Pediatrics Study Guide
Table of Contents
Foundations of Pediatric Nursing 2
Atraumatic Care 2
Health Supervision 2
Developmental
Surveillance/Screening 2
Injury and Disease Prevention 3
Screening tests 3
Immunizations 3
Health Promotion 4
Health Assessment 4
Physical Exam 4
Infancy 5
Development 5
Reflexes 5
Vaccine Schedule 6
Assessing vitals 6
Milestones 7
Interventions 8
Toddler 9
Development 9
Signs of delay 9
Milestones 10
Interventions 10
Preschooler 11
Development 11
Signs of delay 11
Milestones 12
Interventions 12
School-Age Child 13
Development 13
Developmental Concerns 14
Interventions 14
Adolescence 15
Development 15
Physiologic Changes 16
Developmental Concerns 16
Interventions 16
Key Pediatric Nursing Interventions 17
Rights of Pediatric Medication
Administration 17
Determining Correct Dose 17
Routes of Administration 18
IV Therapy 19
Enteral/Parenteral Nutrition 19
Common Labs and Diagnostic Tests 20
Fever 20
Sepsis 20
Pediatric Health Disorders 21
Infectious and Communicable Diseases 21
CAMRSA, Scarlet Fever, Diphtheria 21
Pertussis, Tetanus, Botulism 22
Osteomyelitis, Septic Arthritis 23
Rubella, Rubeola, Varicella Zoster 24
Hand, Foot, Mouth Disease, Mumps 25
Cat-Scratch Disease 25
Lyme Disease 26
Rocky Mountain Spotted Fever 26
Lice, Scabies, Pinworm 26
Neurologic Disorders 27
Epilepsy, Febrile Seizures, Neonatal
Seizures 27
Neural Tube Defects 28
Trauma 28
Bacterial Meningitis, Reye Syndrome 29
Disorders of the Eyes 30
Strabismus, Amblyopia 30
Conjunctivitis 31
Disorders of the Ears 31
AOM, OME 31
Otitis Externa 32
Respiratory Disorders 32
Common cold, Sinusitis, Influenza
33
Pharyngitis, Tonsillitis, Infectious
Mononucleosis, Croup 34
Pneumonia, Tuberculosis, RSV 35
Asthma, Cystic Fibrosis 36
Cardiovascular Disorders 37
Cardiac Catherization 37
Tetralogy of Fallot 38
ASD, VSD, PDA 39
COA, AS 40
Heart failure 41
Gastrointestinal Disorders 42
Ostomy 42
Cleft lip/palate, Hernias 43
Vomiting 43
Diarrhea, Dehydration 44
Thrush, Hypertrophic Pyloric
Stenosis, Appendicitis 45
Intussusception, GERD 46
PUD, Constipation 47
IBD, Celiac Disease 48
Genitourinary Disorders 49
UTI 49
Enuresis 50
Neuromuscular and Musculoskeletal
Disorders 50
Casts 50
DDH, Scoliosis 51
Integumentary Disorders 52
Bacterial Infections, Fungal
Infections 52
Dermatitis (Atopic, Diaper,
Contact), Hives 53
Foundations of Pediatric Nursing
Atraumatic Care
Care that minimizes or eliminates the psychological and
physical distress experienced by children and their families
in the health care system. *Do no harm*
Decrease/prevent physical stressors
Decrease/prevent child-parent separation
Family-centered care - partnership between the
child, family and health care providers in planning,
providing and evaluating care
Promote sense of control
Communication with child: age-appropriate, respect
their space, do not force to talk
Be honest with parents
Health Supervision
Ensures child is growing and developing appropriately;
focus = wellness; three components:
Developmental Surveillance/Screening
Injury and Disease Prevention
Health Promotion
Developmental Surveillance/Screening
Surveillance = skilled observations
Screening = assessment procedures
Pediatric nurse must understand normal growth and
development and be able to screen for problems
At any time if a child 'loses' a developmental milestone
(had it and now cannot do it) - needs immediate full
evaluation
Add'l tests performed
Screen for autism - 18-24 months
Risk assessment for tobacco, alcohol, drugs - 11-21 yrs
Depression screening - 12-21 yrs
Child Life Specialist (CLS) - provides
programs to prepare children for
hospitalization, surgery and other
procedures
Therapeutic hugging - holding position
that promotes close physical contact
btwn child and parent or caregiver
In hospital - all invasive procedures
performed in room other than child's
room (to remain safe/secure area)
Distraction methods:
Ask child to squeeze hand
Encourage counting out loud
Sing a song with child
Have child blow bubbles
Play music child likes
Visit Schedule
Health supervision visits
recommended:
Birth, 1st wk, 1 mo, 2 mo, 4
mo, 6 mo, 9 mo, 12 mo
15 mo, 18 mo, 24 mo, 30 mo
Then yearly until age 21
Visits include:
History/physical
assessments
Developmental/behavioral
assessment
Sensory screening
(vision/hearing)
At-risk screening (e.g. lead,
anemia, cholesterol)
Immunizations
Health promotion and
guidance
Foundations of Pediatric Nursing
Health Supervision, cont.
Injury and Disease Prevention
Screening tests:
Vision
Hearing
Need to ID hearing loss by 6 mo to reduce
impact on child's development
Should be done before discharge from
birthing unit; if not must be done by 1
month
Objective testing at 4, 5, 6, 8, 10 years;
with audiometry once btwn 11-14 yrs, once
btwn 15-17 yrs and once btwn 18-21 yrs
Fe-deficiency Anemia
Fe deficiency is the leading nutrient
deficiency in the U.S.
Assess at 4, 15, 18, 24, 30 months then
annually plus Hct/Hgb at 12 months
Immunizations:
Performed at every health
supervision visit
<6 months use b/w patterns, no
color
<3 yrs evaluate child's ability to
fixate on and follow objects
Hypertension
Screening begins at 3 yrs old
Measure via auscultation
Must be noted on repeat visits
before a dx of HTN given
Metabolic
→
Preventable environmental health
threat; blood level > 5ug/dL
Educate parents to avoid exposure
(esp. lead-based paint)
Screen at 6, 9, 12, 18, 24 months
then 3, 4, 5, 6 years if at risk
Hyperlipidemia
May be linked to atherosclerosis in
children
Universal screening 1x btwn 9-11 yrs
and again btwn 18-21 yrs
Newborns all screened
e.g. phenylketonuria, sickle cell
anemia, cystic fibrosis
When the immune system recognizes an antigen (foreign material) it
produces antibodies (immunoglobulins)
Immunity - ability to destroy and remove a specific antigen from the body
Passive - when immunoglobulins of 1 person transferred to another (via
injection or mother fetus); lasts weeks or months
Active - when person's own immune system generates the immune
response; lasts many years lifetime
Vaccines mimic characteristics of natural antigen
Vaccine storage and administration affect efficacy
Side effects: most common are mild - redness, tenderness, swelling at site,
low-grade fever, fussiness; usually resolve within 3 days
Must provide Vaccine Information Statement (VIS) and get parent to sign
consent form
Clinically significant adverse event that occurs after immunization must be
reported to VAERS (Vaccine Adverse Event Reporting System)
Children severely immunocompromised should not receive live vaccines
Contraindications - conditions that justify withholding an immunization
Precautions - conditions that increase the risk of an adverse reaction; the
presence of a moderate to severe acute illness with or w/o fever is a
precaution for all vaccines
→
Lead
Vaccine Administration Routes:
Intramuscular:
DTaP, DT, Tdap
Hep A and Hep B
Hib
Influenza (RIV; IIV)
Pneumococcal
conjugate vaccine
(PCV)
HPV
MCV4
IPV
Subcutaneous
IPV
MMR
Varicella
MPSV4
Intranasal
Influenza (LAIV)
Foundations of Pediatric Nursing
Health Supervision, cont
Health Promotion
Identify risk factors for a disease and facilitate lifestyle changes to eliminate or reduce risk factors
Provide anticipatory guidance
Promote:
Oral health care - poor oral health can have significant negative effect on systemic health
Healthy weight - address healthy eating patterns/physical activity; 'health centered'
Personal hygiene - *handwashing*
Safe sun exposure - avoid 10 a.m. - 4 p.m. hours
Health Assessment
Pediatric assessment involves:
Health interview and history
Observation of parent-child interaction
Assessment of the child's emotional,
physiologic, cognitive and social
development
Physical exam; will focus on chief
complaint (reason for visit)
Health history:
Demographics
Chief complaint and history of present illness
Past health history
Family health history
Review of systems
Developmental history
Functional assessment
Family composition, resources, home environment
Physical Exam
Note general appearance
Vital signs
Temperature - use least invasive method
Pulse - <10 yrs apical pulse; >10 yrs radial
Respiratory rate - 1 full minute
Oxygen saturation - via pulse oximetry
Blood pressure - cuff size important
Pain assessment - FLACC or Pain Faces scale
Body measurements
Length or height
Weight
Weight for length - up to 24 months
BMI
Skin
Inspection - color, lesions, rashes, burns
Palpation - temp, moisture, turgor, edema
Hair and nails - distribution, condition
Head
Inspection - shape/symmetry
Palpation - fontanels
Neck - symmetry, excess skin, flexibility
Eyes
External - symmetry and spacing,
PERRLA
Internal - usually done by MD or NP
Ears
External - symmetry and placement
Internal - usually done by MD or NP
Nose and sinuses - no drainage/edema,
palpate sinuses for tenderness
Mouth and throat - no inflammation or
edema; moist, pink lining
Thorax and lungs - symmetry; auscultate
(listen for stridor, grunting, wheezing)
Breasts - shape, position, palpate lymph
nodes
Heart and peripheral perfusion
Inspection - note pallor, cyanosis,
mottling, edema; apical impulse
Palpation - note any lifts, heaves,
thrills in chest; palpate apical pulse
Auscultation - upright and reclined
Abdomen
Inspect - size, shape, symmetry
Auscultate - use bell of
stethoscope; 1 full minute for
each quadrant
Percuss
Palpate - child in supine position
Genitalia and anus - ensure privacy;
usually performed by MD or NP
Musculoskeletal
Clavicles/shoulders - palpate and
test cranial nerve XI
Spine - note position and
alignment of trunk; scoliosis
check
Extremities - check mobility
Neurologic
LOC
Balance/coordination - gait
Sensory testing -cranial nerve V
Reflexes
Developmental screening
Infancy
Development
Birth - 12 months
How to Assess Milestones
Sequential process by which
infants & children gain various
skills/functions
The order in which these skills are
acquired is consistent
Ask parent/caregiver
Infant may demonstrate
Nurse elicits the skill
Physical Growth
↑
All measurements increase rapidly
during 1st 12 months
Weight - typically doubles by ~5
months and triples by 1 year
Length - increases 50% by 1 yr
Head circumference - increases 10
cm by 1 yr
Birth
→ 2-5 months
Root - infant's cheek stroked,
infant turns to that side,
searching w/mouth
Birth
→ 3 months
Palmar grasp - Infant
reflexively grasps when
palm is touched
Birth
→ 4-6 months
Step - With one foot down
on surface, the other foot is
placed down as if to step
Birth
→ 4-8 weeks
Use infant's adjusted age
Adjusted age = Subtract # of
weeks premature from the
infant's chronological age
Physiologic Changes to Note
Brain wt 2 1/2 times from birth to 12 months; fontanels
remain open to accommodate growth; posterior closes by 2
months, anterior by 18 months
1st teeth usually erupt by 6-8 mos.
Usually lower central incisors.
After birth erythrocyte production decreases low Hgb and
Hct ~2-3 mo old (known as physiologic anemia of infancy)
→
Primitive Reflexes
Suck - reflexive sucking
when finger or nipple
placed in mouth
Assessing Premature Infants
Protective Reflexes
Moro - sudden extension of
hands; arms abduct and
move upward forming a 'C"
Birth
→ 4 months
Babinski - Stroking along lateral bottom
part of foot causes fanning and
hyperextension of the toes
Birth
→ 12 months
Asymmetric tonic neck - 'Fencing position' supine, where head is turned, arms and legs
extended on that side; flexed on other side
Birth
→ 4 months
Plantar grasp - Infant reflexively grasps
with bottom of foot when pressure
applied to plantar surface
Birth
→ 9 months
Neck righting - When body
is tilted, neck keeps head
in upright position
4-6 months
→ persists
Parachute sideways Arms extend to side when
tilted to the side (sitting)
6 months persists
→
Parachute forward - Arms
reach forward when held in
air and moved forward
6-7 months
→ persists
Parachute backward - Arms
extend backward when
tilted backward
9-10 months
→ persists
Infancy
Psychosocial Development
Birth - 12 months
Cognitive Development
Erik Erikson - Trust vs Mistrust
Sense of trust crucial in first year
If infant needs met consistently
infant develops sense of trust
Feeding, changing diapers,
cleaning, touching, holding, talking
Jean Piaget - Theory of Cognitive Development
Sensorimotor stage - birth 2 years
Infants use senses & motor skills to learn about the world
Object permanence - develops 4-8 months old
Looks for objects that were hidden
Essential for self-image
→
→
Pediatric Vaccine Schedule Birth - 6 years
Birth
Hepatitis B
2 months
Hepatitis B
DTaP
Hib
Polio (IPV)
PCV13
RV
4 months
6 months
12-18 months
Hepatitis B
DTaP
Hib
Polio (IPV)
PCV13
RV
Influenza (yearly)
DTaP
Hib
Polio (IPV)
PCV13
RV
4-6 years
DTaP
DTaP
Polio
(IPV)
Hib
MMR
PCV13
Varicella
MMR
Influenza
Varicella
(yearly)
Hepatitis A In 2 doses (12 mos and 18 mos)
Influenza (yearly)
Assessing Infant Vital Signs
Sequence: Respirations, heart rate, temperature, weight, length, head circumference, chest circumference
1 Respirations
2
Normal = 30-60 breaths per
minute
Count for 1 full minute (due
to irregular breathing)
Watch rise and fall of chest
Heart Rate
3 Temperature
Normal = 36.4 - 37.4°C (97.5 - 99.3°F)
Axillary (armpit)
4 Weight
Remove clothing
Change soiled diaper
Normal:
< 1 month old = 100-190 bpm
1 month - 1 year old = 90-180 bpm
Count apical pulse (4th intercostal space)
Auscultate for 1 minute
5
Length
6 Head Circumference
Normal = 33-38 cm
Measure in cm
Measure largest diameter of
head (just above eyebrows)
7 Chest Circumference
Normal = 1-2 cm less than head
Measure in cm
Wrap tape around chest at
nipple line
Normal = 18-22 inches
Lay infant on paper
Measure from head to heel
Mark head midline and heel with extended leg
Measure marks w/measuring tape
Gross Motor Skills
Infancy Milestones
1
Month
Prone position: lifts and turns head
Head lag when pulled to sitting
Rounded back when sitting
2
Months
Raises head and chest; holds position
Improved head control
3
Months
Prone position: raises head to 45
degrees
Slight head lag in pull-to-sit
Fine Motor Skills
Fists clenched
Involuntary hand
movements
Birth - 12 months
Language Skills
1-3 months: coos,
shows differentiated
crying
Holds hands in front
of face
Hands open
Big smile/gurgle
Bats at objects
4-5 months: simple
vowel sounds, laughs
out loud; responds to
Grasps rattle
''No' and his/her
name; makes
'raspberries'
Lifts head and looks around
Rolls from prone to supine
Head leads body when pulled to sit
5
Months
Rolls from supine to prone & back
again
Sits w/back upright when supported
6
Months
Tripod sits
Releases object in
hand to grab
another
Squealing and yelling;
babbling begins
7
Months
Sits alone with some use of hands
for support
Transfers object
from one hand to
another
Distinguishes
emotions based on
tone of voice
8
Months
Sits unsupported
Gross pincer grasp
(rakes)
9
Months
Crawls with abdomen off floor
Bangs objects
together
10
Months
Pulls to stand
Cruises
Warning Signs
12
Months
Sits from standing position
Walks independently
Arms and legs are stiff or floppy
Cannot support head at 3-4 months
Reaches with one hand only
Cannot sit w/assistance by 6 months
Does not crawl by 12 months
Cannot stand supported by 12 months
Full hearing at birth
Recognize people by
sight at 1 month
Real smile
4
Months
11
Months
Social/Emotional/
Sensory
Responds to
simple commands
Attaches meaning
to 'mama,' 'dada'
Imitates sounds
Fine pincer grasp
Puts items in box &
takes out
Offers objects to
others and releases
them
Babbling progresses
to strings
Feeds self w/cup &
spoon; makes simple
mark on paper
Babbles w/inflection
Uses 2-3 words with
meaning
Mimics facial
movements
Patty-cake and
peek-a-boo
Full color vision
Stranger anxiety;
recognizes when
separate from mom
Separation anxiety
Tries to imitate
words, 'uh-oh'
No sounds by 4 mos
No laugh/squeal by 6
mos
No babble by 8 mos
No single words
w/meaning by 12
mos
Gross motor skills develop in cephalocaudal fashion (from head to tail)
Fine motor skills develop in proximodistal fashion (from center to periphery)
No smile at 3 mos
Refuses to cuddle
Does not seem to
enjoy people
No interest in peeka-boo by 8 mos
No response to loud
sounds
Does not focus on
near objects
Does not turn to
locate sounds
Nursing Interventions - Infancy
Nutrition
0 - 6 Months
Breast feeding:
Assist w/feeding problems if any
Encourage to feed on demand
Bottle feeding:
Only use iron-fortified formulas
10-12 mg Fe/liter
Always hold baby while feeding
Feed on cue
Burp 2-3 times/feeding
1/2 - 1 oz at each feeding at 1st; increasing up to 2 - 3
oz/feeding in the first few days; by 6 mos 4-5x/d 6-8 oz each
Up to 6 months: Feed ~6-10 times/day
Spitting up: may be due to overfeeding or poor burping; feed
small amounts; spitting up normal if wetting at least 6
diapers/24 hrs and gaining weight
Early signs of hunger:
Sucking motions, sucking on hands,
fist to chin
6 - 8 Months
6 months old: instruct to add solid foods
Ready when:
Tongue extrusion reflex disappears (4-6 months)
Able to swallow solid food
Able to sit upright in high chair
Good choice first solid food: iron-fortified cereal mixed w/small
amount of breast milk or formula
Introduce 1 new food every 3-5 days to ID food allergies
Peanut foods introduced ~ 6 months if negative skin prick test
6-8 months: introduce cup
No fruit juice until 6 months (and only 2-4 oz/day)
Educate!
