Health Assessment of Infants and Children - idiot
● Philosophy of Pediatric Nursing - protection, promotion, and optimization of health and
abilities, prevention of illness, and prevention of injury; advocate for children and their
families
● Atraumatic Care - using interventions that eliminate or minimize the psychological and
physical distress experienced by children and their families in the health care system
○ Provide privacy and choices if possible
● Communication
○ Introduction - introduce yourself
○ Respect - address parents by Mr./Mrs. regardless of their age
■ Ask pronouns and identity; find out how people would like to be
addressed
○ Maintain privacy and confidentiality
○ Avoiding communication blocks
■ Avoid information overload
■ Do not socialize, give unrestricted advice, offer premature reassurance,
use stereotyped comments, defend a situation, use close-ended questions,
talk more than the interviewee, form prejudged ideas, interrupt and finish
the person’s sentences
○ Interview at the most opportune time - this encourages the parents to talk
○ Communicating with Children
■ Interview the parent first to ease the child’s anxiety
● Include the child
■ Discuss the child’s interests
■ Break the ice as much as possible, but give extra time if they do not give
you a response
■ Talk to doll or toy of child if they also address them
■ Be at eye-level with them
■ The child may need distractions during the interview
● Anticipatory guidance - dealing with a situation before it becomes a problem
○ Provide families with information on growth and development and nurturing child
rearing practices
■ Ex: Injury prevention, children’s changing behaviors
● Observations
○ Assess parent-child relationship
■ How does the parent console the child?
■ Observe touching interactions between both parent and child
■ Do the parents have necessities with them? (formula, diapers, consoling
toys)
● Chart observations
● Infants - stupid
○ Always respond to their nonverbal behavior
■ Respond to firm, gentle handling
■ They cry when hungry, in pain, or lonely
■ Smile and coo when content
○ May be comforted by parental presence
○ Use a soft-spoken voice
■ Infants may be frightened by loud, harsh sounds and sudden movements
● Early childhood (<5 years)
○ Egocentric - only care about themselves and see things in relation to themselves
○ Be direct and concrete - they interpret words literally
○ Tell them what they can do and how it will make them feel
○ Let them play with equipment when appropriate
■ Animism - thinking equipment is alive
○ Cannot understand/work with abstractions or analogies
■ Ex: literal understanding of “stick in the arm” or “butterflies in the
stomach”
● School-age children (6-12 years)
○ Use simple explanations
■ Usually want explanations for everything
○ Speak with a quiet, unhurried, and confident voice; speak clearly using simple
words and short sentences
○ Be honest with them
○ Offer choices if they exist
○ Allow them to express their concerns and fears
■ Rely on what they know vs. what they see
● If they think the shot will hurt vs. seeing roommate get it and be
fine → will still believe what they “know”
■ May be very concerned about threats to body and body integrity
● Communicating with Adolescents
○ Fluctuate between adult-like thinking vs. child-like thinking and behavior
○ Always be straightforward, respectful, and listen
■ Don’t judge or criticize them
■ Discuss sex, substance abuse, and relationships with their peers and
parents
■ Need to feel respected
○ Set good examples
○ Confidentiality - unless expression of suicidal ideation or abuse
○ May want/need to talk without parents in the room
■ Parents and adolescents usually have two different perspectives
● Health Hx
○ Identifying information
○ Allergies, chief complaint, present illness, dietary hx, previous
illness/injury/surgeries, current medications, habits
○ Birth hx, immunizations, growth and development
● Nutritional Assessment
○ Get a dietary history
○ Assess overall nourishment
■ 24 hr dietary hx - food diary
○ 400IU of Vitamin D recommended for breastfed babies
○ Anthropometry - the scientific study of the measurements and proportions of the
human body; essential parameter of nutritional status
■ Height and head circumference reflect past nutrition
■ Weight, skinfold thickness, and arm circumference reflect present
nutrition
■ BMI - body mass index
● (Weight in lbs/ (height in inches x height in inches)) x 703 = BMI
○ Obesity and malnutrition
■ Although childhood obesity rates are increasing, children are still getting
poor nutrition
■ Skin will be scaling, dry, rough, pallor, or jaundice
■ Hair will be dull, dry, and thin
■ May have delayed sexual development, visual problems, constipation,
cavities, and a visible thyroid
○ Height
■ 0-36 months - use recumbent length (lying supine and flat) in cm
● Hold head midline and push knees flat
■ 2-18 years - can stand on the wall without shoes
○ Weight
■ Always balance scale
● Infants should be weighed naked
● Weigh at the same time every day and use the same scale
■ In a school setting, make sure they're not holding anything - no shoes,
backpack, phones, etc.
○ Head circumference
■ Always measure the greatest circumference; this will usually be slightly
above the brows and pinna of ears
● Measure all children ages 3 and younger, unless there is a problem
○ Reflects brain growth
■ Use paper or metal tape - cloth stretches
■ The chest is 2-3 inches larger in childhood
● Born with heads larger than chests; chests and heads even out
when they’re 1-2 years old
○ Skinfold thickness and arm circumference
■ Becoming increasingly recommended
■ Use Lange calipers for skinfold
● Common site used include the triceps, subscapula, suprailiac,
abdomen, and upper thigh
■ Record the average of 2 measurements in 1 site; use the same site each
visit
■ Arm circumference is an indirect measure of muscle mass
○ Growth Charts
■ Used for ages newborn-36 months; also 2-18 yo
■ Percentiles measure normal range for height and weight
● The goal is to be between the 5th and the 95th percentiles while
being consistent
● Physiological measurements or Vital signs
○ Temperature
■ Routes
● Oral - standard for temperature, need to be at least 5 yo
● Axillary - used as a screening tool, but not interchangeable with
rectal; used on infants less than 1 month
● Aural (ear based) - not a precise measurement; diameter of ears too
small
● Rectal - remains the gold standard for precise diagnosis for fever in
infants and children
○ Lubricate tip; insert 1’’ for children and 0.6’’ for
infants
● Temporal Artery - infrared sensor probe across forehead, measures
temporal artery; used as a screening tool ages 3 months - 4 years
○ Pulses
■ Measure apical pulse for 1 full minute
● Chart behavior while taking it
■ Measure while asleep if possible because it is more accurate
■ Compare radial pulses and femoral pulses during infancy
○ Respirations
■ Count for 1 full minute
■ Infants are diaphragmatic breathers, so observe the abdomen
■ Movements are irregular
○ Blood pressure
■ Should be measured annually from 3yo-adolescence or with symptoms of
hypertension, renal disease, or heart defects
■ Auscultation is the recommended method
■ Automated device for newborn and young infants - hard to palpate;
automated device for frequent measurements in ICU
■ Cuff size is the most important factor for accuracy of reading
● Inner inflatable bladder should be 40% of arm circumference or
⅔ length
● Too small cuff reads abnormally high; too big cuff reads
abnormally low
○ Bigger cuff is preferred if that’s all thats available
■ Place on different extremity to fit
■ Do not document the reading if the child is upset while it was taken
■ Factors affecting BP
● Age, height, gender
● Movements during reading
● Medicines
● Usually systolic BP is higher in lower extremities
● A difference in sites could indicate abnormalities
○ Know the expected norms for age, orders for frequency
○ Chart route for temp and policy at
your institution
○ Chart extremity of blood pressure
● Preparing child for exam
○ Room should be well lit
○ Sequence of exam should be head-totoe, but may need to alternate
○ Should be pleasant - minimize stress
and anxiety
■ Involve child in examination
■ Use toys if necessary
○ Allow sitting then lying down
○ Minimize distractions
● General Appearance
○ Subjective impression of child’s physical appearance
○ Assess posture and body movement
○ Observe hygiene and cleanliness
○ Mental acuity and behavior
● Skin
○ Observe color, texture, temperature, moisture, turgor, lesions, and rashes by using
inspection and palpation
■ Normal texture is smooth and slightly dry
■ Turgor should be elastic
○ Light skin children
■ Cyanosis - bluish tinge
■ Pallor - pale, no rosy glow
■ Erythema - redness
■ Ecchymosis - bruise; seen anywhere
■ Petechiae - small, distinct, purplish pinpoint
■ Jaundice - yellow staining sclera, skin, soles, palms, fingernails, oral
mucosa
○ Dark skin children
■ Cyanosis - ashen gray
■ Pallor - ashen gray in black skin; yellowish in brown skin
■ Erythema - must palpate for warmth or edema
■ Ecchymosis - bruising; difficult to see
■ Petechiae - usually invisible except oral mucosa
■ Jaundice - assessed in hard palate, sclerae, palms, soles
○ Mongolian spots - usually found in the sacral and gluteal areas seen in Asian,
Latin, and African American infants
■ Congenital bluish-green birthmark
○ Cafe-au-lait spots - light brown, flat patches
○ Strawberry Nevus - raised hemangioma; becomes red and raised, majority
resolves before age 10
○ Mottling - a lacy pattern of small reddish and pale areas
■ Very common because of the normal instability of the blood circulation at
the skin's surface
■ Occurs with cold or crying infants
○ Neonatal acne - acne on face
○ Palmer crease - having 2 creases is abnormal; having 3 is normal
■ Abnormal can occur in Down’s Syndrome and renal abnormalities
