Transcript
Lutheran Medical Center Clinical Reference Manual
Nursing Student Information
Lutheran Medical Center is located at 8300 W. 38th Ave. several blocks west of Wadsworth. If you are coming from the east, turn west onto 38th Ave. The second light you come to, turn left into the hospital grounds. Follow it to the visitor’s parking lot. If coming from the west, turn east on W. 38th Ave. You will pass the hospital and reach a stop light on the east end of the building. You can only make a right turn. Again, follow the road to the visitor’s parking lot.
FIRE SAFETY
"Mr. Gallagher is wanted" is the code for an actual fire situation. Drills are always announced as drills. The five steps to the Emergency Fire Procedure are: " R A C E."
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R A C E P A S S
escue the patient / evacuate the area. larm and call 5555 in the hospital (call 911 at other sites). Give your location as accurate as possible. The alarm box is hooked into a computer system that identifies the box and its specific location to the operator as well as the Power Plant and the Fire Department. lose the door. Doors remain closed until the "all clear" is announced over the PA system. xtinguish the Fire - if possible.
For use of a fire extinguisher, remember "P A S S." ull the pin. im the nozzle. queeze the trigger. weep back and forth at the base of the fire.
ELECTRICAL SAFETY
In patient care areas, knowledge on reporting equipment malfunctions and the purpose of red electrical outlets is required. Do's 1. 2. 3. Report malfunctioning or damaged equipment immediately. Attach repair tag and remove such equipment from service. Report any equipment that is dropped, spilled on, etc., even if it appears that the equipment is all right. 1. 2. 3. Don'ts Attempt to repair equipment yourself. Put liquids (drinks, IV solution, etc.) on top of equipment. Run over power cords with wheeled equipment. Transport monitors or pumps on bedside tables.
4. 5.
Visually inspect all equipment prior to use. 4. Pay particular attention to power cords. Save parts that may break off machines. Tape them to machine.
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WORKING WHILE YOU'RE SICK*
Susan Dolan MS RN and James Todd MD In a hospital setting, the patient population is a primary concern as many of these patients are already compromised by their current illness. Acquiring a nosocomial infection on top of this can lead to morbidity and/or mortality. In certain instances, employees and students who are mildly ill and who do work can do so if the appropriate precautions are strictly adhered to. Completely Illness Type Severe Symptoms Mild or Resolving Symptoms Resolved Symptoms
Respiratory Fever (>100o), productive cough, uncontrollable secretions (e.g., unable to contain runny nose. No - you need to stay home. No - stay home. Mild symptoms, fever absent, able to contain secretions. Yes - wear mask**, WASH HANDS. No - care for low-risk patients and/or patients with like-illness, avoid touching face. Mild symptoms, infrequent stools. Yes - wash hands (esp. after using restroom). No - care for low-risk patients and/or patients with like illness. Symptom free.
Can you work? Should you care for high-risk*/uninfected patients? Can you work? Should you care for high-risk*/uninfected patients?
Yes - WASH HANDS. Yes - WASH HANDS.
(Herpes Simplex)Cold Sore (Sore Throat)Pharyngitis Gastrointenstinal
Fever (>100o), vomiting, diarrhea. *** No - stay home. No - stay home.
Symptom free. Yes - WASH HANDS. Yes - WASH HANDS.
Can you work? - If Strep Cx (+) - If Strep Cx (-) or no Cx is indicated. Should you care for high-risk*/uninfected patients?
Sore throat, fever (>100o), excudate on tonsils/throat, cough absent. No. No. No.
Mild symptoms, fever absent, cough absent. Yes - after you have taken appropriate antibiotics for 24 hours. Yes - wear mask**, wash hands, avoid touching your face. No - care for low-risk patients and/or patients with like illness. Lesion(s) crusted. Yes - WASH HANDS. Yes.
Symptom free. Yes - WASH HANDS. Yes - WASH HANDS. Yes - WASH HANDS.
Can you work? Should you care for high-risk*/uninfected patients?
Draining or vesicular lesion(s) on the face or mouth. Yes - wear mask**. No - consult with charge nurse of nursery areas to determine if need for employee to work if no replacement available and patient care would be jeopardized.
Symptom free. Yes - WASH HANDS. Yes.
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High-Risk Patients (with non-infectious conditions):
• • Moderate to severe BPD. High risk cardiac conditions. • • Immunodeficiency (hypogram, chronic steroids). Chronic pulmonary disease. • Infants < 2 months.
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Masks - need to be changed when they become moist and/or upon leaving isolation rooms. Diarrhea - may include one or more of the following:
• More frequent than normal. • Blood, pus, mucous (stool culture recommended).
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Fever (> 100o).
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Water loss.
Remember 1. Handwashing is the most effective step in preventing the spread of infection. 2. All staff members who are ill should report to Employee health. 3. If you develop mild symptoms at work, (e.g., scratchy throat, stuffy nose): • Take appropriate precautions immediately (e.g., mask if respiratory related and WASH HANDS!!). • If symptoms worsen, notify your supervisor and go to Employee Health.. If you have been exposed to a known contagious illness (e.g., chicken pox, measles) and you do not have immunity, you need to 3
contact Employee Health immediately. You will not be able to work during the incubation period. Should you develop symptoms, you may not return until it is determined that you no longer are contagious.
DAILY NURSING GUIDE 0640-0645 0645-0715 0715-1000 Review changes in Kardex and medication sheets before report Report Head-to-toe assessment: Vital signs (include Temp. HR., RR. BP.) Equipment room check, stock with supplies, and straighten room Cor equipment check Medications and treatments as ordered Bath, oral care, linen change Assist with feeding patient Catch up on charting. Computer charting entered each hour. Meds and treatments as ordered Nutritional support with age-appropriate choices of food and liquids Developmental support Play room activities prn Head-to-toe assessment Vital signs if q 4 hrs Assist with nutritional support Charting Meds and Tx as ordered. All 1400 meds must be given before leaving for clinical conference. Report to CTA before going to conference Developmental support. Playroom activities prn Clinical conference: Room placement to be announced Try to be on time as there are often guest speakers Head-to-toe assessment: Vital signs Meds and TX as ordered Total 8 hour I&O Complete charting Prepare written draft for report and review with CTA or instructor Recheck pt. room for adequate supplies Report
1000-1200
1200-1400
1400.1500
1500-1845
1845-1915
ADDITIONAL CARE THROUGHOUT 12 HOUR SHIFT * Plan linen, bed change, bath around treatments and rehab schedule. Needs to be completed by end of day shift.
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IV site assessment and maintenance and recording of I & O hourly. Continually update CTA on status of your patient, report changes. Developmentally appropriate interventions (comfort, play, diversional activities)
Weekly Clinical Appraisal
Raven Starr STUDENT COMMENTS
Comment on your preparation for this clinical experience:
Date: FACULTY COMMENTS
Comment on the quality of your written work (nursing care plan, charting):
Comment on the technical skills you performed:
Comment on your interpersonal skills, caring and rapport (communication with peers, health care team, faculty, clients and their families both verbally and non-verbally.
Comment on how you applied your knowledge of growth and development in your care of the client and family:
Comment on how you set priorities and your ability to adapt to spontaneous changes during the clinical experience and how you sought out your own learning experiences.