Safety
Infant car seats:
Face rear of car through infancy
In center back seat
Crib slots: distance between slots < 6 cm
Crib sheets well fitting
Restrain on changing tables, in baby swings
Safety gates at top and bottom of stairs
Electric outlets covered
Cabinets/drawers/doors child safety latches
Choking: avoid popcorn, small hard candy, grapes, nuts, hot
dogs; toys/stuffed animals with small parts
Suffocation: no pillows, comforters, stuffed animals, etc in
crib; keep plastic bags away; keep window blinds and
drapery cords out of reach
Water: never leave unattended in bath; pools should have
surrounding locked gates
→
Sleep
Sleep time:
Newborns: ~10-19 hrs/day
3 months: 7-8 hrs/night w/3 naps
6 months: 8-10 hrs/night w/2 naps
12 months: 9-12 hrs/night w/1-2 naps
Educate on SIDS: sleep on back, firm mattress, no pillow or
comforter, away from A/C vents, open windows and open
heaters
~4 months: start evening routine:
e.g. bath, singing, reading
8 - 12 Months
8 months: Introduce soft, smashed table foods without large
chunks; finger foods like peas or Cheerios
10-12 months: strained, pureed, mashed meats
Warning!
Foods to avoid in infancy: honey, popcorn, grapes, citrus,
strawberries, wheat, cow's milk, eggs, small hard food
If infant not growing, assess caloric intake:
Limit juice intake or discontinue
Use human milk fortifier for breast
milk or higher calorie formula and
solid foods
Other
No milk/juice bottles to bed
1st dental visit at 1 yr
Teething signs: drooling, biting on hard objects, finger
sucking, irritable, refuse to eat, not sleep well; cold may
soothe gums
Colic - inconsolable crying that lasts 3 hrs + w/no physical
cause; usually resolve in 3 months
Thumb sucking/pacifier use - healthy
self-comforting activity; Ideally wean ~1 yr
No physical punishment during infancy
(cannot understand why)
↑
Toddler
Physical
Gains in ht/wt occur in spurts rather
than linear
Avg wt gain = 1.36-2.27 kg (3-5 lb)/yr
Avg ht gain = 7.62 cm (3 in)/yr
Head circ = 90% of adult size by 2 yrs
Ht at 2 yrs = ~ 1/2 adult height
HR and BP in toddler years
Stools ~1x/day
Bowel control achieved by 3 yrs
Ab muscles weak pot-bellied
appearance; appears swayback
↓
↑
→
Psychosocial Development
Erik Erikson - Time of autonomy
Struggle for self-mastery
Asserting control and autonomy
Big mood swings (happy to crying)
Negativism - always saying 'no';
normal; attempt to assert
independence
Language/Communication
Language develops rapidly
Receptive language - understands
what is being said or asked; advanced
at this age
Expressive language - communicates
one's desires and feelings; not
advanced at this age
Begins to use short sentences
Progresses to vocab of 50 words
by 2 yrs
Echolalia - repetition of
words/phrases without
understanding (until 30 mos)
Telegraphic - contains only the
essential words to get point across
Children in bilingual household - may
be hard to diagnose speech delay
1 year - 3 years
Cognitive Development
Jean Piaget - Theory of Cognitive Development
Toddlers finish Sensorimotor stage - 12-24 months old
Experiment with behavior to see what happens
Imitate behavior they see
Preoperational stage - 2-7 yrs
Symbolic thought
Objects as symbols in play (e.g. bowl on head as hat)
Maternal depression - risk factor for poor cognitive development
Emotional/Social
Separation - seeing oneself as separate from parent/primary
caregiver
Individuation - exerting control over one's environment
Egocentrism - focus on self - *Power struggles common*
May rely on security blanket to self-soothe (sign of autonomy)
Aggressive behaviors may be displayed
Separation anxiety - may re-emerge in 18-24 month period
Temperament - biologic basis for personality - 3 types
Easygoing, difficult, slow-to-warm-up
Signs of Developmental Delay
After walking independently for several months:
Persistent tiptoe walking
Does not develop mature walking pattern
by 18
Months
Not walking
Not speaking 15 words
Does not understand function of common household items
by 2
Years
Does not use 2-word sentences
Does not imitate actions
Does not follow basic instructions
Cannot push a toy with wheels
by 3
Years
Difficulty w/stairs; frequently falls
Unable to build tower of more than 4 blocks
Difficulty manipulating small objects
Extreme difficulty in separation of caregiver/parent
Cannot copy circle; does not understand simple instructions
Does not play make-believe; no interest in other children
Cannot communicate in short phrases
Unclear speech, persistent drooling
Gross Motor Skills
12
Month
Walks independently
(12-15 months)
Toddler Milestones
Fine Motor Skills
Feeds self- finger foods
Uses index finger to point
(12-15 months)
15
Month
1 year - 3 years
Receptive Language
Expressive Language
Understands common
words
Follows one-step command
w/gesture
Points w/finger
Uses gestures (e.g. waves)
Vocally imitates
First word
Looks at adults when
communicating
Follows one-step command
w/out gesture
Understands 100-150
words
Repeats words s/he hears
Babbles in sentences
18
Month
Climbs stairs with
assistance
Pulls toys while
walking
Able to reach, grasp and
release
Turns book pages
Removes shoes/socks
Stacks four cubes
Understands word 'No'
Understands 200 words
Sometimes answers the
question 'What is this?'
Uses at least 5-20 words
Uses names of familiar
object
24
Month
Runs, kicks ball
Able to stand on
tiptoe
Carries large toy
while walking
Climbs onto and down
from furniture
Stacks 6 or 7 cubes
Shows right or left handed
Imitates circular and
vertical stroked
Scribbles and paints
Tries to turn knobs
Puts round pegs into holes
Points to named body
parts
Points to pictures in books
Enjoys hearing simple
stories
Names a variety of objects
Begins to use 'my' or 'mine'
Vocab of 40-50 words
Sentences of 2-3 words
Asks questions
Uses simple phrases
Uses descriptive words
2/3 of what child says
should be understandable
36
Month
Climbs well
Pedals tricycle
Runs easily
Walks up/down stairs
alternating feet
Bends over easily
w/out falling
Undresses self
Copies circle
Stacks tower of 9 or 10
cubes
Holds pencil in writing
position
Screws/unscrews lids
Understands most
sentences and physical
relationships (e.g. on, in)
Participates in short
conversations
Might follow 3-step
command
Speech understood by
family, 1/2 by others
Asks 'why?'
3-4 word sentences
Talks about past
Vocab of 1000 words
Says name, age, gender
Nursing Interventions - Toddler
Nutrition
Time to set healthy eating habits
Able to consume 3 meals/day and 2 snacks
Encourage water intake
Limit juice intake (4-6 oz/day)
Fats should not be restricted
Needs ~700 mg Ca/Day
Overweight risk:
BMI near 85th percentile for age (2+ years)
Wt for length near 95th percentile for age (12 years)
Goal both <85th percentile
Avoid high-sugar foods (even if toddler won't eat)
Wean from bottle & discourage no-spill sippy cups
by 15 months
Safety
Use car seat at all times
No tobacco smoke
Toddler-proof home
If guns in home make sure
unloaded & locked up
Gates top/bottom of stairs
Helmet when riding bike
Potential poisons out of reach:
(medicines, cleaning products,
antifreeze, alcohol, pesticides,
gasoline, wild mushrooms)
Poison control # nearby
Teach water safety
Educate!
Other
Never spank - Use time-outs instead
By 30 months - full set of teeth
Encourage physical activity
Thrive on routines, love, setting
limits
Parallel play at this age (plays
alongside other children)
Read to toddler every day
Sleep:
18 mos = 13.5 hrs total/d
24 mos = 13 hrs total/d
3 years = 12 hrs total/d
Preschooler
Physical
Avg wt gain = 2.3 kg (4-5 lb)/yr
Avg ht gain = 6.5 - 7.8 cm (2.5 - 3 in)/yr
HR and BP slightly
Stools 1-2x/day
20 teeth present
More slender, erect
More voluntary control over
movements, less clumsy
Musculoskeletal system still not fully
mature, leading to possible injuries
↓
↑
Psychosocial Development
Erik Erikson - Initiative vs Guilt
Feels accomplishment when
succeeding at task but guilt when
fails
Developing a conscience - right vs
wrong; may start lying
Inquisitive, enthusiastic, pride in
accomplishments
Language/Communication
Refinement of language skills
2 yrs = 50-100 words
5 yrs = 2000 words
Uses telegraphic speech (3 yrs old)
Sentences adult-like in structure (by
6 years old)
Stuttering may occur but usually
resolves by 8 yrs; encourage parents
to slow down and give child time
Easily picks up on negative emotions
in conversations
3 years - 6 years
Cognitive Development
Jean Piaget - Theory of Cognitive Development
Preoperational stage - 2-7 yrs
Egocentric; single point of view
Fantasy play
Magical thinking - believes that his/her thoughts are all-powerful
Has imaginary friends
Animism - gives life-like qualities to inanimate objects
Emotional/Social
Active imagination leads to many fears
Experiences many strong emotions; develop a sense of identity
Rituals important for structure; encourage to dress on own
Sense of guilt low self-esteem
Reward for initiative
self confidence
Risk factors for lack of social/emotional readiness for school:
Insecure attachment in early yrs
Maternal depression
Parental substance abuse
Low socioeconomic status
→
→↑
Signs of Developmental Delay
by 4
Years
by 5
Years
Cannot:
Jump in place; ride a tricycle; throw ball overhand
Stack four blocks; copy a circle
Use the words 'me' and 'you' appropriately
Does not:
Grasp crayon with thumb and fingers
Use sentences with 3 or more words
Engage in fantasy play
Ignores other children
Will not respond to people outside the family
Resists using the toilet, dressing, sleeping
Is unhappy or sad often
Little interest in other kids
Unable to separate from parent
Is extremely aggressive
Is extremely fearful or timid
Is unusually passive
Is easily distracted
Cannot build tower of 6-8 blocks
Cannot use plurals or
past tense
Has trouble eating,
sleeping or using toilet
Cannot brush teeth,
wash hands or undress
easily
Preschooler Milestones
Gross Motor Skills
Fine Motor Skills
3 years - 6 years
Communication Skills
3
years
Climbs well
Pedals tricycle
Runs easily
Walks up/down stairs
alternating feet
Bends over easily w/out
falling
Undresses self
Copies circle
Builds tower of 9-10 blocks
Holds a pencil in writing position
Screws/unscrews lids, nuts, bolts
Turns book pages one at a time
4
years
Throws ball overhand
Kicks ball forward
Catches bounced ball
Hops on one foot
Stands on one foot up to 5
seconds
Alternates feet going up
and down stairs
Uses scissors successfully
Copies capital letters
Draws circles and squares
Traces a cross or diamond
Draws a person with two to
four body parts
Laces shoes
Speaks in complete sentences
Tells a story that is easy to follow
75% of speech understood by others
Asks questions using 'who,' 'how many'
Asks many questions
Names many animals, objects
Knows at least one color, few numbers
Vocab of 1500 words
5
years
Stands on one foot 10
seconds or longer
Swings and climbs well
May skip
Somersaults
May learn to skate and
swim
Prints some letters
Draws person with body and at
least six parts
Dresses/undresses on own
Can learn to tie laces
Uses fork, spoon and knife well
Most of speech understood by others
Explains how items are used
Participates in long conversations
Talks about past, future events
Can count to ten
Vocab of 2100 words
Says name and address
Nursing Interventions - Preschooler
Nutrition
Limit sweets and fast foods
Preschoolers are erratic eaters; may eat well one
day and very little the next
Diet should include:
700-1000 mg Ca/day
7-10 mg iron/day
Minimum 19 mg fiber/day
~85 kcal/kg/day
Saturated fats <10%
Offer healthy foods over the course of the day
Offer foods and allow child to decide what to eat;
do not force child to eat
Poor nutrition choices should not be offered just
to get the child to eat
Mealtimes should be structured
Fruit juice limited to 4-6 oz/day
Safety
Continue to use car seat; move
to booster seat only when child
outgrows car seat
No tobacco smoke
If guns in home make sure
unloaded & locked up
Helmet when riding bike
Potential poisons out of reach:
(medicines, cleaning products,
antifreeze, alcohol, pesticides,
gasoline, wild mushrooms)
Poison control # nearby
Teach water safety; never
leave child unattended;
encourage swim lessons
Educate!
Other
Spanking discouraged by AACAP
Reward positive behavior
Time-outs effective
Brush and floss teeth 2x/day
Encourage physical activity
Still thrive on routines, love, setting
limits
Begin to play with other children at
this age; 'make believe,' dress-up
Read to preschooler every day
Sleep: 10-13 hrs/day total
Continue bedtime ritual
School-Age Child
Physical
Prepubescence
6-10 yrs growth slow and progressive
Preadolescence = 10-12 yrs = period of
rapid growth especially for girls
Avg wt gain = 3 - 3.5 kg (7 lb)/yr
Avg ht gain = 6 - 7 cm (2.5 in)/yr
By 12 yrs most girls surpass boys in ht
and wt
10-12 yrs: Boys see slowed growth in ht
& increase in wt may lead to obesity
Brain growth completed by 10 yrs
RR and pulse rate decrease
BP increases
All 20 teeth will be lost and replaced by
28-32 permanent teeth
Caloric needs decrease
Greater coordination and strength
Bones continue to ossify throughout
childhood
Immune system strengthened may
see fewer infections overall
→
→
The 2 years leading up to puberty
Development of secondary sexual characteristics
Rapid growth for girls; continued growth for boys
Girls onset typically 2 years before boys
Early development in girls may cause embarrassment over
physical appearance and self-esteem
Delayed development in boys may cause negative self-concept,
substance abuse
Early development in both may lead to risk-taking behaviors
↓
Psychosocial Development
Social and developmental growth accelerates and increases
in complexity
Become increasingly more independent
Seek approval of peers, teachers, parents
Erik Erikson - Industry vs Inferiority
Develops sense of self-worth via multiple activities
(especially outside of home)
Achieving success increases self-worth and confidence
→
Cognitive Development
Language/Communication
Jean Piaget - Theory of Cognitive Development
Concrete operational thoughts- 7-11 years
Sees things from another's point of view
Thinks through actions and consequences
Uses past to evaluate present
Collects objects
Principle of conservation - matter does not change when
its form changes
Gross Motor Skills
Ride 2-wheeled bike;
jump rope
6-8 yrs: always in motion
8-10 yrs: less active but
energy
10-12 yrs: energy but
more controlled
↑
↑
6 years - 12 years
Sensory
Vision screening at school:
Amblyopia (lazy eye)
Strabismus (eye
malalignment)
Hearing screening done to
diagnose less severe defects
Sense of smell tested
Culturally specific words are used
Enjoys jokes and riddles; words w/double
meanings; metalinguistic awareness
Imitates parents, family role modeling
important
→
Morality
Wants to be a good person
Adult viewed as being right
10-12 years: 'Law and order'
Inserts reason into action, not
just potential consequences
'I'm going to do it b/c it's right,
not just b/c mom would want
me to do it'
School-Age Child
6 years - 12 years
Emotional/Social
Temperament will determine ease of transition
to school atmosphere
Self-evaluation will be filled with either selfconfidence or self-doubt
Children who have mastered autonomy and
initiative face world w/pride vs shame
Fears - shift from pretend to real-world fears
Body image - concerned with peers' views and
acceptance
Peers' opinions will influence perception of self
Peer groups will influence actions and test
parental/family values
Physical maturity does not always correlate with
emotional and social maturity
Nursing Interventions - School-Age Child
Nutrition
*Visits more infrequent during school-age years*
6-8 yrs: 1400-1600 kcal/d; 1000 mg Ca/d
Boys 9-13 yrs: 1800-2200 kcal/d; 1300 mg Ca/d
Girls 9-13 yrs: 1600-2000 kcal/d; 1300 mg Ca/d
MyPlate.gov: Encourage F/V/whole grains
Risk factors for obesity:
Family role modeling
Lack of exercise
Unstructured meals
Sugar-sweetened drinks
Large portion sizes
TV viewing/video games
Encourage exercise; structured sports
Important for parents/nurses to educate about
body changes and promote comfort
Sleep
6-8 yrs: 12 hrs/d
8-10 yrs: 10-12 hrs/d
10-12 yrs: 9-10 hrs/d
Continue rituals with a set
sleep time; maintain sleep
schedule on
weekends/vacations
Educate!