● Refer to a specialist
● Nails
○ Inspect for color, shape, texture, and quality
■ Normal is pink, convex, smooth, and hard; edges should be wihte
■ Short, ragged - habitual biting
■ Poor hygiene - dirty, uncut
● Hair
○ Inspect for color, texture, quality, distribution, and elasticity
○ Should be lustrous, silky, strong, and elastic
○ Record any balding or thin spots
■ Infants losing hair could indicate lying down too much
○ Secondary hair growth denotes puberty
● Head and Neck
○ Assess ROM
■ Pain on flexion could mean meningitis
■ Observe head control - should hold midline and erect by 4 months
● If head lags after 6 months, needs further evaluation (could mean a
cerebral injury)
■ Torticollis (wryneck) - limited range of motion holding to one side; injury
to sternocleidomastoid muscle
○ Palpating fontanels
■ Anterior - closes at between 12-18 months
■ Posterior - closes at 2-3 months
○ Macrocephaly - abnormally large head
○ Microcephaly - abnormally small head with underdeveloped brain
○ Hydrocephalus - abnormal accumulation of Cerebrospinal fluid
○ Craniosynostosis - premature closing of head sutures
■ Best if corrected by 6 months old
● Lymph nodes
○ Palpate nodes during that part of assessment
■ Extend the infant's head to palpate
○ Assess inguinal nodes when supine; assess axillary nodes with arms relaxed and
slightly abducted
○ Nodes should be tender, warm, and enlarged during infection
● Eyes
○ When eye is open, upper lid should fall near upper iris
○ Inspect iris and pupil for color, size, shape, and clarity
■ Permanent eye color of iris stays at 6-12 months
○ Infants can fixate and track by 3-4 months; they can close eyes if you shine a light
○ PERRLA
■ Pupils should be equal, round, and reactive to light and accommodation
○ Strabismus - cross eye
■ One eye deviates
■ Child may become blind if left untreated before 4-6 yo
○ Vision
■ Snellen letter chart - lines of letters decreasing in size
■ Tumbling E - used for children who don’t know letters; E points in
different directions
■ Refer children 3-5 yo who are worse than 20/40 vision
● > 6 yo, refer if worse than 20/30
■ Ishihara test - color field and identifying shapes
● Ears
○ Pinna - entire external earlobe
■ Top of pinna should be aligned with lateral canthi of eye
● Low set ears may denote renal anomalies
○ Inspect for sinuses - may lead to fistulas
○ Inspect hygiene
○ Ear exam
■ Have children sit on parents lap; put legs between parents legs, one arm
around the body of the child and the other arm holding the child’s head
● Could also have the child lie down and have parent lay on top
■ Under 3 yo - pull the pinna down and back
■ Over 3 yo - pull up and back
○ Hearing
■ Newborns - blink to sudden sounds
■ Infants - turn towards sounds and briefly stop activity
■ Older children - whisper from behind them and see if they turn
● Nose
○ Inspect location and make sure it’s not deviated
○ Alau nasi/nares - observe for flaring
○ Check for foreign bodies; assess any discharge
● Mouth
○ Place tongue blade on one side of tongue - prevents gagging
○ Inspect mucus membranes - should be bright pink, smooth, glistening, and moist;
lips should be moist, soft, smooth, and pink
■ Gingiva or gums should be coral pink; dark-skinned children have gums
that are deeply colored and brownish along gum lines
○ Hard palate - located in the front, should be dome shaped
○ Soft palate - located in the back of pharynx
○ Uvula - small midline protrusion
■ Test movement by gag reflex
○ Palatine tonsils - should be same color as mucosa
○ Oral Candidiasis (Thrush)
■ Self-limiting but may last 6 months
■ Caused by antibiotic use or poor hand washing by caregivers
■ Lesions can spread to larynx, trachea, bronchi, and lungs
● May also occur in mouth or diaper area
■ Tx with Nystatin or Fluconazole
○ Teeth
■ Plaque - whitish coating on the surface of teeth
■ Caries - cavities or brown spots in crevices or between teeth
● Inspect upper teeth for nursing bottle caries
■ Fluorosis - chalky white, yellow, or brown stains from excessive fluoride
ingestion
■ Tetracycline/iron can cause greenish-black color of teeth
● Chest
○ Inspect for size, shape, movement, symmetry, bony landmarks, and breast
development
○ Infant AP diameter is equal to transverse diameter - circular shape
○ Children/adolescents have 2:1 transverse to AP
○ <6 yo are abdominal breathers
■ Should always have symmetrical movements
○ Inspect the surface and position of nipples
■ Best development for girls begins 10-14 yo
● Record early or late breast development
■ Gynecomastia - male breast enlargement from hormones or systemic
disorders; usually caused by adipose tissue from obesity
■ If sexual maturity has been reached, palpate breasts for masses or nodules
● Lungs
○ Observe rate, rhythm, depth, and quality
○ Better to auscultate when not paying attention
■ Deep inspiration is best to hear
■ Inspiration to expiration should be 1:1
○ Adventitious sounds
■ Crackles - air passes through fluid or moisture
● Fine crackles - popping, short, high-pitched; not cleared by
coughing
● Coarse crackles - loud, low-pitched, start in early inspiration;
cleared by coughing
■ Wheezes - air passes through narrow passageways
■ Stridor - inspiratory crowing sound; lowder in neck
○ Oxygen
■ Room air; use a device that the child can tolerate
■ Normal saturation greater than or equal to 95%
● Heart
○ Comprehensive evaluation includes all pulses, distended neck veins, clubbing of
fingers, peripheral cyanosis, edema, blood pressure, and respiratory status
○ Auscultation
■ Auscultate for 1 full minute
■ Sinus arrhythmia is common in children - rate increases with
inspiration and decreases with expiration
● Differentiate this rhythm from other arrhythmias by telling the
child to hold their breath - this should steady the rhythm
■ Murmurs - produced by back and forth flow of blood
● Innocent - no anatomic or physiologic abnormality exists
● Functional - no anatomic defect, but may be physiologic
abnormality such as anemia
● Organic - a cardiac defect with or without physiologic abnormality
○ Assessment of heart function
■ Heart rate increases to maintain perfusion
■ Assess skin temperature and color, central and peripheral pulses
● Palpate brachial, temporal, femoral for infants
■ Urinary output 1 ml/kg/hr
■ Write the exact capillary refill time
● Abdomen
○ Include inspection, auscultation, and then palpation
■ Divide into 4 quadrants - LUQ, LLQ, RUQ, RLQ
○ Abdomen protrudes in infants and toddlers
○ Veins can be present, but distended veins should be reported; may see peristaltic
waves on thin children
○ In infants
■ Umbilical stumps are usually black and dry after a couple of days
● Fall off 7-14 days after birth; should never have drainage
○ Auscultate bowel sounds - should hear something every 5-30 seconds
■ Always report absence
■ May take a couple of minutes to hear
○ Palpation
■ Lightly in all areas, then deep palpation
■ Should be soft and flat
● Tense and board-like could be a paralytic ileus
■ Remember that children are ticklish
● GI and GU
○ Be matter of fact
○ Toilet training
■ Know the words used to communicate bathroom activities
○ Always describe stool when charting
■ Wet or dry, color, smell
○ Assess for lesions and hair
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○ Do I&Os on every patient
■ Children become dehydrated very quickly
Male genitalia
○ Inspect if circumcised or not; assess for swelling or secondary hair
■ The penis may appear small in obese boys because of fat folds covering
base
○ Urethral meatus - tip of glans; inspect for discharge
○ Note the location and size of scrotum; palpate testes
Female genitalia
○ Inspect external genitalia for rashes, secondary gair, bruises, lesions, and
discharge or odor
Anus
○ Place the child on abdomen
■ Looking for symmetry of gluteal folds
○ Inspect for inflammation, scratch marks, and any protrusions
Spine
○ Assess general curvature - should be C shaped from thoracic to pelvis
■ Scoliosis - lateral curvature of the spine
● Asymmetry of shoulders and hips, asymmetry of rib cage, slight
limp, crooked hemline, and sore back
Extremities
○ Inspect for symmetry of length and size
■ Refer to orthopedics for an deviation
○ Count digits
■ Polydactyly - extra digits
■ Syndactyly - fusion of digits
○ Legs
■ Bowlegged (gena verum) - lateral bowing of tibia; outward curvature of
both femur and tibia
● Disappears after walking and development of lower back and leg
muscles
■ Knock-knee (gena valgum) - knees close together but feet spread apart;
normal in 2-7 year olds
● If excessive or asymmetric, needs further evaluation
Musculoskeletal
○ Gait
■ Toddlers - broad based gait
■ Some infants normally exhibit twisting of the tibia inward or outward
■ Pigeon toe or “towing in/out” are normal and correct by 2nd year of life
with weight bearing
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○ Joints
■ Evaluate ROM
● Examine infants for congenital hip dislocation and refer to
orthopedics
■ Palpate for heat, tenderness, and swelling
○ Muscles
■ Observe development, tone, and strength
● Test biceps by getting child to “make a muscle”
■ Arm strength, hand strength, leg strength
● Report any weakness or paresis
Neurological
○ Exams should be age specific
○ Factors affecting exam
■ Presence of parent, time of day in relation to meal time/nap time,
alertness, fearful
○ Cerebellum controls the balance and coordination
○ Observe posture, body movements, gait, fine and gross motor skills
Reflexes
○ Reflexes become present at certain ages
○ Loss of reflexes, primitive, or hyperactivity of reflexes is result of cerebral insult
○ Distract child when testing
○ Positive Babinski is normal in children under 2 years old
■ When you touch soul of foot and the toes flare up instead of curl down
Developmental tests
○ Screening is done to assess the developmental level - identifying children who fall
below
○ Denver II - need training to administer