Comment on any concerns you have or things you would like to work on in the future:
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WHERE YOU GET YOUR HOMEWORK INFORMATION 1. Pathophysiology: Be sure to review your pathophysiology. Your textbook contains lots of information, but you may need to use the units' teaching files or the library on the 6th floor of the Health Center. You will encounter many unusual diagnoses, and you will need to know something about your patient's pathophysiology. If you receive a new patient assignment, you will be expected to learn about the pathophysiology during the course of the clinical day. 2. History of Present Illness: This information is obtained from the patient's chart. There is a specific tabbed section of the chart that will give you this information. You may want to look through some of the most recent Progress Notes for an update on your patient. 3. Medical Orders From the Kardex: Use the nursing Kardex to summarize the medical orders. This will give you an idea of what your nursing interventions will include during your clinical day. If there are procedures or tests noted on the Kardex, take some time to look them up in a laboratory reference book or the unit's Policy and Procedure manuals. Before any test or procedure, you will be expected to read about it in Policy and Procedure manual and review it with your CTA and or/Clinical Faculty. 4. Vital Signs, Norms, Ranges: Use the computer to determine what your patient's vital signs have been in the recent past. Note any abnormal findings (use asterisk or highlight). This will alert you to problems/potential problems. The norms may be found at the end of the manual. 5. Growth Parameters and Percentiles: Growth parameters are very important in pediatrics, especially for children under two years of age. Most growth occurs in the first two years of life. If there are growth problems, it is important to detect changes in growth parameters and to intervene as soon as possible. If your patient is under 2 years of age, you should be able to find the child's growth parameters on the admission data base and/or the computer. Once you know your patient's growth parameters, determine the percentiles for weight, height, and OFC (occipital-frontal circumference). 6. Intake and Output Calculations: Once you know your patient's weight, you can use the formulas to calculate hourly intake and output rates. Compare the ideal 24-hour totals to the actual totals (if the actual data are available). Are there any I/O discrepancies or concerns? Most infants and small children are on STRICT I/O. That means we carefully measure and record everything they take in and put out. Infants and small children can QUICKLY develop serious fluid/electrolyte problems, and they require close I/O monitoring. 7. Abnormal lab data:
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Use the computers to access lab values and lab reference norms for your patients. Note any abnormal lab values and try to find rationale in your laboratory reference book. Some of the common values and abnormal lab rationales are in your manual. 8. Developmental Norms: Your manual has a section on developmental milestones. If your patient is developmentally delayed, there should be a notation in the physician's admission note about the child's approximate "developmental age." For instance, you may have a patient who is 4 years old with severe CP/MR (cerebral palsy/mental retardation). The physician has documented in her admission note: "MOC states that last developmental assessment on 3/10/98 places child at 4 month-old developmental level for gross motor and fine motor skills. MOC also states that child socially smiles, laughs at faces and enjoys being held and read to.” You should use 4 MONTH-OLD developmental milestones and tailor your nursing care interventions to the developmental information you have about this child. During the course of your shift, you will be able to make observations and evaluate whether you see the child behaving according to his/her developmental age. You will also need to identify implications for care relative to your patient's developmental delays. Hospitalization, chronic illness, and acute illness can affect children's developmental performance, and you will learn how to compare norms/baseline with your patient’s hospitalized behaviors. 9. Nursing care needs: After you have done the worksheet and researched the pathophysiology, think about potential, important nursing care considerations for your patient and the patient's family. List 3 needs (or more) that you think will be important nursing care issues for your patient. Individualize these care needs as much as possible. You will soon learn that care needs change over time, sometimes quickly. Your initial list of care needs will help alert you to possible care concerns for your patient, but you will have to re-prioritize during the shift. Your CTAs and Clinical Faculty will help you learn how to use nursing process to constantly assess, plan, implement and re-evaluate what is happening with your patient. 10. Medication Worksheets: Use your patient's Medication Administration Record (MAR) sheet to find the medications ordered for your patient. You are responsible for researching medication information and doing medication calculations on scheduled and PRN medications. EXCEPTIONS: You do not need to calculate safe dosage ranges for RESPIRATORY (marked per RT in the MAR) inhaler/nebulizer medications or safe dosage ranges for heparin flushes. The hospital uses many medications that have special dosages and applications for our pediatric patients. The formulary is designed to give information about how to safely and effectively administer these medications to our patients. For legal and safety reasons, this formulary or Lexi-Comp program must be consulted for patient medication information.
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CLINICAL PREPARATION WORKSHEET
Student’ Name: Child’s Initials: Patient’s Dx: Child’s Age: Date: Gender:
Isolation: yes / no Allergies: Type: Brief Review of Pathophysiology and History of Present Illness: (Write information on reverse side of page) Medical Orders from Kardex:
Most Recent Vital Signs Temp: Pulse: Resp: BP:
Norms for Age
Child’s Range (Over the past 36 hrs)
Child’s Values WT: HT: HC*: * < 2 yrs.
% on Growth Curve
INTAKE AND OUTPUT CALCULATIONS:
Calculated Hourly Fluid Intake Needed: Calculated Hourly Urine Output Needed:
Calculated 24-hr Needs: Actual (Past 24 hours)
Calculated 24-hr Needs: Actual (Past 24 hours) Child’s Value Normals Rationale (Related to Diagnosis)
ABNORMAL LAB DATA:
Test
DEVELOPMENTAL NORMS FOR AGE:
Expected Gross Motor: Yes Fine Motor: Yes Language/Cognitive: Yes Personal-Social: Yes No No No No Age Appropriate? Implications for Care
NURSING CARE NEEDS: Prioritized 3 needs you will need to address and one to two interventions:
1. 2. 3.
Author: Roxie Foster PhD,RN (Revised 10/00 by C. San Miguel MS,RN - The Children’s Hospital, Denver) 05/03
CLINICAL PREPARATION WORKSHEET SAMPLE
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Student’ Name: Jane Doe
Date: 04/04/02
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Child’s Initials: KS Patient’s Dx: New onset RAD
Child’s Age: 13 months
Gender: male
Isolation: yes / no Allergies: Amoxicillin Type: droplet Brief Review of Pathophysiology and History of Present Illness: (Write information on reverse side of page) Medical Orders from Kardex: VS q1h while on continuous nebs. Call HO for T> 38.5, RR > 60. Strict I&O. C-R monitor. Keep O2 sats > 90%. Reg diet. Bedrest while on cont. nebs. IV: D5 ¼ NS + 20 meq KCL. IV + PO =36ml/hr
Most Recent Vital Signs Temp: Pulse: Resp: BP: 38.8 Ax 136 56 92/50
Norms for Age Av 37 80 – 180 26 – 34 69-123/38-92
Child’s Range (Over the past 36 hrs) 37.9 – 38.8 142 – 176 56 – 62 R arm 73/50 – 96/70
Child’s Values WT: HT: HC: 9 kg 74 cm 44 cm
% on Growth Curve ~ 10th %ile ~ 10th %ile < 5th %ile
INTAKE AND OUTPUT CALCULATIONS:
Calculated Hourly Fluid Intake Needed: 0 – 10 kg needs 4 ml/kg/hr 9 kg x 4 ml = 36 ml/hr Calculated 24-hr Needs: Actual (Past 24 hours) Test K+ 36 ml x 24 hr = 864ml 1584 ml Child’s Value 5.7 Calculated Hourly Urine Output Needed: 1ml/kg/hr 1 ml x 9 kg = 9ml/hr Calculated 24-hr Needs: Actual (Past 24 hours) Normals 3.5 – 5.5 9 ml x 24 hr = 216 ml 715 ml
ABNORMAL LAB DATA:
Rationale (Related to Diagnosis) ? hemolyzed blood sample
DEVELOPMENTAL NORMS FOR AGE:
Expected Gross Motor:Takes a few steps, can hold cup, finger feeds, likes pull-push toys Fine Motor: Can manipulate potentially dangerous objects; good pincer grasp Language/Cognitive: Understands simple commands Knows name, one word vocals, uses gestures Personal-Social: Plays by self, selective attachments, stranger anxiety Age Appropriate? Yes Yes Yes Yes No No No No Continue interaction, knows mom, point to objects and name them. Keep teddy bear and blanket from home in crib. Mom to help with care and treatments. Implications for Care Pulls self up; keeps removing neb mask Need to keep mask on; help from mom Need to safety proof room.
NURSING CARE NEEDS: Prioritized 3 needs you will need to address and one to two interventions:
1. Respiratory Distress – monitor respiratory status, O2 sats, nebs as ordered. 2. Fever – monitor temperature, administer Tylenol as ordered. 3. Stranger Anxiety – Keep familiar objects in room, enlist the help of the parents.
