Pediatric Lab Checklist, 2015-2016

7/25/2019 Pediatric Lab Checklist, 2015-2016

http://slidepdf.com/reader/full/pediatric-lab-checklist-2015-2016 1/56

Kingdom Of Saudi Arabia

Ministry Of Higher Education

King Abdul-Aziz University

Faculty of Nursing

1

يدوسل يبرل ل

وز رة ليم ل لى

عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت

Child Health Nursing Checklist






Faculty of Nursing

2



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت

cT Ne

tG NNweGe reweG* 3

re ceweNGe* 8

re e* 12

re o ee* 14

re ReNG* 17

re e weGA* 18

re N* 19

N lmNG wN aBath* 21

iGN N eTwe m pe rNA* 24

iGN N eTwe m G rNA* 26

tc leG N see* 27

Ae ceNA m ae* 30

TG* 32

lmNG aR * 34

a aR * 36

lmNG aT* 38

a aT* 39

neTNG rwGNG* 40

ReGNG 46

lGNhe s ceNA 50

lGNwTN lueTG 55






Faculty of Nursing

3



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت

Growth Parameter Assessment

Student Name: …………………………………………….

Purposes:

1. To calculate baby body mass index.

2. To measure healthy versus unhealthy weight, length/height, head and chest circumference , andabdominal girth.

3. To track a child's growth.

Equipment:

1.

Infant/toddler scale.2. Adult scale.

3. Small sheet or paper drape to cover scale.

4. Paper measuring tape marked in centimeters.5. Marker

6. Stethoscope

7. Flat surface or flat measuring board8. Growth chart

9. Calculator

Marks

Marks

CommentMarksProcedural Steps

Assessing Weight for An Infant/Toddler Up to 24 Months of Age

1. Note child’s previous weight.

2. Perform hand hygiene.

3. Place light drape or paper on scale.

4. Adjust the scale balances to 0, or push the appropriate pads on

the digital scales, using a protective barrier on your hand.

5. Completely undress and safely place infant/toddler on scale.

6. Hold hand slightly above infant while on scale and never turn

your back on the child (to prevent falls or potential injury).7. Note and record child’s weight in kilograms.

8. Diaper infant. Carefully remove infant from scale, redress, and

return infant to parents.

9. Dispose of paper on scale and disinfect scale per hospital policy.

Perform hand hygiene.

10. Document weight on child’s growth chart. The normal weight

range for a newborn is 2.5 to 4 kg.

1.






Faculty of Nursing

4



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت

Measuring Length of Children Younger than 2 Years of Age

1. Note child’s age and previous length.

2.

Perform hand hygiene.

3. Place light drape or paper on flat surface or flat measuring board.

4. Place the child in supine position, placing the vertex of the

infant’s head at the top of the board and the soles of the feet

firmly against the footboard.

5. Hold child’s head at midline point and extends legs fully.

6. Stretch a tape measure from crown of child’s head to heel of

child’s foot, alongside child’s body boundaries.

7. Make sure that the measuring tape remains straight.

8.

Note and record infant’s length in centimeters.9. Carefully remove infant from flat surface and return infant to

parents.


11. Document length on child’s growth chart. Compare your finding

with the normal range. For infant, normal range is between 48 to

53 cm in length

2.

Assessing Weight for Older Children

1. Determine whether child is able to stand and balance on scale.

2.

Note child’s previous weight.3. Place paper or drape on scale.

4. Calibrate scale to zero position.

5. Ask child to remove shoes and heavy clothing.

6. Assist child to stand on scale (to prevent falls or potential

injury).

7. Have child place hands at side of body or hold belly. Ask child

to be still.

8. Note and record child’s weight in kilograms.

9. Assist child to step down from scale or proceed to height

assessment.10. Document weight on child’s growth chart.

3.






Faculty of Nursing

5



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت

Assessing Height for Older Children

1. Determine whether child is able to stand and balance on scale.

2.

Note child’s previous height.

3. Ask child to remove shoes. Child should not be wearing a hat or

hair ornaments.

4. Assist child to stand on scale with back to scale (to prevent falls

or potential injury). The child should look straight ahead without

tilting the head.

5. Raise height rod and extend height assessment bar height over

child’s head.

6. Lower height rod to top of child’s head.

7.

Note and record the child’s height measurement in centimeters.8. Assist child to step down from scale or proceed to weight

assessment.

9. Document height on child’s growth chart.

4.

Assessing Head Circumference

1. Note child’s last recorder head circumference.


3. Place light drape or paper on flat surface.

4.

Place infant/toddler in supine position or seated on paper drape.5. Place tape measure over the most prominent point of the occiput

(occipital prominence), around the head just above the eyebrows

and pinna.

6. Note and record infant’s head circumference in centimeters.

7. Carefully remove infant from flat surface and return infant to

parents.


9. Document head circumference on child’s growth chart. The

average head circumference for a newborn is 33 to 35 cm.

5.






Faculty of Nursing

6



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت

Measuring Chest Circumference

1. Note child’s last recorder chest circumference.

2.

Perform hand hygiene.3. Place light drape or paper on flat surface.

4. Place infant/toddler in supine position on paper drape.

5. Place the paper tape under the infant/toddler 's chest

6. Wrap the tape measure around the chest, placed just under the

axilla and at the nipple line.

7. Note and record the infant’s chest circumference.

8. Document chest circumference on child’s growth char t. The

average chest circumference for a newborn is 30.5 to 33 cm.

6.

Measuring Abdominal Girth

1. Check records and medical history information to determine

previous abdominal girth measurements.

2. Perform hand hygiene

3. Auscultate bowel sounds with stethoscope before measuring

abdominal girth. (Manipulating the abdomen may affect bowel

sounds).

4. Place the child in supine position with the child’s knees flexed or

for an infant, hold the legs flexed at the knees and hips. (Flexing

the knees helps the child’s abdominal muscles to relax).

*Remove or move aside clothing that interferes with the ability

to apply measuring tape around the abdomen. Do not measure

over clothing.

*Measure girth with the child in the same position each time

(ensure consistency and accuracy of results).

5. Visualize the child’s abdomen to evaluate for symmetry,

contour, peristalsis, and abnormalities such as distension or a

mass.

6. Place your palm under child’s waist and slide paper tape through

under the child’s abdomen. 7. Place tape snugly across the umbilicus, but not cinching the

waistline. Ensure that the tape measure is laying flat underneath

the child for an accurate measurement.

*Take measurements at the end of expiration.


9. Evaluate previous assessment and note any changes in abdomen,

including girth, firmness, colour, and bowel sounds.

7.






Faculty of Nursing

7



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت

Total Grade ………………………….

Instructors Name ………………………………………

*Note abdominal girth, date, and time of measurement, and

factors pertinent to abdominal assessment.

*Document any abdominal pain. Calculating Body Mass Index (BMI)

*BMI= Weight in Kilograms ÷(Height in Meters) ²

8.






