessment

Question Answer
What are indicators that is chronically in pain/distress?Missed/Lost milestones (regression), Lethargic, No eating, No playing
What is the NIPS pain scale? Neonatal Infant Pain Scale (points for facial expression, crying, breathing, arms, legs, state of alertness); Score adds up to 0-10 points
What is the FLACC pain scale?Face, Legs, Activity, Cry, Consolability; Score adds up to 0-10 points - used to assess children btwn 2 months - 7 years (or people who are unable to communicate their pain)
What is the Wong-Baker pain scale?Facial expressions representing levels of pain - patient should choose the face that best decries his/her pain

Blood Transfusions

Question Answer
Why would a patient receive a transfusion?Restore blood volume (hemorrhage, burns, vessel damage); To combat shock; To treat chronic anemia (increases oxygen-carrying capacity of blood)
What equipment is needed for a transfusion?Blood/blood product, NS, Tubing with filter, 16-19G needles for venous access
What is the first thing the nurse should ask the client about prior to transfusion?Allergies or previous blood reactions
Why is the blood type And cross-matched?To ensure that donor's and recipient's blood are compatible (should be re-typed/cross-matched if client has received 6-8 units)
What ID checks must be performed by two nurses?Health care provider's order, Hospital ID band name/number, Blood component tag name/number matched to client, Blood type & Rh
When should VS (esp. temp) be checked?Immediately prior to transfusion (baseline), 15 mins after infusion started, then hourly until completed + hourly for 3 additional hours post infusion
When should the IV line be changed?For each unit of blood (Also check each unit for bubbles, dark color, or cloudiness)
How long should the nurse stay with the client after infusion is started?15 minutes - blood should be run at about 2 mL/min during this time; If no untoward effects may increase rate
What symptoms should the nurse ask the client to report?Itching or flank pain (over kidneys)
Client may complain of aching in arm d/t cool temp of blood, how may the nurse treat?May use a warm pack, or warmed blankets

Blood Transfusion Reactions

Question Answer
Acute Hemolytic (Incompatibility) - Most DangerousN&V, Pain in lower back, Hypotension, Increased pulse, Decreased UO, Hematuria (Occurs within minutes-24 hours)
Allergic (Hypersensitivity)Mild - urticaria, itching, flushing; Anaphylaxis - hypotesion, dyspnea, decreased o2 sat, flushing (Occurs immed-24 hours)
Febrile (Antibodies to donor platelets/leukocytes) - Most CommonFever, Flushing, Chills, Nausea, HA, Tachycardia, Palpitations (Occurs minutes-hours)
Bacterial infection (Contaminated blood products)Hypotension, Tachycardia, Fever, Chills, Shock (Occurs minutes- within 24 hours)
Circulatory overload (Large volume over short time)Dyspnea, Crackles, Increased RR, Tachycardia (Occurs minutes-hours)

Blood Group Compatibility

Question Answer Column 3
OCan give to: O, A, B, ABCan receive: O
ACan give to: A, ABCan receive: O, A
BCan give to: B, ABCan receive: O, B
ABCan give to: ABCan receive: O, A, B, AB
Rh NegativeCan give to: Rh Negative, Rh PositiveCan receive: Rh Negative
Ph PositiveCan give to: Rh PositiveCan receive: Rh Negative, Rh Positive

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