Safety
Continue to use booster seat; most children under 13 years still in back seat
No tobacco smoke
If guns in home make sure unloaded & locked up
Helmet when riding bike
Potential poisons out of reach: (medicines, cleaning products, antifreeze,
alcohol, pesticides, gasoline, wild mushrooms)
Poison control # nearby
Teach water safety; encourage swim lessons
Under 10 yrs do not walk on streets alone
Fire - watch for burns if helping cook/iron; have fire safety plan
Abuse - teach children concept of 'good touch' vs 'bad touch'
Discipline
Encourage good role modeling
Discipline with consequences
Do not belittle
Give praise; identify areas of
competence and focus on them;
don't set expectations too high
Teeth
Brush 2-3x/day for 2-3 minutes each (help until 7-10 yrs)
Replace toothbrush every 3-4 months
Floss at least 1x/day
Dentist every 6 months
Encourage sealants/fluoride
Brush more often if have braces
Developmental Concerns
Technology:
Set time limits
Be aware of what child is watching/doing online
No technology during meals
No technology in bedroom
Teach internet safety
At risk for bullying:
Children who appear/act 'different'
Low self-esteem
Lying/cheating/stealing:
6-8 yrs old don't understand ownership
Stealing/lying common in boys 5-8 yrs
8-12 yrs may lie if unable to meet expectations
Need to discuss alcohol/drugs at this age
Monitor behavior changes may indicate school/social
problems
→
Adolescence
11 years - 20 years
Physical
Some overlap w/late school age
Time of rapid growth
Dramatic changes in body size and
proportions
Sexual characteristics develop
Reproductive maturity achieved
Growth in height:
Girls: starts before menarche and
ends 2 - 2 1/2 yrs later; fat deposits
increase
Boys: growth spurt anywhere
between 11 - 17 yrs; muscle mass
Avg gain for boys: 10-30 cm (4-12 in); 730 kg (15-65 lb)
Avg gain for girls: 5-20 cm (2-8 in); 7-25
kg (15-55 lb)
Metabolism slows, BMR reaches adult
level
RR and HR
All teeth in but wisdom (erupt 17-20 yrs)
Increased levels of testosterone acne
and oily hair
↑
↓
→
Moral/Spiritual
Begins to question the status quo
Choices based on emotions
Develops his/her own morals
Increased spiritual/religious
activities associated with healthy
behaviors and risky behaviors
↓
Emotional/Social
Attempts to establish independence
More time with peers
Peer groups play essential role in identity;
can have positive or negative effect
May lead to stress for teenager and family
Puberty
Puberty - biologic changes that occur during adolescence;
physical development, hormonal changes, sexual maturation
Girls enter puberty 9-10 yrs; boys 10-11 yrs
Girls estrogen development of breast tissue/pubic hair
Boys testosterone changes in male genitalia/pubic hair
Menarche - 1st menstrual period; avg 12.8 yrs old; African
American girls earlier than caucasian girls
Thelarche - breast budding (9-11 yrs)
Boys - first sign - testicular enlargement; during late puberty first ejaculation often while sleeping (nocturnal emissions; wet
dreams)
↑
↑
→
→
Psychosocial Development
Erik Erikson - Achieve a sense of identity
If unable to achieve a sense of identity may end in role
confusion
Teenager groups help form identity
10-13 yrs: focus on bodily changes; mood changes; conforming
to peers; start emancipation from parents
14-16 yrs: need for acceptance; interest in attracting
opposite gender; greatest time of parental conflict
17-20 yrs: understands implications of behavior; secure
w/body image; matured sexual identity; emancipation from
parents almost complete
↑
Cognitive Development
Jean Piaget - Theory of Cognitive Development
Formal operational period
Moves to abstract thinking
10-13 yrs: egocentric
14-17 yrs: thinks invincible risky behavior; makes
independent decisions
17-20 yrs: abstract and critical thinking; less risky
behavior; goals and career plans
→
Physiologic Changes of Adolescence
10-13
years
14-16
years
17-20
years
11 years - 20 years
Female Changes
Male Changes
-Early Adolescence-
-Early Adolescence-
Pubic hair begins to curl and spread
Genitalia pigmentation increases
Breast bud and areola enlarge; no separation of
breasts
First menstrual period (avg 12 years)
-Middle Adolescence-
Pubic hair coarse in texture; amount increases
Areola and papilla separate and form secondary
mound
-Late AdolescenceMature pubic hair distribution and coarseness
Pubic hair begins to curl and spread
Genitalia pigmentation increases
Growth and enlargement of testes in scrotum
Continued lengthening of penis
Extremities growing faster than trunk leggy look
→
-Middle Adolescence-
Pubic hair coarse in texture; adult distribution
Testes and scrotum continue to grow; scrotal skin
darkens; penis grows in width; glans penis develops
May experience breast enlargement
Voice becomes more masculine
-Late Adolescence-
Mature pubic hair distribution and coarseness
Breast enlargement disappears
Testes, scrotum and penis adult size; scrotal skin
darkens
Nursing Interventions - Adolescent
Educate!
Nutrition
Boys:
Girls:
~2200-2800 kcal/d
~2000 kcal/d
~1300 mg Ca/d
~1300 mg Ca/d
11 mg Fe/d
15 mg Fe/d
52 g pro/d (14-18 yrs)
46 g pro/d (14-18 yrs)
Recommend:
Myplate.gov as guidance
Eating breakfast daily
fast food/junk food intake
Exercise more at home
Physical activity 60 min daily
Parents role model a healthy lifestyle
nonactive computer and smartphone use
and video/TV viewing
↓
↓
Safety
Vehicles:
Encourage driver education; seatbelt use
Discuss danger of cell phone use while driving
If guns in household, unloaded and locked away; firearm
safety class
Sports: watch for early signs of fatigue, dehydration,
injury
Educate about protection from the sun
Developmental Concerns
School:
Transition hardest from elementary to middle school and then
middle to high school
Important to observe for problems during these periods;
failing grades or behavior problems
Technology guidelines for parents:
Set time limits
Evaluate websites children visit
Discuss online activity/what dangers to watch for
Piercings/tattoos can lead to health risks
Make sure sterile conditions
Watch for complications (infection, etc)
Encourage parents/teens to have discussions about sexuality:
saying 'no,' STDs, pregnancy, contraceptive use
Children at risk for violence:
Crowded housing; low socioeconomic status; limited parental
supervision; poor family functioning; low self-esteem; racism;
aggression
Children at risk for suicide:
Depression, family history of suicide, poor school
performance, family disorganization, LGBTQ, substance abuse,
having no close friends
Key Pediatric Nursing Interventions
Rights of Pediatric Medication Administration
Right med - check order and expiration date;
ensure med that is provided is what is ordered
Right route - use most effective and safest route; if
need to change route, check with prescriber
Right patient - confirm identity 2 ways: child may
switch beds or remove ID bracelet
Right dose - calculate recommended dose and
double-check calculations; verify large or tiny doses
Right time - give within 20-30 minutes of ordered
time
Right approach - consider child's developmental
level; provide age-appropriate explanations
Pediatric Pharmacokinetics
A drug's absorption, distribution, metabolism may
be affected in infants and young children
Oral, IM and SQ administration may lead to erratic
and decreased absorption
Topical absorption may be increased due to greater
BSA and greater permeability of skin
Distribution affected by body water, body fat,
liver immaturity, immature blood-brain barrier
Metabolism affected by hepatic enzyme
production, metabolic rate, immaturity of
kidneys
↑
↓
↑
Determining Correct Dose
Make sure you know if safe dose range is 24 hrs
(mg/day) or single dose period (mg/dose)
Dose based on body weight (kg) or BSA
Body weight:
Weigh child; convert to kg (divide lb by 2.2)
Check drug reference for safe dose range
Calculate low safe dose then high safe dose
Determine if dose ordered is in range
BSA (body surface area):
Commonly used for chemo agents
Verify height and weight
Place on nomogram
Draw line connecting ht and wt
Find pt where line intersects middle line. This is
the BSA
Routes of Administration
Oral
Rectal
Opthalmic
Otic
Nasal
Intramuscular (IM)
Subcutaneous (SQ)
Intradermal (ID)
Intravenous (IV)
When administering medication, always
explain:
Why drug is needed
What child will experience
What is expected of child
How parents can assist
Administer promptly and reward child
after
Key Pediatric Nursing Interventions
Routes of Administration
Oral
< 5 or 6 yrs: crush/open tablet or
capsule & mix w/ liquid or applesauce
Do not crush or open enteric-coated
or time-release tablets or capsules!
Shake liquid bottles
Dropper or oral syringe - place in
posterior of mouth
Do not force to take
and do not hold nose
Otic
Usually ear drops
Keep room temperature
Supine or side-lying position
<3 yrs - pull pinna downward and back
>3 yrs - pull pinna upward and back
Stay in same position for several min.
Rectal
Usually suppository
Not preferred method, erratic
absorption and invasive
Used when child vomiting or NPO
Intradermal (ID)
Just under epidermis
Preferred site: forearm
Used for TB screening and allergy
testing
Intravenous (IV)
Less traumatic for child compared
to multiple injections
Must pay attention to amount
given to avoid overdose or toxicity
Syringe pump primary method
Nasal
Usually drops and sprays
Keep room temperature
Blow nose or use bulb syringe to clean nasal passage
Drop:
Supine; head hyperextended
Do not touch nares w/dropper
Leave head there for 1 min.
Spray:
Upright, head back slightly
Hold one nostril closed,
breathe in while spraying
Opthalmic
Drops or ointment
Keep room temperature
Supine position
Retract lower lid
Place drop in lower conjunctival sac
Place ointment in thin ribbon from inner canthus
outward
Subcutaneous (SQ)
Into fatty layers
Usually used for insulin, heparin,
some immunizations
Preferred site: anterior thigh, lateral upper arms,
abdomen
Intramuscular (IM)
Used infrequently in children (painful and lack
muscle mass)
<12 months - vastus lateralis preferred site
>12 mo - 3 yrs - vastus lateralis preferred or deltoid
>3 yrs - deltoid if enough muscle mass
Make sure parents know exactly what meds
and how much to give at home!
Key Pediatric Nursing Interventions
IV Therapy
Sites:
Peripheral - hands, feet, forearms; scalp veins in neonates and young
infants
Central - subclavian, femoral, jugular or vena cava
Atraumatic:
Ensure adequate pain relief (pharmacologic and nonpharmacologic
methods)
Only 2 attempts to gain access; then find another individual to attempt
Use device to transilluminate the vein
Gauze under tourniquet to avoid pinching skin
Encourage parent participation
Monitor fluid infusion often (may be every hr)
Monitor output (1-2 mL/kg/hr)
Monitor for inflammation/infiltration
Change IV site/flush per agency protocols
Management
IV Fluid Administration
Amount of fluid administered in a day (24 hrs)
Determined by wt (kg)
100 mL/kg for 1st 10 kg
50 mL/kg for next 10 kg
20 mL/kg for remainder of kg
Example: 25 kg
100 mL X 10 = 1000
50 mL X 10 = 500
20 mL X 5 = 100
Total 1600 mL over 24 hrs
1600/24 = 66.7 or 67 mL/hr
Enteral Nutrition
Tube into GI tract via nose, mouth or opening into abdominal area; tube
ends in stomach or SI
Nasogastric - nose to stomach; 'gavage feeding'
Orogastric - mouth to stomach; for infants; 'gavage feeding'
Nasoduodenal - nose to duodenum
Nasojejunal - nose to jejunum
Gastrostomy - opening in ab wall to stomach
Jejunostomy - opening in ab wall to jejunum
Used for: unable to eat enough orally, unconscious, FTT, unable to suck,
difficulties swallowing, surgery, severe GERD or trauma
Tube length - must know your facility's policy
Intermittent (bolus) feeding - feeding solution given over short period
Continuous feeding - slower rate over long period of time
Feeding:
Management
Check tube placement
Measure length of tube
Assess ab for distention/bowel sounds
Measure gastric residual (amount remaining in stomach) by
aspirating the gastric contents with syringe
Flush tube
Keep child supine with head and shoulders elevated 30 degrees
Administer feeding; flush with water when finished
Stay there for 1 hr post feeding
Burp infant during/after feeding
Monitor skin around insertion site for infection
Gastrostomy and jejunostomy - clean site at least 1x/day
Infants on tube feedings - provide pacifier during feeding to
increase saliva, promote normal feeding time
Parenteral Nutrition
Peripheral or central venous catheter
Peripheral - fluid, electrolytes, carbohydrate
(dextrose); no protein or fats
Central - TPN (total parenteral nutrition);
carbohydrate, electrolytes, vitamins, minerals,
lipid, protein (amino acids)
Management
TPN:
Hangs for no longer than 24 hrs
Use an infusion pump to control rate of
infusion
Fat emulsions administered periodically
Monitor infusion rate
Cyclic basic or continuous
Check glucose levels every 4-6 hrs at first,
then 8-12 hrs according to policy
Monitor vitals, daily weights, I/O closely
No meds, blood or other solutions through
TPN lumen
If stops unexpectedly, infuse with 5-10%
dextrose at same rate to prevent rebound
hypoglycemia
Pediatric Health Disorders
Common Laboratory and Diagnostic Tests
Indications
Test
Nursing Implications
Complete Blood Count (CBC)
Detect the presence of
inflammation, infection
Erythrocyte Sedimentation
Rate (ESR)
Detect the presence of
inflammation, infection
Standard C-reactive Protein
(CRP)
Detect the presence of infection,
quicker and more sensitive than ESR
Blood culture
Detect the presence of bacteria and
yeast; determine abx to use
Stool culture
Detect pathogens
Urine culture
Detect the presence of bacteria in
urinary tract
Wound culture
Identification of specific organism
Fever
Fever is a protective mechanism the body uses to fight infection
Instructions for parents when child has fever:
Initially fever should be managed by increasing fluid intake and
decreasing activity
Never give aspirin to child (<19 yrs) to reduce fever due to risk of
Reye syndrome
Do not alternate ibuprofen and acetaminophen
Antipyretics are used if the child demonstrates discomfort
Call provider if:
Rectal temp in infant (<3 mos) above 38°C (100.4°F)
Child has fever and is lethargic, listless, no facial expressions
Fever lasts > 3-5 days or fever > 40.6°C (105°F)
Sepsis
Common Causes
E Coli, Group B Streptococcus,
Staphylococcus aureus, Neisseria
meningitidis
High Risk
< 1 month old
Immunocompromised
Debilitating chronic condition
Serious injury
Large incision site
Urinary tract abnormalities or
frequent infections
Indwelling vascular catheter
Normal values will vary
according to age and gender
Send to lab immediately; specimens allowed to
stand for > 3 hrs may affect result
Do not confuse with hs-CRP (evaluates CV risk)
Aseptic technique; 2 cultures from 2
sites; obtain before admin abx
Stool free of urine, water, toilet paper;
deliver to lab immediately
Obtained midstream clean-catch,
catheterization or suprapubic aspiration
Do not take from exudate or eschar; irrigate
with saline if heavy drainage present
Fever Definition per Route
Oral: >37.8°C (100°F)
Rectal: >38°C (100.4°F)
Axillary: >37.2°C (99°F)
Tympanic: >38°C (100.4°F)
Temporal: >38°C (100.4°F)
Dose Recommendations
Acetaminophen: 10-15 mg/kg/dose
No more than every 4 hrs & 5 doses in a 24-hr pd
Ibuprofen: 4-10 mg/kg/dose
Only children >6 months
No more than 4 doses in a 24-hr pd
Systemic response to infection usually from bacteria or viruses
May lead to septic shock
S/S
Fever
Visibly not well
Crying, inconsolable
Hypothermia (neonates)
Lethargic
irritability
Racing heart (older kids)
Poor feeding
Difficulty breathing
Nasal congestion
D/V
urine output
Seizures
↑
↓
Labs
↑
C-reactive protein
WBC ( in severe cases - dangerous sign)
Blood culture - positive for bacteria
Stool/urine culture - positive for bacteria
Cerebrospinal fluid - WBC, pro, glucose
↑↓
↑
↑ ↓
Management
Neonates/infants - to hospital for Abx tx
Monitor for changes, especially shock
Administer abx as ordered
Maintain fluid status; IV fluids if ordered
Monitor I/Os, vitals
Educate parents on fever meds, hygiene
Pediatric Health Disorders
Infectious and Communicable Diseases
Include:
Bacterial infections
Viral infections
Bacterial Infections
Frequent handwashing
most important way to
prevent spread of
infections. Use soap or
alcohol-based products
(gels, rinses, foams).