Faculty of Nursing

8



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت

Assessing Temperature

Student Name: __________________________

Purpose

1. To establish baseline data for subsequent evaluation

2. To detect any abnormality or complication

Equipment

1. Thermometer (Oral – Rectal - Electronic (Interchangeable oral and rectal probes) - Tympanic probe.

2. Cover Sheet.

3. Disposable gloves.4. Alcohol swab, Optional.

5. Water soluble jell 6. Tissue

Mark

Mark

Procedural Steps Marks Comment

1. Wash hands

2. Provide privacy

3. *Explain the procedure to the patient and family

*Assemble the Equipment at the bedside**Show the child and family the equipment you will use and

demonstrate how the equipment is used.

4. Oral Determination

a. Hand washing

b. Select an instrument (oral or electric)

c.

If the thermometer has been stored in chemical solution,rinse it with water and wipe it dry with a soft tissue

d. *Shake a glass thermometer until the mercury is below

the 35.5 c mark. Firmly hold the non-bulb end of the

thermometer and briskly snap the hand at the wrist.*If using an electronic thermometer, remove from

charger and slide cover over probe

e. *Place the bulb under the right side of the child tongue.Have the child close mouth around the thermometer (If






Faculty of Nursing

9



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت

the child is over the age of 6 years)f. *Leave the thermometer under the tongue for 3-5

minutes. Stay with the child while thermometer is in

place*If an electronic thermometer is used, use the oral probe

with a disposable plastic probe cover. The thermometer

will signal when the peak temperature has been reachedg. Remove the thermometer from the mouth and read the

temperature

h. Hand washing

i. After use, wipe thermometer with soft tissue, rinse incold water, and store according to policy

5.

Rectal Determination

a. Select an instrument (Rectal/stubby or electric) and

provide privacy for the child

b. Rinse, wipe and shake the rectal thermometer as in oraltemperature. If an electronic thermometer is used,

remove from charger and slide cover over probe

c. Lubricate the bulb with a water soluble gel

Infant

1. Hand washing2. Place infant in prone position, spread the buttocks with

one hand and insert the thermometer slowly and gently

with other hand

3. *Gently Insert the bulb into the rectum about 1/4 -1/24. *If resistance is felt, remove thermometer and choose

another route

5. Hold the child’s buttock closed with one hand and

keep probe in place with other.

6.

The thermometer will signal when the peaktemperature has been reached. Note the temperature

and remove the thermometer in straight line.7. Discard the probe cover or/and wipe it with soft tissue

and restore the thermometer.

8. Hand washing






Faculty of Nursing

10



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت

Older Child

1.

Hand washing2. Position child on side, separate buttocks to expose the

anal opening

3. *Gently insert the thermometer into the rectum about 1-11/2

4. Hold the child’s buttock closed with one hand and keep

probe in place with other.

5. *Hold thermometer in place for 3-4 minutes or until theelectronic thermometer signal is heard

6. *Never leave child alone with a rectal thermometer in

place

7.

Remove the thermometer in a straight line8. Wipe it off with a soft tissue.

9. If using an electronic thermometer, insert probe into

base and store in charger10. Read the temperature

11. Reposition the child in a comfortable position and clean

thermometer according to the policy12. Hand washing

6. Axillary Determination

1. Hand washing

2.

Select instrument – follow institution policy concerningwhether to use a rectal or oral thermometer

3. *Rinse, wipe and shake the thermometer as suggested in the

procedure for obtaining an oral temperature. If an electronicthermometer is used, remove from charger and place cover on

probe

4. Place the bulb under the arm, well up into the armpit. Bringthe child's arm down close to the body and hold in place

5. Leave in place 10 minutes or until electronic thermometer

signal is heard and note the temperature

6. Wipe it off with a soft tissue.

7.

If using an electronic thermometer, insert probe into base andstore in charger

8. Hand washing






Faculty of Nursing

11



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت



7. Tympanic Determination

1. Hand washing

2.

Select instrument (tympanic instrument)

3. Place disposable cover on the probe tip

4. Retract the pinna posteriorly, upward and backward

5. Insert probe into ear canal while pressing scan button

6. Leave in place until electronic thermometer signal is heard and

note the temperature

7. Remove probe cover and discard it. Wipe the probe with tissue

8. Insert the probe into base and store it.

9. Hand washing

8. Temporal Artery Determination:

1. Hand washing

2. Apply disposable cover to probe, if using covers

3. Position the probe in the middle of the child’s forehead

4. Press the “ON” button. While holding on the “ON” button,

move the probe laterally to the hairline and stop

5. Read thermometer output according to manufacturer’s

instructions

6. Remove the probe cover and/or wipe the tip with tissue

7.

Hand washing






Faculty of Nursing

12



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت

Assessing Pulse

Student Name: …………………………………………….

Purposes:

1. To establish baseline data for subsequent evaluation.

2. When redial pulse is inaccessible or difficult to assess.

3. When radial pulse is not recommended.

4. To determine whether the cardiac rate is within normal range and the rhythm is regular.5. To monitor clients with cardiac disease and those receiving medications to improve heart action (more

accurate).

Equipment:

1. Stethoscope.

2. Watch with second.

3. Paper, pen.4. Alcohol swap.

Marks

Marks


Infant, young child, and all cardiac patients – Apical rate

1. Take the apical rate before any other vital sign measurement

is attempted

2. Calm the child if required. Crying may increase heart rate.


4. *Place the stethoscope between the left nipple and sternum

5. Count the beats for 1 full minute

6. Note the rhythm and quality of sound and report any

alteration

7. Wash hands

8.

Accurately record the following in the medical record:

Pulse rate

Quality of the pulse

Location felt

Regularity or irregularity of rate

Activity of child at time pulse is taken

1.






Faculty of Nursing

13



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت



Older child – Radial rate

1. Place the first, second or third finger along the child's radial

artery and press gently against the radius.

2. Rest the thumb in opposition to the fingers on the back of the

child's wrist

3. Apply only enough pressure, so that the child's pulsating

artery can be felt

4. Count the arterial pulsations for 30 seconds and multiply by

2 to calculate the rate for one minute. If the pulse rate is

abnormal, palpate the pulse for 1 full minute

5. Assess rhythm (regularity versus irregularity), amplitude

(strength of pulsation), and elasticity of the vessel (distension

of vessel) while counting the rate

6. Accurately record the following in the medical record:

Rate

Quality of the pulse

Location felt

Regularity or irregularity of rate

Activity of child at time pulse is taken

2.

Report any changes in pulse characteristics to the physician immediately3.






Faculty of Nursing

14



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت

Assessing Blood Pressure

Student Name: ……………………………………………..

Purpose:

1. To obtain baseline measure of arterial blood pressure for subsequent evaluation.

2. To determine the client’s homodynamic status.

3. To identify and monitor changes in blood pressure resulting from a disease process

and medical therapy.

Equipment:

1. Stethoscope.

2. Sphygmomanometer with appropriate cuff size or, the automated device (electronic).

3. Antiseptic wipes.

CommentMarks Procedural Steps

1. Prepare the equipment and instruments

2. Hand washing

3. Select the site. Do not use extremity that has an injury,

wound, foreign device, or the one that has altered circulation

(shunt or coarctation)

1.

