95%(244)231 out of 244 people found this document helpful
This preview shows page 8 - 11 out of 12 pages.
Changes/Abnormalities in Vital Signs - (1)oPhysical Assessment Findings: Vital Signs to Report (Active Learning Template - Growth and Development, RM NCC RN 10.0 Chp 2)Know vitalsPotential for Complications of Diagnostic Tests/Treatments/Procedures - (2)oCardiovascular Disorders: Cardiac Catheterization Postprocedure Care (Active Learning Template - Diagnostic Procedure, RM NCC RN 10.0 Chp 20)Assess heart and respiratory rate for 1 full minuteAssess pulses for equality and symmetry.Assess temperature and color of affected extremity. A cool extremity with skin that blanches can indicate arterial obstruction.Prevent bleeding by maintaining the affected extremity in a straight position for 4 to 8 hrEncourage the child to void to promote excretion of the contrastmedium.Encourage oral intake, starting with clear liquidsSystem Specific Assessments - (2)oDiabetes Mellitus: Assessing Hyperglycemia (Active Learning Template - System Disorder, RM NCC RN 10.0 chp 33)
Hyperglycemia: blood glucose usually greater than 250 mg/dLThirstPolyuria (early), oliguria (late)Nausea, vomiting, abdominal painSkin that is warm, dry, and flushed with poor turgorDry mucous membranesConfusionWeaknessLethargyWeak pulseDiminished reflexesRapid, deep respirations with acetone/fruity odor due to ketones (Kussmaul respirations)Therapeutic Procedures - (1)Fractures: Findings to Report for a Short Leg Cast (Active Learning Template - Basic Concept, RM NCC RN 10.0 chp 27)Teach the parents and client to report pain that is extremely severe or is not relieved 1 hr after the administration of pain medicationTeach the client and parents that when the cast is applied it will feel warm, but it will not burn the clientMonitor for drainage on the castHemodynamics - (1)oCardiovascular Disorders: Caring for a Child Who Has Heart Failure (Active Learning Template - System Disorder, RM NCC RN 10.0 Chp 20) UNKNOWN need to readoHematologic Disorders: Sickle Cell Crisis (Active Learning Template - System Disorder, RM NCC RN 10.0 Chp 21)Sickle cell crisis is the exacerbation of SCAManifestations and complications of SCA increased blood viscosityobstruction of blood flowTissue hypoxia.Manifestations of SCA are not usually apparent until later in infancy due to the presence of fetal Hgb.Tissue hypoxia causes tissue ischemia, which results in pain.Increased destruction of RBCs occurs.Usually lasts 4 to 6 daysSickle-cell crisis LabsHgb: decreasedWBC count: elevatedBilirubin and reticulocyte levels: elevatedPeripheral blood smear reveals sickled cellsIllness Management - (3)oAcute and Infectious Respiratory Illnesses: Priority Care for a Child Who Has Hyperpyrexia, Severe Dyspnea, and is Drooling (Active Learning Template - System Disorder, RM NCC RN 10.0 Chp 17)Protect airwayProvide humidified oxygen.
oFractures: Teaching Cast Care (Active Learning Template - Therapeutic Procedure, RM NCC RN 10.0 chp 27)Instruct the client not to place any foreign objects inside the cast to avoid trauma to the skin.