Zoonotic and vector-borne infections
Parasitic and helminthic infections
Bacteria - one-celled organisms that live, grow, reproduce
Some are harmless; some are harmful
CAMRSA
Scarlet Fever
Definition
Community-acquired methicillinresistant S. aureus
Staphylococcal infection that is
resistant to certain abx
Ranges from minor rash to lifethreatening infections
Transmission
Person-to-person, respiratory
droplets, blood, sharing personal
items, touching contaminated
surfaces
Resistant to heat and drying
S/S
Bump/lesion on skin that is red,
swollen, painful and warm to
touch
Fever
Purulent drainage
May see necrotic areas, pimples,
abscesses
Dx and Tx
Dx determined via culture
Tx - Abx and wound care (may
need I&D)
Management
*Follow-up key
Educate
Importance of taking abx as
directed and finishing it
Hand hygiene and
handwashing
Do not share personal items
Cuts/scrapes clean and
covered
Definition
Infection from group A streptococci
Usually occurs with strep throat
Bacteria produce a toxin that causes
a rash
Usually 5-15 yrs (rarely <3 yrs)
Transmission
Via droplets (respiratory tract)
No longer contagious after 24 hrs on
abx
Communicability high during acute
infection
S/S
Abrupt fever >101°F
Chills, body aches
No appetite, N/V
Pharynx red and swollen
Tonsils yellow w/white specks of pus
Lymph nodes swollen
Rash - face, trunk, extremities (not
on palms and soles of feet); lasts 5
days
Tongue - thick coat w/a strawberry
appearance; later bright red
Dx and Tx
Dx determined via throat culture pharyngeal or tonsillar
Tx - Abx (amoxicillin or penicillin)
Management
Educate
Importance of taking abx as
directed and finishing it
Suggest cool mist humidifier
Soft foods, warm liquids,
popsicles; fluid intake
↑
Vaccine
Diphtheria
Definition
Affects tonsils and pharynx;
sometimes nose and larynx
Pseudomembrane forms over
pharynx, uvula, tonsils, soft palate
Neck edematous; lymphadenopathy
develops
Airway obstruction and suffocation
Transmission
Via droplets (respiratory tract)
Touching open sores or ulcers of
someone infected
At Risk
Under or unimmunized; living in
crowded or unsanitary living
conditions, compromised immune
system
S/S
Check immunization status
Sore throat
Fever, usually less than 38.9°C
Pseudomembrane
Swallowing difficult
Dx and Tx
Dx by culture of membrane
Tx - abx and antitoxin, airway
management
Management
Administer abx and antitoxin
Monitor respiratory status
Strict droplet precautions
Bed rest
Pediatric Health Disorders
Infectious and Communicable Diseases, cont.
Bacterial Infections, cont.
Vaccine
Pertussis
Definition
Acute respiratory disorder
characterized by paroxysmal cough
(whooping cough) and large
secretions
Risk <1 yr or no immunization
Usually starts with 7-10 days of
cold symptoms then coughing spells
start that last 1-4 weeks
Recovery may take several weeks
to months
Transmission
Via droplets (respiratory tract)
S/S
Check immunization status
Cold/cough hx that progressed to
paroxysmal coughing spells
Coughs about 10-30 times followed
by whooping sound
Red face, cyanosis, protrusion of
tongue
Saliva, mucus, tears flow from
mouth, nose, eyes
Dx and Tx
Dx determined via culture
Tx - Antimicrobial tx; macrolide
abx suggested for all close
contacts regardless of age or
immunication status
Management
High humidity environment
Frequent suctioning
Monitor for airway obstruction
Encourage fluids
Droplet precautions
Vaccine
Tetatus
Botulism
Definition
Acute, often fatal, neurologic disease
caused by toxins from C. tetani
Presents with trismus (masseter
muscles spasm or lockjaw) which
progresses to tonic ctx of skeletal
muscles and intense, painful
muscular spasms in neck and back
Recovery long in hospital
Transmission
C. tetani spores found in soil, dust,
feces enter body through wound, a
burn or by injecting street drugs
S/S
Check immunization status
Headache, stiff neck
Spasms
Crankiness
Difficulty swallowing, lockjaw
Seizures may result
May have fever, BP, HR
Opisthotonos may appear hyperextension of head and neck
↑ ↑
Dx and Tx
Dx no lab test, based on history and
physical exam
Tx Stop toxin production
Control muscle spasms
Tetanus immunoglobulin
IV abx
Support resp & CV function
Management
Monitor s/s of respiratory distress
Manage pain
Administer sedatives/muscle
relaxants/abx per order
Reduce child's and parent's anxiety
Educate: Vaccine and wound care;
not contagious
Definition
Disease caused by toxin produced in
intestines when infected with
Clostridium botulinum
Transmission
3 Types:
Food-borne
Wound
Infant - most common; ingests
spores (ex. honey in <1yr old)
S/S
Diminished gag reflex
Infants:
Constipation, poor feeding,
listlessness, weakness, weak
cry
Older children:
Double vision, blurred vision,
droopy eyelids, difficulty
swallowing, slurred speech,
muscle weakness
Dx and Tx
Dx - possible culture of stool and
serum; noted diminished gag reflex;
hard to diagnose
Tx - supportive, immunoglobulin,
antitoxins
Management
Administer immunoglobulin and
antitoxin as ordered
Monitor respiratory status
Maintain nutrition status
Pediatric Health Disorders
Infectious and Communicable Diseases, cont.
Bacterial Infections, cont.
Septic Arthritis
Definition
Osteomyelitis
Definition
Bacterial infection of the bone
and soft tissue surrounding the
bone
Cause: S. aureus, group A and B
streptococcus, E. Coli bacteria
Transmission
Bacteria enters blood through
wound or lesion and spreads
S/S
Assess risk: impetigo, infected
varicella lesions, recent trauma,
infected burns, prolonged IV line use
Irritability; refuses to walk
Lethargy; change in activity level
Fever
Onset of pain
ROM in affected extremity
Swelling, local warmth and
tenderness
↓
Dx and Tx
Dx - aspiration to confirm and
identify microorganisms
Labs: WBC, ESR & CRP
+ blood cultures
Changes on US, CT scan, MRI
Tx - 4-6 wk abx course;
occasionally IV abx followed by
oral abx
↑
Management
Pain management
IV access for abx
Bed rest initially
Antipyretics if febrile (if ordered)
Instruct on maintenance of
catheter line at home if needed
Instruct on crutches/walker
Bacteria (usually S. aureus) invade
joint space (usually hip or knee)
Typically <3 yrs old
Considered medical emergency b/c
it can destroy cartilage in a few days
Transmission
Bacteria in bloodstream via direct
puncture injections, venipuncture,
wound infection, surgery, injury
S/S
May have hx of respiratory
infection, otitis media, skin or soft
tissue infections or traumatic
puncture wounds in neonate
Sudden onset of fever
Moderate to severe pain
May refuse to bear weight or
straighten joint
Limited ROM, warmth, swelling at
joint
Dx and Tx
Dx - Joint aspiration to determine
organism responsible
Labs: WBC, neutrophil, ESR and
CRP all
Tx Goal = prevent destruction of
joint cartilage
Joint aspiration or arthrotomy
IV abx in hospital, oral abx at
home
↑
Management
Monitor aspiration wound for s/s of
infection
Manage pain w/analgesics
Monitor joint: pain level, swelling, ROM
Child discharged after 72 hrs IV abx
and can tolerate oral abx
Instruct on crutches/walker
Pediatric Health Disorders
Infectious and Communicable Diseases, cont.
Viral Infections
General Mngt for Viral Infections
Viruses - small particles that infect cells; cannot multiply
on own; need host; young children highly sensitive to
viruses; drugs NOT used to control
Viral exanthems - viral infections of the skin; often
present with distinct rash pattern; include rubella,
rubeola, varicella zoster and hand, foot and mouth disease
Rubella
Vaccine
Definition
Vaccine
Fever reduction measures
Relief of discomfort
Protect skin integrity
Encourage hydration
Administer antipyretics and antipruritics
Rubeola
Definition
AKA measles
Caused by measles virus
AKA German measles
Caused by rubella virus
Transmission
Transmission
Droplets (direct/indirect contact)
nasopharyngeal, blood, urine, stool
Mother fetus
Incubation pd: 14 days
Communicable: 7 days before rash
until 7 days after
Droplets (direct/indirect contact)
Highly contagious
Incubation pd: 10-12 days
Communicable: 1-2 days before
symptoms until 4-6 days after rash
appears
→
S/S
Rash first sign
Maculopapular rash starts on face
and spreads to head to foot
Disappears in same order by day 3
Older kids: lymphadenopathy,
grade fever
Mild pruritus
↓
Tx
Supportive
During pregnancy - may result in
miscarriage, fetal death,
congenital malformations
Management
General management plus:
Droplet precautions until 7 days
post rash onset
S/S
For 2-4 days: fever, cough, coryza,
conjunctivitis
Followed by Koplik spots (bright red
with blue/white centers on mucous
membranes)
Then rash appears head downward
Tx
Supportive
Vaccination in unvaccinated within
72 hrs onset of symptoms may
symptoms
IG given within 6 days of exposure
may symptoms
↓
↓
Management
General management plus:
Clean eyes - warm, moist cloth
Cool mist humidifier
Airborne precautions until 4 days
post rash onset
Vaccine
Varicella Zoster
Definition
AKA chickenpox
Caused by varicella zoster virus
(human herpes virus 3)
Transmission
Direct contact with infected
person's nasopharyngeal secretions
or via air-borne spray
Highly contagious
Mother fetus
Incubation pd: 14-16 days
Communicable: 1-2 days before rash
3-7 days after onset of rash
→
→
S/S
Fever, malaise, anorexia, headache,
mild ab pain
Rash - first on scalp, face, trunk then
extremities; prurutic erythematous
macules papules clear, fluid-filled
vesicles which eventually erupt, form
lesions then scab and crust over
More severe in adolescents and
adults than young children
→
→
Tx
Supportive
Skin care to prevent infection
Immunocompromised or pregnant:
antiviral therapy, IG
Management
General management plus:
Air-borne & contact precautions until
8-21 days after exposure
Return to school once lesions crusted
Pediatric Health Disorders
Viral Infections, cont.
Infectious and Communicable Diseases, cont.
Hand, Foot, Mouth Disease
Definition
Caused by coxsackie A virus usually
Normally seen in children 1-4 yr olds
Transmission
Direct contact with infected
fecal or oral (most common)
secretions
Incubation: 3-6 days
Communicable: from time of
infection fever resolves
↑ fever
Vesicles on tongue erode to shallow
ulcers
May lead to anorexia,
dehydration, drooling
Vesicles on hands and feet football shaped with erythematous
rims
→
Vaccine
Tx
S/S
Tx - Supportive
Resolves within 1 week
Management
General management plus:
oral fluids
Numb mouth - sprays, mouthwash
Standard precautions
↑
Mumps
Definition
Caused by Paramyxovirus
Vaccine not 100% effective
Transmission
Airborne droplets or contact
w/infected droplets
Incubation pd: 12-25 days
Communicable: few days before
onset of parotitis 6-9 days
after parotid swelling begins
→
S/S
Low-grade fever
Parotitis - inflammation and swelling
of the parotid gland
Malaise, anorexia
Headache, ab pain
Postpubertal boys - orchitis
(inflammation of testicle) may be
complication
Dx - clinical presentation; serum
tests - mumps IG or IgM antibodies
Tx - Supportive
Management
General management plus:
Ice packs for orchitis
oral fluids
↑
Zoonotic and Vector-Borne Infections
Cat-Scratch Disease
Dx and Tx
Caused by infectious agents transmitted directly or indirectly from
animals (zoonotic) or vectors such as ticks, mosquitoes, etc (vectorborne)
Definition
Caused by Bartonella henselae
In cats' saliva from fleas
Relatively common
Incubation: 7-12 days
Dx and Tx
Dx -Serum test for antibodies
Tx - Supportive; resolves in 2-4
months; abx may be needed
S/S
Headaches
Fever
Anorexia
Fatigue
Lymphadenopathy
Management
Abx administration if ordered
Educate:
Children not to play rough with
cats
Wash bites/scratches right away
Pediatric Health Disorders
Infectious and Communicable Diseases, cont.
Zoonotic and Vector-Borne Infections, cont.
Lyme Disease
Definition
Most common vector-borne infection
Caused by Borrelia burgdorferi
Transmission
Via bite of infected black-legged
deer tick
Dx and Tx
Dx -IG antibody later in disease
Tx - Abx; the earlier the better
>8 yrs Doxycycline
<8 yrs Amoxycillin
S/S
Explore health history for tick bite
Determine when onset of rash
Usually 7-14 days after tick bite
Fever, malaise
Mild neck stiffness
Headache
Myalgia
Arthralgia
Pain in joints
Rash: ring-like, will expand and remain
for 1-2 weeks (if untreated)
Management
Abx administration as ordered
Educate:
Importance of taking abx
Tick removal
Tick must attach for 36-48 hrs
before passing Lyme disease
Rocky Mountain Spotted Fever
Definition
Second most common vector-borne
infection
Occurs throughout the U.S.
Can be fatal without prompt tx
Long-term complications
Transmission
Via bite of infected dog tick and
Rocky Mountain wood tick
Incubation: 2-14 days
S/S
Sudden onset of fever
Headache
Malaise
N/V
Muscle pain
Anorexia
Rash 1-3 days after onset of fever
Small, pink, macular, nonitchy,
blanchable spots on wrists,
forearms, ankles, spreads to body
Parasitic and Helminthic Infections
Head lice
Transmission: via direct contact
w/hair of infested person
S/S: extreme pruritus; nits or lice
may be seen behind ears/on neck
Dx: Seen with naked eye
Tx:
Wash hair with pediculicide
Check every 2-3 days after
treatment to prevent
reinfestation
Helpful to wash clothing and
bedding
* Lice does not live off host
Dx and Tx
↓
Dx - Labs: leukocytes, PLT, Na
Tx - antimicrobial therapy
Doxycycline
Management
Abx administration as ordered
Educate:
Importance of taking abx
Tick removal
Parasites - organisms larger than yeast or bacteria that can cause
infection; live in or on host; children at risk due to poor hygiene
Parasitic examples: scabies, lice
Helminth examples: pinworm, roundworm, hookworm
Scabies
Transmission: via prolonged,
personal contact
S/S: intense pruritus esp. at night;
papular rash on hands/feet/body
folds/fingers
Dx: microscopic examination of
skin scrapings
Tx: Scabicide on entire body;
Retreat 1-2 wks later; Launder
bedding and clothing in hot cycle
* Mites don't live > 4 days off host
Pinworm
Most common helminthic infection
found in the U.S.