Marks

Marks






Faculty of Nursing

15



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت

Auscultation: Brachial Artery

1. Place the infant or child in a sitting or recumbent

position. The forearm is supinated and slightly flexed

2. Remove all clothing from the upper extremity

3. Demonstrate the equipment and procedure to the child

using appropriate terminology

4. Check equipment for connection and function

5. Place the correct size cuff. Bladder width should be

about 40% of the arm circumference midway between

the elbow and shoulder. The lower edge should be 3cmabove the antecubital fossa

6. Locate the artery by palpation at the antecubital fossa

7. Close the air valve and rapidly inflate the cuff to

30mmHg above the expected systolic pressure or until

the radial pulse disappears

8. Place the stethoscope gently over the artery

9.

Slowly release the air valve, permitting the column ofmercury to fall at a rate of 2-3 mm per heartbeat

10. Note the Korotkoff sounds

11. After readings have been made, the cuff is deflated and

removed from the arm

12. Hand washing

13. Record findings, child’s position, and site

2.






Faculty of Nursing

16



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت

Auscultation: Popliteal Artery

1. Place the child in prone position

2.

Place the correct size cuff around the thigh, with thelower edge about 2cm above the popliteal space

3. The leg is slightly flexed, with the stethoscope over the

popliteal artery. The subsequent procedure is identical to

that for the brachial artery

4. Palpation

5. The sphygmomanometer cuff is inflated until the radial pulse cannot be palpated

6. With the palpating digit kept over the artery pressure is

released slowly until the pulse is felt. The end point isrecorded as the systolic pressure

3.

Automated Device Method

1. Obtain the monitor, dual air hose, and the correct size

cuff2. Place the monitor on a firm, immobile surface

3. Stabilize the extremity during measurement

4. Wrap the correct size cuff around the child's limb

5. Turn the power switch to the ON position6. Wait for the readings and record it

4.

Repeat the procedure at least twice to confirm the reading5.

Perform hand hygiene6.

Upon concluding the blood pressure determination record the

following:

a. Reading obtained

b. Extremity used

c. Type of method used

d. Size of cuff used

e. Person notified if reading is of concern

7.








Faculty of Nursing

17



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت

Assessing Respiration

Student Name: ……………………………………………..

Purpose:

To obtain baseline data to assess the general status of each child within the first

hour of admission.

Equipment:

Clock or watch with a second hand.



Marks

Marks

Procedural Steps Marks Comments

1. Note the child’s history and diagnosis of any respiratory problems

2.

Perform hand hygiene

3. Count the respiration by inspection, preferably when the child is awake

and calm

4. *In infant and young children, observe the abdomen movements

*In older children, observe the thoracic movements

5. *If respiration is regular, count number of respiration for 30 secondsand multiply by 2.

*If respiration is irregular, count the number of respiration for full 1

minute.

6. *Note depth and pattern of respirations, presence of anxiety,

restlessness, and irritability

*Observe child’s color for cyanosis and pallor


8. Record results. Respiration rate is recorded by breath per minute






Faculty of Nursing

18



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت

Assessing Pulse Oximeter

Student Name: ……………………………………………..

Purpose:

When a child is undergoing a procedure that requires sedation and need observation.

To adjust oxygen saturation level.

If the child have or at risk for respiratory problems.

Equipment:

Pulse oximeter saturation monitor

Pulse oximeter probe

Tape

Bedside oxygen delivery equipment including oxygen source, flow meter andmask/nasal cannula.


1. Hand hygiene

2. Gather the equipment and supplies. Select appropriate sensor.

3. Attach the sensor to the selected site with light source on one side

and the sensor on the other side, facing each other.

a. Keep the sensor site at the level of the heart.

4.

Tape sensor in place. Loosely but securely.

5. Cover the sensor site with an opaque material.

6. Turn the pulse oximeter monitor on. Ensure that the reading is

present and waveform shows a good trace.

7. Set alarm limit: high rate, low rate, and low pulse alarm

8. Determine with healthcare providers when should be administered

oxygen or increase the level based on Sao2 values.

9. Dispose the equipment and waste in appropriate receptacle.


11.

When responding to alarms, assess for respiratory distress, child’scolor, oxygen equipment is functioning well, and sensor at the heart

level.

12. Rotate the sensor site every 2 hours



Marks

Marks






Faculty of Nursing

19



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت

Assessing Pain

Student Name: ……………………………………………..

Purpose:

To obtain baseline data regarding the comfort status of the child.

To assess the response to treatment regimes

Equipment:

Self-report tool when possible.

Pain scale


1. Review the child’s pain history and previous pain level, when

available

* Note the child’s diagnosis and medical or surgical history

2. Determine whether the child is taking any medications that may

affect perception of pain or ability to communicate pain.


4. Assess for pain indicators, considering child’s age and sleep

pattern.

a) Acute pain:

Subjective: statement of pain. Or ask the parents

Physiologic: increased respiratory rate or heat rate, shallow

breathing, decrease oxygen saturations and pupil dilation

Behavioral: crying, moaning, anxiety, anger, decrease activity

level, facial grimace, touching painful area.

Marks

Marks






Faculty of Nursing

20



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت

b) Chronic Pain:

Vital signs stable

Disturbed sleep

Developmental regression

Change in eating pattern

Depression

Aggression

5. Assess pain level using an appropriate pain assessment tool (pain

scale). Use the same tool over time to compare adequacy of painmanagement

6. Perform physical examination of the painful area.

7. Determine child’s pain level and appropriate intervention. Consider

specific situations, type and intensity of pain.

*Implement pain management intervention.

8. Perform comprehensive reassessment of pain level









Faculty of Nursing

21



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت

Bathing an Infant or Small Child

Student Name: ……………………………………………..

Purposes:

1. To promote proper hygiene and comfortable of the infant

2. To keep the skin fresh and to protect the integrity of the child’s skin

3. To assess the child activity level

4. To assess the stage of development level

5. To assess the child’s physical condition

Equipment:

1. Basin with warm water (40.6°c) 2. Mild soap

3. Cotton balls 4. Soft washcloth

5. Diaper 6. Dry clean clothing

7. Blanket 8. No sterile gloves

9. Alcohol pad (If umbilical cord care is indicated) 10. Comb

11. Baby lotion 12. Towel

CommentsMarks

Procedural Steps

*Explain the procedure to the patient and family.

*Assemble the equipment at the bedside.

1

Wash hands.2

Screen the child.3

Take and record temperature, pulse, and respiration.4

Wash the child from head to feet. Dry washed areas with a towel,

giving added emphasis to skin folds.

5

Moisten a cotton ball with water and wipe eyes from inner canthus to

outer canthus. Repeat with a clean cotton ball on the other eye.

6

Marks

Marks






Faculty of Nursing

22



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت

Wet washcloth and wring. Gently wash one side of the face from

forehead to chin, going around the nose and mouth. Repeat on other

side of the face.

**Do not use soap on the face.

7

Dry infant's face with towel.8

To cleanse the baby's scalp, pick up baby securely by sliding hand

under the baby until the head is well supported in the palm of the

hand. Cover ears with thumb and middle finger. Hold baby's head

over the basin. Soap and rinse head and dry with towel.

9

Continue washing ears and neck, giving particular attention to the skinfolds of the neck, behind the ears, and the external part of the ears.