■ Identifies delays and areas of caution
■ Determines what child can do at a certain age; not an intelligence test
■ Items are scored pass/fail/refusal or no opportunity
■ Premature adjustments up to 24 months
■ Delay = failure to perform any item passed by 90% of children the same
age
Pain
○ Signs and symptoms
■ Vital signs changes
● BP and HR will go up
● Decrease of O2 status
● Pupils will dilate if in pain
■ Sweating and crying
● Eyes closed tight
■ Pallor
■ Facial expression
● Furrowed brow, grimacing
■ Decreased activity
● Thrashing, fist clenching, rigidity
■ Changes in feeding/sleeping
○ Assessment scales
■ Wong-Baker FACES pain scale
■ FLACC pain scale - in ages 2 months-7 years
● 0-10 rating; used for post-op pain usually
○ Face, legs, activity, cry, consolability
■ Infant pain scale - NIPS
● Used in NICU (0-7)
○ 1 - breathing (0-1)
○ 2 - Face (0-1)
○ 3 - Arms (0-1)
○ 4 - Legs (0-1)
○ 5 - Cry (1-0)
○ 6 - Arousal (1-0)
Immunizations
●
Hepatitis B - 3 doses
○ Given at birth, 2 months, and 6 months
○ Should receive all doses by 11 years old
○ Preterm infants with hep B negative moms can be vaccinated as early as 30 days;
preterm infants who weigh less than 2000 g should be held for vaccination until
they are released from the hospital
○ Do not give in the dorsogluteal area - low antibody seroconversion
■ Give in the vastus lateralis
● Rotavirus - 2-3 doses
○ RV1 - 2 doses at 2 months and 4 months
○ RV5 - 3 doses at 2 months, 4 months, 6 months
■ The maximum age for 1st dose is 14 weeks and 6 days
■ The maximum age for the last dose is 8 months
● Diphtheria, tetanus, acellular pertussis (DTaP) - 5 doses
○ Doses at 2 months, 4 months, 6 months, 15-18 months, 4-6 years
■ If the 4th dose is given after 4 yo, the 5th dose is not given
● Tdap and Tetanus
○ Given every 10 years, given to pregnant adolescents for each pregnancy, and
given for dirty wounds
● Inactivated Poliovirus (IPV) - 4 doses
○ Doses at 2 months, 4 months, 6-18 months, 4-6 years
● Measles, Mumps, Rubella (MMR) - 2 doses
○ Doses at 12-15 months, 4-6 years
■ 1 dose can be given between 6-11 months if traveling internationally
● If given before 12 months, will need two more doses
○ Do not give during pregnancy - no pregnancy for 28 days after vaccination
● Measles, Mumps, Rubella, and Varicella - 2 doses
○ Doses at 12-15 months and 4-6 years
○ Do not give to HIV children - risk of febrile seizures
● Varicella - 2 doses
○ Doses at 12-15 months and 4-6 years
○ 2nd dose can be given before 4 years old if 3 months after 1st dose
● Hepatitis A - 2 doses
○ Doses at 12-23 months and 6-18 months following the first dose
○ Hepatitis A is caused by fecal-oral route with ingestion of contaminated food and
water
● Meningococcal conjugate (MenACWY) - 1 dose
○ Dose at 11-12 years; may be given as early as 2 months if high risk
○ Caused by neisseria meningitidis which is the leading cause of bacterial
meningitis
○ Booster at 16 years old
● Human papillomavirus (HPV) - 3 doses
○ First dose 11-12 years, 2nd dose 1-2 months after the first, third dose 24 weeks
after the first dose
○ Recommended for males and females
○ Gardasil
● Side effects of Vaccines
○ Usually occur within a few hours - days
■ Include local tenderness, erythema, swelling at site, low grade fever
○ Make sure the correct needle is used for placement in the muscle when
administering the vaccine
● Contraindications - condition that increases the risk for a serious adverse reaction
○ Do not give to people with severe febrile illness and known allergic reactions
■ Do not give live vaccine if there is altered immune system or passive
immunity from blood transfusion, immunoglobulin, or maternal antibodies
● Precautions - may increase the risk for adverse reactions or compromised immunity
○ May give with common cold
● Misconceptions - caused by unfounded fears and lack of knowledge
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○ Combined vaccines may cause overload, administering too many vaccines will
decrease immunity, causes autism, pain, compromised immunity/death
Documentation
○ Informed consent - informed of risks and benefits
○ Give parent vaccines information statement
○ Document day, month, year, and site given; document manufacturer and lot #
■ Name, address, title of person administering
○ IIS - immunization information system
Use standard precautions - universal for blood and body fluids
Airborne precautions - dissemination of droplet nuclei small particle less than or equal to
5 mm
○ Remains suspended in air for long periods
○ Special air ventilation necessary - airborne infection isolation room (instead of
calling it negative pressure room)
○ Wear N95 mask, gown, gloves
Droplet precautions - used for large particles greater than 5 mm
○ Absorbed through conjunctiva, mucous membranes, nose, and mouth
○ Usually travels 3 feet or less
○ Do not stay suspended in air
○ Surgical mask, gown, gloves
Contact precautions - skin to skin
○ Direct contact transmission
○ Wear gown and gloves
Infants to Adolescence
● Case Study #1
○ The parents of a 6 month old come into the emergency room for fever and a
cough. As you are taking their history, you discover this is their first child and
they are extremely nervous and not sure what to expect from a 6 month old. As
the nurse, what advice would you give the parents on developmental
expectations?
● Infant
○ Psychosocial: Erikson
■ Trust vs. Mistrust
● Trust of self, others, and the world - basic needs of feeding,
comfort, stimulation, and caring will be met
● Mistrust occurs if the needs are either not met OR are met before
the child senses the need therefore never learns to develop a sense
of control over the environment.
● Primary narcissism = total concern for oneself is at its height.
(cry to get attention) as physiology matures (vision, motor
movement and vocalization) the child learns to reach out for a hug
rather than to scream, etc…
○ Tactile stimulation is very important at this age
○ Cognitive: PIAGET (0-24monthS); 1st 4 stages in birth -1 year
■ 1st Stage - Use of Reflexes
■ 2nd Stage - Primary Circular 1-4 months: reflex → voluntary movements
● Smiles reflexively not for a reason; but by the end of this period of
time begins to see that smiling will illicit a smile back which in
turn send endorphins (good feeling), not quite purposeful yet
● At 2 months begins to recognize mother/primary caregiver
● Separation of self and others - no separation anxiety yet, bored
when left alone
● Development of object permanence (playing “peek a boo”
promotes this)
■ 3rd Stage → Secondary Circular 4-8 months:
● Begins to smile purposefully, imitates sounds and simple gestures
● Separation anxiety 6-8 months - becomes anxious when taken
away from mom
● Beginning of Object permanence - play peek a boo to promote
● Can imitate
● Begins to feed self
● Affect → (Outward manifestations of emotions and feelings)
develops during secondary circular stage
■ 4th Stage → Coordination of secondary schema - occurs at the end of first
year
● Able to apply things like: “bye-bye” means that person is leaving
me.
● Use of symbols and mental representation (beginning to
understand meaning of words, “mama” dada” become connected to
a person)
● An infant’s ability to attach is dependent on the successful
attainment of recognition of the mother (as separate from self) and
object permanence
○ Physical Growth (First Six Months)
■ Weight -- ­ increases 1½ lbs (680g) per month (Doubled by 6 months)
■ Length -- ­ increases 1 inch (2.5cm) per month
■ Head Circumference -- increases ½ inch (1cm) per month
■ By the end of the 1st year the infant's birth :
● Weight has approximately tripled
● Height has increased by approximately 45%
● Head circumference has increased by approx. 33%
○ Organ Systems’ Maturation
■ Respiratory
● Respiratory Rate - gradually decreases with age
● Respiratory Infections - more susceptible to respiratory infxns and
otitis media
○ Lower levels of IgH → increase the likelihood of infections
● Respiratory Distress Syndrome- prevention is key
■ Cardiac
● Maternal Regulation to Self Regulation
● Heart Rate Decreases and rhythm Stabilizes
● BP Fluctuates - increases, can fluctuate with emotion and activity
● Physiologic Anemia - introduce Iron supplement at 6 months if
breastfeeding or iron fortified formula if not
■ Gastrointestinal - Immature GI tract at Birth
● Digestive Enzymes - 4-6 months
● Swallowing - becomes more coordinated
● Tooth Eruption - begins around 6 months, infants body is
preparing to digest solid food
● Changes in Stool
○ Meconium stool comes first
○ Yellow stools in breastfed babies
■ Immune – full immune system until early childhood
● Endocrine - risk of hypoglycemia due to immature liver and
endocrine system
○ Need to be fed regularly every 2-3 hours
● Thermoregulation - importance of swaddling
● Renal - fluid management will start to improve
○ As the renal system matures, urine will become more
concentrated
● Neurons
○ Myelination requires fat consumption
■ Do not switch to low-fat milk until age 2
● Neural Synapse - created and reinforced the first two years
○ Language
■ Birth: baby’s first language is crying.
■ 1st month: “ooooh ahhhh”
■ 2-4 months: Followed by laughing and squealing
■ 3-9 months: single syllables, Non specific “Mama and Dada”
● Not necessarily specific
■ End of 1st year: Followed by specific “Mama Dada”
● 1-5 words
○ Purposeful Movement
■ Development Motor Skills
● Gross
Fine
○ 2-3 mos.
Bare some weight
smiles resp.
○ 5-6 mos.
Pulls to sit/head lag; Reaches
○ 6-9 mos.
Stands holding on
Grasps
○ 9-12 mos.
“Cruising”
Palmer to pincer grasp
○ Sensory Changes
■ Visual, Auditory
Vision
Auditory
Birth
20/100-20/400
Responds to bell
Follows to midline
2-3 mos. Vision improves
Turns to bell
Follows passed mid line
5-6 mos. Searches for object
Turns to voice
6-9 mos.
Develops hand eye and depth perception
Responds to name
9-12 mos.