Author: Roxie Foster PhD,RN (Revised 06/01 Bonnie Cavanaugh PhD RN - The Children’s Hospital, Denver) 05/03
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BASIC MEDICATION INFORMATION
For each medication know basic information (route, amount), and determine:
A. Amount to give: This will be based on the concentration used by the pharmacy. This is on the MAR sheet. DOUBLE-CHECK the pharmacy's calculations. B. Safety dosage range: Refer to page 27 for practice problems and answers. These are examples to get you started. Remember: The dosage range calculations are based on your patient's WEIGHT. The FORMULARY will provide you with necessary information for doing this calculation. IV maximum concentration: If the medication is being given IV, you will need to determine the maximum concentration or minimum dilution for the safe administration of the medication. This information is found in the formulary under the "Nursing Implications" section.
C.
D. Why is the child receiving this medication r/t diagnosis? Use the formulary and your knowledge of the patient. E. Teaching needs: This will also depend on information in the formulary and your knowledge of the patient.
You MUST have your homework completed BEFORE clinicals unless there are special circumstances. This preparation may take several hours the night before clinicals. Because of safety considerations, your CTA and Clinical Faculty may send you home if you are unprepared. This could result in failure of the clinical portion of this course.
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MEDICATION INFORMATION WORKSHEET
Drug: (p. Amount Ordered (i.e., mg/ml) / Frequency: ) Route: (If IV, over minutes)
Calculate amount to give (ml / suppository / tablet): (Concentration from Pharmacy: Safe Dosage Range / kg / dose or day:
) Weight of Child: Kg Is the dosage safe?
π Yes π No
(Show safe dosage and, if needed, calculation of maximum or final concentration for IV administration.)
Why is the child receiving this medication related to diagnosis? The nurse/family should be aware of what teaching needs? Drug: (p. Amount Ordered (i.e., mg/ml) / Frequency: ) Route: (If IV, over
minutes)
Calculate amount to give (ml / suppository / tablet): (Concentration from Pharmacy: Safe Dosage Range / kg / dose or day:
) Weight of Child: Kg Is the dosage safe?
π Yes π No
(Show safe dosage and, if needed, calculation of maximum or final concentration for IV administration.)
Why is the child receiving this medication related to diagnosis? The nurse/family should be aware of what teaching needs? Drug: (p. Amount Ordered (i.e., mg/ml) / Frequency: ) Route: (If IV, over
minutes)
Calculate amount to give (ml / suppository / tablet): (Concentration from Pharmacy: Safe Dosage Range / kg / dose or day:
) Weight of Child: Kg Is the dosage safe?
π Yes π No
(Show safe dosage and, if needed, calculation of maximum or final concentration for IV administration.)
Why is the child receiving this medication related to diagnosis? The nurse/family should be aware of what teaching needs?
Revised 05/02 Karen LeDuc, MSN RN CPN CNS The Children's Hospital, Denver
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MEDICATION INFORMATION WORKSHEET
Drug: Acetaminophen (p. 31-2 ) Amount Ordered (i.e., mg/ml) / Frequency: 225 mg every 4 hours PRN 80 mg : 0.8 ml = 225 mg : X 80X : 180 X = 2.25 ml to administer Weight of Child: 15.7 kg Route: (If IV, over PO minutes)
Calculate amount to give (ml / suppository / tablet): (Concentration from Pharmacy: 80 mg / 0.8 ml
)
Safe Dosage Range / kg / dose or day: Is the dosage safe? 4 Yes 10-15 mg/kg/dose π No (Show safe dosage and, if needed, calculation of maximum or final concentration for IV administration.) 10 mg x 15.7 = 157 mg/dose 15 mg x 15.7 = 235.5 mg/dose Why is the child receiving this medication related to diagnosis? The nurse/family should be aware of what teaching needs? Drug: Ranitidine (p. 488-89 ) Pain or fever, Temperature of 38.8°C (101.3°F) Rate of absorption may be decreased when given with food (increased carbohydrates). Overdose can cause liver/kidney necrosis, GI disturbances. Do not exceed 5 doses in 24 hours. Route: (If IV, over 15-30 minutes)
Amount Ordered (i.e., mg/ml) / Frequency: 15 mg / 0.6 ml every 8 hours 25 mg : 1 ml = 15 mg : X ml 25X : 15 X = 0.6 ml to administer Weight of Child: 15.7 kg
Calculate amount to give (ml / suppository / tablet): (Concentration from Pharmacy: 25 mg/ml
)
Safe Dosage Range / kg / dose or day: Is the dosage safe? 4 Yes 0.5 mg to 1.0 mg/kg/dose every 6-8 hours π No (Show safe dosage and, if needed, calculation of maximum or final concentration for IV administration.) 0.5 mg x 15.7 kg = 7.85 mg/dose Dilution: final concentration not to exceed 2.5 mg/ml 1.0 mg x 15.7 kg = 15.7 mg/dose 2.5 mg : ml = 15 mg : X 2.5X = 15 X = 6.0 ml (add 5.4 ml of diluent to make a total of 6 ml)
Why is the child receiving this medication related to diagnosis? The nurse/family should be aware of what teaching needs? Drug: Gentamicin (p. 270-71 )
Inhibit gastric acid secretion. Use with caution in patients with liver or renal impairment. Monitor liver enzymes, serum creatinine, maintain gastric pH > 4.0. Route: (If IV, over 30 minutes)
Amount Ordered (i.e., mg/ml) / Frequency: 38 mg / 0.95 ml every 8 hours 40 mg : 1 ml = 38 mg : X 40X : 38 X = 0.95 ml to administer
Calculate amount to give (ml / suppository / tablet): (Concentration from Pharmacy: 40 mg/ml
)
Safe Dosage Range / kg / dose or day: Weight of Child: 15.7 kg Is the dosage safe? 4 Yes 2.5 mg/kg/dose every 8 hours π No (Show safe dosage and, if needed, calculation of maximum or final concentration for IV administration.) 2.5 mg x 15.7 kg = 39.25 mg/dose / every 8 hours Dilution: final concentration not to exceed 40 mg/ml Therefore, no dilution required
Why is the child receiving this medication related to diagnosis? The nurse/family should be aware of what teaching needs?
Gram positive staphylococcal infection of the right hand. Monitor urine output and serum creatinine. Draw peak & trough levels around 3rd dose. Be alert to ototoxicity.
Revised 07/03 BMC PhD RN CNS The Children's Hospital, Denver
Author: Susan B. Clarke, MS RNC- The Children’s Hospital, Denver
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PEDIATRIC MEDICATION CALCULATIONS
1. Calculate safe dose (mg/kg) mg/kg x pt. wt. 2. Calculate amount to administer (ml) Dose on hand } mg : mg ordered ml x 3. Calculate final concentration or dilution for IV medications concentration for administration } mg : mg ordered ml x 4. Calculate rate of infusion Volume x 60 Desired minutes
Remember to consider the amount of flush required to completely infuse the medication into the patient. Children weighing 6kg or less: use the syringe pump with a tubing volume of 1.0ml. Baxter pump tubing has a volume of 16ml plus the filter = 20ml to clear the tubing.
The medication & dilution are infused together. When the burretrol empties, the flush is then added to clear the tubing at the same rate. Variables to consider with pediatric IV medications: 1. 2. 3. 4. 5. Patient weight Patient fluid status/maintenance rate Patient diagnosis (fluid restrictions) Additional medications to administer Volume of IV tubing
After all calculations are made and variables considered; a nursing judgment is made to safely give the medication.
All pediatric medications are given with supervision!