*Wipe washed areas repeatedly to rinse off soap.

10

Remove infant's shirt. Wash trunk and arms. Wash between fingers.

Turn infant one on side to wash back.

11

Cover infant with a blanket. Rinse and wring washcloth, then wipe

away soap. Repeat to ensure removal of soap.

12

Dry area with towel. Cover trunk after drying.13

Remove diaper, exposing lower half of body. Keep upper half of body

covered with blanket.

14

Lightly soap washcloth, wipe over abdomen and around umbilical

cord. Work down each leg to the foot, using long stroking motions.

Wash between toes. Clean around umbilical cord with alcohol swab or

sterile applicator.

15

Rinse washcloth and wipe soap off body, paying particular attention to

skin creases.

16

Wash genitalia with cotton balls. Spread apart the female's labia and

clean between folds, using a front to back motion. Use each cotton

ball for one stroke only.

17

The male genitalia should be washed with cotton balls from penis to

anus. **Do not retract the foreskin of the penis.

18






Faculty of Nursing

23



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت

Next wash the anus and between the gluteal fold and buttocks.19

Dry lower half of body. Re-diaper, redress, and position the infant in

the isolette or bassinet.

20

Document any abnormalities in the skin surface in the medical record

a. Desquamation – peeling of the skin during the first 2-4weeks of life.

b. Milia – tiny, white papillae occurring on the nose and

chin that are caused by obstruction of the sebaceous

glands. These disappear in 1-2 weeks.c. Jaundice – yellow discoloration of the skin that appears

between the thirds and seventh day of life.

d.

Telangiectatic nevi (Stork bites) – flat, red localizedarea of capillary dilatation forming a variety of

angiomas, most notably on the upper eyelids; these

disappear usually by 2 years of age.e. Forceps marks – marks left on part of the body where

the blades exerted pressure.

21

Document the infant's tolerance of the bath process.22

Replace equipment.23

Wash hands.24








Faculty of Nursing

24



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت

Obtaining a Specimen for Urine Analysis

Student Name: ……………………………………………..

Purposes:

1. To confirm the diagnosis of urine infection.

2. To decide the best antibiotic to use.

Equipment:

1. Sterile container

2. Urine collection bag

3. Label specimen clearly

4. Deliver specimen immediately to the lab (Bacteria may grow at room temperature)

CommentsMarks

Procedural Steps

Wash hands1

Provide privacy2

Explain the procedure to the patient and family.

Assemble the Equipment at the bedside.

3

a. Apply newborn and pediatric urine collection

1. The skin must be clean and dry

2. Avoid oils, baby powder and lotion soap

3.

Application must begin on the tiny area of skin between the anus andgenitals

4. The narrow bridge on the adhesive patch keep feces from contaminating

the specimen and help position the collector correctly

4

Put the child on his/her back, spread the legs and wash each skin fold in

genital area.

**Do not use a scrub soap solution

5

Marks

Marks






Faculty of Nursing

25



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت

Wash the anus last; allow a few moments for air-drying.6

Remove protective paper from the bottom half of the adhesive patch.7

For girls: Stretch the perineum to separate the skin folds and expose the

vagina.

For boys: Begin between the anus and the base of scrotum.

8

Press adhesive firmly against the skin and avoid wrinkles, remove paper

from the upper portion of adhesive patch.

9

Use a sterile container or apply a urine collection device.10

If a bag is used, secure the diaper over the bag11

Check bag every 20 to 30 minutes12

Label all specimens clearly and attach the proper laboratory slip.

**Collected specimens should be transported in plastic bag (check

institution policy).

13

Wash hands.14

Document procedure.15








Faculty of Nursing

26



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت

Obtaining a Specimen for Stool Analysis

Student Name: ……………………………………………..

Purpose:

To determine whether the type of bacteria or parasite may be infecting the intestines.

Equipment:

1- Clean container

2- Tongue blade

CommentsMarks

Procedural Steps

Prepare the equipment and instruments1

Provide privacy

Explain the procedure to the child and/or parent

2

Wash hands well and wear gloves to obtain specimen3

Obtain stool specimen directly from the diaper (If it has not

been contaminated by urine).

With the tongue blade or use the tongue blade to receive thespecimen from the collection device

4

The specimen is labeled properly and the laboratory slip is attached

**Some specimens must be sent to the laboratory while they are warm

5

Replace equipment6

Wash hands7

Document procedure

a. Charts the time, color, amount, and consistency of the stool b.

The purpose for which it was collected (e.g., blood, ova,

parasites, bacteria) and any related information

8



Marks

Marks






Faculty of Nursing

27



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت

NGT Insertion and Feeding

Student Name: ……………………………………………..

Purposes:

1. To feed the child

2. To administer medications

3. To assess gastrointestinal function

Equipment:

1. Sterile rubber or plastic catheter

2. Round – tip, size 5 -14

3. Clear, calibrated reservoir for feeding fluid4. Syringe

5. Stethoscope

6. Water for lubrication

7. Tape – hypoallergenic

8. Feeding fluid, room temperature

9. Pacifier

CommentsMarks

Procedural Steps

Preparatory phase for NGT insertion

a. Place the infant on side or back with a diaper roll placed under shoulders.

**A mummy restraint may be necessary to help maintain this position.

b. Measure feeding catheter and mark with tape, measure distance from tip of

nose to ear to xiphisternum.

c.

Have suction apparatus readily available.

1

Performance phase for NGT insertion

Lubricate catheter with sterile water or saline. Stabilize the patient head with one hand and use the other hand to

insert catheter.

a. Insertion through nares:

Slip the catheter into nostril and directed toward the occiput in ahorizontal plane along floor of nasal cavity

2

Marks

Marks






Faculty of Nursing

28



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت

b. Insertion through the mouth:

Pass the catheter through the mouth toward the back of the throat

Depress anterior portion of tongue with forefinger, insert catheter alongforefinger and tilt head slightly forward

If the patient swallows, passage of the catheter may be synchronized with the

swallowing

**Do not push against resistance.

***Gently rotating the tube if resistance is met

3

If there is no swallowing, insert the catheter smoothly and quickly4

Observe the infant for vagal stimulation (i.e. bradycardia (Slow heart rate)

and apnea

5

Once the catheter has been inserted to the premeasured length, tape the

catheter to the patient face

6

Test for correct position of the catheter in the stomach:

a. Inject 0.5-5 ml air into the catheter and stomach

*Listen to the typical growling stomach sound with a stethoscope

placed over the epigastric region

*Aspirate injected air from the stomach

b. Aspirate small amount of stomach content and test acidity by pH tape

Observe and gently palpate for tip of catheter, avoid inserting catheter

into the infant's tracheac. Abdominal X-ray

7

Performance phase for NGT feeding:

a. Position should be right side lying, with head and chest slightly

elevated

b. Attach reservoir to catheter and fill with feeding fluid

c. Encourage infant to suck on pacifier during feeding. Hold infant when

possible

8

Aspirate tube before feeding begins

**If over half the previous feeding is obtained, withhold the feeding

** If small residual of formula is obtained, return it to stomach and subtract

the amount from the total amount of formula to be given

The flow of the feeding should be slow. **Do not apply pressure

Elevate reservoir 15-20 cm above the patient's head

9






Faculty of Nursing

29



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت

Feeding given too rapidly will interfere with peristalsis causing abdominal

distension and regurgitation

10

Feeding time should last approximately as long as when a correspondingamount is given by nipple, 5ml / 5-10 min or 15-20 minutes total time

11

When the feeding is completed, the catheter may be irrigated with clear water12

Before the fluid reaches the end of the catheter, clamp it off, withdraw it

quickly or keep in place for next feeding

13

Discard feeding tube and any leftover solution14

Follow – up phase:

1. Burp the patient2. Place the patient on right side for at least 1 hour

3. Observe condition after feeding, bradycardia and apnea may

still occur

4. Note any vomiting or abdominal distension5. Note infant's activity

15

Accurate and descriptive recording/Documentation:

1. Time of feeding2. Type of gavages feeding

3. Type and amount of feeding, fluid given

4.

