NUR2310 Exam #1 Blueprint - 60 questions total
Growth & Development
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Object permanence
o Piaget: sensorimotor stage (birth to 24 months)
 Infants progress from reflexive to simple repetitive to imitative activities
 Separation, object permanence, mental representation - 3 important tasks accomplished in this
stage
 Separation: Infants learn to separate themselves from other objects in the environment
 Object permanence: Process where infants learn that an object still exists when it is out of
view this occurs at approximately 9 to 10 months of age
 Mental representation: The ability to recognize and use symbols
o Piaget: Sensorimotor stage transitions to the preoperational stage around 2 years of age
 The concept of object permanence becomes fully developed
Play: parallel, associative, therapeutic, cooperative
o Play should provide interpersonal contact and educational stimulation
o Infants have short attention spans and will not interact with other children during play (solitary play)
 Appropriate toys and activities that stimulate the senses and encourage development include:
 Rattles
 Soft stuffed toys
 Teething toys
 Nesting toys
 Playing pat-a-cake
 Playing with balls
 Reading books
 Mirrors
 Brightly colored toys
 Playing with blocks
o Solitary play evolves into parallel play, in which toddlers observe other children and then might engage in
activities nearby
 Appropriate activities
 Filling and emptying containers
 Playing with blocks
 Looking at books
 Push-pull toys
 Tossing balls
 Finger paints
 Large-piece puzzles
 Thick crayons
o Parallel play shifts to associative play during the preschool years. Play is not highly organized, but
cooperation does exist between children
 Appropriate activities include:
 Playing ball
 Putting puzzles together
 Riding tricycles
 Playing pretend and dress-up activities
 Role playing
 Hand puppets
 Painting
 Simple sewing
 Reading books
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 Wading pools
 Sand boxes
 Skating
 Computer programs
 Musical toys
 Electronic games
o Therapeutic Play
 Makes use of dolls and/or stuffed animals
 Encourages the acting out of feelings of fear, anger, hostility, and sadness
 Enables the child to learn coping strategies in a safe environment
 Assists in gaining cooperation for medical treatment
o Competitive and cooperative play is predominant
 Children from 6 To 9 Years of Age
 Play simple board and number games
 Play hopscotch
 Jump rope
 Collect rocks, stamps, cards, coins, or stuffed animals
 Ride bicycles.
 Build simple models
 Join organized sports (for skill building)
 Children from 9 To 12 Years of Age
 Make crafts
 Build models
 Collect things/engage in hobbies
 Solve jigsaw puzzles
 Play board and card games
 Join organized competitive sports
Car seat safety in infants
o Newborn infants should be placed in a federally approved car seat at a 45-degree angle to prevent slumping
and airway obstruction. The car seat is placed rear facing in the rear seat of the vehicle and secured using
the safety belt. The shoulder harnesses are placed in the slots at or below the level of the infant’s shoulders.
The harness should be snug, and the retainer clip placed at the level of the infant’s armpits
o Infants and toddlers remain in a rear-facing car seat until the age of 2 years, or the height recommended by
the manufacturer
o The safest area for infants and children is the backseat of the car
o Do not place rear-facing car seats in the front seat of vehicles with passenger airbags
Accident prevention strategies in toddlers
o Aspiration of foreign objects
 Small objects (grapes, coins, colored beads, candy) that can become lodged in throat should
be avoided
 Toys that have small parts should be kept out of reach
 Age-appropriate toys should be provided
 Clothing should be checked for safety hazards (loose buttons)
 Balloons should be kept away from toddlers
 Parents should know emergency procedures for choking
o Bodily harm
 Sharp objects should be kept out of reach
 Firearms should be kept in locked boxes or cabinets
 Toddlers should not be left unattended with any animals present
 Toddlers should be taught stranger safety
o Burns
 The temperature of bath water should be checked
 Thermostats on hot water heaters should be turned down to less than 49° C (120° F)
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Working smoke detectors should be kept in the home
Pot handles should be turned toward the back of the stove
Electrical outlets should be covered
Toddlers should wear sunscreen when outside
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Toddlers should not be left unattended in bathtubs.