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TIPS FOR MEDICATION ADMINISTRATION
ROUTE CONSIDERATION
Otic Nasal
• • •
Eye
• • • •
•
Oral
• • •
• • Rectal Subcutaneous (SQ) • • •
•
• Intramuscular (IM) • • • • • • • • •
Intravenous (IV) Long-term Venous Access Devices
Children < 3 years of age, pull pinna down and back. Children > 3 years of age, lift pinna up and back. Have parent hold the child across their lap with the child's head down. Place the child's arm closest to the parent around the parent’s back. Firmly hug the child's other arm and hand with their arm; snuggle the head between the parents body and arm. Explain the procedure. Tell the child the medication will feel cool. Have the child lie on their back with their hands under their buttocks. Have the child look up. Provide distractions. Infants: Administer medication in nipple, follow with 5cc of sterile water. Medication can also be administered with a syringe and dropper; place the syringe / dropper between the gum and cheek. Administer no more than 1/2cc of medication at one time. Chewable tablets: Do not administer to children without teeth. Give them something to drink afterwards. Caplets: Do not crush enteric-coated caplets. Capsules: Do not open up if medication is sustained - release. Check with pharmacy before opening any capsules for administration. Avoid mixing medications with formula as the infant may refuse the formula thereafter. When mixing medications with food or fluids, use as little as possible, because they may not be able to finish all the food or fluids. Consult a pharmacist prior to cutting a suppository; the medication is not necessarily distributed evenly through the suppository (i.e., acetaminophen suppositories must be divided lengthwise, not widthwise). Usual amount of administration is 0.5 - 1.0cc. Sites include deltoid, anterior thigh, anterior abdominal wall, or inter/subscapular region. Insert needle at a 90o angle. Needle size: Infant or thin child 25 or 26g, 3/8". Larger child 25 or 26g, 5/8". See discussion in this skill station. For the immunocompromised child, cleanse the site with Betadine and alcohol. Consider placing a wrapped ice cube on the site for approximately one minute prior to injection. Use as little diluent as needed. May require a special needle to pierce the port (e.g., MediPort requires a Huber needle). Certain catheters are above the skin (Groshong catheters) while others are under the skin (Port-a-Cath, Infus-A-Port, MediPort). May require daily or weekly flush to maintain patency (Hickman / Broviac and Groshong catheters). Implanted ports must be flushed monthly and after each infusion. Above the skin catheters may be damaged by sharp instruments and are at risk of being pulled out. The Hickman / Broviac catheter must be clamped or have a clamp nearby; the Groshong catheter should not be clamped (contains a two-way valve).
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DEVELOPMENTAL STAGES
INFANT 0-2 MONTHS
1. Physical Development - hands held in fisted position - lifts head 45 degrees in prone position - rolls part way to side from supine - tonic neck reflex dominant in supine position - head lag in pulling to sit - step reflex - head droops in the prone position - roots to turns to nipple - suckling response - good swallowing pattern - lip closure present - will bring hand to mouth 1. Physical Development - hands held in open position - maintain grasp - bilateral reaching - midline play - lifts head to 90 degrees in prone position - props on elbows - slight head lag when pulled to sitting - curve in sitting, head bobs 2. Psychosocial/Cognitive - needs constant adult supervision - regards face - visually follows moving person - visually fixes on object - tract object - responds to auditory stimuli
3 MONTHS
2. Psychosocial/Cognitive - needs constant adult supervision - tracts to 180 degrees - attempts to locate sound source - good suck and swallow coordination - regards own hands - cuddles and conforms when held - recognizes mother/father - responds to verbal stimulation - smile response to smile - vocalizes to social stimulation - some consonant sounds 2. Psychosocial/Cognitive - needs constant adult supervision - reaches for familiar adult - laughs out loud - looks at pellet - attempts to locate sound source for a variety of sounds - turns eyes - turns head
4 MONTHS
1. Physical Development - ulnar palmar grasp - pivot prone position - symmetrical position in supine - sits 30 seconds with support at low back - light weight bearing in supported standing - plays with own hands - brings object to mouth - anticipates being picked up
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5 MONTHS 1. Physical Development - radial palmar grasp - wrist rotation - volitional reach and grasp - purposeful repetition of activity - retains one cube - props on extended elbows - rolls from prone to supine - assists in pull to sifting - head control in supported sitting - takes pureed food from spoon 1. Physical Development - raking grasps - transfers objects hand to hand - lifts head in supine - rolls to prone from supine - sits 30 seconds with arm support - eye-hand coordination in reaching - picks up and retains 2 cubes - pats and attempts to hold bottle - gumming action on solid food 1. Physical Development - uses thumb in opposition on cube - unilateral reaching - inferior pincer picks up pellet - begins pulling apart activities - moves from prone to sitting - belly crawls - assumes creeping position in prone - sits alone readily - takes full weight in supported standing 1. Physical Development - reaches with forearm in mid-position - begins isolated finger movements - puts cube in cup - looks at pictures in a book - creeps reciprocally - goes from creeping position to sitting - pulls to standing - lowers self from furniture to floor - holds spoon - uses upper lip to remove food from spoon
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2. Psychosocial/Cognitive - remembering object in visual field - initiates noise production with rattle - smiles at mirror image - expressive babbling
6 MONTHS
2. Psychosocial/Cognitive - plays by banging - attention to detail of objects - imitates speech sounds - stranger anxiety
7-8 MONTHS
2. Psychosocial/Cognitive - needs constant adult supervision - uncovers toys - differentiated exploration of objects - stranger anxiety - touches and pats mirror image - chews crackers/semi-solid food - drinks from cup when it is held for them - finger feeding - holds own bottle 2. Psychosocial/Cognitive - needs constant adult supervision - says first words - uses expressive jargon - responds to verbal requests and gestures - imitative play
9-10 MONTHS
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11-12 MONTHS
1. Physical Development - adaptive grasp of crayon - imitates scribbling - voluntary release - neat pincer - bangs 2 cubes together - puts 2 to 3 cubes in cup - pokes at holes in pegboard - creeps - cruises - walks with one hand held - turns pages in book 1. Physical Development - points with index finger - spontaneous scribbling - builds tower of 2 blocks - walks alone 2-3 steps - falls by sitting 2. Psychosocial/Cognitive - needs constant adult supervision - extends to show without release - plays pat-a-cake - says mama or da da specifically - social games - separation anxiety
13-15 MONTHS
2. Psychosocial/Cognitive - needs constant adult supervision - carries or hugs doll - vocabulary of 1-3 words - uses 1 word sentences - identifies common objects - uses exclamatory expressions - gives toy on request - solitary play - separation anxiety
16-18 MONTHS
1. Physical Development - uses both hands at midline - puts cover on box - seldom falls - walks backward and sideways with pull toy - turns pages 2-3 at a time - uses stick to obtain objects outside of reach - builds tower of 3 blocks - feeds self with spoon, spills - drinks from cup unassisted - takes off shoes 1. Physical Development - circular scribbling - builds tower of 5-6 cubes - runs stiffly - squats in play - walks up stairs holding rail - unwraps candy - finds 2 hidden objects
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2. Psychosocial/Cognitive - needs constant adult supervision - uses gestures - vocabulary of 6-7 words - selects 2 - 3 common - points to body parts named - follows simple instructions - solitary play - separation anxiety
19-21 MONTHS
2. Psychosocial/Cognitive - needs constant adult supervision - 2 word sentences - begins to indicate need for toilet/change - solitary play - takes pants off - takes socks and shoes off - separation anxiety
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22-24 MONTHS
1. Physical Development - holds crayon with thumb and finger - imitates vertical crayon strokes - walks with heel toe progression - runs well, avoids obstacles - seats self easily - picks up object from floor without falling - kicks stationary ball 2. Psychosocial/Cognitive - lacks impulse control and needs constant adult supervision - parallel play - names object in picture 3 out of 6 - names body parts - turns pages one at a time - undresses completely - separation anxiety 2. Psychosocial/Cognitive - lacks impulse control and needs constant adult supervision - names 5 pictures - understands on, under, big - understands concept of one - understands simple pronouns - selects picture from memory - pretends to engage in familiar activities - doesn't share well yet - wants own way - separation anxiety