Amount retained or vomited5. How the patient tolerated feeding

6. Activity before, during, and after feeding

16

Wash hands17








Faculty of Nursing

30



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت

Oxygen Therapy for Children

Student Name: ……………………………………………..

Purposes:

Relieve hypoxaemia and maintain adequate oxygenation of tissue and vital organs, as

assessed by SpO2 /SaO2 monitoring and clinical signs.

Prevents excessive CO2 accumulation, i.e., selection of the appropriate flow rate and delivery device.

Reduce the work of breathing.

Maintain efficient and economical us eof oxygen.

Equipment:

1.

Oxygen device of appropriate size2. Oxygen supply with a flow meter and adapter

3. Humidifier with distilled water or tap water according to agency protocol

4. Padding for the elastic band (for cannula and face mask)

CommentsMarks

Procedural Steps


Determine the need for oxygen therapy, and verify the order by checking:

(a) The order for oxygen, including the administering device and the liter flow

rate (L/min)(b) The levels of (PaO2), (PaCO2) in the client’s arterial blood

(c) Whether the client has COPD or not

2

Maintain a clear airway by suctioning, if necessary3

Measure oxygen concentration every 1-2 hours when a child is receiving

oxygen through incubator hood or tent

Measure when the oxygen environment is closed

Measure the concentration close to the child's airway

Record oxygen concentrations and simultaneous measurements of pulse

and respiration

4

Observe the child response to oxygen5

Organize nursing care so that the interruption of therapy is minimal

Periodically check all equipment during each tour of duty

6

Clean equipment daily and change it at least once each week7

Marks

Marks






Faculty of Nursing

31



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت

Keep combustible/flammable materials and potential sources of fire away

from oxygen therapy

a.

Avoid using oil or grease around oxygen connections b. Do not use alcohol or oils on a child in an oxygen tent

c. Do not permit any electrical devices in or near an oxygen tentd. Avoid the use of wool blankets and those made from some synthetic

fiber because of the hazards resulting from static electricity

e. Prohibit smoking in areas where oxygen is being used

f. Have a fire extinguisher available

8


Assist the child to a semi-Fowler’s position if possi ble.10

Set up the oxygen equipment and the humidifier by:(a) Attach the flow meter to the wall outlet or tank. The flow meter should be

in the off position.

(b) Make sure the humidifier or nebulizer is filled with water to the appropriate

mark.

(c) Attach the prescribed oxygen tubing and delivery device to the humidifier.

11

Turn on the oxygen at the prescribed rate and ensure proper functioning.12

Check that the oxygen is flowing freely through the tubing.13

Apply the mask to the patient’s face and adjust the straps so the mask fits

securely

14

Pad the band behind the ears and over bony prominences15

Check the liter flow and the level of water in the humidifier in 30 minutes and

whenever provide care to the client.

16

Be sure that water is not collecting in dependent loops of the tubing.17

Terminate oxygen therapy gradually

a. Slow/reduce liter flow

b.

Open air events in incubators

18

Continually monitor the child's response during weaning.

a. Observe for restlessness

b. Increase pulse ratec. Respiratory distress, cyanosis

19








Faculty of Nursing

32



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت

Suctioning

Student Name: …………………………………………….

Purposes:

1- To maintain airway patency by removing pulmonary secretions.

2- To decrease the risks of hypoxemia and potential for infection.

3- To enable collection of sputum for diagnostic purposes.

Equipment:

1- Appropriately sized resuscitation equipment (mask, valve, bag)

2- Appropriately sized suction catheter (#8 to #10 French for children, #5 to #8 French for infants)

3-

Mask and gloves4- Suction source (wall suction or portable suction machine)

5- Oxygen source and delivery source

Marks

Marks

CommentsMarksProcedural Steps

Gather equipment. 1

Set suction pressure levels as follows:

80 – 100 mm Hg for infants and children under 10 – 12 years

100 – 120 mm Hg for older children

2

Ensure appropriate resuscitation equipment at the bedside.3

Wash hands. 4

Pure some normal saline into cup. 5

Identify an assistant to help position, hold, and comfort child as

necessary.

**Place head of the bed at a 30° angle.

6

Be prepared to maintain airway and initiate resuscitation. 7

Don mask, gloves (as needed). 8

Oxygenate child above baseline oxygen saturation. 9






Faculty of Nursing

33



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت



Encourage the child to cough to help mobilizing the secretions or

perform CPT.

10

Be prepared to maintain airway and initiate resuscitation.11

With dominant hand, remove protective covering, pick up suction

catheter and connect it to the suction tubing using non-dominant hand.

12

Determine the correct distance to advance suction catheter.13

Place the tip of the catheter on the normal saline cup. 14

Apply intermittent suctioning by covering the suction control hole with

thumb.

15

Gently rotate the catheter while withdrawing the catheter. 16

Limit continuous suction within the airway to no more than 5 (infants) –

15 (child) seconds.

17

Only if there is thick secretion, instil drops of normal saline into the

tube.

**Avoid excessive use of normal saline.

18

Repeat as needed to clear the airway. 19

Re-oxygenate the child in between each interval. May use ambu bag for

hyper-oxygenation.

20

Allow 20 – 30-second intervals between each episode of suctioning.

**Limit suctioning to a total of 5 minutes.

21

Assess respiratory status.22






Faculty of Nursing

34



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت

Infant CPR (from Birth to 1 Year)

Student Name…………………………………….

Purposes:

1- To restore and maintain breathing and circulation.

2- To provide oxygen and blood flow to the heart, brain and other vital organ.

For child and infant CPR sequence, initiate CAB: Circulation, Airway, and Breathing.

Marks

CommentsMarkProcedural Steps

Checking response by taping the infant foot.1

If no response, call for help.2

If the child is unresponsive and you are alone, start CPR

immediately, continue for 2 minutes, and then call for help.

3

Check brachial pulse, no more than 10 seconds (located on the

inside of the upper arm between the elbow and shoulder).

4

If no pulse or less than 60 beats/minutes, start chest compression.5

Place the child on a firm, flat surface, in supine position.6

**Place the two fingers between the child nipples (One rescue).**The two-thumb encircling hands technique (Two rescues).

7

The arm should be straight while giving the chest compressions.8

Perform 30 chest compressions at rate of 100

compressions/minutes.

