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Denver II Developmental Screening Test

a. Assess for cognitive development
2. Best teaching for adolescents
a. Adolescents are capable of expressing individual concerns
b. talking separately with caregivers and with adolescents
c. need certain accommodations to preserve their self-respect and
3. Special considerations when assessing/teaching adolescents
a. Using bulletin boards
b. Placing informational pamphlets in a brochure rack
4. Phases of anxiety
a. Protest- cries and reacts aggressively, rejecting healthcare
b. Despair- inactive and sad, uninterested in food and play
c. Denial- pretends to reject family caregiver
i. The need for caregivers is more intense than ever
5. Techniques for gaining cooperation of a 5 yr old
a. Communicate with the child and make him/her comfortable and
i. Tell them what to expect and help them avoid the feeling of
abandonment and punishment.
ii. Communicate at their own level of comprehension
iii. Make them feel comfortable and relaxed
iv. nurse can collect most of the admission data for a small
child while he or she sits on the caregiver's lap
6. average range of pulse/respirations for an infant
a. average pulse = 80-180 bpm; average respirations= 20-40 bpm
7. correct order of assessing VS
a. respiration---pulse----temperature----blood pressureweight and
8. recommended guidelines for taking temp in children
a. take a tympanic, axillary, or rectal temperature -younger than 6
years, disoriented, unconscious, or in severe respiratory distress
b. take an oral or tympanic temperature - older than 6 years
c. take the radial pulse- older than 2 years
d. take apical pulse- younger than 2 years
e. do not take rectal temp- child has had any immune or
hematologic disorder, rectal surgery or diarrhea
f. do not take tympanic- ear surgery or has ventilating tubes or
g. axillary method- if other methods are not possible
h. regardless of the method--- remain with the child while taking
temp to ensure safety
i. do not use glass and mercury thermometer
9. guidelines for taking BP in children

a. use smaller cuff for children

b. cuff should cover approx. two-thirds of the upper arm
c. bladder of the cuff- should belong enough to encircle the arm
without overlapping
d. Thigh pressure is approximately 20 mm Hg higher than arm
e. If using radial artery (wrist)- radial blood pressure is 10 mm Hg
lower than that of the brachial artery
Normal head-to-chest ratio
a. Newborn- head is larger than the chest
b. 1-2 yrs old- head and chest approx. equal
c. By age 5- childs chest is about 2-3 inches (5-7.6 cm) larger than
Procedure for measuring head-to-chest ratio
a. measure the occipital-frontal circumference (OFC) of the head for
children up to 3 years of age and for any child with a head size
that is in question.
b. plot measurements on a growth chart and compare them against
normal sizes for the child's age group to determine any
Safety measures- Providing for Pediatric Safety/Safety Devices
in-practice 71.2
Guidelines for applying restraints
a. physician's order is usually required for application of any
restraint device
b. release and reapply restraints every 1 to 2 hours, and check the
child's skin and circulation each hour
restraint uses
a. papoose board
i. used for brief procedures such as starting an IV line,
because it is uncomfortable
b. mitt or glove- prevents the child from scratching or pulling on
c. armbaord- used to protect IV cites
d. mummy restraint- used to restrain the entire body with a blanket
e. arm board for IV- pad the board with a towel and fasten it with
techniques to provide children with protection from contagious
a. change the gown at least once each shift and more often if
needed, then discard it after use.
b. Wear isolation protection
c. Scrub before putting on the gown and scrub thoroughly after
removing it






d. Wear gloves when in contact with the body fluid or substances

Actions to monitor IV therapy while on a pump
a. change central line dressings every 24 hours, if using gauze, and
every 72 hours, if using a transparent dressing (e.g., Tegaderm)
b. monitor for signs and symptoms of infection at the site: redness,
pain, elevated white blood cell count, and temperature
monitoring IV therapy while on a pump
a. keep a check on the IV site to ensure that the catheter is in the
technique for administering suppositories to children
a. Use a clean glove
b. Lubricate the suppository with water-soluble lubricant before
c. Insert the suppository and hold it in place by gently pressing on
the childs anal sphincter from the outside until the child no
longer feels the urge to expel it
Teaching new parents how to bathe their infants
a. Does not need to bath everyday
b. Some children need shampoo daily- prevent seborrhea- scaly
scalp condition known as cradle cap
c. Cleanse the eyes first with water from the inner to outer canthus
using a separate cotton ball for each eye. Then wash the rest of
the face
d. Application of diaper ointment- Destin or A&D
e. Dress the infant, comb the hair. Clean childs fingernails and
Use of an oxyhood
a. place a bath blanket on top of bed linens to absorb moisture so
the child stays warm and dry in a mist tent, but not in an
b. O2 must be warmed to prevent loss of heat by the body
c. oxygen must be humidified and not dry to prevent damage to
respiratory mucosa
d. flow rate must be significantly high enough so that carbon
dioxide flushes out of the hood
e. keep O2 away from sources of flame and sparksoxygen
supports combustion
f. keep suctioning equipment available- children in respiratory
distress may be inclined to vomit
treatment for child with a fever <102 degrees/ >102 degrees
a. <102F = keep the child quiet and prevent the child from crying
b. >104F = sponged with lukewarm water, and the child's
temperature is taken every 10 minutes