20/40-20-60; Follows fast movements
Listens actively
○ Solitary Play
■ Primary narcissism - usually only involves one sense at a time
(chewing/touching/looking)
○ Gender Identity
■ Hormonal Cues - identifies the gender in utero- estrogen and testosterone
■ Social Cues - Parents teach infants how to react to different stimuli via
their response to infant behavior
● Example: Infant Behavior: Infant hits older brother
○ Parental Response: Girl “Be sweet” Boy “what a tough
guy”
● Infants begin identifying and acting responsively through social
and hormonal cues throughout infancy. Parental response to the
infants pleasure seeking behavior can influence his/her evolution in
sexual identity
○ Teething
■ When
● Between 6-8 months, as early as 4 months
■ How many
● Can develop 2-4 teeth at one time
■ Dental Care
● Non-fluoride toothpaste - use finger or toothbrush for babies
■ Signs and Symptoms
● Fever, difficulty sleeping related to pain, might rub ears, decreased
appetite of solid foods; can be difficult to differentiate between
illnesses
○ No vomiting or diarrhea in teething
■ Interventions
● Gnawing on cold teething ring
● Baby motrin/tylenol - for over 6 months of age
● Brushing teeth with non-fluoride toothpaste
● No bottle propping/juice or milk at bedtime
● First dental visit at the first year of life
○ Safety Considerations
■ Accidents are the Leading cause of death in infants
● Think about development: ability to roll over, crawl, stand up,
placing items in mouth etc.
○ Lower crib mattress, never be left unattended on high
surfaces (can roll off)
○ Placing items in mouth - lock cabinets
● Most common causes
○ Death: Suffocation, MVA, and Drowning
■ Ex: grapes, bathtubs
● Check temperature of bath
● Backyard and outdoor safety
○ Injury: Falls, Ingestions, and Burns
● Aspiration
○ Inspect toys
○ Small objects out of reach
○ Avoid certain foods and balloons
● Drowning
○ Bathing (temperature) - stay with infant at all times
○ Backyard/Outdoor safety
● Sleeping
○ SIDSInfant- Back to Sleep Campaign
■ Laying on back, firm bed, no extra blankets, no
mattress pads, crib rails up, crib in the lowest
position
● Falls
○ Place gates at top and bottom of stairs
○ Never leave unattended on a raised surface
● Toddlers
○ Erikson’s Stage
■ Autonomy vs. Shame & Doubt - (2-3 yrs )
● Trust - provides foundation to achieve autonomy
● Ritualism - thrive on routine
○ Will be repeating tasks all over again
● Negativism - asserting themselves by saying “no”
○ Want to have some control
● Physical Competence
○ Sphincter control; want to make sure they’re meeting
developmental milestones
● Need to set realistic limits
○ Piaget Sensorimotor & Preoperational (2-7 yrs.)
■ Primary Characteristics
● Egocentric - unable to see the world from any one else’s
perspective
● Transductive - (Cause-Effect Thinking – Playing the “Blame
Game”)
○ Transductive logic - Two events occurring closely in time
receive cause-effect attributes
■ Explaining events in their world. Children tend to
take one specific event and generalize from that
specific event. He slammed the door and they had a
severe earthquake. Unable to go "meta" or “outside”
or “above” the experience, the child believed his
bad behavior "caused" the earthquake.
● Global Organization - Belief that if something changes in one part
of a whole so does everything else.
○ Ex: child refuses to sleep in room because position of bed
has changes - relates back to ritualism
● Centration - Focusing on one aspect rather than the whole or other
aspects. (Maybe fascinated with nose)
○ Ex: refusing to eat food because of its color regardless of
what it tastes/smells like
● Animism - Giving living qualities/characteristics to inanimate
objects (Talking to animals)
● Irreversibility - Inability to undo an action that has been started
physically
● Magical thinking - Believing thoughts are all powerful and can
cause events (No concept of logical cause and effect)
■ Importance of Understanding Developmental Stages
○
○
○
○
○
● Timing, Cooperation, Literal Meaning of Words, Other
Perspectives
○ Will start to become more cooperative
● Recommendation of no more than 2 hours of screen time a day
Physical Growth
■ Toddler transforms from a squat pot belly stature into pre-school stature.
● Weight -- ­ increase by 4 to 6 lbs per year
● Height -- grow 3 inches per year
● Head circumference – 1 inch during second year; ½ inch during
third year
○ After 36 months, stop measuring head circumference
Language Development
■ 12-15 mos.
● 2-6 words
■ 15-18 mos.
● Speech becomes understandable
■ 18-24 mos.
● 300 words, Combines words, Names 1 picture, IDs 6 body parts
■ 24-36 mos.
● Names a friend, 3 Word Sentences, Names Activities, Names a
Color
Movement - Gross and Fine Motor
■ 12-15 months
● Walks well, removes clothes, uses spoon and fork, imitates
activities, builds tower of 2 blocks
■ 15-18 months
● Kicks ball/begins, walks up stairs, brushes teeth with help, feeds
doll
■ 18-24 months
● Throw ball/jumps up, tower of 6 blocks, wash and dry hands
■ 24-36 months
● Tower of 6 blocks, puts on shirt, thumb wiggle
Vision and Auditory
■ 12-15 mos.
● Improved: Depth perception
● 20/40 vision
● Auditory processing Improves
■ 15-18 mos.
● Integration of sensory perception
Integration of Modalities
○
○
○
○
○
■ 18-24 mos.
● Brain Development
○ Broca’s Area → Speech Development
○ Cortical area → Improved leg muscle movement
○ Sphincter Control → physical ability to potty train
■ 24-36 mos.
● Improved Neuromotor Control and Voluntary Functions
● Improved Respiratory Ratios- Less at risk for RDS than an infant
but still at risk
The Role of Family Role Modeling and the Media
■ Strong Families - Healthy Growth and Development
● Commitment
● Appreciation & Encouragement
● Time, Purpose, and Congruence
● Communication
● Clear Values, rules, & Beliefs
● Problem Solving
● Positive Attitude
● Flexibility & Adaptability
● Balance
■ “Roles are learned through the socialization process.”
Parallel plays - the toddler plays alongside, not with, other children
Toilet Training Readiness - Importance of having all three in place to have
success
■ Physiologic - sphincter control
■ Cognitive - language ability to express themselves
■ Psychological - need sense of trust and autonomy
Gender Identity and Sexuality
■ Body Image/Cognitive
● Recognition -Recognize gender difference by age 2
○ Teach children the correct terminology for privates
■ Gender Identity - developed by age 24 months
■ Personal Space
■ “Research suggests that gender is something we are born with; it can’t be
changed by any interventions. It is critically important that children feel
loved and accepted for who they are.” HealthChildren.org
Important Tasks of Toddlerhood
■ Separation and Individuation
● Want to know that parents will be there when they’re gone
■ Personal Social Behavior
■ Temper Tantrums - trying to establish autonomy
● Trying to teach them to use their words
○ Dental Care
■ Brushing and Flossing
● Will start going to dentists at age 1
● Start to use fluoride after the age 2
○ How Much Fluoride is Enough?- Fluoride should be in
drinking water; a pea sized portion of toothpaste when
toddler/preschool. DO NOT use a fluoridated toothpaste
until the child is 2 years old.
■ Jack-o-lantern smile
○ Safety Considerations
■ The same safety measures that apply to infant apply to toddler plus
● Lock up Medicines and Detergents
● Supervise Near Water, Monitor outdoor play
● Avoid toys with small pieces and parts
● Eating
● Pre School
○ Physical Growth and Development
■ Average weight gain per year is about 2-3 kg. aor 4.5-6.5 lbs.
■ A toddler transitions to a slender yet sturdy, agile, and postural erect
preschooler
■ Gross Motor
● 3 yrs. Rides tricycle, runs, jumps
● 4 yrs. Skips, hops on 1 foot, catches ball
● 5 yrs. Skips, jumps rope, skates, and swims
■ Fine Motor
● Transitions to rudimentary holding of writing with finger rather
than fist grasp
● Allows for more controlled copying of shapes and drawing (picture
of drawings on page 586)
● Transitions from toddler scribbling to rudimentary shapes to
detailed pictures
○ Psychosocial Developmental Stage - Erikson
■ Initiative vs. Guilt - 3-5 yo
● Conflict can occur when they surpass abilities
■ Psychosocial Milestones
● Superego - begin to develop consciousness and starting to
understand morality
● Moral Judgment
● Socially Acceptable Behavior
○ Cognitive Development - Piaget
■ Preoperational Phase
● Can verbalize thoughts without acting out their thinking
○ Language Development - 3-4 years
■ Specifically Understandable
■ Telegraphic Speech
● Ex: not using articles in a sentence, only the “important words”
■ Can Name A color and A friend
○ Play
■ Associative to cooperative
○ Safety Considerations
■ Best form of Prevention is Supervision
● Lock up medicines and detergents
● Supervise near water
● Monitor outdoor play
● Avoid toys with small parts
● Problems and Diseases - Infancy and Early Childhood
○ Iron Deficiency Anemia
■ Interventions
● 16 oz (two cups) maximum cow’s milk/day for toddlers and
preschoolers; Do not switch to 2% until over 2 yrs.
○ Children less than 2 yrs. Require fat to myelinate their
neuronal sheaths
● Give iron supplements with OJ if possible for better absorption
○ Still need a source of calcium and Vitamin D every day
■ Parental Teaching
● Iron absorption - Formula
○ Iron fortified cereal
○ Breastfed need to receive an oral iron supplement
● Best Indicators - stool will be darker if receiving enough iron
○ FTT - Failure To Thrive
■ Characteristics of Child
● Weight - under the 5% for their age
● Developmental Milestones
● Apathetic - may be avoiding eye-contact
● Appetite
○ Kwashiorkor - weight may be okay but there is a lack of
protein
■ Recognizing Parent/Caregiver’s Behaviors (non organic FTT)
● How do they handle the infants?