9

Depth of compressions 1-1.5 inches (4 cm).10

The chest should allowed rising completely after each compression.11

Perform C/E technique while giving breathing by Ambu Bag.12

Give 2-rescue breathing (look for chest raise).13

**Perform cycles of compressions and ventilations 30-2 (one

rescue) **Perform cycles of compressions and ventilations 15-2(two rescuers)

14

Reassess the pulse after 5 cycles (2 minutes).15






Faculty of Nursing

35



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت



When to stop CBP?

* When the patient responded

* When 15-30 minutes are over since CBR started.* When emergency system responded.

16






Faculty of Nursing

36



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت

Child CPR (1 Year to Puberty)

Student Name…………………………………….

Purposes:

1- To restore and maintain breathing and circulation.

2- To provide oxygen and blood flow to the heart, brain and other vital organ.

For child and infant CPR sequence, initiate CAB: Circulation, Airway, and Breathing.


Check response by shaking the child’s shoulder and shout (Are you

ok?)1

If no response, call for help.2

If the child is unresponsive and you are alone, start CPR

immediately, continue for 2 minutes, and then call for help.3

Check carotid pulse, no more than 10 seconds (located on the side

of the neck between the trachea and sternocleidomastoid muscles).4

If no pulse or less than 60 beats/minutes, start chest compression.5

Place the child on a firm, flat surface, in supine position.6

Place the heel of one hand between the child nipples.7

The arm should be straight while giving the chest compressions.8

Perform 30 chest compressions at rate of 100compressions/minutes.

9

Depth of compressions 2 inches (5cm).10

The chest should allow recoiling after each compression to allow

the heart to refill with blood.

11

Perform C/E technique while giving breathing by Ambu Bag.12

Give 2 rescue breathing (look for chest raise).13

**Perform cycles of compressions and ventilations 30-2 (one-rescue)

**Perform cycles of compressions and ventilations 15-2 (two-

rescuers)

14

Marks






Faculty of Nursing

37



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت

Reassess the pulse after 5 cycles (2 minutes).15

When to stop CBP?

* When the patient responded* When 15-30 minutes are over since CBR started.

* When emergency system responded.

16








Faculty of Nursing

38



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت

Infant Chocking

Student name………………………………..

Foreign bodies may cause either mild or severe airway obstruction

Mild Airway Obstruction Severe Airway Obstruction

-Good air exchange. -Poor or no air exchange.

-Responsive and can cough forcefully. -Weak, ineffective cough or no cough at all.

-May wheeze between coughs. -High-pitched noise while inhaling or no noise

at all.

-Increased respiratory difficulty.

-Possible cyanosis.

-Unable to speak. -Clutching the neck with the thumb and fingers,making the universal chocking sign.

Follow steps to relieve chocking in responsive infant:


Foreign body airway abstraction may cause mild to severe airwayobstruction. If there is mild obstruction, allow an infant to clear the

airway on its own.

1

If severe obstruction, Kneel or site with the infant in your lap and bare the infant chest.

2

Hold the infant prone with the head slightly lower than the chest,

resting on your forearm.

3

Deliver up to five backslaps forcefully in the middle of the back useheal of your hand.

4

Place your free hand on the infant’s back with the palm of onehand supporting the face and jaw.

4

Turn the infant as unit and provide up to 5 quick down ward chest

thrust.

5

Repeat the sequence until the object is removed or infant becomeunresponsive.

6

If the infant become unresponsive start CPR.7








Faculty of Nursing

39



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت

Child Chocking

Student name………………………………..


Foreign body airway abstraction may cause mild to severe airwayobstruction. If there is mild obstruction, allow an infant to clear the

airway on its own.

1

Ask the child *Are you choking*?2

If he/she nods, tell him/her that you are going to help him/her.

**(Use the Heimlich maneuver).3

Kneel or stand behind child and wrap your arms around him/her.4

Make fist with one hand.5

Place the thumb side of one fist midline on the abdomen above the

navel and below the xiphoid process.6

Grasp the fist with your other hand.7

Give quick up ward, inward thrust into abdomen.8

Repeat until object expelled or child become unresponsive.9

If the child become unresponsive start CPR.10








Faculty of Nursing

40



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت

Administering Medications

Student name: …………………………………………

Purposes:

1. Easy, safe, effective, and economic route of administration

2. Provide local effect of GIT or systemic effect

ASSESSMENT

1. Assess Allergies to medication(s)

2. Clients' ability to swallow the medication and presence of vomiting or diarrhea that would interfere with

the ability to absorb the medication and specific drug action, side effects, interactions, and adverse

reactions

3. Client's knowledge of and learning needs about the medication

4. Perform appropriate assessments (e.g., vital signs, laboratory results) specific to the medication.

5. Determine if the assessment data influence administration of the medication (i.e., is it appropriate to

administer the medication or does the medication need to be held and the prescriber notified?).

Equipment:

a. Medication administration record

b. Medication tablet or liquid

c. Medication cups, dropper, syringe, nipple

d. Juice or water if needed

e. Disposable gloves (optional)

Marks

Marks






Faculty of Nursing

41



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت


Check the medication administration record (MAR), for the drugname, dosage, frequency, route of administration, and expiration

date for administering the medication, if appropriate. (Checked at

Least Three Times According to the six Rights).

1

Identify the client.2

Inform the child if he/she understands.

The nurse should explain to the parent the intended action of

medication as well as any side effects or adverse effects that might

occur.

3

Verify the client's ability to take medication orally.4

Hand washing.5

Prepare the medication:

Calculate the medication dosage accurately.

Desired dose X Quantity on handDose on hand

Prepare the correct amount of medication for the requireddose, without contaminating the medication.

6

Provide privacy7

Administer the medication in the prescribed dosage, by the route

ordered, at the correct time.8

Record the name of the drug, dosage, method of administration,

specific relevant data such as pulse rate (taken in most settings priorto the administration of digitalis), and any other pertinent

information.

The record should also include the exact time of administration and

the signature of the nurse providing the medication.

9

Evaluate the client's response to the drug. The kinds of behavior that

reflect the action or lack of action of a drug and its unwanted effects.

10






Faculty of Nursing

42



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت

Routs of Medication Administration

Dropper:

a. Wash hands.

b. Hold the infant in the cradle position and stabilize the headagainst your body. Hold infant's arm with your free arm.

Press on the infant's chin to open mouth. Squirt the

medication to the back and side of the mouth in small

amount.

Syringe:

a.

Hold the infant or toddler in the cradle position,supporting the head and holding the arms.

b. Place the syringe to the back and side of the mouth

and give the medication slowly, allowing the child to

swallow.

Nipple:

a. Hold the infant in the cradle position, squirting the

medication from the syringe into the nipple pour the

medication from a cup into the nipple.

b.

Allow the infant to suck the medication from the nipple

c. Follow the medication with 2-3 ml of water.

Medicine cup:

a. A cup can be used for the older infant, toddler, preschooler,

school age child, and adolescent.

b. For the younger clients, apparent or child may hold the cup.

c. Stay with the child until the entire dose is swallowed.

d. A spoon is an effective alternative to the medicine cup.

e. Disguise a disagreeable taste in a small amount of food like

applesauce.

f. Syrup is also good for mixing medications that do not

dissolve in water.

g. Dilute alcohol – based elixirs with water before administering.