Toilet lids should be kept closed
Toddlers should be closely supervised when near pools or any other body of water
Toddlers should be taught to swim
Drowning
Falls
 Doors and windows should be kept locked
 Crib mattresses should be kept in the lowest position with the rails all the way up
 Safety gates should be used across the top and bottom of stairs
o Motor-vehicle injuries
 Infants and toddlers remain in a rear-facing car seat until the age of 2 years or the height
recommended by the manufacturer
 Toddlers over the age of 2 years, or who exceed the height recommendations for rear-facing
car seats, are moved to a forward-facing car seat
 Safest area for infants and children is the backseat of the car
 Do not place rear-facing car seats in the front seat of vehicles with deployable passenger
airbags.
o Poisoning
 Exposure to lead paint should be avoided
 Safety locks should be placed on cabinets that contain cleaners and other chemicals
 The phone number for a poison control center should be kept near the phone
 Medications should be kept in childproof containers, away from the reach of toddlers
 A working carbon monoxide detector should be placed in the home
o Suffocation
 Plastic bags should be avoided
 Crib mattresses should fit tightly
 Crib slats should be no farther apart than 6 cm (2.375 in)
 Pillows should be kept out of cribs
 Drawstrings should be removed from jackets and other clothing
Medication administration
o IM injection in a toddler
 Intramuscular
 Use a 22- to 25-gauge, 1⁄2- to 1-inch needle
 Vastus lateralis is the recommended site in infants and small children
 Position the child supine, side-lying, or sitting
 Many risks, so verify the injection is justified
 Angle of administration: 90 degrees
 Amount
o Children, older adults, thin patients: up to 2 mL
o Small children and older infants: up to 1 mL
o Smaller infants: up to 0.5 mL
 Ventrogluteal
 Position the child supine, side-lying, or prone
 Inject 0.5 to 1 mL, depending on muscle size of infant
 Inject up to 2 mL in children
 Deltoid
 Explain the procedure to the child and guardians
 Position the child sitting or standing
 Inject up to 1 mL
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Provide atraumatic care
o Apply lidocaine and prilocaine topical ointment to the site for 60 min prior to
injection.
o Change needle after puncturing a rubber stopper
o Use the smallest gauge of needle possible
o Use therapeutic hugging
o Secure the child firmly to decrease movement of the needle while injecting
o Use distraction
o Encourage guardians to hold the child after
o Offer praise
o Use play therapy
o Offer sucrose pacifiers to infants
Medication compliance in adolescence
 Low compliance
 use of negotiations and agreements with adolescence may increase compliance
 firmness, gentleness, choices, and respect must all be balanced during care of adolescence
Fluid maintenance calculations
 For the first 10 kg of body weight
 100 mL /kg
 For the next 10 kg of body weight
 50 mL / kg
 For each kg above 20 kg of body weight
 20 mL / kg
 Example: The order is for IV fluid maintenance for a child who weighs 35 kg.
 35 – 10 = 25
25 – 10 = 15
 (10 x 100) + (10 x 50) + (15 x 20) =
Hospitalization
o Regression
 During stress, insecurity, or illness, preschoolers can regress to previous immature behaviors or
develop habits (nose picking, bed-wetting, thumb sucking)
 Families and children can experience major stress related to hospitalization. The nurse should
monitor for evidence of stress and intervene as appropriate.
o Separation anxiety during hospitalization manifests in three behavioral responses.
 Protest: screaming, clinging to parents, verbal and physical aggression toward strangers
 Despair: withdrawal from others, depression, decreased communication, developmental regression
 Detachment: interacting with strangers, forming new relationships, happy appearance
o Impact of Hospitalization
 Experiences separation anxiety (Toddler and Preschooler)
 Behavior can regress (Toddler)
Separation anxiety begins around 4 to 8 months. Infants will protest when separated from parents, which
can cause considerable anxiety for parents. By 11 to 12 months, infants are able to anticipate the mother’s
imminent departure by watching the behaviors
o Stranger fear becomes evident between 6 and 8 months of age, when infants can discriminate between
familiar and unfamiliar people
o Preschoolers generally do not exhibit stranger anxiety and have less separation anxiety.