○ Perspectives
● Nursing Considerations
○ 6 am daily weight, naked
○ Do not rush during mealtime, quiet atmosphere, structured
feeding routine, role modeling (includes education to the
patents)
○ Lead Poisoning - Plumbism
■ Sources
● Lead-based paint, water from old lead pipes, diet deficient in Iron
and Calcium
■ Clinical Manifestations
● Blood Lead Level - greater than 10-70 mg/dL
● Hearing loss, anemia, kidney problems, lead encephalopathy,
hyperactivity/aggression, short attention spans
■ Treatment & Interventions
● Dietary Calcium and Iron
● Chelation Therapy
■ Education and Follow Up
● Environment
○ Children shouldn’t have access to lead-based paints
● Nutrition - monitor good hydration status
● Lab
○ Otitis Media - bacterial infection of the inner ear
■ Clinical Manifestations
● Often Follows an URI
● Earache
● Fever
● Fussy and irritable
● Tendency to hold or pull affected ear
● Rolls head from side to side
● Loss of appetite
■ Treatments
● Antibiotics, Analgesics (Ibuprofen or Tylenol), Myringotomy
■ Nursing Considerations
● Relieve pain
● Understand pathophysiology for why infants are susceptible to ear
infections
○ Shooter eustachian tubes
● Educate the family
○ Always complete the entire dose of antibiotics as directed
○ Do not prop the bottle
○ Prevent complications or recurrence
○ Varicella (Chickenpox)
■ Clinical Manifestations
● Vesicles that crust over; severe pruritus
● Lesions begin at neck or trunk
■ Vaccine is best prevention
● Keep fingernails short and clean when child has chickenpox
● Applying pressure instead of scratching
○ Atopic Dermatitis (Eczema) - chronic inflammatory process occurring on the skin
as a result of various factors
■ Etiology
■ Manifestations
● Extremely Itchy, Erythema, Vesicles, Papules, Weeping, Oozing,
Crusting
● Infants: generalized usually cheeks and scalp, trunk
■ Treatment
● Keep skin well hydrated
● Avoid environmental triggers allergens or infectious
● Control pruritus
● Avoid or treat infection
○ Medical tx → topical steroids
○ Acetaminophen Poisoning
■ Recognition and Prevention
● Cannot have more than 15 mg/kg per dosing every 6-8 hours
■ Signs and Symptoms:
● May not occur for 24 hours
● Nausea and Vomiting, Loss of appetite
● Elevated liver enzymes
● LATE s/s include the s/s that go along with hepatic failure
(jaundice, acholic stools, dark urine)
■ Treatment - the earlier this is caught the better the outcome
● N-Acetylcysteine (Mucomyst)
○ Safety
■ ⅔ of all Injuries Occur in the Home
● Focus on Teaching and Prevention
● School-Age Child - also known as Middle Childhood (Extends from 6 years – 12 years)
○ A time of gradual growth and development
○ Physical Growth
■ Weight - ­ 4 ½ - 6 ½ pounds per year
■ Height - 2 inches per year
● Boys and girls are about the same size until the end of the schoolage years when girls begin to surpass the boys in height and
weight.
○ Maturation of Systems
■ GI
● Fewer stomach aches, better maintenance of blood sugar levels,
increased stomach capacity → retention of foods for longer
periods, caloric needs are lower
■ Heart
● Heart rate and respiratory rate steadily decrease
■ Immune System
● Becomes more competent caused by increased exposure in school
to other children
○ Tend to have more infections in the first 1-2 years of school
and then the frequency decreases
■ CNS
● The organization of the CNS is like an adult’s, although the frontal
lobes, the site of reasoning ability, is still maturing
■ Musculoskeletal
● Body proportions change
○ Lower center of gravity
○ Increase in leg length, in head size, and in waist size
● Muscles
○ Increase in muscle mass relative to body weight
○ Still immature and vulnerable to injury
● Bones
○ Continue to ossify but mineralization not complete until
maturity
○ Prevent alterations in structure
■ Well fitting shoes; chairs and desks that allow
correct posture
○ Preadolescence – the period that begins toward the end of middle childhood and
ends with the 13th birthday
■ Preadolescence for girls – rapid growth
■ Preadolescence for boys – continued steady growth
■ Puberty – signals the beginning of the development of secondary sex
characteristics
○ Psychosocial Development
○
○
○
○
■ Erikson - Industry vs. Inferiority
● Achieve a sense of personal and interpersonal competence through
the acquisition of technologic and social skills
● Children who do not experience themselves as competent socially,
physically, or intellectually develop a sense of inadequacy or
inferiority
○ Peer group play becomes very important at this age
Social Development and Play
■ Less intense emotions
■ Begin to identify more with peers
● Sex-role learning - boys associate more with boys and girls play
more with girls- differences increase in the later school years
● Formation of clubs
■ Play more in groups and teams - Teams are important to learn group vs
individual goals, competition, and division of labor to achieve goals.
■ Bullying - recurring activity with intention to cause harm or control over
another person. Imbalance of power.
● Significant long term consequences - depression, low self esteem,
anxiety, etc
Piaget - Concrete Operations – ages 7-11 yrs
■ “3 C’s”
● Conservation
● Classification - grouping concepts
● Combination
○ Numbers and Language → Ability to read
Dental Health
■ At 6 yo – still have all of deciduous (primary) teeth but permanent
(secondary) well formed and begin erupting
■ Assess for caries, malocclusion
■ Children should visit dentist at least once a year, preferably every six
months
● Parents should still be supervising
■ Establishing good oral hygiene habits is extremely important. Always take
opportunities to educate parents/children about good dental hygiene
Injury prevention - Risk taking behavior
■ Motor Vehicle Accidents
● Belt-Positioning Booster seat – until big enough to fit properly in a
seat belt. Should stay in harness until reaches the height and weight
limit for the car seat, roughly 65lbs
● Adult seat belt
○ AAP recommends when child reaches 4’9”, generally 812yrs old
○ Fits correctly when - shoulder belt lies across middle of
chest and shoulder, not neck or throat; Lap belt low and
snug across upper thighs, not belly; can sit against back of
seat with knees bent without slouching, feet hanging down
○ Children under 13 should not ride in front seat
■ Bike Safety - make sure the bike is fitted appropriately to the child.
● Always wear helmet
● Review traffic safety rules
○ Light or bright colored clothing
○ Listen for vehicles
○ Check tires for air
○ Go with the direction of traffic
○ Head Lice (Pediculosis Capitis) - an infestation of the scalp by pediculus humanus
capitis
■ Nits – oval-shaped; white, tan or gray eggs
■ Diagnosis – presence of a live louse on scalp or in hair and/or presence of
nits within 1 cm of the scalp
● Grow well with warm temps and high humidity
■ Mode of transmission - direct head to head contact
● Indirect via fomites – brushes, combs, bedding, headgear, and
helmets
■ Clinical manifestations
● Could be asymptomatic
● Itching – typically the first clinical symptom
○ Scratch marks, inflammatory papules
○ Nits found more frequently in occipital and posterior
auricular regions of the head
■ Differential diagnosis – dandruff, hair casts, dried hair products can be
easily shaken off
■ Treatment - Over the counter
● Pyrethrins shampoo – e.g. Rid, Pronto
● Permethrin 1% cream rinse – NIX (cost » $20/tx)
○ Kills lice and eggs (incompletely)
○ Recommended by AAP as first-line therapy
● Prescription
○ Spinosad (NatrobaTM) – kills lice & eggs; no need for nitcombing, most effective product on the market, however
costs $270/treatment
○ Ivermectin 0.5% (SkliceTM) – newest product. Kills lice and
eggs
● Alternative
○ Occlusive agents – petroleum jelly, olive oil, mayonnaise
■ Usually left on overnight
○ Soaking scalp in vinegar for 10” before using a
pediculicide
■ Education
● No sharing of combs, brushes, hats, headgear
● Hair grooming items should soak in boiling water for 5-10 minutes
● Clothing and linens should be washed in hot water (min. 122o F)
and dry in hot dryer for at least 20 minutes
○ Non-washable items (stuffed animals) should be sealed in
plastic bags for 2 weeks
● Upholstered furniture should be vacuumed
● Treatment and combing hair –usually repeat in 7-10 days; comb
and remove nits daily
● Only treat those with definite infestation; no prophylactic tx of
friends/family members
● School - no longer recommended to send home from school
○ Impetigo Contagiosa - Common skin infection: bacteria enters through a break in
the skin
■ Description - single red macule or papule → vesicular/pustular lesion →
ruptures dries to a honey-colored crust
● Lesions can spread rapidly - form a group of lesions in circle or arc
● Pruritus is common; No scarring
■ Epidemiology
● Caused by staphylococcus, group A beta-hemolytic streptococci
(GABHS), MRSA
■ Mode of transmission
● Autoinoculation via hands, towels, clothing, or nasal
discharge/droplets
■ Increased Incidence
● Summer months - early fall
● Areas with poor hygiene; crowded living conditions
● Warm humid climates
■ Prevention
● Good health and hygiene
○ Thoroughly clean minor cuts and scrapes with soap and
water
■ Treatment
● Wash with antibacterial soap, Prescription strength abx ointment
(mupirocin/bactroban)
● Oral antibiotics may be necessary
■ Education
● Good Handwashing and keep their hands away from their face
● May return to school after 24 hours of ointment treatment was
started
○ ADHD: inattention, impulsiveness, and hyperactivity
■ Age on onset - 7 years most common; More common in boy than girls
■ Etiology - unknown
■ Clinical manifestations - Wide range
● Learning difficulties evident in school age
■ Complete multidisciplinary evaluation, medical, and developmental
evaluation
■ Therapeutic Management