Transmission: via fecal-oral route
S/S: may be asymptomatic; anal
itching at night; wt loss; enuresis
Dx: visualized in perianal area
when child is sleeping; microscope
to see eggs
Tx: Single dose of mebendazole,
pyrantel pamoate and albendazole;
repeat in 2 wks
Pediatric Health Disorders
Neurologic Disorders
Include:
Seizure Disorders
Structural Defects
Trauma
Infectious Disorders
Seizure Disorders
Level of Consciousness- earliest indicator of
improvement or deterioration of neurologic status;
5 stages:
Full consciousness: awake, alert, oriented to time,
place, person
Confusion: disoriented, responds inappropriately
Obtunded: limited responses; falls asleep easily
Stupor: only responds to vigorous stimulation
Coma: child cannot be aroused
Most seizures caused by disorders that originate outside the brain: e.g. high fever,
infection, head trauma, hypoxia, toxins, cardiac arrhythmias
Epilepsy
Febrile Seizures
Definition
Condition in which seizures are
triggered recurrently and
unprovoked from within the brain
Cause: brain injury, familial, unknown
S/S
Staring, appearing confused/hazed
Jerking arms/legs
Stiffening of body
Loss of consciousness
Loss of bladder control
Periods of rapid blinking
Dx:
Tx:
Lack of response to
painful stimuli is
abnormal and may mean
life-threatening
condition
Immediately report
sudden presence of fixed
or dilated pupils
Dx and Tx
Labs: serum glucose, electrolytes,
Ca to rule out metabolic causes
LP (analyze CSF) to rule out
meningitis and encephalitis
Skull xrays - fracture, trauma
MRI/CT - bleeds, tumors
Anticonvulsants
If remain uncontrolled: surgery,
keto diet, vagal nerve stimulator
Management
Administer appropriate meds as
ordered
Educate family:
How to respond during seizure
Assist in coping with seizures,
anxiety
Neonatal Seizures
Definition
Most common type of seizure <5 yrs
old; peak age 12-18 months
Associated w/fever related to viral
illness
S/S
Rapid rise in temp to 39°C (102.2°F)
or higher
Seizure lasts few seconds to 10
minutes (less than 15 minutes) and
occurs only once in 24 hr pd
Dx and Tx
Dx: by history, physical exam,
determining source of fever
Tx: determine/treat cause;
Control the fever; does not
warrant antiepileptic agents
Rectal diazepam - may be used
in kids at high risk or whose
parents are extremely anxious
Management
Provide parents
support/education; reassure
benign in nature
Discuss controlling fever, keeping
child safe during seizure
Instruct on admin of rectal
diazepam if ordered
Definition
Seizures that occur within the 1st 4
weeks of life (usually 1st 10 days)
Causes:
Hypoxic ischemic encephalopathy
Metabolic disorders (hypoglycemia,
hypocalcemia)
Neonatal infections meningitis/encephalitis
Cerebral infarction
Intracranial hemorrhage
S/S
Seizures; or may have no clinical
signs with EEG changes
Dx:
Dx and Tx
Labs: serum glucose,
electrolytes, Ca to rule out
metabolic causes
LP (analyze CSF) to rule out
meningitis and encephalitis
Cranial ultrasound
MRI/CT - bleeds, tumors
Tx: Treat aggressively to avoid
any more seizures
Address underlying cause
May use phenobarbital or
antiepileptic meds
Management
Monitor neurologic status
Prevent injury during seizure
Provide support/education to
family
Pediatric Health Disorders
Neurologic Disorders, cont.
Seizure Disorders, cont.
How to respond when child has seizure
Remain calm
Ease child to ground
Time the seizure, record movements
Remove/loosen tight clothing or jewelry
Place child on side and open airway
Do not restrain child
Remove hazards in area
Remain with child until conscious
Document length of seizure
Document movements noted
Call EMS if:
Child stops breathing
Child injured
Seizure lasts > 5 minutes
This is first seizure
After seizure, child does not
respond to painful stimuli
Structural Defects
Neural Tube Defects
Definition
Serious birth defects of the spine
and brain
Majority of the congenital anomalies
of the CNS
Cause not known, may be:
Drugs
Malnutrition
Chemicals
Genetics
Possibly low folic acid ingestion
during pregnancy
Ex. Spina Bifida/Occulta,
anencephaly, encephalocele
Trauma
Defect of spine with no protrusion
Benign, asymptomatic
No neurologic signs
Often goes undetected
Often called 'spina bifida'
Spine does not fully develop; no
motor or sensory function beyond
that point
May have paralysis, deformities,
bowel or bladder incontinence
Tx: multiple surgeries
Leading cause of childhood morbidity and mortality
in the U.S.
Head trauma - falls, MVA, pedestrian and bicycle
accidents, child abuse
Traumatic brain injury (TBI) - when a head trauma
results in a disruption of the normal function of the
brain
Prognosis depends on severity & complications
Take detailed history, ask:
Loss of consciousness?
Irritability?
Lethargy?
Abnormal behavior?
Vomiting?
Seizures?
Headaches, visual
changes?
Small or missing brain hemisphere
Upper end of neural tube fails to
close
Incompatible with life
Management: comfort
Myelomeningocele
Definition
S/S
Anencephaly
Spina Bifida Occulta
Dx and Tx
Dx - Xrays/CT/MRI
to assess extent and
severity or type of
trauma
Tx - Will depend on
type and severity of
trauma
Encephalocele
Protrusion of brain through skull
defect
Failure of neural tube to close
Tx: repair (surgery)
Management: pre and post
operative care; monitor for
increased ICP
Assess neurologic function as soon as they are seen
LOC, pupillary response, any seizure activity
Warning signs:
Fixed and dilated pupils
Management
Fixed and constricted pupils
Sluggish pupillary reaction to light
Spine must remain stabilized after head injury until spinal injury
ruled out
Note any liquid fluid draining from ear or nose notify MD or NP;
if fluid tests positive for glucose leaking CSF
Management depends on severity
Mild/moderate at home:
Stay w/child for first 24 hrs
Wake child every 2-4 hrs; make sure moves normally, recognizes
caregiver, responds appropriately
Observe child for few days
Call MD or NP if headaches get worse, slurred speech, dizziness,
abnormal behavior, vomiting > 2 times, oozing from nose or ears,
unequal-sized pupils, unusually pale, trouble waking up, seizures
For severe injury: May go to ICU, maintain airway, monitor
breathing, circulation, neurologic status
→
→
Pediatric Health Disorders
Neurologic Disorders, cont.
Infectious Disorders
Bacterial Meningitis
Definition
Infection of the meninges, the lining
around the brain and spinal cord
Causes inflammation, swelling,
purulent exudates and tissue damage
to the brain
Can lead to brain/nerve damage,
deafness, stroke, death
Medical emergency
Needs rapid assessment and tx
Hib vaccine - greatly decreases
incidence
Cause:
Secondary infection to URI, sinus
or ear infections
Direct intro through LP, skull
fracture or head injury
S/S
Preceding illness/sore throat
Fever, chills
Headache
Vomiting
Photophobia
Stiff neck
Rash
Irritability
Drowsy/lethargic
Muscle rigidity, seizures
Infant - opisthotonic position,
bulging fontanels, weak cry
Transmission
Close contact w/respiratory
droplets from nose or throat
Dx:
Dx and Tx
↑
Lumbar puncture (LP) - CSF, WBC,
protein and glucose
Blood, urine, nasopharyngeal culture
↓
Tx:
IV abx immediately after LP/blood
cultures obtained
Corticosteroids for inflammation
Management
Administer abx ASAP
Isolation precautions - droplet isolation
until 24 hrs after abx started
Administer antipyretics per order
environment temp, cold compresses
Ensure proper ventilation
↓
Reye Syndrome
Definition
Very rare - a reaction triggered by use of salicylates or salicylatecontaining products to treat a viral infection *aspirin*
Primarily affects children <15 years recovering from viral illness
Causes brain swelling, liver failure and death in hours if not
treated
Dx and Tx
Dx: physical findings plus elevated liver function tests and serum
ammonia levels
Tx: Control swelling, maintain liver function; May give
corticosteroids, diuretics
S/S
Recent viral illness and ingestion of
salicylate-containing products
Severe and continued vomiting
Changes in mental status, Irritable/confused
Lethargy, hyperreflexia
Management
Administer meds as ordered
Monitor fluid status
Manage ICP
Maintain cerebral perfusion
Pediatric Health Disorders
Disorders of the Eyes
Strabismus
Amblyopia
Definition
Misalignment of the eyes
Exotropia - eyes turn outward
Esotropia - eyes turn inward
Often seen in infants but resolves by 3-6 months
Constant strabismus - refer to ophthalmologist
Important to treat in early years
S/S
Usually brought up by parents
Blurred vision
Tired eyes
Squinting or closing one eye in bright sunlight
Tilting head to focus on object
Definition
Vision in one eye reduced because the eye and brain
aren't working together properly
One eye stronger 'lazy eye'
May lead to blindness in one eye if not treated
Important to treat in early years
Cause: strabismus, astigmatism, trauma, ptosis
→
Usually brought up by parents
Asymmetry of corneal light reflex
Dx:
Dx and Tx
Dx:
Assess for exotropia or esotropia
Assess the symmetry of the corneal light
reflex
Tx: Patching of stronger eye, surgery, corrective
lens
Management
Assist family with eye patch if prescribed
Encourage eyeglass wearing if prescribed
Corneal Light Reflex
In proper eye alignment, a
light reflection appears
equally centered on both
pupils
In strabismus or amblyopia
the reflection is NOT
centered on the pupils
S/S
Tx:
Dx and Tx
Assess the symmetry of the corneal light
reflex
Screen all preschoolers for amblyopia
Visual acuity testing by age 3 years
Strengthen weak eye:
Patch strong eye
Atropine drops in strong eye (blurs the eye
and makes the weak one work harder)
Vision therapy
Eye surgery (if cause is strabismus)
Management
Encourage use of patch or drops if prescribed
Promote eye safety; if better eye becomes
injured, both eyes may become blind
Visual Impairment in
Children
Refers to acuity between
20/60 to 20/200 in the
better eye
'Legal blindness' - vision of
<20/200 or peripheral <20°
Pediatric Health Disorders
Disorders of the Eyes, cont.
Conjunctivitis
Definition
Inflammation of the bulbar or palpebral conjunctivia; either
infectious, allergic or chemical
Infectious - caused by virus or bacteria; very contagious
Allergic - from exposure to particular allergens (usually pollen);
genetic predisposition; affects school-aged and adolescents more
than infants and young children
S/S
Redness of eyes
Edema
Bacterial - thick colored discharge
Tearing
Viral - clear or white discharge
Discharge
Allergic - watery discharge
Eye pain
Itchy eyes (allergic)
Dx and Tx
Dx: physical findings; bacterial - lab culture to decide on abx
Tx: Depends on cause:
Bacterial - opthalmic abx preparation (drops or ointment)
Viral - no topical meds; self-limiting
Allergic - eye drops w/antihistamine; oral antihistamine
Management
Alleviate symptoms, prevent spread if infectious
Educate: eye drops, ointment, warm compress to
loosen crust; cold compress for itchiness, wash
hands often if infectious, do not use Visine (does
not help)
Disorders of the Ears
Otitis Media
Inflammation of the middle ear with the presence of fluid. Either AOM or OME.
AOM - Acute Otitis Media
OME - Otitis Media with Effusion
Definition
Resulting from infection (bacterial or viral) of fluid in the
middle ear
Partly caused by short length and horizontal position of
Eustachian tube
Usually preceded by URI
Often caused by viral pathogens and resolves spontaneously
Occurs mostly fall spring
Most significant risk factors: dysfunction of Eustachian tube
and recurrent URIs
→
S/S
Fever
Otalgia (ear pain)
Fussy/irritable
Inconsolable crying
Tugging at ears
Not feeding
Lethargy
Difficulty sleeping
Include:
Otitis Media and Otitis Externa
Tx
May wait to see if clears on own;
if not improved in 48-72 hrs,
return for abx
No treatment for viral cause
Abx if bacterial
Management
Supportive
Pain management (acetaminophen, ibuprofen)
Warm heat/cool compress
Numbing ear drops
Definition
Presence of fluid within middle ear space without
signs or symptoms of infection
May occur independent of AOM or present after
AOM resolves
Risk factors:
Passive smoking
Not breastfed
Frequent viral URIs
Allergies
Eustachian tube dysfunction
S/S
May experience popping ears
Otoscopic exam shows dull, opaque tympanic
membrane (white, gray, bluish)
Management
Usually resolves spontaneously but should be
rechecked every 4 weeks
May take several months to resolve
Need to check effect on hearing
If Chronic OME (>3 months) - send to hearing
specialist for hearing evaluation
May need pressure-equalizing tubes placed
Pediatric Health Disorders
Disorders of the Ears, cont.
Otitis Externa
Infection and inflammation of the skin of the external ear canal.
Definition
Infection and inflammation of the skin of the external ear canal
'Swimmer's ear'
Caused by bacteria or fungi and moisture in the canal
S/S
Dx and Tx
Significant ear pain
White, colored discharge in
ear canal
Canal red and edematous
Dx: Based on clinical
findings; may need culture
Tx: Pain relief, abx or
antifungals
Pediatric
Hearing Loss:
0 - 20 dB: Normal
20 - 40 dB: Mild Loss
40 - 60 dB: Moderate Loss
Alterations in gas exchange
Gas exchange - the process by which
oxygen is transported to cells and carbon
dioxide is transported from cells
Often the first sign of respiratory illness
in infants and children is tachypnea
In &
Out
Management
Analgesics/warm compress/heating pad
Administer abx/antifungal ear drops
Wick - assist with insertion and education
Educate - keep canals dry; no headphones or
earphones; earplugs when swimming
60 - 80 dB: Severe Loss
> 80 dB: Profound Loss
May be congenital or acquired
Respiratory Disorders
Respiratory dysfunction more severe in children than adults because:
Newborns: nose breathers until at least 4 weeks; produce little mucus (which
serves as a cleansing agent); very small nasal passages
Infants/children: airway lumen smaller than adults (capacity for air passage
diminished), larynx is funnel shaped (more narrow), chest walls pliable which
makes it hard to support the lungs; RMR higher and demands more oxygen
(therefore develop hypoxemia faster)
Atopy - genetic tendency toward asthma, allergic
rhinitis, atopic dermatitis
Grunting - occurs on expiration and is produced by
premature glottic closure
Attempt to preserve or increase functional
residual capacity
May occur with alveolar collapse or loss of lung
volume
Atelectasis - collapsed or airless portion of the lung
Stridor - high pitched, readily audible inspiratory
noise; a sign of upper airway obstruction
Retractions - the inward pulling of soft tissues with
respiration
Can occur in the intercostal, subcostal,
substernal, supraclavicular, or suprasternal
regions
Can be mild, moderate or severe
Seesaw (paradoxical) respirations - chest falls on
inspiration and rises on expiration
Clubbing - enlargement of the terminal phalanx of
the finger, resulting in a change in the angle of the
nail to the fingertip
Wheezing - High pitched sound usually on
expirations, results from obstruction in the lower
trachea or bronchioles
If wheezing clears when cough secretions in
the lower trachea
If wheezing does not clear when cough
obstruction of the bronchioles
Rales - crackling sounds - result when the alveoli
become fluid filled
→
→
Pediatric Health Disorders
Respiratory Disorders, cont.
Common Cold
Sinusitis
Definition
AKA viral upper respiratory
infection (URI), nasopharyngitis
Causes - most common is rhinovirus
Children may have 6-9 colds/year
Spontaneous resolution occurs after
~7-10 days
Transmission
Viral particles through air or
person-to-person contact
Definition
AKA rhinosinusitis
A bacterial infection of the
paranasal sinuses
Acute (symptoms <30 days) or
chronic (symptoms >4-6 weeks)
Young children: maxillary and
ethmoid sinuses main sites
10+ years: frontal sinuses more
commonly involved
Transmission
S/S
Stuffy, runny nose
Discharge thin and watery
progressing to thicker and discolored
Sore throat, cough
Fever
Fatigue
Watery eyes
Decreased appetite
Dx and Tx
Dx -Clinical presentation; no labs
Tx - Symptom relief
Management
Symptom relief
Cool mist humidifier; hydration
Normal saline nasal wash/spray
followed by suctioning
No antihistamines (drying)
No over-the-counter cold preps with
decongestant if <4 yrs
Educate - watch for:
Prolonged fever
Increased throat pain
Worsening cough
Earache, headache
Skin rash
↑
Influenza
Sinusitis bacterial infections are not
contagious
S/S
Persistent s/s of cold
Cough and fever
Does not improve after 7-10 days
In preschooler & older children:
halitosis
May have eyelid edema
Irritability
Poor appetite
Dx and Tx
Dx -Clinical presentation
Tx - abx (usually 14 days)
For chronic sinusitis that is
recurrent or with nasal polyps
surgery may be necessary
Management
Abx plus symptom relief as with cold
Normal saline drops or spray
Cool mist humidifier
Adequate oral fluid intake
Educate on continuing full course of
abx
Definition
AKA flu
Complications - bacterial infections
of the respiratory system; otitis
media; acute myositis
Due to potential for complications, a
prolonged fever or one that returns
must be investigated
Transmission
Inhalation of droplets or contact
with fine-particle aerosols
Children shed virus 1-2 days before
symptoms and up to 2 weeks after
S/S
Abrupt onset of fever
(>39.5°C/103.1°F)
Facial flushing
Chills
Headache
Myalgia
Malaise
Cough
Coryza (nasal discharge)
Photophobia
Tearing/burning
Eye pain
Infants/young children: wheezing,
rash, diarrhea
Dx and Tx
Dx - rapid assay test
Tx - supportive; antivirals if
administered within 1st 48 hrs
Management
Symptom relief
Ensure proper hydration
Treat cough/fever
Administer antivirals if ordered
Pediatric Health Disorders
Respiratory Disorders, cont.