Psychosocial Theories (Erikson, Freud, Piaget, Kohlberg)
o Freud
 early childhood experiences form the unconscious motivation for actions in later life
 sexual energy is centered in specific parts of the body at certain ages
 Unresolved conflict and unmet needs at a certain stage lead to a fixation of development at that
stage
 Oral (Birth to 1 Year)
o The infant derives pleasure largely from the mouth, with sucking and eating as
primary desires.
 Anal (1 to 3 Years)
o The young child’s pleasure is centered in the anal area, with control over body
secretions as a prime force in behavior.
 Phallic (3 to 6 Years)
o Sexual energy becomes centered in the genitalia as the child works out relationships
with parents of the same and opposite sexes.
 Latency (6 to 12 Years)
o Sexual energy is at rest in the passage between earlier stages and adolescence.
 Genital (12 Years to Adulthood)
o Mature sexuality is achieved as physical growth is completed and relationships with
others occur.
o Erikson
 Trust Versus Mistrust (Birth to 1 Year)
o The task of the first year of life is to establish trust in the people providing care.
Trust is fostered by provision of food, clean clothing, touch, and comfort. If basic
needs are not met, the infant will eventually learn to mistrust others.
o Achieving this task is based on the quality of the caregiver-infant relationship and
the care received by the infant
o The infant begins to learn delayed gratification. Failure to learn leads to mistrust
o Trust is developed by meeting comfort, feeding, stimulation, and caring needs
o Mistrust develops if needs are inadequately or inconsistently met, or if needs are
continuously met before being vocalized by the infant
 Autonomy Versus Shame and Doubt (1 to 3 Years).
o The toddler’s sense of autonomy or independence is shown by controlling body
excretions, saying no when asked to do something, and directing motor activity and
play. Children who are consistently criticized for expressions of autonomy or for lack
of control—for example, during toilet training—will develop a sense of shame about
themselves and doubt in their abilities
o Independence is paramount for toddlers, who are attempting to do everything for
themselves.
o Toddlers often use negativism, or negative responses, as they begin to express their
independence.
o Ritualism, or maintaining routines and reliability, provides a sense of comfort for
toddlers as they begin to explore the environment beyond those most familiar to
them
 Initiative Versus Guilt (3 to 6 Years)
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The young child initiates new activities and considers new ideas. This interest in
exploring the world creates a child who is involved and busy. Constant criticism, on
the other hand, leads to feelings of guilt and a lack of purpose.
o Preschoolers become energetic learners, despite not having all of the physical
abilities necessary to be successful at everything
o Guilt can occur when preschoolers believe they have misbehaved or when they are
unable to accomplish a task
o Guiding preschoolers to attempt activities within their capabilities while setting
limits is appropriate
Industry Versus Inferiority (6 to 12 Years)
o The middle years of childhood are characterized by development of new interests
and by involvement in activities. The child takes pride in accomplishments in sports,
school, home, and community. If the child cannot accomplish what is expected,
however, the result will be a sense of inferiority.
o A sense of industry is achieved through the development of skills and knowledge
that allows the child to provide meaningful contributions to society
o A sense of accomplishment is gained through the ability to cooperate and compete
with others
o Children should be challenged with tasks that need to be accomplished, and be
allowed to work through individual differences in order to complete the tasks
o Creating systems that reward successful mastery of skills and tasks can create a
sense of inferiority in children unable to complete the tasks or acquire the skills
o Children should be taught that not everyone will master every skill
Identity Versus Role Confusion (12 to 18 Years)
o In adolescence, as the body matures and thought processes become more complex,
a new sense of identity, or self, is established. The self, family, peer group, and
community are all examined and redefined. The adolescent who is unable to
establish a meaningful definition of self will experience confusion in one or more
roles of life.
o Adolescents often try different roles and experiences to develop a sense of personal
identity, and come to view themselves as unique individuals
o Group identity: Adolescents become part of a peer group that greatly influences
behavior
Piaget
 Sensorimotor (Birth to 2 Years)
 Infants learn about the world by input obtained through the senses and by their motor
activity. Six substages are characteristic of this stage.