● Behavioral therapy - prevention of behaviors
● Classroom structures, family education and counseling,
environmental manipulation
● Medication, psychotherapy
○ Not all children benefit from medications
○ Stimulants
○ Side effects - insomnia, anorexia and weight loss,
hypertension, may suppress growth if used long term
● Health Promotion of the Adolescent
○ Classifications
■ Early adolescence (11-14 years)
● Changes of puberty and responses to those changes
■ Middle adolescence (15-17 years)
● Transition to a dominant peer orientation with all the stereotypic
adolescent preoccupations
■ Late adolescence (18-20 years)
● Transition into adulthood including adult work roles and
relationships
○ Opportunity to teach self-advocacy skills
■ Health Screening - Identify assets and threats to an adolescent’s well being
● SAFETIMES, GAPS, RAAPS
● Threats
○ Unintentional injury - MVA’s; Homicide, Suicide
■ Reinforcement of safety measures while driving
○ Adolescent’s have different health concerns. These areas of concern should be
addressed at each visit:
■ H- home environment
■ E- education/employment
■ E- eating/nutrition
■ A- activities, physical activities
■ D- drugs
■ S-sexuality
■ S- suicide/depression
■ S- safety
○ Communication & Interview process: Development of Trust
■ Introduction
■ Active listening
● Responding to adolescent’s emotions
■ Ensuring confidentiality while explaining limits of confidentiality
■ Avoiding a surrogate parent role, avoiding an adolescent or friend role,
avoid power struggles
● Facilitate adolescents coming to their own conclusions
● Allow and encourage the adolescent to assume the responsibility
for their treatment regimen and/or health
● Assess for any unrevealed concerns
○ Adolescence - Puberty
■ Predictable sequence of hormonal and physical changes
● Tanner stages
● Sequence is predictable but ages at which they occur are variable
■ Encompasses both physical and sexual maturation
■ Sexual maturation in girls
● Early puberty - Begins between 8-13 years
○ Thelarche – development of small bud of breast tissue. 4
out 5 girls this is earliest sign
○ Pubarche – development of pubic hair – follows thelarche
by 2-6 mos (1 out of 5 girls this is first)
○ Increase­ in normal vaginal discharge
● Midpuberty
● Late puberty - hallmark is menarche (1st menstrual period)
○ Occurs about 2 years after appearance of breast buds
■ Sexual maturation in boys
● Early puberty – 9 ½ - 14 years
○ Testicular enlargement, Appearance of pubic hair
● Midpuberty
○
○
○
○
○ Penile enlargement; continued growth of testes, pubic hair
○ Increase in­ muscularity; voice changes; development of
facial hair
○ Gynecomastia - common at this time . Important to
emphasize that it is temporary but that they should be
evaluated by a health care practitioner
● Late puberty
○ Continued development of penis, testicles, pubic hair
reaching adult proportion
○ Final voice changes
○ Changes completed within 4 years of onset
Psychosocial development - Erikson
■ Identity vs. role confusion (diffusion)
● Task is to develop a stable, coherent picture of oneself that
includes integrating one’s past and present experiences with a
sense of where one is headed in the future
● Ability to maintain a commitment to choices under all conditions
○ Sexual identity becomes part of this
Cognitive Development - Piaget
■ Formal operational thought - Begins between 11 – 14 years
● Abstract terms - can make better decisions but are still egocentric
● Possibilities
○ Imaginary audience - Think that everyone is watching them
○ Personal fable - “that will never happen to me”
● Hypotheses
● Future time perspective
Tobacco Use
■ Prevalence of daily use
● 4.4% 8th graders, 15.6 % 12th graders
■ E-cigarettes
■ Prevention/Cessation
● Education
○ Teach about short-term consequences
● Media/Internet
● Parents/Peers
● Health Care Professionals
Car Seat Safety - All children in back seat
■ Infants
● Rear-facing car seat until 2 years
● Never place car seat in front seat of a car with airbag
■ Toddlers/Pre-K
● Car seat until 40 lbs → then can use Booster Seat
○ Child must be at least 4 for belt positioning booster
● Children in car seat/booster seat until 4ft 9in. and between ages of
8and 12yo
● Children under 13 yo should be in the backseat with the
appropriate seatbelt fit
○ Acne vulgaris
■ Types
● Non-inflamed lesions
○ Closed comedones – whiteheads
○ Open comedones – blackheads
● Inflamed lesions – Papules, pustules, nodules, cysts
■ General measures for prevention and control
● Adequate rest, Moderate exercise, Well balanced diet, Reduction
of emotional stress, Eliminating any foci of infection, Developing
a good skin care regimen
■ Skin care
● Cleansing
○ Mild cleanser 2 times a day (Dove, Cerave)
○ Antibacterial soaps can be ineffective and drying
● Moisturizing – non comedogenic, non-acnegenic
● Protection – UVA protection (non comedogenic, non-acnegenic) to
avoid post inflammatory hyperpigmentation
■ Topical tx
● Benzoyl peroxide - first line of treatment
○ Bactericidal
○ Effective for superficial inflammatory and noninflammatory lesions
○ Not associated with antibiotic resistance
○ Teach about bleaching effect on linens and clothes
● Salicylic acid products
○ Topical retinoids - destroy comedones and prevent new
ones
■ Has anti-inflammatory activity
■ Tretinoin (retin-A), tazarotene, adapalene (OTC)
● Do not apply topical retinoid and benzoyl peroxide at the same
time (unless a combination product). Apply topical retinoid at
bedtime.
■ Topical antibacterial agents - Indicated for inflammatory lesions
● Erythromycin, clindamycin, tetracycline and others
● Combinations abx/retinoid or abx/benzoyl alcohol available
■ Oral antibiotics, Oral contraceptives
■ Isotretinoin (accutane) - reserved for severe cystic acne not responsive to
other tx
● Highly teratogenic
● Monitor lipid panel for elevated triglycerides and cholesterol
■ Nursing considerations
● Assess, do not underestimate psychosocial effects
● Encourage early medical treatment if needed
● Stress to avoid sun/use sunscreen for retinoids and tetracyclines
● Instruct not to pick or squeeze lesions
● Explain gentle cleansing with mild soap
● Length of time to expect improvement
● Encourage compliance and return appointments
● Contraception
○ Acne Questions
■ Brian, 16 years of age, has acne vulgaris. He is beginning to use tretinoin
(retinoic acid, Retin-A) and benzoyl peroxide as topical medications. The
nurse should explain that significant improvement usually takes how long
after initiation of therapy?
● A- 1 week
● B- 2 weeks
● C- 1 month
● D- 2 to 3 months
■ When giving instructions for application of these two topical medications,
the nurse should tell Brian to apply
● A- benzoyl peroxide and tretinoin at the same time.
● B- benzoyl peroxide in the morning and tretinoin at bedtime.
● C- both medications after cleansing his face and expressing
comedones.
● D- both medications only to lesions, avoiding unaffected skin
Fluid and Electrolyte Imbalances in Children
● Distribution of Body Fluids
○ Total body fluid is made up of ICF and ECF
■ ECF is made up of interstitial and intravascular fluid
● Systemic perfusion is a direct reflection of intravascular
volume; means that Na is within normal limits
■ ICF
● Brain cells in children are very sensitive to changes in fluid balance
- when there is an increase in ICF, there may be an increase in
fluid in the brain → can lead to increase ICP
● Osmolality
○ Osmotic pressure is the physical force or “pull” created by a solution of high
concentration across a semipermeable membrane; fluid moves from a lesser
concentration to a greater one
■ Plasma has 3 major determinants for osmotic pressure - sodium, glucose,
and protein
● Serum osmolality is usually double serum sodium; normally 275295 mOsm/kg H2O
■ Water moves to where there is more concentration; therefore, if
intravascular Na, glucose, and protein is greater than interstitial Na,
glucose, and protein, water will mover intravascularly
○ Osmolality Rules - body will do whatever is necessary to maintain normal serum
osmolality
● Factors Affecting F&E Balance in Children
○ Greater % of body weight is H2O
■ Infants and toddlers have extra extracellular water
○ Increased ­Body Surface Area
■ BSA of premature neonates is 5x greater than adults; infants have a BSA
2-3x greater than adults
■ Water loss through the skin, intestine, and lungs is greater because the
proportion to weight is greater
○ Increased ­Metabolic Rate/­Peristalsis
■ Increase metabolic rates → increase heat production → increase
insensible fluid loss
○ Immature Kidney function - less able to concentrate or dilute urine
● Conditions which ­increase fluid requirements in children
○ Fever, Vomiting/Diarrhea
○ High output renal failure
○ Diabetes Insipidus
○ Burns, Shock, Tachypnea
● Conditions which decrease fluid requirements in children
○ Congestive heart failure
○ Syndrome of inappropriate antidiuretic hormone (SIADH)
○ Mechanical ventilation, Postoperatively
■ Less energy being used
○ Oliguric renal failure
○ Increased intracranial pressure
● Daily Fluid Requirements by Body Weight - “Maintenance Fluids”
○ < 10 kg → 100 ml/kg/24hr
○ 11-20 kg → 1000 ml + 50ml/kg for each additional kg between 10 & 20
○ 20+ kg → 1500 ml + 20 ml/kg for each additional kg over 20 kg
■ Never use D5W as maintenance fluids because they contain no sodium →
can cause increased intracranial pressure
■ Hyperosmolar (TPN) fluids have a high risk of infiltrates that can damage
the skin
● Need to know the % glucose when administering
■ Normal saline and Lactated ringers are the two solutions used in
emergency or resuscitation situations
● Minimum Urine Output
○ Infant – 2ml/kg/hr.
○ Older infants & children - 1ml/kg/hr.
○ Older child (≈ 8 y.o.) to adolescent - 0.5 ml/kg/hr.