Pharyngitis and Tonsillitis
Definition
Often occur together
Pharyngitis - inflammation of throat
mucosa
Tonsillitis - inflammation of tonsils
Cause - bacterial (Group A Strep) or
viral
If pharyngitis caused by Group A
Strep = 'strep throat'
Transmission
Pharyngitis - Person-to-person via
saliva or nasal secretions
Tonsillitis - inhaling respiratory
droplets
S/S
Fever
Headache
Sore throat, difficulty swallowing
Ab pain
Petechiae on palate
Tongue - strawberry appearance
Rash on trunk or abdomen
(pharyngitis)
Dx and Tx
Dx -Throat swab/culture
Tx - Symptom relief; abx for
bacterial
Tonsillectomy - for recurrent
tonsillitis from strep or massive
tonsillar hypertrophy
Management
Symptom relief
Saline gargles (8 oz warm water and
1/2 tsp table salt)
Acetaminophen/Ibuprofen
Cool mist humidifier
Antibiotics if bacterial
After 24 hrs on abx discard
toothbrush and may return to school
→
Infectious Mononucleosis
Definition
AKA 'Mono,' 'Kissing Disease'
Caused by Epstein-Barr virus
Teenagers have more symptoms
that young children (often goes
unnoticed)
Transmission
Oropharyngeal secretions
Spread through saliva via kissing or
sharing glass/food utensils
S/S
Fever
Malaise
Sore throat
Lymphadenopathy
May have petechiae on palate
Pharynx and tonsils may be
inflamed with gray exudate
3-5 days - pharynx may be
edematous
Rash may appear
Dx and Tx
Dx - Monospot or Epstein-Barr virus
titers
Tx - symptom relief
Corticosteroids for
inflammation
Management
Symptom relief
Salt-water gargles
Analgesics
Bed rest if febrile
Fatigue may persist 6+ weeks
Administer corticosteroids if ordered
Croup
Definition
AKA laryngotracheobronchitis
Affects 3 mo - 3 yr most often; rare
after 6 yrs
Cause - usually parainfluenza virus
Inflammation of larynx, trachea,
bronchi produce symptoms
Mucus production also causes
symptoms
Self-limiting in 3-5 days
Transmission
Inhalation of respiratory droplets
S/S
Symptoms appear suddently at night
and resolve by morning
Barking/seal cough
Stridor
Hoarseness
Dx and Tx
Dx - physical presentation
Tx Corticosteroids
Racemic epinephrine aerosols
Management
Symptom relief
Cool mist humidifier
Steamy bathroom
Administer meds if ordered:
Dexamethasone and/or racemic
epinephrine
If child with croup presents with
fever, toxic appearance, increasing
respiratory distress despite tx: may
have bacterial tracheitis notify
MD or NP
→
Pediatric Health Disorders
Respiratory Disorders, cont.
Tuberculosis
Pneumonia
Definition
Inflammation of lung parenchyma
Cause: virus, bacteria, Mycoplasma
or fungus (usually respiratory virus)
Viral pneumonia better handled than
bacterial pneumonia (but recovers
well with abx)
CAP - community-acquired
pneumonia - when a previously
healthy person contracts pneumonia
outside the hospital setting
Self-limiting
Aspiration pneumonia - from
aspiration of foreign material into
lower respiratory tract
Transmitted via respiratory droplets
S/S
Recent viral URI
Fever
Cough
respiratory rate
Lethargy
Poor feeding
Chills
↑
Headache
Dyspnea
Chest pain
Ab pain
N/V
Infants:
diarrhea
Dx and Tx
Dx:
Tx :
↓
Pulse oximetry (O2 sat )
Chest radiograph
Sputum culture
WBC count (may be )
↑
Less severe: antipyretics,
hydration, close observation
Severe (tachypnea,
significant retractions, poor
oral intake, lethargy):
hospitalization
Management
Supportive at home
Hospitalized: Hydration (important),
analgesics, supplemental O2, abx
Discuss importance of vaccine
Child presenting w/recurrent
pneumonia should be tested for
chronic lung disease like asthma or cf
Bronchiolitis (RSV)
Definition
Definition
Bacilli multiply in alveoli and alveolar
ducts form inflammatory exudate
spread by bloodstream and
lymphatic system to various parts of
body
Highly contagious!
Children who test + but no symptoms
= latent infection
→
→
Transmission
Inhalation of droplets (bacilli)
Incubation: 2-10 weeks
S/S
Fever
Malaise
Wt loss
Anorexia
Pain and tightness in chest
rr
breath sounds
Crackles
↑
↓
Dx and Tx
Dx: + Mantoux test, chest radiograph
Tx:
Less severe: supportive care
with oral therapy (6 months)
Severe: hospitalization (isolate)
Management
Symptom relief
Outpatient for most
Administer oral therapy
Children with latent tuberculosis are
treated with isoniazid for 9 months
to prevent progression to active
disease
Bronchiolitis is acute inflammation of
the bronchioles and small bronchi
When caused by RSV (respiratory
syncytial virus) RSV Bronchiolitis
RSV - highly contagious virus
contracted through direct contact
with respiratory secretions or from
contaminated objects
RSV enters through nasopharynx
lower airway small airways
becomes obstructed
hyperinflation, atelectasis,
alterations in gas exchange
Usually self-limiting
→
→
→
→
Pharyngitis
grade fever
Clear runny nose at onset
Cough 1-3 days into illness
Poor feeding
↓
S/S
→ wheeze
Dx and Tx
Dx:
↓
Pulse oximetry (O2 sat )
Chest radiograph
Blood gases - CO2 retention
and hypoxemia
Nasal-pharyngeal washings
(positive for RSV)
Tx :
Supplemental O2; nasal suctioning;
oral or IV hydration; inhaled
bronchodilator therapy (racemic
epinephrine or albuterol)
Infants w/tachypnea, significant
retractions, poor oral intake,
lethargy hospitalized
→
Management
Supportive
Antipyretics, hydration
Maintain airway - suctioning
Cohorts in hospital
Educate:
Signs of worsening - call MD
Not eating - call MD
Cough may persist for weeks
Pediatric Health Disorders
Respiratory Disorders, cont.
Asthma
Tx
Definition
Chronic inflammatory airway disorder
Most common chronic illness of children
Varies - from exercise-induced to daily
asthma
Characteristics:
Airway hyperresponsiveness
Airway edema
Mucus production
↓
Dx
Pulse oximetry (O2 sat )
Chest radiograph
Blood gases
Peak Expiratory Flow Rate (PEFR)
Allergy testing to determine triggers
Focuses on control/reduction of inflammation; avoidance of triggers
Short-acting bronchodilators used for bronchoconstriction
Long-acting bronchodilators used to prevent bronchospasm
Inhaled steroids for long-term prevention
Exercise-induced: longer warm-up period
S/S
Cough, especially at night; hacking
which eventually produces sputum
SOB, tight chest, chest pain, dyspnea
with exercise, wheezing
Skin pink cyanosis (worst case)
Barrel chest (with persistent asthma)
Lungs - wheezing
Breath sounds diminished
→
Management
Educate family:
Action (management) plan
Maintenance meds
Nebulizer/inhalers/spacers/
PEFR use
Avoiding allergens
Cystic Fibrosis
Definition
Autosomal recessive disorder (gene
mutation)
Causes generalized dysfunction of the
exocrine glands
Respiratory system:
Thickened secretions difficulty
clearing
Airway obstruction
Respiratory distress/ impaired gas
exchange
Chronic cough
pulmonary function
Clubbing
Recurrent pneumonia, sinusitis
Gastrointestinal system:
Retainment of fecal matter
Vomiting, ab distention
Anorexia
Bowel obstruction
Intussusception
Obstructive cirrhosis
Gallstones
GERD
FTT
Hyperglycemia diabetes
→
↓
→
S/S
Undiagnosed:
Salty taste to skin
Difficult or late passage of
meconium
Ab pain/trouble passing stool
Bulky, greasy stools
Poor wt gain and growth
Chronic cough/URIs
Barrel chest
Clubbing of nail beds
Dx
Sweat chloride test (>60mEq/L)
Pulse oximetry (O2 )
Chest radiograph
PFTs
↓
Management
Tx
Aimed at maximizing lung function,
preventing infection, facilitating
growth
If pulmonary involvement chest
physiotherapy (CPT) several
times/day to mobilize secretions
Recombinant human DNase daily to
sputum viscosity
Inhaled bronchodilators/antiinflammatory agents
Aerosolized abx
Pancreatic enzymes/fat-sol vitamins
calorie/ protein diet
→
↓
↑
↑
Promote growth - assist with
calorie/ protein diet;
supplements and vitamins
Decrease pulmonary complications
- assist with CPT instructions;
breathing exercises; encourage
exercising
Infection prevention - provide
aerosolized abx
Facilitate coping - encourage
support groups
↑
↑
Pediatric Health Disorders
Cardiovascular Disorders
Include:
Congenital Heart Disease - structural
anomalies present at birth
Acquired Heart Disease - disorders that
occur after birth
Physical Exam
*Changes to note that may indicate heart disease*
Skin color - cyanosis
Edema
Neck veins - engorgement/abnormal pulsations
Ab/chest distention
Femoral pulse weak compared to brachial pulse
Bounding pulse
Hepatomegaly
Tachycardia, bradycardia, rhythm irregularities
Cyanotic newborn who does not improve with
oxygen administration suspect CHD
→
Cardiac Catherization
Main study for infants and children with cardiovascular disease
Almost routine
Highly invasive
Procedure lasts 1-3 hrs
Catheter is inserted into a blood vessel and guided to the heart;
then contrast material is injected; radiographic images are taken
Pre:
Heart rate Infant: 90-160 bpm
Toddler/preschooler: 80-115 bpm
School age/adolescent: 60-100 bpm
Blood pressure Infant: 80/55 mm Hg
Toddler/preschooler: 90-110/55-75 mm Hg
School age: 100-120/60-75 mm Hg
Adolescent: 100-120/70-80 mm Hg
Management
Ht/wt
Review allergies (esp. to iodine shellfish)
Vitals (no fever)
Review meds (make sure anticoagulants held)
Review labs (note hgb and hct)
Physical exam (esp peripheral pulses; use indelible pen to
mark pedal pulses)
Educate child/parents about procedure
Withhold foods and fluid 4-6 hrs before (as ordered)
Decreased peripheral pulses, thready pulse
Heart murmur
Abnormal splitting or intensifying of S2 sounds
Ejection clicks
Clubbing - softening of nail beds followed by
rounding of the fingernails then shininess and
thickening of the nail ends
Usually does not appear until after 1 yr old; implies
chronic hypoxia due to severe congenital heart
disease
Management
Day of:
Informed consent signed
Have child void and administer sedative (if ordered)
Educate on possible complications (bleeding, low-grade
fever, loss of pulse in extremity used, arrhythmia)
Post:
Monitor for complications (bleeding, arrhythmia,
hematoma, thrombus formation, infection)
Monitor vitals
Monitor neurovascular status of LE
Pressure dressing over site:
q 15 min for 1st hr
q 30 min for next hr
Assess distal pulses bilaterally; color/temp of extremity
Check capillary refill
Make sure extremity is held straight for 4-8 hrs
Monitor I/O (ensure hydration); provide IV fluids as ordered
Encourage oral fluid intake as ordered
Educate on home care
Pediatric Health Disorders
Cardiovascular Disorders, cont.
To body
Congenital Heart Disease
Cause - exact cause unknown - may be a combination
of genetics and maternal exposure to environmental
factors
Categorized based on blood flow patterns in the
heart:
Decreased pulmonary blood flow - blood flow
from right side shunts to left side
Increased pulmonary blood flow - blood flow
from left side shunts to right side
Obstructive disorders
Mixed disorders
Decreased Pulmonary Blood Flow
There is an obstruction of blood flow to heart
Pressure in right side of heart increases and becomes
greater than that of the left side of the heart
Blood from right side shunts to left side
Therefore causing deoxygenated blood to be mixed with
oxygenated blood on left side of heart
Tetralogy of Fallot
Aorta
Pulmonary
Artery
Superior
Vena
Cava
Pulmonary
Veins
Right
Pulmonary
Atrium
Valve
Pulmonary
Veins
Left
Atrium
Mitral Valve
Aortic
Valve
Left
Ventricle
Tricuspid Valve
Inferior
Vena
Cava
Right
Ventricle
This mixed blood (low in oxygen) is pumped to body tissue
Children may exhibit:
Mild to severe oxygen desaturation 50-90%
Cyanosis
Kidneys produce erythropoietin stimulates more
RBC production
RBCs (polycythemia)
E.g. Tetralogy of Fallot
→
→↑
Definition
Composed of 4 heart defects:
Pulmonary stenosis - narrowing of pulmonary valve and
outflow tract; creates an obstruction of blood flow from the
rt ventricle to the pulmonary artery
Ventricular Septic Defect - opening between the rt and lt
ventricular chambers of the heart
Overriding aorta - enlargement of the aortic valve
Right ventricular hypertrophy
Pathophysiology:
Due to pulmonary stenosis, blood flow from right ventricle is
obstructed
Decreased blood flow to lungs for oxygenation
Decreased oxygenated blood returning to the left atrium
from the lungs
The obstruction increases the pressure in the right ventricle
Right ventricle has to work harder right ventricular
hypertrophy
Poorly oxygenated blood shunted across the VSD into the
left atrium
This mix of oxygenated and deoxygenated blood enters
circulatory system
Leads to decreased oxygen saturation and cyanosis
→
S/S
History of color changes associated with
feeding, activity or crying
Hypercyanosis (may be noted)
Develops suddenly
cyanosis, hypoxemia
Dyspnea, agitation
Older kids: prefer fetal position (knees to
chest)
Walking infant or toddler squat often
Clubbing
Pulse oximetry notes O2 sat
Heart auscultation - loud, harsh murmur
↑
↓
Dx and Tx
Dx during 1st weeks of life due to murmur
and/or cyanosis:
Labs - Hct, Hgb, RBC all
Echocardiography
ECG
Cardiac catherization and
angiography
Tx: Surgical intervention required during
first year
↑
Pediatric Health Disorders
Cardiovascular Disorders, cont.
Congenital Heart Disease, cont.
Atrial Septal Defect (ASD)
Increased Pulmonary Blood Flow
Defects of the heart will shunt blood from left to
right side
A greater amount of blood will move through the
heart
Leads to right ventricular hypertrophy
Children may exhibit:
Tachypnea or tachycardia
Poor wt gain
growth and development
Na and fluid retention
May eventually cause pulmonary
vasoconstriction and pulmonary HTN
E.g. ASD, VSD, PDA
Hole in the wall (septum) that divides the right and left atrium
If small, may close on own by 18 months
If not closed by 3 yrs old will need surgery
Blood flows from left right atrium
Causes increased blood flow to lungs
→
→↓
Ventricular Septal Defect (VSD)
Opening between rt and lt ventricular chambers of the heart
Spontaneously closes in 50% pts by 2 years old
Others will need surgery; if not heart failure may occur
May be asymptomatic at birth
Patent Ductus Arteriosus (PDA)
Definition
Pathophysiology:
Failure of ductus arteriosus to close within 1st few weeks of
life
Ductus arteriosus - the blood vessel that connects the
aorta to the pulmonary artery in a fetus (closes soon
after birth)
Leaves a connection between the aorta and pulmonary
artery
Blood returning to the left atrium passes to the left
ventricle, enters the aorta, travels to the pulmonary artery
via the PDA instead of entering systemic circulation
This increases the workload of the left side of the heart and
pulmonary pressure
Leading to right ventricular pressure increase (to
compensate) right ventricular hypertrophy
At risk:
Premature infants
Those born at high altitudes
→
S/S
Murmur - harsh, continuous
HR
Widened pulse pressure (Diastolic is )
S/S of heart failure
Fatigues easily, sweats with activity
Difficulty breathing
Weight loss, FTT
Heart auscultation - loud, harsh murmur
↑
Dx:
↓
Dx and Tx
Echocardiogram reveals extent and
confirms dx
Electrocardiogram
Chest radiography
Tx: Many small PDAs close on own; large
ones will need surgical repair
Meds to close DA (in premature
infants or very young infants) prostaglandin inhibitors
(Indomethacin)
Children: Heart catheterization to
shut opening or surgery to tie it shut
Pediatric Health Disorders
Cardiovascular Disorders, cont.