25-30 MONTHS
1. Physical Development - snips with scissors - copies circular design - copies cross - walks backward 10 feet - stands on either foot momentarily - jumps off floor with both feet - throws ball overhand - builds tower of 8 cubes
31-36 MONTHS
1. Physical Development - cuts well with scissors - holds pencil with adult-like grasp - walks tip toe for 10 feet - ascends stairs alternating feet - attempts to brush teeth - rides tricycle 2. Psychosocial/Cognitive - lacks impulse control and needs constant adult supervision - spontaneous greeting - says first and last name - holds fingers up to show age - identifies 2 - 3 pictures and action of pictures - plays guessing games - repeats 3 digits - remembers 3 objects - spontaneous play - group play - sharing - imaginary playmates - separation anxiety - greatest fear is separation from parents and harm to body including fears of castration after age 3 and punishment for wrongdoing
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PRESCHOOL (4-5 YEARS OF AGE)
1. Physical Development - pulse, respiratory rates and blood pressure decrease - height and weight remain constant - first permanent teeth erupt - right and left handedness firmly established - walks down stairs with alternating feet - throws and catches a ball well - ties shoelace in bow by age 5 - hops on one foot - uses scissors, pencil and simple tools well - slight farsightedness and unrefined hand-eye coordination (not ready for small print) 2. Psychosocial Development - at age 4 is very independent and aggressive - show off and tattles on others - can be selfish and impatient - greatest fear is separation from parents and harm to body - imaginary play very important (may have imaginary playmate - at age 5 is less rebellious - ready to accomplish tasks and wants to do things right - has fewer fears - says first and last name - imaginary playmates - relies on adult authority to control world - cares for self, dressing, brushing teeth, etc. - play is more cooperative with other children - will try to follow rules but, may cheat to avoid losing - play is very important - development of conscience - may view forbidden activities and wishes as punishable by physical mutilation, body damage, and castration - more independent with strangers, less anxiety with strangers - at age 4 identifies strongly with parent of opposite sex - at age 5 tends to seek out parent of same sex - improving impulse control but, still needs constant adult supervision 4. Effects of Hospitalization - feels loss of control over usual routines when hospitalized - difficult to differentiate between reality and fantasy because of magical thinking and fear of mutilation - may think he/she caused the illness/injury resulting in the hospitalization - may regress in behavior or become withdrawn, angry, aggressive, noncompliant, clingy, or have tantrums
3. Cognitive - views world in terms of self and literal concrete terms - starts to understand rules and conformity - may notice prejudices - still somewhat egocentric but, developing more social awareness - understands time in association with daily events - by age 5 can follow three commands given in a row - has a vocabulary of 2,100 words, counts, and identifies coins - uses 6-8 word sentences, describes drawings in detail
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SCHOOL AGED (6-12 YEARS OF AGE)
1. Physical Development 2. Psychosocial - by age 6, height and weight gains slowly - lacks good impulse control until around age - dexterity increases 7 years (needs constant adult supervision - very active until age 7 and then can be less supervised - use hand as tool, draws, prints, colors well for short periods only) - by age 7, grows at least 2 inches per year - greatest fear is body injury, disability, loss of - posture becomes more tense and stiff control, loss of status - more graceful - separation anxiety decreases - repeats activities to become proficient - developing sense of industry and - loose teeth and ugly duckling stage independence - by age 8, fine motor control is well developed, - eager to learn, school activities important movements smoother - more emphasis on emotional and intellectual - good hand-eye coordination growth - can completely dress self - greater capacity to express emotion - by age 12, pubescent changes begin - can assume independent chores - remainder of teeth erupt - peer group important - posture more adult-like - playmates often same sex - enjoys hobbies, physical activities, sports - by age 12, more self-critical - develops interest in opposite sex - family relationships important, but may test limits 3. Cognitive - developing concept of time and time intervals - has 2,550 to 2,600 word vocabulary - develops complex sentence structure - uses words to express ideas, feelings - views world as something to experience or manipulate - combines own with others viewpoints - can relate to past, present, and future - may still think concretely about some things (gray areas are difficult for the child to grasp - by age 12, can separate cause and intent from outcome - by age 12, understands body and body functions - after age 9, understands that illness has multiple causes 4. Effects of Hospitalization - loss of control, autonomy, and competence - may interpret medical procedures as punishment loss of contact with peer group may be difficult - school routines interrupted
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ADOLESCENTS (12-18 YEARS OF AGE)
1. Physical Development - adult stature by 18 years (female) and 20 years (male) - puberty changes in females * see Tanner Stages * axillary and pubic hair * labia matures * vaginal discharge * breast development * menstruation - puberty change in males * see Tanner Stages * deepening voice * gynecomastia * axillary, pubic, facial, and body hair (coarsens) * penile enlargement * testes enlargement * nocturnal emission - acne - orthodontia 3. Cognitive - problem-solving abilities - Piaget - concrete thinking to formal operations (the ability to conceptualize and hypothesize) - school progress 5. Anticipatory Guidance - accident prevention (drivers ed, swimming lessons, sports) - infectious disease (mononucleosis, URI, herpes, condyloma, hepatitis, gonorrhea, HIV/AIDS) - sexual activity (knowledge, birth control, safe sex) - nutrition - females (menstruation) - males (nocturnal emission) - substance abuse (changes in behavior, grades, family withdrawal) - abusive relationships - suicidal ideations
8/97 Compiled by: Judy Malkiewicz, PhD, RN
05/03
2. Psychosocial Development - greater self-direction and competence - increasing confidence and self-esteem - family group involvement - peer group involvement - increasing ability to be responsible for own actions and make independent decisions - ability to accept others in a diverse society - less impulsive behavior - ability to delay gratification - ability to give and accept affection - increasing leadership abilities - Erikson's self-identity vs. role confusion
4. Effects of Hospitalization - may struggle with dependence on parents and need for independence - regressive behavior
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PEDIATRIC ASSESSMENT GUIDE
A. Physical Assessment Measurements: 1. Temperature (record type). 2. Pulse. 3. Respiratory. 4. Blood pressure. 5. Height or length. 6. Weight. Value and percentile for age and gender 7. Head circumference.
}
B. General Appearance: 1. Describe child's activity and alertness. 2. Does the child appear well nourished? 3. Describe quality of voice or cry. 4. Is there anything about child's appearance which is particularly striking? C. Skin: 1. Color and temperature. 2. Turgor (Skin has resiliency and returns to a normal position after pinching.) 3. Lesions, bruises, abrasions, rashes. 4. Birthmarks. 5. Hair (color, texture, sheen, distribution). 6. Nails.
D. Head: 1. Symmetry. 2. Are sutures or ridges felt? (Ridges may be felt up to 6 months.) 3. Are fontanels open or closed? (Posterior closes by 2 months, anterior by 18 months.) 4. Is head clear of lesions and scaling? E. Eyes: 1. Pupils: a. Are they equal and round in shape? b. Do they constrict and dilate in response to light? 2. Does child follow objects side-to-side, up and down, obliquely? (By 4 months can follow 180o side-to-side.) 3. Do eyes converge when an object is brought close to the nose? 4. Is there a muscle imbalance? (Strabismus may be normal for 6 months.) 5. Are eyes sunken? 6. Are sclerae and conjunctiva clear? Ears: 1. Ears symmetrically placed and well shaped? 2. Hearing appears normal to whispered voice?
F.
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G. Nose: 1. Is there nasal drainage or crusting? 2. Is bridge of the nose unusually flat or broad, considering heredity? 3. Is there pain or tenderness when pressure is applied over sinuses? H. Mouth: 1. Mucous membranes. 2. Tongue (Symmetry). 3. Condition of gums. 4. Palate. 5. Number of teeth. (Estimate of average number of teeth is obtained by subtracting 6 from age in months up to 20 primary teeth.) 6. Are cavities apparent? Neck: 1. Is there mobility and symmetry? 2. Is pain evident when neck is flexed chin to chest?
I.