Faculty of Nursing

43



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت

Chewable tablets:

a. Tablets may be chewed by the child or cursed and given in a

fruit syrup or applesauce.

b. Check with the pharmacist to see if crushing the tablet will

affect drug absorption or action

c. Do not give a child a tablet if he or she resists, as the child

could easily aspirate.

Capsules:

Older children may enjoy swallowing a capsule

a.

Place the capsule on the back of the tongue and have themswallow a lot of fluid.

b. Stay with child until all the medicine is swallowed.

c. Some capsules may also be opened and the contents

sprinkled on a spoonful of food.

d. Check with the pharmacist to see which capsules can be

opened.

Nose drops:

a.

Hold the infant in the cradle position, stabilizing the headwith your arm, and tilting it back slightly

b. Squeeze the drops into each nostril as you try to comfort

& hold the infant in this position for at least 1 minute.

c. Place a toddler's head over a pillow.

d. Squeeze the drops into each nostril.

e. The school age child and adolescent may give themselves

their own medication since they can sniff the medication

into the nasal passage.

Ear drops:

a. Position infants & toddlers on their sides.

b. The pinna of the ear is to be pulled down and back.

c. Instill warm drops into the external canal and gently

massage the area anterior to the ear.






Faculty of Nursing

44



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت

d. For children over 3 years, pull the pinna upwards and

back

e.

After instillation, the child should maintain the positionfor 5-10 minutes.

f. A cotton pledged placed into the ear canal can prevent

the medication from leaking out , however , it must be

loose enough to allow discharge to drain from the ear

canal

Eye drops or ointment:

a.

Place the child in a supine position.

b. Restraining him or her as necessary to safely instill the

medication.

c. Pull the lower eyelid down and out to form cup.

d. Drop the solution into cup.

e. The medicine will enter the conjunctiva.

f. Close the eye gently and attempt to keep it closed for a

few moments.

g. Ointments are applied along the inner canthus in outward

direction.

h. Avoid touching the tip of the dropper or ointment tube to

the body part.

Rectal medications:

a. Place the child in aside – lying or prone position.

b. Lubricate the suppository with a water soluble gel

c. Using a finger cot, gently insert the suppository into the

rectum

d. Do not insert your finger more than 1/2 inch.

e. The buttocks should be held tightly together for 5-10 minutes






Faculty of Nursing

45



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت

Dropper:

a. Wash hands.

b.

Hold the infant in the cradle position and stabilize the headagainst your body.

c. Hold infant's arm with your free arm. Press on the infant's

chin to open mouth.

d. Squirt the medication to the back and side of the mouth in

small amount.








Faculty of Nursing

46



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت

Restraint

Student name: …………………………………………

Purposes:

Restraints are protective measures to limit movement.

Restraints can be a short-term restraint to facilitate examination and minimize the child's discomfort

during special tests, procedures, and specimen collections.

Restraints can also be used for a longer period of time to maintain the child's safety and protection from

injury.

Equipment:

Jacket (For jacket restraint)

Blanket or sheet large enough to fit the child

Soft padding (as needed)

Tongue blades (for certain types of restraints)

Large dressing, gauze bandage, adhesive tape

Safety pins (For elbow restraint)

Elbow restraint


JACKET RESTRAINT

1. Check physician's order and agency policy regarding use of

restraints.

2. Gather equipment.

3. Wash hands

4. Explain purpose of restraints to child and parents. Reassure child

that restraint is not a punishment

5. Place the jacket on the patient gown and tie it from back.

6. Ensure that patient's gown and jacket are not wrinkled and

appropriate size.7.Secure each tie to unmovable portion of the bed, using half

bowknot, which is easily removed.

8.Secure shoulder straps to head of the bed

9.Secure abdomen straps on either sides

10. Reposition the child, release immobilizing restraints and perform

range of motion every 1 – 2 hours.

Marks

Marks






Faculty of Nursing

47



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت

MITT OR HAND RESTRAINT

1. Place a large folded dressing in patient's palm

2. Separate the fingers with a pieces of large dressing

3. Put a padded dressing around the wrist

4. Place two large dressings over the hand one is first placed

from the back of the hand over the fingers to the palm and the

other is then wrapped from side to side around the hand

5. Cover these dressing by placing stockinet dressings over

the hand or elastic bandage, using the recurrent pattern

6. Secure the stroknette or elastic bandage with adhesive tape

ELBOW RESTRAINE

1. Check the restraints to make sure that the tongue depressors are

intact and in place

2. Apply elbow restraint over gown sleeves

3. Make sure the end of the tongue depressors are covered by

padded material

4. Place elbow in the center of restraint

5. Warp the restraint smoothly around the arm

6. Secure the restraint, using safety pins, ties or strings

7. Ensure that it is not too tight so not to occlude blood






Faculty of Nursing

48



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت

CLOVE HITCH RESTRAINT

1. Prepare the equipment

Bandage 5-8 cm wide and 90 – 120 cm long

Cotton

Commercially made restraint

2. Apply 2-3 layers of cotton around ankle or wrist

3. Make 2 loop forming finger of 8

4. Pick up the two loops

5. Make sure that the loops are small to fit patient hands

6. Using half – bow knot attach the end of restraint to the end of

the bed spring

7. Check every two hours and readjust accordingly

MUMMY RESTRAINT

1. Prepare the equipment

Blanket or sheet

Safety pins or adhesive tape

2. Lay the blanket or sheet on flat dry surface

3. Fold down one corner of the blanket and place the baby on it

the supine position, make sure that the infant shoulder touches

the upper border of the blanket

4. Fold the right side of the blanket over the infant’s body andtuck it under his back leaving the left arm free






Faculty of Nursing

49



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت

CRIP NET RESTRAINT

1. Prepare the equipment (A stretch net with long strap)

2. Place the net over sides and ends of the crib

3. Secure the tie to bed frame

4. Tie the strap in half – bow knot

DOCUMENTATION

- Type and location of restraint.

- Time and reason for application.

-

Condition of the skin under the restraint, distal circulation, and removal of restraints for range of motion

and skin care as appropriate.

- Need for continued use.

- When device was removed (time & date)








Faculty of Nursing

50



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت

Intravenous Fluid Therapy

Student name: …………………………………………

Purposes:

1. Not able to take food or fluids by mouth.

2. Venous access is also used in children for infusion of IV fluids

3. Parenteral nutrition

4. Routine IV medications, emergency medications, or blood products

5.

