Wong's Nursing Care of Infants and Children, 11th Ed., Hockenberry, Wilson & Rogers | Registered Nurse (RN) School Study Aid
Preoperative Care
- Surgical Procedure
- NPO
- Turn, Cough, Deep Breathe, Incentive Spirometer
- Lower Extremity Exercises
- Compression Stockings or SCD's
- Pain Management
- Informed Consent
- Physical Preparation
- Preop Checklist
- Handoff to Surgery
- Universal Precautions
Postoperative Care
- Head to Toe Assessment
- Hemorrhage
- Clotting
- Pain
- Dehiscence or Evisceration
- Respiratory Complications
- Paralytic Ileus
- Infection
Pressure Ulcers
- Prolonged Immobilization
- Neurologic Disease
- Decreased Level of Consciousness
- Stage 1: Intact Skin with Non-blanchable Erythema
- Stage 2: Partial Thickness Skin Loss
- Stage 3: Full-thickness Skin Loss without Fascial Involvement
- Stage 4: Full-thickness Skin Loss with Fascial Involvement
- Wound Care
- Surgery
- Septicemia
- Osteomyelitis
- Prevention
Interventions for Impaired Skin Integrity
- Signs of Skin Breakdown
- Pain
- Redness
- Decreased Skin Turgor
- Bleeding
- Bony Prominences
- Reposition Q2H
- Pressure Relief
- Maintain Clean and Dry Skin
- Adequate Nutrition and Hydration
Fever
- Flushed skin, warm to touch
- Chills
- Sweating
- Change in LOC
- Provide adequate fluids
- Monitor Electrolytes and Fluid
- Monitor vital signs, esp temperature
- Remove excess clothing and blankets
- Sponge bath with tepid water
Aspirin (Acetylsalicylic Acid)
- Inhibits Platelet Aggregation
- NSAID
- Thrombotic Event Prevention
- General Pain
- Inflammatory Conditions
- Fever
- Pancytopenia
- GI Ulcers
- Bleeding
- Withhold Before Surgery 7-10 Days
- Reye's Syndrome
Prevention of Falls
- Physical Aging
- Polypharmacy
- Environmental
- Call Light within Reach
- Assistive Devices Available
- Bed Alarms
- Improve Lighting
- Remove Home Hazards
- Promote Exercise
- Fall Risk Assessment
Standard Precautions
- Hand Hygiene
- Wash In / Wash Out
- Alcohol-Based Hand Rub
- Hand Washing
- Personal Protective Equipment (PPE)
- Gown
- Face Mask
- Goggles/Face Shield
- Gloves
- Donning and Removing PPE
- Discard Sharps in Puncture-Resistant Container
- Cough Etiquette
Droplet-Airborne Precautions
- Private Room
- Droplets Larger than 5 Microns
- Being Within 3 Feet of Patient
- Surgical Mask with Face Shield
- Type of Infection or Condition
- Airborne Infection Isolation Room (AIIR)
- Droplets Smaller than 5 Microns
- N95 Respirator
- Type of Infection or Condition
Contact Precautions
- Private Room
- Wash In / Wash Out
- Personal Protective Equipment (PPE)
- Gloves
- Gown
- Limit Time Patient Leaves Room
- Leave Equipment In Room
- Special Linen Handling
- Same Pathogen, Same Room
- History of Contact Isolation
- Preventative Education
Use of Restraints
- During Emergency
- Protecting From Harm
- For Limited Time
- Last Resort
- May Further Agitation
- Frequent Observation
- Obtain Order Within 1 Hour
- Quick-Release Tie
Lumbar Puncture
- CSF Sample
- CSF Pressure
- Empty Bladder
- Side-lying Position
- Between 3rd and 4th Lumbar Vertebrae
- Number Tubes
- Supine Position After Procedure
- Increased ICP (Intracranial Pressure)
- Infection at Puncture Site
Needle Sizes and Uses
- Adjust Size Based on Height/Weight
- Subcutaneous Injections
- 3/8 or 5/8 inch
- Intramuscular (IM)
- 1-1.5 inches
Routes of Administration Part Two (Parenteral)
- Intradermal
- Subcutaneous
- Intramuscular (IM)
- Intravenous
- Epidural
- Intrathecal
- Intraosseous
- Intraperitoneal
Intramuscular Medication (IM) Administration
- Injury to Nerves, Bone, and Blood Vessels
- Deltoid
- Vastus Lateralis
- Ventrogluteal
- Selection of Needle Length
- Aseptic Technique for Drawing Up
- Z-Track
- 90 Degree Angle
- Max Amount (2-5 mL Adult, 1 mL Child)
- Techniques to Reduce Pain
Routes of Administration Part One
- Oral
- Sublingual
- Buccal
- Rectal
- Tubes
- Transdermal
- Drops/Spray
- Vaginal
- Inhalation
Eye Medication Administration
- Supine with Neck Hyperextended
- Wash Away Crusts
- Cotton Ball on Cheekbone
- Instill Drops into Conjunctival Sac
- Repeat if Missed or Patient Blinks
- 5 Minutes Before 2nd Medication
- Thin Stream Along Inner Edge
- Inner Canthus to Outer Canthus
Ear Drops Medication Administration
- Earwax Buildup
- Ear Infections
- Child - Back and Downward
- Adult - Back and Upward
- Side-Lying with Ear Up
- Instill Medication
- Stay for 2-3 Minutes
- Room Temperature
- May Massage Tragus
- Perforated Eardrum
Enema Administration
- Tap Water/Soapsuds
- Normal Saline
- Hypertonic Solution
- Medication
- Oil Retention
- Procedure Education
- Wear PPE
- Put Patient in Sims Position
- Insert Tip
- Start Flow Slowly
- Stop With Discomfort
- Potential for Vagus Response
Total Parenteral Nutrition (TPN)
- Nutrition Given Outside GI
- Hyperglycemia
- Hyperlipidemia
- Refeeding Syndrome
- Nausea and Vomiting
- Slow IV Infusion
- Use Large Central Vein
- No Added Meds to TPN Line
Ileostomy Care
- Antibiotics
- Monitor Skin Breakdown
- Drains Continuously
- Fluid and Electrolyte Imbalance
- Low Fiber Diet
Colostomy Care
- Wash with Warm Water
- Cut 1/8 inch Around Stoma
- Decreases Skin Irritation
- Empty When 1/3 to 1/2 Full
- Change 3-7 Days
- Avoid Odor Causing Foods
- Irrigate at Same Time