J. Chest: 1. Is chest symmetrical? 2. Lungs: a. Respiratory rate and regularity. b. Breath sounds. 3. Heart: a. Heart rate and quality. b. Murmurs. K. Abdomen: 1. Symmetrical, protruding. (Children's abdomens normally protrude until puberty.) 2. Does umbilicus protrude? 3. Bowel sounds in 4 quadrants. 4. Can femoral pulses be felt equally and bilaterally? L. Genitalia and Anus: 1. Male genitalia: a. Is meatus at tip of penis? b. Is meatus clear of any inflammation? c. Is the foreskin loose (if circumcised)? d. Is the foreskin constricting (if not circumcised)? e. Are both testes palpable in the scrotal sac? 2. Female genitalia: a. Is the meatus and vaginal opening visible? b. Is there a discharge from the vagina? c. Is the clitoris small? d. Is the labia symmetrical, not enlarged or adherent? 3. Anus: a. Does anal sphincter appear well constricted? b. Are fissures present?
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M. Extremities: 1. Mobile with full range of joint movement. 2. Of equal length, strength, mobility, and temperature. 3. Legs straight. (Bowing of legs normally up to 2 1/2 years. Knock-knees from 2 to 3 1/2 years.) 4. Walks easily with good balance. (Broad-based gait normally to 3 years.) S. Hands are symmetrical with no simian crease. 6. Digits of hand are in proportion and not clubbed. N. Back: 1. Back is symmetrical. 2. Spine straight and mobile. 3. No indentations or tufts of hair noted on spine. 4. Scapulas are at an equal level when standing or when child bends over to touch toes. 5. Iliac crests at equal level. O. Neurological: 1. Infants: a. Babinski reflex positive. b. Hand grasp equal. c. Tonic neck reflex noted. (Lasts up to 5 months.) d. Moro reflex noted. (Lasts up to 5 months.) 2. Older child: a. Fine and gross motor coordination appears normal for age. b. Senses of touch, taste, smell are intact. c. Demonstrates age-appropriate language skills. d. Demonstrates appropriate long and short-term memory for age. e. Demonstrates ability to do abstract thinking.
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NEUROLOGICAL RECORD
General Comments A coma score needs to be documented once a shift on every neuro/rehab patient. When "neuro checks" are ordered by an MD or done on nursing judgment, the entire record should be completed as often as ordered. The seizure activity columns are to be left blank if there is no observed seizure activity. In infants or toddlers with open fontanels, an assessment of the fontanel should be done every shift, using all descriptors that apply. Example: Fontanel 0800 - pulsatile, soft, and flat 1600 - pulsatile, soft, bulging 2300 - non-pulsatile, tense, bulging
Coma Score Reflects the child's general level of consciousness. • Maximum score = 15. • Minimum score = 3. To be documented once a shift on every patient. Eye Opening (EO) is scored as follows: (4) Opens eyes independently when awake or to moderate touch when asleep. (3) Opens eyes only to voice. (2) Opens eyes only to deep pain. (1) Does not open eyes to any stimulation. If both eyes are swollen shut post-operatively, a CC for "cannot check" is written. If one eye is swollen shut, score based on the response with the functional eye. Best Verbal (BV) is scored as follows: (5) Verbalization (cooing, babbling, words/sentences) appropriate to chronological age is developmentally normal, or if delayed (i.e., signs or communicates in other fashion) communicates to their norm per caregivers. (4) Comprehension of directions and verbal response inappropriate or garbles for age or norm. (3) Unable to console or calm; child with persistent shrieking crying and agitation. (2) Moaning or grunting. (1) No verbal response. A child who is unable to speak (e.g., tracheostomy) but who is able to communicate should receive a score reflecting their cognitive ability to communicate. A child who is crying persistently during an assessment but calms when not bothered should be scored appropriate to their general behavior rather than to the behavior during the exam.
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Best Motor (BM) is scored as follows: (6) Withdrawal and attempt to remove stimulus. (5) Only minimal withdrawal from stimulus. (4) Response only to touch, pin or deep pain. (3) Decorticate posturing: upper extremities flexed to midline; lower extremities stiff and pointed. (2) Decerebrate posturing: upper extremities extended, pronated away from body, lower extremities stiff and pointed. (1) No response at all. Pupil Size The column denoting "=, <, >" is to note pupils that may both be in the same size category but still slightly different. The actual measured size of the five size designations are: P = 1mm; S = 2mm; M = 4mm; L = 5mm; D = 7mm. Pupil Reaction Hippus is defined as a rhythmical and rapid dilation and contraction of the pupil. A CC for "cannot check" can be charted if the child's eyes are swollen shut. Extra-Ocular Movements (EOM): Document all letters that apply. Example: F, T, C indicates normal eye movements. (F) (T) (C) (D) (N) Focus: Appears to focus and fix on object or light. Track: Follows objects in all four fields. Conjugate: Eyes move together in following objects. Disconjugate: Eyes do not move together and gaze is abnormal. Nystagmus: Involuntary, cyclical movement of eyeball noticed in any field when testing gaze.
Limb Movements (spontaneous or on command; not reflex): (F) (L) (N) (Fl) (P) Full spontaneous movement. Limited movement; IV board or cast limiting movement. No movement. Limb is flaccid as in a hemiparesis or hemiplegia. Posturing, either decorticate or decerebrate.
The type of posturing is noted in the BM column of the coma score. Seizure Activity Type is designated as either "C" for a convulsive seizure with any motor component or "N" for a non-convulsive or absence seizure with staring or unusual behaviors.
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PEDIATRIC BLS GUIDELINES
COMPONENTS INFANT ( < 1 YEAR) CHILD (1 - 8 YEARS)
Airway Breathing Initial Subsequent Circulation Pulse Check Compression Area Compression:
Depth Rate
• • • • . • •
• • •
Head-tilt / chin-lift. Jaw Thrust (trauma). 2 breaths at 1.0 - 1.5 sec/breath. 20 breaths/min. Brachial / femoral. 1 finger's width below nipple line, compress with 2 fingers
1/3 to 1/2 the depth of the chest 0.5 - 1.0 inch At least 100 / min.
• • • • • •
• • •
Head-tilt/chin-lift. Jaw Thrust (trauma). 2 breaths at 1.0 - 1.5 sec/breath. 20 breaths/min. Carotid. Lower third of sternum with heel of one hand.
1/3 to 1/2 the depth of the chest 1.0 - 1.5 inches. 100/min. 5:1 (pause for ventilation).
Compression / Ventilation Ratio Foreign Body Airway Obstruction
• •
5:1 (pause for ventilation). Neonates 3:1 with interposed compressions / ventilation. Back blows (up to 5) then chest thrusts (up to 5).
•
Heimlich maneuver up to 5 times.
BLS for HealthCare Providers (American Heart Association) 2001 Reviewed by Cindy San Miguel, MS, RN, 05/2003
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UNDERSTANDING LAB VALUES
WBC
> <
HCT
Hbq
Segs Monos Lymphs Platelets
Na CL K Bi/carb
<
BUN CR Glucose
EVALUATE THE WHITE BLOOD CELL COUNT WITH DIFFERENTIAL: Total White Blood Cell Count: Increased = leukocytosis Decreased = leukopenia Hemoglobin: Hematocrit: Red Blood Cell Count: Structural Variations: Decreased = anemia Decreased = anemia Age-dependent Anisocytosis = marked variation in size. Poikilocytosis = abnormal shape (thalassemia, sickle cell, liver disease) Basophilic stripping = lead poisoning
RBC INDICES: MCH (mean corpuscular Hg = color of an average RBC). normal color = normochromic too much color = hyperchromic too little color = hypochromic MCV (mean corpuscular volume = size of an average RBC). normal size = normocytic too large = macrocytic too small = microcytic MCHC (mean corpuscular Hg content = average amount of hg on a RBC). PLATELETS DIFFERENTIAL: Thrombocytes Increased in acute infection, iron deficiency anemia Neutrophils = phagocytosis: Bands & Segs Lymphocytes Basophils (inc. in leukemia, irradiation, splenectomy) Eosinophils (inc. with allergy, parasites) Monocytes (inc. with TB, Rocky Mountain Spotted Fever, bacterial endocarditis, monocytic leukemia) LEFT SHIFT: RIGHT SHIFT: Increased Neutrophils Bands & Segs = Bacterial Increased Lymphocytes = Viral
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COMMON LAB VALUES and ASSOCIATIONS
- increased values
LAB VALUES
(Remember all lab values are not absolute - they are ranges!)
