Nursing 104

N104: Essentials of Nursing Care – Health Safety Study Guide The physical exam for the child will include the same systems described for adults. These techniques are critical in children who may not have the verbal skills to tell the nurse what is wrong. Some of the differences for the pediatric patient might include: • Vital signs will be different for children. • General appearance will allow the astute nurse to determine if the patient is well fed and if cleanliness and hygiene might be an issue. In addition, the nurse might note signs that the child is in pain or having some difficulty in particular areas. • The skin of children is typically smooth and soft. Skin should be uniformly warm and differences in the temperature should be reported. Skin turgor or the amount of elasticity should be assessed by gently pinching the skin on the abdomen, pulling it taut, and then releasing it. In a child with normal turgor, the skin will immediately return to its normal position. If the skin remains "tented" the child may have nutritional or hydration issues. • A well child's hair will typically be silky, strong, and elastic. Alterations in the hair quality may indicate poor nutrition. The hair and scalp should be examined for head lice and general cleanliness. A child's finger and toenails will usually be pink, smooth, and hard. Analysis/Diagnosis During the analysis phase, the nurse and family or caregiver collaborate to identify nursing diagnoses related to pediatric care. Common diagnoses related to pediatric care are: • Breastfeeding: Interrupted related to hospitalization of the child • Family coping: Compromised or ineffective • Family processes: altered • Injury: High risk for • Parenting: Altered • Skin integrity: Potential for altered • Specific diagnoses related to conditions caused by the child's illness or injury Planning During the planning phase, the nurse and patient's caregivers collaborate to identify goals, outcomes, and interventions related to the child's care. Care of the family unit is very important when caring for the child. Therefore, many of the expected outcomes may be related to the child in the context of the family. Expected outcomes related to the pediatric care might include: • The patient's caregiver will identify areas for risk in the child's care. • The patient's health status will be maintained or improved. • The patient's caregivers will identify appropriate health choices for the child. • The patient's caregivers will actively participate in the treatment regimen. • The patient's caregivers will identify the stressors on the family unit. • Stressors on the patient's caregivers will be diminished. • The patient's physiologic status will be stable. • The child's skin will be intact. • Other outcomes related to the actual disease or illness should also be included.

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