● Dehydration - slides 12 through 14 in PP
○ Degree
■ Can be Mild, Moderate, or Severe
● If blood pressure drops, that is a final sign → severe dehydration
○ Type
■ Can be Isotonic, Hypotonic, or Hypertonic
● Isotonic is the most common, hypertonic is the least common
● Systemic Perfusion - the delivery of blood to the various organs, tissues of the body
○ Indicators of good systemic perfusion
■ Normal mentation (awake and alert), skin warm, evenly colored, pulses
good, capillary refill brisk, urine output normal
○ Perfusion is a good indicator of hydration in a person with normal sodium
● Isotonic Dehydration -a condition in which electrolytes and water losses are balanced
○ Lab values
■ Serum sodium will remain the same; Hct, BUN, and urine specific gravity
will all increase in dehydration
○ Treatment
■ Fluids
● Mild – Moderate Dehydration may use only oral rehydration
○ Use approved Oral Rehydration Solutions (ORS)
■ Consider the Sodium - soft drinks, fruit juices,
chicken broth are NOT recommended
● Coca Cola – 4.3 mEq Na/L, Gatorade - 24
mEq Na/L, Chicken Broth – 250 mEq Na/L,
■ Approved include Pedialyte – 45 mEq Na/,
Rehydralyte – 75 mEq Na/L
■ ORAL REHYDRATION
● Step 1 - replace the estimated loss
○ Give 50 (mild)– 100 (mod) ml/kg of Oral Rehydration
Solution (ORS) over 4 hours
● Step 2 - provide maintenance fluids
○ For infants, their normal formula intake would suffice
■ *Breastfeeding infants should continue to
breastfeed
● Step 3 - provide for ongoing losses
○ Give 10 ml/kg for each stool or emesis (small children), or
5-8 oz for older children
● What to do if child is also vomiting
○ Give 5-10 ml every 5-10 minutes
■ If the child vomits again, wait one hour and then try
again
■ Moderate – Severe Dehydration Treatment
● IV Fluids
○ Give 20ml/kg of LR or NS, 2-3 boluses over the 1st hour
■ The patient should be fully assessed after each bolus
● Check for mentation, eyes, fontanels, mouth,
RR (crackles), CV system, skin, and urine
● Threats of moderate-severe dehydration are decreased perfusion
→ lead to anaerobic metabolism → lead to acidosis
● Intraosseous Access - should not be in longer than 24 hours
○ Benefits - Delivers fluid, blood, & medication, easy, quick
access, non collapsible vein
○ Risks - Osteomyelitis, Compartment syndrome
○ Location - Distal tibia & proximal tibia
● Nursing Management
○ Identify those at risk and assess for early signs
■ Monitor VS with neuro checks, systemic perfusion, intake and output,
daily weight, lab data
○ Do NOT add KCL to IVF until after 2nd void
■ Because of renal disease, KCL is not excreted properly and can build up in
the bloodstream → causes cardiac arrhythmias; voiding indicates no
renal failure
○ Monitor, evaluate response to rehydration
● Hypotonic/Hyponatremic Dehydration
○ Serum Sodium < 135mEQ/L
○ Most common cause - plain water; basically the administration of fluid that is too
low in sodium to a child who is already dehydrated
○ Nursing Considerations
■ Early signs of decreased perfusion - pulses and capillary refills will be
poor, tachycardic
■ If Na is less than 120 mEQ/L of Na → place on Seizure precautions
● May place child on 3% NaCl if Na is extremely low
● Hypertonic/Hypernatremic Dehydration
○ Serum Sodium-abnormally high
■ Most dangerous because late signs of dehydration, complications with
rehydration
■ Caused by diabetes insipidus
○ Systemic perfusion remains good until the dehydration is severe.
■ Replace fluid losses more slowly (over 48 hours not 24) to prevent
increased ICP
● Do not want to decrease the Na level more than 15 mEq/day
○ Use full strength N/S, not ¼ NS or ½ NS
● Conditions which cause F & E Imbalances
○ Diarrhea - increase in frequency, fluidity, and volume of stools; most common
cause of dehydration in children
■ Acute Diarrhea
● Most infectious causes are self-limiting (Lasting 14 days); most
frequent pathogen is Rotavirus
● Frequently associated with URI, UTI, and OM
■ Manifestations
● GI – cramps, nausea, vomiting, large volume stools, light in color,
loose or watery, soupy, greasy, foul-smelling
● Electrolyte Imbalances
● Metabolic Acidosis
■ Medical and Nursing Management
● Assessment of F & E Imbalances
○ Assess for impending or compensated shock - BP would
still be normal but there would be other signs of shock
● History
○ Duration, severity, associated symptoms
■ Has there been a decrease in urine output?
○ Possible causes
○ Stool specimen - ordered when there is blood in the stool,
diarrhea is severe, or hx of foreign travel
● Rehydrate
○ Replacement of ongoing losses
● Reintroduction of adequate diet (continue breastfeeding)
● Assessment/education of caregivers
○ Monitor for changes in skin color/temp, changes in
behavior
○ When to call back to the ER
● Antidiarrheals are contraindicated; Probiotics, such as
Lactobacillus, are currently being considered
● Case Study
○ Lilly, an 8 month old, 8 kg infant, comes into the pediatrician’s office with a
history of vomiting and diarrhea for 2 days. After you have assessed airway,
breathing and circulation, what is the next most important question to answer?
■ Has there been a decrease in the number of wet diapers? What kind of
fluids have been given? Is there a possibility of impending shock?
○ Lilly seems very irritable. Her anterior fontanelle is flat, eyes normal but no
tearing, mucous membranes dry, color pale, skin warm, pulses 2+, cap refill <2
sec, HR – 188, RR – 30, T – 98.6 ax, BP 90/60. Mom states she is not sure if she
has urinated because her bowel movements are so watery, she cannot tell the
difference. What is your assessment?
■ Mild dehydration
○ The practitioner advises mom to give 400 cc (~ 13oz) of Pedialyte over the next 4
hours, continue her regular amount of feedings of formula if no emesis, to give an
additional 80 cc (~3 oz) ORS every time she has a diarrheal stool, observe for
urine output and call back if no urine over 6 hours or for any concerns
○ Mom took Lilly home. She vomited once. Mom followed the directions as written
and within 8 hours had been able to give her the appropriate amount of fluids.
There were only two more episodes of loose stools, no further emesis, and the
baby was fine
The Child with Renal Dysfunction
● Review of the GU System - Kidneys, Ureters, Urethra, Bladder
○ Kidneys - maintains the composition and volume of body fluids for equilibrium,
forms urine, promotes tubular reabsorption (lumen → blood), tubular secretion
(blood → lumen), and excretion of urine
■ Humoral functions - produces renin which helps increase BP, produces
erythropoietin which stimulates RBC production by the bone marrow,
metabolizes Vitamin D to its active form - necessary for Ca metabolism
■ Nephron - structural and functional unit of kidney composed of complex
system of tubules, arterioles, venules and capillaries
■ Blood Supply
● Constitutes 1/5 of total cardiac output
○ Trauma can result in profuse bleeding
■ Renal Development - kidney development begins in the first weeks of
embryonic life and is not completed until 1 y.o.
● Nephrons not fully functional at birth, meaning that newborns
have trouble concentrating and diluting urine
● Kidneys grow in size until adolescence
● Enuresis - Bedwetting; Inappropriate urination at least 2X/week for 3 months
○ Primary enuresis: never been free of bed-wetting
○ Secondary enuresis: started bed-wetting after development of urinary control
○ Risk factors for Enuresis
■ Family hx
■ Bladder dysfunction disorders
■ Males
■ Emotional factors
○ Education
■ Have child empty bladder before bedtime
■ Restrict fluids in the evening
■ Wear underwear and avoid diapers
■ Use positive reinforcement - no punishment
■ Make environmental change for easy access to the bathroom (no bunk
beds, night light, etc.)
■ Have child change own wet bed linens
■ Avoid constipation - backed up stool can press on bladder and cause
urination
○ Medication for Enuresis
■ Desmopressin acetate - reduces volume of urine
■ Imipramine hydrochloride (Tricyclic antidepressant) - inhibits urination
■ Oxybutynin chloride (Anticholinergic) - reduces bladder contractions
● Urinary Tract Disorders
○ Urinary tract infections
■ Cystitis – infection of the bladder
■ Pyelonephritis – infection of the kidney
● Caused by ascending bacteria – most common is E. coli (also
group B strep, K. pneumoniae, Proteus, Enterobacter,
Enterococcus, Staph, fungi, viruses)
● More likely in females (infants and older) - because urethra is
shorter
■ Factors - age, gender, race, circumcision status
■
■
■
■
● Highest rates among caucasians-unknown, females, uncircumcised
boys
● Females 2-4X higher prevalence
Main cause is urinary stasis - infrequent emptying
Clinical Manifestations of UTI’s
● Infants
○ Fever or hypothermia in neonate
○ Irritability, Poor feeding
○ Vomiting
○ Dysuria, Change in urine odor or color
○ Dehydration
● Children
○ Abdominal or suprapubic pain, flank pain
○ Frequency, urgency
○ Dysuria, hematuria
○ New or increased incidence of enuresis
Diagnostic Evaluation for UTI
● Urine culture
○ Must be collected by sterile technique before
administration of antibiotics
● Sterile catheterization
● Suprapubic aspiration - <2y.o. (need consent)
○ Must be fresh: <1hr. Room temp; <4 hr. Refrigerated
● Positive for infecting organisms
● *Do not encourage large water volumes - may alter cultures
● Urinalysis (U/A) on pt with a UTI
○ pH - weak acid or neutral alkaline
○ Protein- positive
○ Glucose-positive
○ Ketones-positive
○ Leukocytes-positive
○ Nitrites-positive
Children with Pyelonephritis
● Same symptoms as children with UTI’s
○ Fever
○ Back pain
○ Costovertebral angle tenderness
○ Nausea and vomiting
○ Appear “sick”
● Diagnostic Evaluation
○ U/A, Culture and sensitivity
○ Renal scan
○ Renal ultrasound
○ VCUG (voiding cystourethrogram)
○ IVP (intravenous pyelogram)
■ Assessment
● History and s/s from child and family
● Vital signs - presenting as any infection
○ Fever, tachycardic
● CVA tenderness - indication of pyelonephritis
● Exam of genitalia
● U/A
■ Interventions
● Antibiotics
○ Most commonly used antibiotics
■ Trimethoprim-sulfamethoxazole (Bactrim)
■ Amoxicillin (Amoxil)
■ Nitrofurantoin (Macrodantin)
■ Cephalexin (Keflex)
■ Gentamicin (Garamycin)
■ Ceftazidime (Fortaz)
● Promotion of comfort
● Maintain good hydration
● Prepare for diagnostic procedures
● Monitor for response to tx and complications
■ Teaching - How to Prevent UTI’s
● Adequate fluid intake - can prevent stasis
● Void frequently
● Avoid bubble baths
● Wear cotton underwear
○ Vesicoureteral Reflux (VUR) - Refers to the retrograde flow of bladder urine into
the ureters (p. 790)
■ Increases the chance for and perpetuates infections, but does not cause
them
■ 20-30% spontaneously resolve for each 2-year period throughout
childhood
■ Familial Incidence
● Only 1% of population, Siblings have 27% incidence, 36%
offspring of affected parents
■ Higher in females and children w/ prenatal hydronephrosis
■ Interventions
● Low-dose antibiotic therapy
● Frequent urine cultures
● Importance of hygiene & frequent voiding
● Surgical intervention for anatomic abnormalities of the
ureterovesical junction, recurrent UTIs, high grades of VUR,
medication noncompliance, intolerance to antibx., & VUR after
puberty in females
○ Glomerulonephritis - defined as a group of kidney diseases where the glomerulus
is injured
■ Capillaries of glomerulus are inflamed
■ Occurs from infection, systemic disease process, or as a primary defect in
the glomerulus itself
■ Acute post-streptococcal glomerulonephritis (APSGN) is the most
common type of glomerulonephritis
● Is an immune-complex disease which can occur 1-3 weeks after a
strep infection of the throat or skin
● Clinical manifestations
○ Hematuria (smoky or tea – colored)
○ Edema (especially around the eyes)
○ Decreased urine output
○ HTN, Fatigue, Feels “sick”
● Diagnosis
○ U/A (hematuria, proteinuria, & ^ urine specific gravity),
increased BUN and Creatinine levels
○ ASO (antistreptolysin O) titer provides indirect evidence
of previous strep infection (~10 days after the initial
infection).