- decreased
Critical Values
(Low) (High)
Common Associations with each Lab Value:
ALBUMIN Infant: (4.4 - 5.4g/dl) Child: (4.0 - 5.8g/dl) Adult: (6 - 8g/dl) AMYLASE 38-108 IU/L @ 37o C BICARBONATE (serum) Arterial 21 - 28mmol/L Venous 22 - 29mmol/L BILIRUBIN Child: direct 0.2 - 0.4mg/dl indirect 0.4 - 0.8mg/dl BUN Infant: (4 - 16mg/dl) Child & Adult: (5 - 20mg/dl) CALCIUM (total serum) Newborn: (6 - 10.6mg/dl) Child: (2.0 - 2.6mg/dl) Adult: (2.1 - 2.6mg/dl) CARBON DIOXIDE (partial pressure - arterial) Child: (32 - 48mmHg) CHLORIDE Infant: (97 - 110meq/1) Child: (98 - 106meq/1) CHOLESTEROL Adult Range: (100 - 200mg/dl) Child: (5 - 100mg/di) CLOTTING TIME (whole bid) CREATININE < 6 yrs: (0.5 - 0.8mg/dl) > 6 yrs: (0.8 - 1.3mg/dl) ESR Child: (3 - 13mm/hr) Adult: (0 - 10mm/hr) GLUCOSE (Serum) FASTING Newborn: (50 - 100mg/dl) Child: (60 - 100mg/dl) Adult: (70 - 110mg/dl) HEMATOCRIT Newborn: (30 - 40%) Child 6-12 yr: (31 - 43%) Adult: (37 - 49%) HEMOGLOBIN Newborn: (42 - 50%) Child: (30 - 35%) Adult: (30 - 42%) IRON (total serum) Infant: (40 - 100ug/dl) Child: (50 - 120ug/dl)
dehydration, exercise. liver disease, severe malnutrition, diarrhea, burns, starvation. inflammation of pancreas / salivary glands, acute pancreatitis, peptic ulcer. chronic pancreatitis, liver necrosis, burns. alkalosis. acidosis (bicarbonate ion concentration is regulated by the kidneys). erythroblastosis fetalis, sickle cell, hepatitis. iron deficiency anemia, drug influence-ASA, PCN. dehydration, impaired renal function, GI bleeding, shock. starvation, severe liver damage, poor absorption-Celiacs, low protein diet, overload of fluids, infancy. too much dietary intake, hyperparathyrodism, myeloma, metastatic carcinoma, thiazide therapy. diarrhea, extensive chronic infection, bums, hypoparathyroidism, (chronic renal failure pancreatitis). decreased alveolar ventilation (acidosis). increased alveolar ventilation. diarrhea, hypernatremia, renal disease, dehydration, hyperventilation. prolonged vomiting, burns, ulcerative colitis, gastroenteritis, diabetes mellitus. atherosclerosis, nephrosis, pancreatic disease, increased dietary intake. poor nutrition intake. time - whole bid 1-8 min (glass tubes) 5.15 min (room temp). renal failure, shock, urinary tract obstruction, lupus, acromegaly. muscular dystrophy, pregnancy, eclampsia, severe liver disease. collagen disease, infections, cell destruction. polycythemia, sickle cell, rheumatic fever. diabetes mellitus, pancreatitis; Cushings, Tepinephrine intake. adrenocortical insufficiency, hepatic necrosis. dehydration, hypovolemia, diarrhea, stress, burns. acute blood loss, anemias, malnutrition, leukemia. dehydration, polycythemia, stress, burns. iron; deficiency anemia, cirrhosis of liver, hemorrhage. hematochromatosis, excessive iron intake, liver necrosis. anemia, hereditary immunodeficiency, leukemia, lymphoma, nephrotic syndrome. 300 ul/dl 40 mg/dl ~ 300 mg/dl
3.0 mg/dl
17 mg/dl
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LAB VALUES
PCO2 Child & Adult
(Remember all lab values are not absolute - they are ranges!)
Common Associations with each Lab Value:
Critical Values
(Low) 20 mmHg 7.0 (High) 75 mmHg 7.6
(34 - 45)
PH ARTERIAL Newborn: (7.11 - 7.36) Child & Adult (7.3 - 7.45) P02 Child & Adult: (75 - 100 Torr) POTASSIUM Infant: (0. 1 - 5.3 mg/1) Child & Adult: (3.4 - 4.7 mmol/L) MAGNESIUM Child: (1.4 - 2.9 meq/1) Adult: (1.5 - 2.5 meq/1) PLATELET Newborn, Infant & Child: 150 - 400 x 103 / mm3 (ul) Adult: (280 - 400,000 mm3) PT / PTT PT: (11- 1 5 seconds) PTT: (60 - 85 seconds) RETIC COUNT Child: (0.5 - 2.0%) Adult: (0.5 - 1.5%) SODIUM Child: (138 - 145mmol/L) Adult: (136 - 146mmol/L) TOTAL PROTEIN Child: (6.2 - 8.0gm/dl) Adult: (6 - 8gm/dl) TRIGLYCERIDES Child: (5 - 40mg/dl) Adult: (10 - 190mg/dl) WBC Child: (6,000 -17,000) l wk - 4 yrs Older Child: (5,000 - 15,000) 5-15 yr
acute respiratory acidosis, hypoventilation. respiratory alkalosis, hypoxia, hyperventilation, anxiety. metabolic alkalosis, GI loss-vomiting. metabolic acidosis, renal tubular acidosis, hypoxia, diarrhea. breathing oxygenated enriched air. carbon dioxide exposure, anemias, pulmonary disorders. oliguria, anuria, renal failure, acidosis, massive tissue damage (bums). vomiting, diarrhea, malnutrition, stress, injury, dieuretics. severe dehydration, renal failure, leukemia. malnutrition, cirrhosis of the liver, chronic diarrhea. Polycythemia leukemias, aplastic anemias. SLE deep thrombocytopenia, salicylates, steroids, trauma. immune thrombocytopenia, anemias, pneumonia, allergies. hemolysis, hemolytic anemia, hemorrhage. red cell aplasia, renal disease, drug ingestion. dehydration, low total body sodium from excessive sweating, glycosuria, mannitol use) coma, Cushings, DI. burns, diarrhea, vomiting, severe nephritis, CHF, SIADH. dehydration, chronic inflammation. over hydration, hepatic insufficiency, malnutrition. familial hypertriglyceridemia, nephrotic syndrome. malnutrition. UTI, bacterial infections, toxic states, tissue damage. infectious typhoid fever, systemic lupus, drug reactions.
3.0 mmol/L
7.0 mmol/L
120 mmol/L
165 mmol/L
PRBC'S
PLATELETS WBC'S
• • • • • • • • • • • • • • • • •
FFP
ALBUMIN
Blood packed at a HCT of 70%. A T&C is required. Type A may receive A or 0. Type B may receive B or 0. Type AB is the universal recipient. Type 0 is the universal donor and receives only Type 0. Positive may receive negative but negative cannot receive positive. A cross match is unnecessary. • Platelets can be given push or drip. Negative should receive negative. • The dose is 0.2 units/kg to a maximum of 10 units. A cross match is needed because of the red cells in the product. The Blood Bank should be notified the day prior to administration. In the room have Tylenol, Demerol, SoluCortef, Decadron, Benedryl, Epinephrine, 02, and the Core Cart close by. Pre-wet the filter and hang over 20 - 60 minutes. Observe closely. ABO group necessary but cross-matching is not. If given for clotting factors-it must by used within 4 hrs. If given for volume expander it must be used within 24 hours. Comes in 5% and 25% from pharmacy. If undiluted use within 4 hrs. Administer slowly and observe for shock.
