Safety and Infection Control
Accident/Error/Injury Prevention
1. Routine screening for lead levels at 1, 2, and 3 years of age
2. Provide case management for children who have elevated lead levels
3. Make appropriate referrals (community nurse, teacher, early intervention)
Health Promotion and Maintenance
Health Promotion/Disease Prevention
1. Sudden infant death syndrome is the sudden, unpredictable death of an infant without an
identified cause, even after investigation and autopsy
2. Preventive measures should be taught to families
3. Some client teaching includes, place the infant on the back for sleep, use a firm,
tight-fitting mattress in the infant’s crib, offer pacifier at naps and night
Psychosocial Integrity
Abuse/Neglect
1. Maltreatment of infants and children is attributed to a variety of predisposing factors,
which include parental, child, and environmental characteristics. Child maltreatment can
occur across all economic and educational backgrounds and racial/ethnic/religious
groups
2. Maltreatment of children is made of several specific types of behaviors which includes,
physical, sexual, emotional, and neglect
3. Some characteristics and expected findings include, divorce, alcohol, or substance use
disorder, poverty, vague explanation of injury, and other injuries discovered that are not
related to the original client concern
Basic Care and Comfort
Mobility/Immobility
1. Assess neurovascular status of the affected body part every hour for 24 hr and every 4
hr after that
2. Maintain body alignment and realign if the client seems uncomfortable or reports pain
3. Avoid lifting or removing weights
Pharmacological and Parenteral Therapies
Medication Administration
1. For liquids, including suspension and elixirs, follow directions for dilution and shaking. To
prepare the medication, place a medicine cup on a flat surface before pouring, and
ensure the base of the meniscus is at the level of the dose
2. Have clients sit upright at a 90 degree angle to facilitate swallowing
3. Do not mix with large amounts of food or beverages in case clients cannot consume the
entire quantity
Parenteral /Intravenous Therapies
1. The nurse uses clinical judgment to determine client outcomes desired and/or achieved
as indicated by evidence-based practices
2. Nurses must continuously set and reset priorities in order to meet the needs of multiple
clients and to maintain client safety
3. Discontinuing IV therapy - check the prescription, prepare the equipment, perform hand
hygiene, don clean gloves, clamp the IV tubing, remove the tape and dressing, stabilize
the IV catheter
Reduction of Risk Potential
Diagnostic Tests
1. Screening for SCA in newborns is mandatory in all 50 US states and territories
2. Sickle-turbidity screening tool detects the presence of HbS but will not differentiate the
trait from the disease
3. Hemoglobin electrophoresis separates the various forms of Hgb and is the definitive
diagnosis of sickle cell anemia
Laboratory Values
1. CSF analysis indicative of meningitis. There is bacterial and viral:
2. Bacterial= cloudy color, elevated WBC count, elevated protein content, decreased
glucose content, positive Gram stain
3. Viral = clear color, slightly elevated WBC count, normal or slightly elevated protein
content, normal glucose content, Negative Gram stain
System Specific Assessments
1. Cochlear damage (hearing loss), vestibular damage (loss of balance)
2. Monitor for tinnitus, headache, hearing loss, nausea, dizziness, and vertigo
3. Adolescent 16 to 20/min - values listed are general guidelines and may vary according to
reference, as well as the child’s specific age and activity level
Therapeutic Procedures
1. Premedicate as prescribed prior to wound care, administer hydroxyzine or
diphenhydramine for pruritus
2. Splints are removable and allow for monitoring of skin swelling or integrity
3. Check dressings for excessive drainage and reinforce as needed. Report excess
drainage to the surgeon
Physiological Adaptation
Illness Management
1. Insulin - Short Acting is regular insulin with onset of 0.5 to 1 hour, peak 1 to 5 hours, and
duration 6 to 10 hours
2. Splenomegaly is an expected finding of infectious mononucleosis
3. For burns, maintain urine output of 0.5 to 1 ml/kg/hr if the child weighs less than 30 kg.
Maintain urine output of 30 ml/hr if the child weighs more than 30 kg. Be prepared to
administer blood products as prescribed
Medical Emergencies
1. The ABC framework identifies, in order, the three basic needs for sustaining life. An open
airway is necessary for breathing so it is the highest priority. Breathing is necessary for
oxygenation of the blood to occur. Circulation is necessary for oxygenated blood to
reach the body’s tissues
2. The severity of manifestations should also be considered when determining priorities. A
severe circulation problem can take priority over a minor breathing problem
3. Early indications of respiratory distress include retractions, restlessness, tachypnea,
tachycardia, diaphoresis, nasal flaring, grunting, dyspnea, and wheezing
Pathophysiology - Spastic CP
1. Nonprogressive impairment of motor function, especially that of muscle control,
coordination, and posture
2. Can cause abnormal perception and sensation; visual, hearing, and speech
impairments; seizures; and cognitive disabilities. Manifests differently in each child.
Developmental outcomes vary and are dependent on the severity of the injury
3. Hypertonicity; increased deep tendon reflexes; clonus; and poor control of motion,
balance, and posture