To provide salts and other electrolytes needed to maintain electrolyte balance

6. To provide glucose (dextrose), the main fuel for metabolism

7. To provide water-soluble vitamins and medications

8. To establish a lifeline for rapidly needed medications

ASSESSMENT

Assess the following:1- Vital signs (pulse, respiratory rate, and blood pressure) for baseline data

2- Skin turgor

3- Allergy to latex (e.g., tourniquet), tape, or iodine

4- Bleeding tendencies

5- Disease or injury to extremities

6- Status of veins to determine appropriate venipuncture site

Marks






Faculty of Nursing

51



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت

Equipment:

1- Infusion set

2- Sterile, saline-filled, 3-ml syringe

3- IV fluid as prescribed (50 ml-1000 ml) and IV stand

4- Kidney tray

5- Adhesive or non-allergenic tape

6- Clean gloves

7- Tourniquet

8-

Antiseptic swabs

9- Antiseptic ointment (check agency policy)

10- Intravenous catheter (20 to 24 gauge)

11- Dressing materials (Sterile gauze dressing or transparent occlusive dressing)

12- Arm splint (arm board), if required

13- Towel or pad

14- Electronic infusion device or pump to control the volume (The nurse decides what device is needed as

appropriate to the client's condition.)

15- Label and pen

16- Calculator and watch (calculation formula)


Preparatory phase:

1. Check physician's order

2. Introduce self and verify the client's identity

3. Prepare child and family by explaining the procedure and its

purpose to them to encourage cooperation and understanding**Infant: Provide with a pacifier

**Old child: Explain the procedure and its purpose

4. Check child for allergies or contraindication for IV insertion

5. Identify vein and insertion site

Marks






Faculty of Nursing

52



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت

6. Gather the equipment for IV catheter placement and select theappropriate catheter size (20 – 24 gauge) to promote organization and

efficiency.

7. Perform hand hygiene8. Open and prepare all supplies.

9. Check the IV fluid for clearance and expiratory date

10. Remove the metal seal from IV container without touching therubber top

11. Insert the end of the administration set into the container's

opening, Fill the IV tub with solution

• Apply medication label• Hang the fluid

• Fill the drip chamber• Fill the tube then close clamp.

12. Promote the cooperation of the child and position the child(Restrain as necessary)

Performance phase:

1-Hand washing again to perform the vein puncture procedure.

The persons starting the IV and holding the infant should wear gloves

2-Clean the skin of the chosen insertion site with antiseptic swab and

allow area to dry for 30 sec.

3-Apply the tourniquet

4-Puncture the skin of IV site with 45 degree with the bevel up using

dominant hand

5-Reduce the angle of the catheter needle and insert into the vein

until blood flow appears in the catheter

6-Release tourniquet

7-Advance catheter into vein while gently removing inner needle

from catheter leaving only catheter sheath in place

8-Stabilize catheter in place and connect heparin lock to catheter

9-Infuse 2 – 3 ml of saline from the syringe into the vein.

10-Check patency of the system.

11-Secure IV by taping or semipermeable transparent dressing to site

to reduces the risk of needle becoming dislodged from the vein.






Faculty of Nursing

53



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت

12-Initiate flow of saline through the catheter and assess for signs of

infiltration

13-Begin IV fluids as prescribed and regulate IV infusion (Regulatethe IV rate pump)

14-Secure the line with additional tape and arm-board as needed to

prevent accident removal

15-Check the restraints at intervals and adjust them as necessary

16-Comfort and reassure the child

17-Discard used supplies, Remove gloves. Perform hand hygiene to

18-Reduce transmission of microorganisms.19-Record on the container or reservoir rate flow

a. Time that infusion began

b. Name of the physician or nurse who started the IV siteof administration

c. Reaction of the child to the procedure

d. Return the child to room

Follow up phase:

1-Check the child at least hourlya. Note the location of IV

b. Note the color of the skin at the needle point

c. Check for swelling of skin at the needle pointd. Feel the area around the site fluid or sponginess or leak age

e. Check for blood return into the tube when the flow of fluid is

stopped

f. Make certain that the child is adequately restrainedg. Check function of the pump – rate set versus amount infused






Faculty of Nursing

54



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت

2-Observe closely for complication of Local reaction*Compromised circulation

*Pressure sores

*Thrombo-phlebitis*Fluid and electrolyte disturbance

3-*Maintain an accurate record of intake and output

*Weigh the child at regular intervals, using the same scales each

time

4-Record essential information

* Reading on the container

*Amount of fluid absorbed in the hours*Total amount of fluid absorbed

*Rate of flow

*Apparent condition of the child

5-Change the IV container and tubing 24 h or as per hospital policy

*If a catheter is used, check the dressing 4 h and change according to

policy

6-Disconnect the IV when prescribed or if it has obviously infiltrated

7-Record that the IV was discontinued

3

Documentation

1. Insertion site.

2. Type and gauge of needle or catheter used.3. Date and time.

4. Person who placed the IV.

5. IV solution started and rate of infusion.

6. Type of dressing over site.








Faculty of Nursing

55



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت

Intramuscular Injections

Student Name:……………………………………..

Purposes:

1. Administer medication deeply into muscle

2. Administer medication that are absorbed more quickly than oral and subcutaneous because

of the greater blood supply to the body muscle

3. Muscle can take a larger volume of fluid without discomfort than SC tissue can

4.To administer medication irritant by subcutaneous routeEquipment:

1. Medication administration record

2. Medication vial or ampule3. Sterile syringe (1-3 ml)

4. Needle (gauge 20-22)

5. Alcohol swab


Prepare the equipment1

Explain to the child where you are going to give the injection

(site) and why you are giving it

2

Allow the child to express fears3

Hand washing4

Carry out procedure quickly and gently. Have needle and syringe

completely prepared and ready before contact with child

5

Infants:

Selection the acceptable site includes rectus femoris (mid anterior

thigh), vastus lateralis (middle third) or ventrogluteal

6

Toddlers and school age children: a. Rectus femoris

1. Place the child in a secure position to prevent

movement of the extremity

2. Do not use a needle more than 2.5 cm3. Use upper quadrant of the thigh

4. Insert needle at a 45 angle in a downward

direction, toward the knee

7

Marks

Marks






Faculty of Nursing



عبد لزيز

ج لك

ي لريض

ض

لب

يحصل دجب

ن ت

b. Vastus lateralis1. Place the child in a prone or supine position

2. Area is a narrow strip of muscle extending

along a line from the greater trochanter tolateral femoral condyle below

3. Insert needle perpendicular to skin 2-4 cm

deep – needle parallel to floor

c. Ventrogluteal

1. Place the child on back2. Place the index finger on the anterosuperior

spine

3. With the middle finger moving dorsally, locate

the iliac crest, drop finger below the crest. Thetriangle formed by the iliac crest, index finger

& middle finger is the injection site4. Inject needle perpendicular to the surface on

which the child is lying

d. Posterogluteal1. Do not use a needle longer than 2.5 cm

2. Position the child in a prone position

3. Place thumb on the trochanter4. Place middle finger on the iliac crest

5. Let index finger drop at a point midway between the

thumb and middle finger to the upper outer quadrant

of the buttock Insert needle perpendicular to the

surface on which the child is lying, not to the skinE. Deltoid

1. Determine injection site as with an adult

2. Inject needle perpendicular to the skin

2-3 cm deep

F. Lateral & anterior aspect of the thigh

1. Do not use a needle longer than 2.5 cm2. Use the upper outer quadrant of the thigh

3. Insert needle at a 45 angle in a downward

direction, toward the knee



Pediatric Lab Checklist, 2015-2016

Documents

Transcript of Pediatric Lab Checklist, 2015-2016