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RBC Newborn: 5.1 Infant: 4.7 - 5.1 Child > 2 Yrs: 4.6 - 4.8
MCH Newborn: Infant: Child > 2 Yrs:
36 30 25
MCV Newborn: Infant: Child > 2 Yrs:
103 90 80
Normal Urine ph - Newborn: 5.0 - 7.0 Child: 4.8 - 7.8 Specific Gravity: 1.001 - 1.030 Sugar: None
Normal Arterial Blood Gas
PH PCO2 HCO2 PO2 Neonate 7.32 - 7.42 30 - 40mmHg 20 - 26mEq/L 60 - 80mmHg Child 7.35 - 7.45 35 - 45mmHg 22 - 28mEq/L 80 - 100mmHg
Cerebrospinal Fluid
Pressure: Appearance: WBC: Glucose: 40 - 200mm H20. Clear. Neonates: 8-9 > 6 months: 0 > 6 months: .40 Protein: Chloride: Sodium: SG: > 6 months: < 40 110 - 128 138 - 150 1.007 - 1.009
Hazinski, M.F. (1992) Nursing Care of the Critically III Child. Mosby
Respiratory Alkalosis pH > 7.45 Metabolic
PaCO2 < 35mm Hg
HCO3 Pt. Attempting to Compensate HCO3 Normal No Pt. Compensation PaCO2 Pt. Attempting to Compensate PaCO2 Normal No Pt. Compensation HCO3 Pt. Attempting to Compensate HCO3 Normal No Pt. Compensation PaCO2 Pt. Attempting to Compensate PaCO2 Normal No Pt. Compensation
HCO3 > 26 mEq/L
Acid Base Imbalance Respiratory PaCO2 > 45mm Hg
Acidosis ph < 7.35 Metabolic HCO3 < 22mEq/L
From: Reese and Eland. Acid / Base Hyperland Stack, University of Iowa, School of Nursing, Iowa City, IA 1988.
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PEDIATRIC NORMAL RANGES
Pulse
Age Average Range
Respiratory Rate
Age Range
Premature Infant 0 - 24 Hours 1 - 7 Days 1 Month 1 Mo to 1 Year 2 Years 4 Years 6 Years 10 Years 12 - 14 Years 14 - 18 Years
135 / min 120 / min 140 / min 160 / min. 125 / min 110 / min 100 / min 100 / min 90 / min 85 - 90 / min 70 - 75 / min
110 - 160 / min. 70 - 170 / min 100 - 180 / min 110 - 188 / min 80 - 180 / min 80 - 140 / min 80 - 120 / min 70 - 115 / min 70 - 110 / min 60 - 110 / min 50 - 95 / min Blood Pressure
Premature Infants Birth 1 Month to 1 Year 2 Years 2 - 6 Years 6 - 10 Years 10 - 18 Years
35 - 60 / min 30 - 60 / min 26 - 34 / min 20 - 30 min 20 - 30 / min 18 - 26 / min 15 - 24 / min
Age (Years)
Systolic Mean
Range
Diastolic Mean
Range
0.5 - 1 1-2 2-3 3-4 4-5 5 6 7 8 9 10 11 12 13 14 15
90 96 95 99 99 94 100 102 105 107 109 111 113 115 118 121
65 - 115 69 - 123 71 - 119 76 - 122 78 - 112 80 - 108 85 - 115 87 - 117 89 - 121 91 - 123 93 - 125 94 - 128 95 - 131 96 - 134 99 - 137 102 - 140
61 65 61 65 65 55 56 56 57 57 58 59 59 60 61 61
42 - 80 38 - 92 37 - 85 46 - 84 50 - 80 46 - 64 48 - 64 48 - 64 48 - 66 48 - 66 48 - 68 49 - 69 49 - 69 50 - 70 51 - 71 51 - 71
Temperature: 36 – 375; Fever = 385C (101.5F) Intake and Output
Maintenance Fluid Intake Daily Calorie Requirements
0 - 10kg weight needs 4ml/kg/hr 11 - 20kg weight needs 2ml/kg/hr additional 21kg plus weight needs 1ml/kg/hr additional (E.g.: 23kg child needs 10kg x 4ml plus 10kg x 2ml plus 3kg x 1cc = 63ml/hr)
Age Premature Birth - 6 Months 6 Months - 1 Year 1 -10 Years 10 - 18 Years
Kcal/kg/24 hrs. 110 117 108 80 50 - 80
Minimum Urine Output 1 – 2ml/kg/o 33
Normal Stool Output Less than 20gm/kg/24 hrs
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GUIDELINES FOR GIVING REPORT
DURING CLINICAL ROTATIONS
These two suggested formats come from compilation of various forms from clinical faculty. Use these to guide your "giving report." Clinical faculty will assist you and offer suggestions.
EXAMPLE 1
• • Speak clearly and loudly. Summarize your patient’s status and care concisely, so be brief. (Your Name) , (Name of University) nursing student.
Introduction: • This is
Patient Information: • Patient name. • Room number. • Age. • Medical Diagnosis (diagnoses). • Medical or surgical treatments. • Surgical treatments - helpful to give surgery date and/or post-op day. Problem or main concern regarding your patient's course of stay: • Any changes from previous reports. • Unusual reactions. • PRN meds given - drug, time, and patient response. • Treatments or procedures carried out. • Unusual assessment findings. • Concerns with I & O. Review of IV or other parenteral therapy: • Type of therapy (maintenance or "unusual" such as Heparin, insulin, etc.). • cc/hr ordered. • Amount of IV or other parenteral therapy that is "up" for the next shift. • • • • • • Briefly review Kardex if necessary. Dietary. Intake and output. Treatments. Mobility or activity status. Oxygen therapy. Special procedures / lab work.
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EXAMPLE 2
• • •
Patient name_________________________ • Room___________________________ Age (days, months, years)_________ Hospitalized on ___________ for (diagnosis or reason for hospitalization)_____________
BRIEF ASSESSMENT • General Appearance:
activity well nourished deficits neuro checks interactions with POC / RN developmental level speech, ROM paresthesia AVPU
•
-
Neurological:
alert responsive
•
-
Respiratory:
reg unlabored respiratory effort symmetrical breath sounds clear to auscultation (BS CTA) equal aeration any adventitious sounds (effort, aeration, color, respiratory rate, breath sounds) sputum oxygen pulse oximetry edema IV fluids and sites C-R monitor
•
-
Cardiovascular:
heart tones strong and regular apical for 1 minute with S1 and S2 periph pulses (+1 to +3) cap refill time (CRT) <2sec
•
-
Gastrointestinal:
abdomen soft nontender bowel sounds (active or hypoactive) BMs parenteral / NG feeding diet discharge
•
-
Genitourinary:
frequency and amount (in cc's) dysuria description - specific gravity (sg) deformities traction - rash - intact verbalization communication P:__________ - affect
•
• -
Musculoskeletal:
active ROM weakness edema inflammation casts CMS checks ulcers
Skin / Lymph: warm and dry (W & D) color
•
• -
Psych / Social:
appearance behavior T:__________ mood appropriate
Vital Signs: Summarize ranges for shift.
- R:__________ BP:__________
•
• •
Intake / Output: __________ / __________ Specific Kardex Information: (dressing change, respiratory treatments, etc.) Medications: Note if difficulty with administration or support measures required. Include PRN meds and patient response.
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Important Remarks: Laboratory Results:
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CLINICAL EVALUATION DIRECTIONS
Your midterm and final evaluations will be determined by your adherence to professional standards of behavior and your weekly self-evaluations. You must complete a WEEKLY CLINICAL APPRAISAL each week with a detailed description of what you accomplished during the shift. The more you say about yourself, the more your faculty will be able to review with you and to comment on. This should be filled out during the course of the shift and turned in before you leave at the end of the day. You must make enough copies for each clinical week! MIDTERM: A conference may be held at the discretion of the clinical faculty. NOTE: CU students will receive written evaluation at midterm. FINAL: Your Clinical Faculty and you will complete a final evaluation. Clinical Faculty may add additional comments to your Final Evaluation sheet. Clinical Faculty will provide specific requirements for final evaluation.
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