○ Decreased C3 (serum complement level) initially, but
returns to normal 8-10 weeks after onset of
glomerulonephritis
○ CXR – cardiac enlargement, pulmonary effusion &
congestion
● Interventions - No specific treatment!
○ V/S, Weight, I&O’s
○ Na / fluid restriction - HTN or edema
○ Antihypertensives
○ Antibiotics only with evidence of persistent strep infection
● Diagnostic Evaluation
○ Voiding cystourethrogram (VCUG)
○ Renal scan for scarring and function
○ Urodynamic studies for voiding dysfunction
○ Nephrotic Syndrome - most common presentation of glomerular injury in children
■ Characterized by
● Massive Proteinuria, hypoalbuminemia, hyperlipidemia, edema
■ Types of nephrotic syndrome
● Minimal-change nephrotic syndrome (MCNS) - Most common
type in children (80%)
○ More common in preschoolers, Males 2:1
○ Cause is obscure, but often preceded by a viral upper
respiratory infection
● Secondary nephrotic syndrome - Occurs after or in association
with glomerular damage of known etiology
○ Could be from toxicity to drugs, stings, or venom
○ Is the main presenting symptom of renal disease in
pediatric AIDS
○ Rare other causes include SS disease, hepatitis, malaria,
TB, etc.
● Congenital nephrotic syndrome- Finnish Type
○ Autoimmune Recessive gene
○ Are SGA, with proteinuria and edema - occurs within first
few days/months of life
○ Death occurs without tx. - Requires IV Albumin, dialysis or
renal transplant
○ Hemolytic Uremic Syndrome - acute renal disease characterized by the triad of
AKI, thrombocytopenia, and hemolytic anemia
■ Occurs in 6 mos.-3 y.o.; predominantly Caucasians
■ Types
● Diarrhea (D+) - 90% of cases; caused by ingestion of Shiga toxin
producing E. Coli
○ 95% survival rate
● Diarrhea (D-) - atypical HUS caused by malignancies, disturbance
in complement system, non-enteric infections, or genetic
○ Less favorable outcomes than D+
■ Primary site of injury is endothelial lining of small glomerular arterioles;
Liver, brain, heart, pancreatic islet cells, and muscles could be involved
● Toxins enter the bloodstream and destroy RBCs
● Intravascular coagulation occurs with fragmented RBC’s causing
acute hemolytic anemia → hemolytic process lasts few days-2
weeks
○ Occurs after prodromal period of diarrhea and vomiting
■ Symptoms include pallor, bruising, purpura, rectal bleeding, LOC/seizures
and stupor; Death occurs from renal impairment, CNS injury
■ Education
● Avoid undercooked meat, unpasteurized apple juice and unwashed
raw vegetables, alfalfa sprouts, public pools, no antimotility meds
● Support child and family
○ Acute Renal Failure (ARF) - inability of kidneys to excrete wastes, concentrate
urine, and conserve electrolytes
■ Causes of ARF
● Prerenal- decreased renal perfusion; dehydration from diarrhea and
persistent vomiting
● Intrinsic- diseases causing damage to glomeruli, tubules, or renal
vasculature
● Postrenal- obstructive uropathy
■ Usually reversible but mortality still high
■ Manifestations of ARF
● Oliguria- < 1ml/kg/hr
● Edema
● Drowsiness
● Circulatory collapse
○ Cardiac arrhythmia - from hyperkalemia
○ Seizures - from hyponatremia or hypocalcemia
● Tachypnea from acidosis
■ Nursing Care
● Treat underlying cause, Admit to PICU
● Assess F&E balance
○ Fluid restriction
● Daily wts. And Vital signs
■ Hyperkalemia - most dangerous
● Mannitol and Furosemide - provokes urinary output
● Calcium gluconate - reduces serum K+
● Sodium bicarbonate- increases serum pH and shifts fluid to reduce
K+ levels
● Glucose 50% and insulin drip - facilitates glucose movement into
cells to reduce K+
● Sodium polystyrene sulfonate - Kayexalate
● DIALYSIS
○ Chronic Renal Failure (CRF) - presents differently than adults – most commonly
with a complaint of growth impairment
■ Kidneys decompensate after <50% function because too many nephrons
are destroyed
■ Final stage of CKD - Chronic kidney disease or ESRD-End Stage Renal
disease is IRREVERSIBLE
■ Diet
● Dietary protein RDA, but restricted along w/ milk
● Fat-soluble vitamins (A, E, K) not supplemented unless necessary
● Active or inactive Vitamin D prescribed
● Calcium carbonate supplements - Tums
● Calcitriol - increases Ca+ absorption through GI tract
■ Acidosis - caused by the inability to excrete waste
● Decrease dietary protein
● Sodium bicarbonate - Bicitra, Polycitra
● Correct acidosis after Ca+ levels elevated to prevent tetany
■ Anemia - caused by decreased production of erythropoietin
● Folic acid and iron correct (hard w/ decreased protein)
● Recombinant human erythropoietin (r-HuEPO) medicine given
■ Hypertension
● Low Na+ diet and Fluid restriction
● Diuretics - Thiazides or Furosemide
● Oliguria - strict Na+ intake
● Severe HTN - beta blocker and vasodilator
■ Growth Retardation
● Worse the earlier renal failure dx.
● Grow poorly before and after dialysis
● Recombinant human growth hormone given
● Renal Replacement Therapy
○ Dialysis - separates colloids and crystalline substance by their rate of diffusion
through a semipermeable membrane → osmosis, diffusion, and ultrafiltration
occurs
■ Hemodialysis - blood is circulated outside the body through artificial
cellophane membranes that permit a similar passage of water and solutes
● Preferred for acute life-threatening conditions - hyperkalemia or
poisoning
● Difficult in small children < 20kg.
● Preferred if parents aren’t compliant with PD
● Access by graft, fistula, or external catheter
■ Peritoneal Dialysis - slow, gentle process that decreases the stress on body
organs
● Used on neonates, severe cardiac disease, or poor vascular access
● Most often performed at home so independent families or long
distance
○ Continuous Venovenous Hemofiltration(CVVH)
■ Acute care settings only
■ Fluid balance achieved in 24-48 hrs.
■ Critically ill that need volume-expanding fluids (Hyperalimentation,
Albumin, PRBC’s), Children who would not survive rapid volume
changes - can’t afford fluid shifts
○ Transplantation
■ Offers opportunity for relatively normal life
■ Received from living donor or deceased (brain-dead) donor
■ No limit to age
● Structural Disorders
○ Obstructive uropathy - any structural or functional abnormality that obstructs
normal flow
■ Proximal site of obstruction causes increased pressure
■ Corrected by surgical procedure that bypasses obstruction and diverts flow
● Ex. - nephrostomy or ureterostomy tubes
○ Bladder exstrophy - eversion of the posterior bladder through anterior bladder
wall and lower abdominal wall
■ Bladder, urethra, and ureters exposed through suprapubic area
■ Epispadias present
■ Cover exposed area w/sterile gauze and immediate surgery
○ Hypospadias - urethral opening located below or behind the glans penis; also
ventral surface of penile shaft
○ Phimosis - narrowing or stenosis of the preputial opening of the foreskin
■ Unable to retract foreskin
■ Normal finding and usually disappears as child grows
○ Cryptorchidism - failure of one or both testes to descend
■ Inability to palpate testes
■ Occurs 45% in preterm males
● Retractile testes descend in 75% cases
■ Orchiopexy performed at 6-24 mos.
○ Hydrocele - fluid in the scrotum
■ Enlarged scrotal sac
■ May resolve spontaneously or surgery after 1 year
■ Transillumination as diagnostic tool