Congenital Heart Disease, cont.
Obstructive Disorders
Narrowing of a major vessel
Affects peripheral circulation or blood flow to
lungs
Causes increased workload on heart
Children may exhibit:
Often asymptomatic, may not dx until older
Cyanosis
Frequent epistaxis
Leg pain with activity
Dizziness, fainting, headaches
Soft or moderately loud systolic murmur
Easily fatigued, irritable
E.g. COA, AS
Coarctation of the Aorta (COA)
Narrowing of the aorta, most often near the ductus arteriosus
Blood flow impeded, causing BP to be increased in upper
portions of body and heart and decreased in the lower body
Left ventricular afterload is increased
Collateral circulation may also develop
May be asymptomatic until school age
Tx is surgery
Aortic Stenosis (AS)
Obstruction of blood flow between the left ventricle and aorta
Leads to CO, left ventricular hypertrophy and possibly left
ventricle failure (heart failure may result in infants)
Often asymptomatic
Tx typically surgery
↓
Management for child with CHD
Improve oxygen:
Assess airway patency; suction as needed
Fowler/semi-Fowler position
Monitor vitals (esp. hr and rr)
Monitor color and O2 sat levels
Observe for tachypnea, nasal flaring, grunting,
retractions
Auscultate lungs for adventitious sounds
Provide humidified supplemental oxygen (warmed) as
ordered
Nutrition:
Provide in whatever form necessary to help with
growth and development:
Breast milk/formula
Oro/nasogastric tube
Small, frequent feedings
TPN as prescribed
Family:
Encourage parents to participate in care
Encourage attachment and bonding
Prevent infection:
Instruct on proper hand hygiene/dental care
Prophylaxis for infective endocarditis as needed
Under 24 months - if surgery during RSV season
vaccination with palivizumab
→
Pre-op Temp and wt mmnts
Examine extremities (peripheral edema and pulses, clubbing)
Auscultate heart
Respiratory assessment (rr, work of breathing, auscultate lungs)
Obtain labs/tests for baseline
Educate parents/child on procedure/NPO per orders
Post-op Vitals - q hr until stable (per facility protocol)
Assess:
Color of skin/mucous membranes
Capillary refill
Palpate peripheral pulses
Cardiac rate and rhythm
Auscultate heart rate/rhythm/sounds
Auscultate lungs
Assess oxygen levels/administer supplemental O2 as needed
Site care, chest tube drainage, dressing
Monitor I/O hourly
Monitor IV infusion rate
Assess LOC
Obtain ordered lab tests; report abnormal results
Administer meds as ordered
Child:
Encourage to turn, cough, deep breaths
Assess pain levels and provide analgesics as needed
Assist OOB , comfortable position
Daily wts
Small, frequent meals
Pediatric Health Disorders
Cardiovascular Disorders, cont.
Acquired Heart Disease
Cause - due to an underlying condition or other cardiac disorders that
are not congenital; most common is heart failure
Heart Failure
Definition
Often due to congenital heart disease
Otherwise secondary to other conditions
Refers to a set of clinical signs and symptoms that
shows the heart's inability to pump effectively
Management for child with HF
Management is supportive
Promote oxygen:
Semi-upright position
Suctioning
Chest physiotherapy
Postural drainage
Supplemental oxygen as ordered
Monitor oxygen sat via pulse oximetry
Meds as prescribed:
Watch for s/s of digoxin toxicity
BP before/after ACE inhibitors; notify HCP if
BP falls > 15 mm Hg
Watch for s/s of hypotension
Weight daily and I/Os
Monitor K level; admin K supps if prescribed
Nutrition: cals
Infants: upwards of 150 cal/kg/day
Small, frequent feedings
Infants may require continuous or
intermittent gavage feedings
Lots of rest to minimize cardiac demand
↑
S/S
Failure to gain wt or rapid wt gain
FTT
Difficulty feeding
Fatigue
Dizziness, irritability
Exercise intolerance
SOB
Sucking then tiring quickly
Syncope
number of wt diapers
Tachycardia, tachypnea (may be first signs)
Diaphoresis, edema
Nasal flaring, retractions
Infants: difficulty feeding and tiring easily
Drinks small amount, stops, then wants to eat again soon
Perspires during feeding
Not comfortable lying flat
Possible: murmur, gallop rhythm, crackles, wheezing
Extremities: cool, clammy, pale
↓
Dx
Chest radiograph
Electrocardiogram
Echocardiogram
Physical findings
Labs: Hct, Hgb,
↓ ↓ ↓Na, ↑K
Tx
Supportive
Meds:
Digitalis
Diuretics
Inotropic agents
Vasodilators
Antiarrhythmics
Antithrombotics
May require stay in ICU
Pediatric Health Disorders
Gastrointestinal Disorders
Include:
Structural anomalies of the GI tract
Acute GI disorders
Chronic GI disorders
Physical Exam
Color:
Jaundiced skin
Icteric (yellow) sclerae
Both may indicate high bilirubin levels
related to liver dysfunction
Abdomen:
Distended veins (abdominal or vascular
obstruction)
Protuberant (bulging outward) while
lying supine (ascites, fluid retention,
gaseous distention, tumor)
Depressed (obstruction)
Muscle tone of lower esophageal sphincter
not fully developed until 1 month old
GI tract not fully developed until age 2
*Changes to note that may indicate GI disorder*
Skin:
↓turgor or skin turgor tenting (dehydration)
No tears when crying (dehydration)
Auscultate:
Hyperactive (diarrhea/gastroenteritis)
Hypoactive or absent (obstruction; report to MD or NP immediately)
Palpate:
Able to palpate kidneys (may be tumor or hydronephrosis)
Note areas of firmness or masses (tumor or stool in abdomen)
Tenderness in abdomen - not normal (may be liver enlargement or
appendicitis) * Immediately report any + findings
Stool Diversion/Ostomy
A portion of the small or large intestine is brought to
the surface of the abdomen, creating an ostomy;
usually ileostomy (from ileum) or colostomy (from
colon)
Pouches worn over the ostomy site to collect stool
Ostomy needs to be correct size and fit properly
Large
Intestine
Colostomy
Ileostomy
Small
Intestine
Management
Empty the pouch and measure for stool output several
times/day
Remove with wet washcloth or adhesive remover
Pay attention to stoma and surrounding skin (acid from
stool may burn skin)
Stoma should be moist and pink/red
Clean stoma and skin; allow to dry
Measure the stoma, mark the new pouch backing and cut
the new backing to size; apply pouch
Pouches should be changed every 1-4 days
Notify MD if:
Stool output greatly increases
Stoma is prolapsed or retracted
Educate:
Avoid tight or constricting clothing around stoma site
Store ostomy supplies in cool, dry place
Pediatric Health Disorders
Gastrointestinal Disorders, cont.
Structural Anomalies of the GI Tract
Cleft Lip and Palate
Inguinal and Umbilical Hernias
Cleft Lip and Palate
Definition
Management
Lip and/or palate do not fuse during pregnancy
Occurs often in association with other anomalies
(e.g. Heart defects, ear malformations)
Problems:
Forming seal around nipple
Excessive air intake
Gagging, choking, nasal regurgitation
All leading to insufficient growth
Tx: Repair surgery around 2-3 months (lip) and 6-9
months (palate)
Breastfeeding best option for infant due to
better suction on breast vs bottle
Post-op - protect suture line or palatal operative
site
Supine or side-lying position
Petroleum jelly
Butterfly bandage
Arm restraints may be necessary
Prevent vigorous crying
Inguinal and Umbilical Hernias
Inguinal
When processus vaginalis fails to close properly
More common in boys and premature infants
S/S: Bulging mass in lower abdomen or groin area
Tx:
Surgery when several weeks old & thriving
Reduction:
Temporary fix (done by MD or NP)
Push bulge back into inguinal ring
If reduction does not work hernia may be
incarcerated (lead to bowel strangulation)
Acute GI Disorders
Vomiting
Diarrhea
Umbilical
Incomplete closure of umbilical ring
More common in premature infants and African Americans
S/S: Bulge or swelling near navel; may only be seen when
infant cries, coughs or strains
Tx: Usually spontaneous closure by 4 yrs, if does not close
or is very large surgery (rare)
→
Management
Instruct on how to reduce; reduce as needed and notify HCP
immediately if becomes hard, discolored, or painful
Dehydration
Thrush
Hypertrophic Pyloric Stenosis
Appendicitis
Intussusception
Vomiting
Definition
3 phases:
Prodromal period - nausea and
signs of ANS stimulation
Retching
Vomiting
Considered to be a symptom of
some other condition
S/S
Questions to ask:
When vomiting occurs (will help
determine cause)
If projectile or effortless
What are contents (bilious,
bloody)
Associated with diarrhea or pain
Management
Oral rehydration; if not possible,
IV fluids and/or antiemetics
(ondansetron)
Ginger may help (over 2 years
old): capsules (10 mg), tea or
candied
Pediatric Health Disorders
Gastrointestinal Disorders, cont.
Acute GI Disorders, cont.
Diarrhea
Definition
Increase in frequency or decrease in consistency of
stool
Acute or chronic (lasts for > 2 weeks)
Cause:
Acute - virus usually, or bacteria/parasites
Risk: day care, well water, foreign travel,
undercooked meats
Dehydration
→
↑
Dx: may do stool
analysis
Tx: supportive - fluid
maintenance and
nutrition support
Focuses on restoring fluid and
electrolyte balance
Instruct on diet sources to
increase fluid intake; avoid fluids
high in glucose (fruit juice, etc)
which may worsen diarrhea
Definition
Most common result of a GI illness is dehydration
due to:
Infants/children have proportionately greater
amount of body water than adults. This results
in a greater relative fluid intake which puts
children at a greater risk of fluid loss w/illness
(due to not drinking enough fluids)
Fever increases fluid loss at a rate of ~ 7
mL/kg/24 hr pd (and children at greater risk of
fever than adults)
Newborns have 2-3x BSA ratio relative to body
mass than adults
Young infant have renal immaturity do not
concentrate urine as well as older children and
adults
Left unchecked leads to shock
Risk factors:
Diarrhea/vomiting
oral intake
Sustained fever
DB ketoacidosis
Extensive burns
↓
Management
Dx and Tx
Management
Assess hydration status:
HR, BP
Skin turgor, fontanels
Oral mucosa, eyes
Temp and color of extremities
Mental status
Urine output
Severely dehydrated:
Fontanels and eyes sunken
Oral mucosa dry
Skin tenting
HR increased moving to bradycardia
BP normal moving to hypotension
Extremities cool, mottled or dusky
Significantly decreased capillary refill
UO significantly <1 mL/kg/hr
Mild to moderate: Oral rehydration
ORS (75 mmol/L sodium chloride and 13.5 g/L glucose) (e.g.
Pedialyte, Infalyte, Ricelyte)
Not acceptable: tap water, milk, undiluted fruit juice, soup
and broth
50-100 mL/kg over 4 hrs reevaluate
Severe: IV fluids; 20 mL/kg NS or LR, then reassess
Be aware of risk of overhydration! Needs continuous evaluation
of hydration status
→
Pediatric Health Disorders
Gastrointestinal Disorders, cont.
Acute GI Disorders, cont.
Oral Candidiasis (Thrush)
Management
Definition
Fungal infection of the oral mucosa
Most common in newborns and infants
Risk: immune disorders, corticosteroid
inhalers, immune suppression, abx
Can transmit via breastfeeding
S/S
Thick, white patches on the tongue,
mucosa or palate, resembling curdled
milk; does not easily wipe off
Also look for candidal diaper rash
(beefy-red rash with lesions)
Tx: Oral antifungal agents
(Nystatin or fluconazole)
Fluconazole:
Monitor for hepatotoxicity
Give with food to N/V
side effects
Mother to receive antifungal tx
as well if she is infected
↓
Hypertrophic Pyloric Stenosis
Definition
The circular muscle of the pylorus
becomes hypertrophied
Leads to gastric outlet obstruction
which leads to nonbilious vomiting
between 3-6 weeks old
Vomiting becomes frequent, forceful,
projectile
Cause: not 100% known, probably
multifactorial
S/S
Forceful, nonbilious vomiting,
unrelated to feeding position
Hunger soon after vomiting
Wt loss
Dehydration, lethargy
May find hard, moveable 'olive' in RUQ
surgical consult required
No mass found - ultrasound may be
ordered
→
Management
Tx: Surgery
Pre-op:
Maintain fluids and correct
electrolyte imbalances
Educate family about
surgery to reduce anxiety
Post-op:
Infant return to normal
feeding after 1-2 days
Appendicitis
Definition
Acute inflammation of the appendix
Peaks in 2nd decade of life
Left untreated may rupture
Cause: Closed-loop obstruction of the
appendix; possibly fecal material
Pathophysiology:
Obstruction causes increase in
intraluminal pressure of the appendix
Leads to mucosal edema and
bacterial overgrowth
Leads to perforation
Leaks fluid and bacterial contents
into abdominal cavity leading to
peritonitis surgical emergency!
→
S/S
Gradual vague pain in RLQ (does not come and go)
N/V
Small volume, frequent soft stools
Low-grade fever (high-grade if perforated)
Palpate: very tender over McBurney's point in RLQ
↑
Dx and Tx
Dx: CT scan, Labs: WBC and
CRP
Tx:
Surgery via laparoscopic
technique
If perforated open surgical
procedure
→
Management
Surgery will be needed
If perforated, will need 7-14
days of IV abx post-op
If pain stops immediately
without intervention, suspect
perforation and notify HCP
immediately
Pediatric Health Disorders
Gastrointestinal Disorders, cont.
Acute GI Disorders, cont.
Intussusception
Definition
When a proximal segment of bowel 'telescopes' into a
more distal segment
Leads to edema, vascular compromise, partial or total
bowel obstruction
Usually occurs around 1-2 years old
Cause: a lead point may cause the telescoping (e.g. polyp,
tumor, cysts)
S/S
Sudden onset of intermittent crampy abdominal pain
Children usually draw up knees and scream
Vomiting/diarrhea
Stools - currant-jelly, gross blood, hemoccult + stools
Palpate for presence of sausage-shaped mass in upper
midabdomen *hallmark
Symptoms may flare and regress as it reduces on own
Dx and Tx
Dx: air or barium enema
Tx:
Barium enema reduces most cases
Surgical reduction for those that don't reduce
May need portion resected if surgery not
successful or if bowel necrosis has occurred
Chronic GI Disorders
GERD
PUD
Management
Bowel preparation prior to examination if ordered
Educate that stool will be light colored for a few
days
Educate about surgery if enema does not reduce
Notify HCP immediately of any bilious vomiting
(indicative of obstruction)
Constipation
IBD
GERD
Celiac Disease
S/S
Definition
Gastroesophageal reflux disease
Gastric contents move into
esophagus causing complications
(due to the damage of the
refluxate)
Common during 1st year of life
Usually resolves by 12-18 months
May lead to esophagitis,
esophageal stricture, Barrett
esophagus, anemia, laryngitis,
asthma, recurrent pneumonia
Conservative:
Elevate HOB
Upright for 30 min after eating
Smaller, more frequent meals
Recurrent vomiting or regurgitation
Not all children will vomit
Wt loss or poor wt gain
Irritability (infants)
Respiratory symptoms
Hoarseness/sore throat
Halitosis
Heartburn
Abdominal pain
Abnormal neck posturing (Sandifer
syndrome)
Dysphagia
Poor dentition
↓
Tx
Meds to acid production and to
empty stomach quicker
Surgery if meds don't work (e.g.
Nissen fundoplication)
Management
Educate:
Proper feeding position and
amount
Burping
Thicken formula w/rice or
oatmeal cereal
Keep upright 30-45 minutes
after feeding
No swings or infant seats (puts
ab pressure)
Maintain airway
Postop: gastrostomy tube care and
slow feedings once bowel sounds
heard and HCP allows
Dx
Upper GI series
Esophageal pH probe
EGD
CBC
Hemoccult
Pediatric Health Disorders
Gastrointestinal Disorders, cont.
Chronic GI Disorders, cont.
PUD - Peptic Ulcer Disease
Tx
Definition
Disorders of the upper GI tract resulting from
gastric secretions
Mucosal inflammation and ulceration occur
Primary ulcers:
Due to H. pylori bacteria
Found mostly in duodenum
Secondary ulcers:
Due to stress, meds, excess acid
production, etc
Found mostly in stomach
Dx
Antibody testing
Urea breath test
Biopsy
Upper GI series
Upper endoscopy
Abx if due to H. pylori, or
Histamine agonists or
Proton pump inhibitors
If esophageal or gastric
hemorrhage:
NG tube placed to
decompress stomach
May require IV line for H2blockers or PPIs
S/S
Ab pain (most common)
Vomiting
GI bleeding
Pain - worse after meals;
wakes child at night;
periumbilical or epigastric
Occ. blood in stool
Management
Educate:
Medications
Dietary (determining which foods affect stomach)
Safety (in case of child ingesting substances)
Stressors (decrease as much as possible)
Constipation
Definition
Failure to completely evacuate the
lower colon
Bowel habits will vary with all children
Encopresis Soiling of fecal contents into the
underwear beyond 4-5 years old
Often seen as result of chronic
constipation and withholding of
stool
Stool withholding rectal muscle
stretched fecal impactions
Cause: constipation in children is
usually from withholding it, not from a
disease or organic cause (e.g. spina
bifida)
→
→
S/S
Altered stooling patterns
Pain w/defecation
Withholding behaviors
Abdominal pain/cramping
Poor appetite
Diarrhea leakage
Soiling of undergarments
Dx
If organic cause is suspected:
Stool sample for blood
Sitz marker study
Barium enema
Rectal manometry or
suction biopsy
Tx
Rule out disease/organic cause first
Then treat with fiber, fluids
May need laxative therapy
Management
Educate:
Identify withholding
Help recondition child:
Sit on toilet 2x/day for 5-15
minutes (after breakfast
and dinner)
Positive reinforcement
Dietary changes ( fiber and
fluids)
Enema instructions if needed
Medication instructions
↑
Pediatric Health Disorders
Gastrointestinal Disorders, cont.
Chronic GI Disorders, cont.
Tx
Inflammatory Bowel Disease (IBD)
Definition
Consists of both Crohn's disease and ulcerative colitis (UC)
Both are chronic inflammatory disorders of the GI tract
Cause unknown; possibly immunologic or inflammatory
response to trigger such as virus or bacterium
Onset - usually 10+ years
Dx
Rectal exam
Upper GI series w/ small bowel series
Crohn's - usually has skin tags/fissures in
perianal area
Upper endoscopy or colonoscopy
CT scan
Meds:
5-ASA (to prevent relapse-UC)
Abx (Crohn's)
Immunomodulators (maintain remission)
Cyclosporine (maintain remission in UC)
Methotrexate (to manage Crohn's)
Anti-tumor necrosis antibody therapy (Crohn's)
Surgery if does not respond to meds
Management
S/S
Ab cramping
Waking at night due to pain
Fever
Wt loss
Poor growth
Delayed sexual development
Educate:
About disease
Nutrition: Pro and carb, no lactose,
vits and Fe supplements
Administer prescribed meds
Help set up counseling
↑
Celiac Disease
Definition
AKA Celiac sprue
Immunologic disorder in which gluten
causes damage to the small intestine
The villi of the small intestine are
damaged due to the body's immunologic
response to digestion of gluten
The damaged villi are unable to absorb
nutrients leading to malnutrition
Dx
Blood tests (for antibodies)
Small bowel biopsy
May do genetic testing
S/S
Diarrhea
Steatorrhea (fatty stools)
Constipation
FTT or wt loss
Ab distention/bloating
Poor muscle tone
Irritability
Listlessness
Anemia
Delayed onset of puberty
Typical appearance:
Distended abs
Wasted buttocks
Very thin extremities
Tx
Strict gluten-free diet
Management
Instruct on gluten-free diet, avoid:
All wheat products
Breaded vegetables, canned
baked beans
Malted milk, flavored or
frozen yogurt
Commercial salad dressing,
prepared soups, condiments,
sauces, etc
Dietitian consult
Pediatric Health Disorders
Genitourinary Disorders
Urethra naturally shorter in all women than men therefore
increased risk of bacteria entering bladder via urethra
In infants or young girls this risk also increased by
proximity of urethral opening to rectum
Boy's urethra much shorter than man's
Any child with congenital urologic malformations at high
risk for development of latex allergy (may end in
anaphylaxis)
Therefore primary prevention of latex allergy is necessary
in all children with urologic malformations
Latex-free gloves, tubes, catheters
Urinary frequency - needing to void often
Urinary urgency - urge to void immediately
Dysuria - difficulty or pain with voiding
Hematuria - blood in urine
Double diapering - used to protect the urethra and stent or
catheter after surgery; inner (smaller) diaper keeps stool,
outer keeps urine. Slit cut in inner diaper for stent or
catheter
Urine output:
Infant: 0.5-2 mL/kg/hr
I year old: 400-500 mL/d
Teen: 800-1400 mL/d
Urinary Tract Infection
Definition
Infection of the urinary tract (usually
affects the bladder)
Cause: most often caused by bacteria
ascending to the bladder via the urethra;
urinary stasis and decreased fluid intake
may contribute
Untreated may lead to pyelonephritis
Infants have different sign/symptoms
than children
Tx
Oral or IV abx
Hospitalization and IV abx for:
< 3 months old
Dehydrated
Toxic appearance
Sepsis
Protracted vomiting related to UTI
Suspected pyelonephritis
Increased fluid intake
Fever management
S/S
Infants
Fever
Irritability
Vomiting
FTT
Jaundice
Children
Fever/chills
N/V
Dysuria
Frequency
Hesitancy
Urgency
Pain (ab/back/flank)
Lethargy
Foul-smelling urine
Burning/stinging with
urination
Enuresis in previously
toilet-trained child
↑
Dx
Urinalysis
Urine culture and sensitivity to determine
bacteria
Management
Administer oral/ IV abx and/or IV fluids as
ordered
Administer antipyretics if ordered
Instruct to increase oral fluid intake and
void often
Encourage voiding in sitz or tub bath
Instruct to prevent UTIs:
Drink enough fluids
Drink cranberry juice (acidifies urine)
Avoid colas and caffeine
Urinate frequently
Avoid bubble baths/tight jeans or pants
Wipe front to back
Wear cotton underwear
Wash perineal area daily w/soap & H2O
Change sanitary pads frequently
Pediatric Health Disorders
Genitourinary Disorders, cont.
Enuresis
Tx
Definition
Continued incontinence of urine past the age of toilet training
Primary - child has never achieved voluntary bladder control
Secondary - child previously achieved bladder control over a period
of at least 3-6 consecutive months
Diurnal - daytime loss of urinary control
Nocturnal - nighttime bedwetting
Nocturnal usually subsides by 6 years old; if not, further
investigation/treatment is warranted
May occur secondary to a physical disorder (e.g. diabetes mellitus or
insipidus, sickle cell)
Other causes: UTI, constipation, emotional distress
Daytime mostly due to dysfunctional voiding or holding of urine
Nocturnal may be due to increased fluid intake in evenings, inappropriate
family expectations, sexual abuse
Physical cause treated if applicable
Behavioral tx for all others
Meds if child is older and behavioral
treatments do not work
Management
Administer meds if prescribed
Diurnal - drink more during day and set fixed
schedule to void
Nocturnal Decrease fluid intake before bedtime
Limit chocolate and caffeine
Wake child to void at 11 p.m.
Use enuresis alarm
Encourage parents not to shame child
Neuromuscular and Musculoskeletal Disorders
Myelinization completed by 2 years old
Infant muscle mass = 25% total body weight; 40% for adult
Infants and young children - bones more flexible and
porous; therefore will bend rather than break
Epiphysis - end of a long bone
Casts
Definition
Used to immobilize a bone that has been injured or a
diseased joint
Gore-Tex - may be used in casts to make them
waterproof; cannot be used for all types of fractures;
may not be covered by insurance
Management
Before cast application:
Note:
Color (cyanosis or other discoloration)
Movement (note inability to move toes/fingers)
Sensation (loss anywhere?)
Edema
Quality of pulses
Premedicate as ordered
Discuss process with child
Physis - cartilaginous area connected to epiphysis
Epiphysis + physis = 'growth plate'
Growth plate is where growth occurs; traumatic force to
this area may affect growth
Children's bones heal quicker than adults
Management
During: Use distractions for child
After:
Allow to dry
Neurovascular checks to check for:
Increased pain
Increased edema
Pale or blue skin color
Skin coolness
Numbness/tingling
Prolonged capillary refill
Decreased strength or absent pulse
If plaster cast use moleskin or soft
material around edge (petaling)
Ice for 24-48 hrs
Elevate on pillow
Instruct on crutches
Pediatric Health Disorders
Neuromuscular and Musculoskeletal Disorders, cont.
Developmental Dysplasia of the Hip (DDH)
Definition
Abnormalities of the developing hip: dislocation,
subluxation, dysplasia of the hip joint
Femoral head does not align with acetabulum:
Frank dislocation - no contact
Subluxation - partial dislocation
Dysplasia - acetabulum that is shallow or
sloping (not cup-shaped)
Hip may not develop normally if femoral head
not seated properly within acetabulum
Leads to limited abduction of the hip and
contracture of muscles
More common in females
Cause:
Genetic
Higher incidence in Native Americans and
Eastern European descent
Possibly: oligohydramnios, breech position
Management
Instruct on use of harness and assessing skin
around harness
Post-surgery care similar to cast management
Scoliosis
Dx and Tx
Dx: Ultrasound of hip; hip x-rays if > 6 months old
Tx:
Goal: maintain hip joint in reduction while femoral head and
acetabulum develop properly
<6 months old will wear Pavlik harness fulltime for ~ 3
months
6 months - 2 years closed reduction (manipulate femur back
into position, under general anesthesia)
Followed by cast for 12 weeks
Then abduction brace fulltime
Then brace at night until acetabulum developed
>2 years open surgical reduction and period of casting
→
→
→
On assessment note:
In prone position, asymmetry of thighs or gluteal folds
Limb-length discrepancy
Knee height unequal (legs bent in supine position)
ROM on each side (abduction) not equal
Trendelenburg gait (trunk shifts over affected side
while walking)
'Clunk' noise when performing Barlow and Ortolani
tests
Definition
Lateral curvature of the spine that exceeds 10°
Congenital, associated with other disorders, or idiopathic (unknown cause)
Idiopathic most common, AKA adolescent idiopathic scoliosis
Results in:
Asymmetry of the shoulder and waistline
Displacement of the ribs and rib asymmetry
Changes in the shape of the thoracic cage
Respiratory and cardiovascular compromise may occur
Dx and Tx
Dx: Full-spine radiographs
Tx: Goal: prevent progression of
the curve and decrease impact on
pulmonary and CV function
Tx based on age, severity of
curve, expected future growth
Curve 25-45° will need bracing
Curve >45° will need surgery
S/S
No pain - just mild discomfort
On assessment note:
Posture: asymmetry in
shoulders, waist, ribs
Observe from behind: child
bends forward w/arms
hanging freely; note if 'hump'
on one side
Observe leg-length
S/S
Management
Discuss compliance to wearing brace with
adolescent
Inspect skin for rubbing from brace
Instruct on proper fit and to check daily
for proper fit and rubbing
Post-surgery:
Neurovascular checks when checking
vitals
Log-roll technique to avoid flexion of
back
No back flexion or extension allowed
Provide pain meds as prescribed
Provide prophylactic abx if prescribed
Assess for drainage from operative
site and excess blood loss
Confined to bed for 1st few days
Maintain Foley patency
I/Os
Pediatric Health Disorders
Integumentary Disorders
Child's epidermis thinner than adult's and blood vessels lie
closer to surface. Therefore:
Children lose heat faster
Children absorb substances faster
Bacteria gain access quicker
Less pigmentation = higher risk of UV damage
Bacterial Infections
Definition
Skin infections usually caused by S. aureus or group A
ß - hemolytic streptococcus
Impetigo:
Nonbullous - from skin trauma or other bacterial
infections; has crusting
Bullous - from toxin produced by S. aureus
Periorbital cellulitis:
Bacterial infection of the eyelids and tissue
surrounding eye; redness, swelling
CA-MRSA: (Community-acquired MRSA)
Caused by methicillin-resistant S. aureus (MRSA)
If rash does not respond to tx, culture for MRSA
Staphylococcal scalded skin syndrome (SSSS):
Toxin produced by S. aureus causes exfoliation
leading to erythema (reddening of the skin)
Administer abx as ordered
Educate family:
Cleansing infection
Applying abx
Proper hygiene to avoid future infections
Isolate children as necessary
Fungal Infections
Definition and S/S
Tinea - fungal disease of the skin
Tinea pedis - of the foot (athlete's foot)
Rash on soles of feet and between toes
Tinea corporis - arms/legs *contagious
Ringworm
Circular red lesion with clearing in center
Tinea versicolor - trunk and extremities
Hypopigmented scaly lesions
Tinea capitis - scalp, eyebrows, eyelashes
Breakage and loss of hair
Tinea cruris - groin
Erythema, scaling, maceration in creases
Dark-skinned children:
Healed area see hypo or hyperpigmentation
often (temporary or permanent)
Have more prominent papules, hypertrophic
scarring and keloid formation
Dx and Tx
Dx: Clinical presentation and possibly blood culture
Tx:
Topical or systemic abx
Appropriate cleansing of infection
Periorbital cellulitis: IV abx during acute phase
followed by oral abx; warm soaks 20 min q 2-4 hrs
Impetigo: soak lesions with cool compress to
remove crusts before applying abx
SSSS: No corticosteroids; apply soothing ointments
MRSA: isolation
S/S
Depends on type of infection: Visual rash, edema,
exfoliation, crusting, fever, papules, erythema,
lymphadenopathy
Management
Notify HCP immediately if:
Conjunctival redness
Change in vision
Pain with eye movement
Eye muscle weakness or paralysis
Proptosis
Management
Tx is antifungals; administer as ordered
Tinea corporis - allowed to return to school once
treatment has begun
Tinea capitis - hair will regrow in 3-12 months;
wash sheets and clothes in hot water
Tinea pedis - keep feet clean and dry; flip-flops
around pools and locker rooms
Tinea versicolor - skin pigmentation will return to
normal within several months
Tinea cruris - wear cotton underwear and loose
clothing
Pediatric Health Disorders
Integumentary Disorders, cont.
Atopic Dermatitis
Tx
Definition
AKA eczema
Chronic disorder - extreme itching and inflamed,
reddened swollen skin
Associated with food allergies, allergic rhinitis,
asthma; response to allergen (food/environment)
Inflamed, reddened, swollen skin
Erythema, warmth
Wiggling or scratching
Dry skin
Irritability
Red, dry, scaly skin
Wheezing - if associated with asthma
<2 years old: on face, scalp, wrists
>2 years old: often in flexor areas
Skin hydration
Topical corticosteroids/immune modulators
Oral antihistamines
Abx (if secondary infection occurs)
S/S
Diaper Dermatitis
AKA diaper rash
Cause: response to skin irritant
S/S: erythema, maceration, flat, red rash in the
convex skin creases, red and shiny
Cause: possibly C. albicans
Tx: go diaperless if possible for period of time
each day; blowdry diaper area on low 3-5
minutes
Prevention - provide barrier; ointment and
creams, zinc oxide and petroleum
Urticaria (Hives)
Immunological response
Cause: foods, drugs, animal stings, infections,
environmental stimuli, stress
S/S: edematous hives, prurutic, blanch when
pressed, may migrate
Tx:
Remove trigger
Discontinue abx if on any
Administer antihistamines,
corticosteroids, topical antipruritics
Dx
IgE levels may be
increased
Skin prick allergy
tests
Management
Instruct:
Avoid:
Hot water
Skin, hair products with perfumes, dyes, fragrances
Tight clothing; synthetic fabrics or wool
Use mild soap
Do not rub skin; leave moist
Administer ointments/creams
Moisturizer over ointments (e.g. Aquafor, Eucerin)
Moisturize multiple times/day
May use antihistamine at bedtime to stop nighttime itching
Contact Dermatitis
Occurs 24-48 hrs after exposure or contact with substance
Cause: possibly - nickel/cobalt in clothes; chemicals in hygiene
products/cosmetics; plants
Not contagious
Does not spread, may get worse with itching
S/S: rash that varies depending on offending substance:
pruritic, vesicular, lesions may be weeping, some may be
crusted over; asymmetric linear pattern
Tx: corticosteroids
Management for lesions:
Wash daily with mild soap
Lightly debride crusted lesions
Tepid baths; no hot water
Do not cover lesions unless weeping
Apply corticosteroids
No topical antihistamines, benzocaine, or neomycin