 Infants progress from reflexive to simple repetitive to imitative activities
 Separation, object permanence, mental representation - 3 important tasks accomplished in
this stage
o Separation: Infants learn to separate themselves from other objects in the
environment
o Object permanence: Process where infants learn that an object still exists when it is
out of view this occurs at approximately 9 to 10 months of age
o Mental representation: The ability to recognize and use symbols
 Use of Reflexes (Birth to 1 Month)
 The infant begins life with a set of reflexes such as sucking, rooting, and grasping. By using
these reflexes, the infant receives stimulation via touch, sound, smell, and vision. The
reflexes thus pave the way for the first learning to occur.
 Primary Circular Reactions (1 to 4 Months)
 Once the infant responds reflexively, the pleasure gained from that response causes
repetition of the behavior. For example, if a toy grasped reflexively makes noise and is
interesting to look at, the infant will grasp it again.
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Coordination of Secondary Schemes (8 to 12 Months)
 Intentional behavior is observed as the infant uses learned behavior to obtain objects,
create sounds, or engage in other pleasurable activities. object permanence (the knowledge
that something continues to exist even when out of sight) begins when the infant
remembers where a hidden object is likely to be found; it is no longer “out of sight, out of
mind.” However, the concept of object permanence is not fully developed. The infant knows
the parent well, objects to new people, and seems very worried when the parent leaves.
Other caretakers may be rejected because the infant does not understand that the parent
will return. This phase of “stranger anxiety” is quite common and heralds the infant’s
growing recognition of and desire to be cared for by the parent.
Tertiary Circular Reactions (12 to 18 Months)
 Curiosity, experimentation, and exploration dominate as the toddler tries out actions to
learn results. At this age, children turn objects in every direction, place them in their
mouths, use them for banging, and insert them in containers as they explore their qualities
and uses.
Mental Combinations (18 to 24 Months)
 Language pro- vides a new tool for the toddler to use in understanding the world. Language
enables the child to think about events and objects before or after they occur. Object
permanence is now fully developed as the child actively searches for objects in vari- ous
locations and out of view. The child who has had success- ful separations from the parents
followed by their return, such as hours spent in another’s home or childcare center, begins
to understand that the missing parent will return.
Preoperational (2 to 7 Years)
 The young child thinks by using words as symbols, but logic is not well developed. Two substages characterize this stage.
 The concept of object permanence becomes fully developed
 Toddlers have and demonstrate memories of events that relate to them
 Domestic mimicry (playing house) is evident
 Preoperational thought does not allow for toddlers to understand other viewpoints, but it
does allow them to symbolize objects and people to imitate previously seen activities
 The preconceptual thought transitions to the phase of intuitive thought around the age of 4
years
 The phase of intuitive thought lasts until the age of 7 years
o The preschooler moves from totally egocentric thoughts to social awareness and the
ability to consider the viewpoints of others
o Preschoolers make judgments based on visual appearances
o Variations in thinking during this age include:
 Magical thinking: Thoughts are all powerful and can cause events to occur
 Animism: Ascribing lifelike qualities to inanimate objects
 Centration: Focus on one aspect instead of considering all possible
alternatives
 Time: Preschoolers begin to understand the sequence of daily events. Time
is best explained to them in relation to an event. By the end of the
preschool years, children have a better comprehension of time-oriented
words
Preconceptual Substage
 During the preconceptual sub- stage (2 to 4 years), vocabulary and comprehension increase
greatly but the child is egocentric (i.e., unable to see things from the perspective of
another).
Intuitive Substage
 In the intuitive substage (4 to 7 years), the child relies on transductive reasoning (drawing
conclusions from one general fact to another). For example, when a child disobeys a parent
and then falls and breaks an arm that same day, the child may ascribe the broken arm to
bad behavior.
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Cause-and-effect relationships are often unrealistic or a result of magical thinking (the belief
that events occur because of thoughts or wishes).
 Additional characteristics noted in the thought of preschoolers include centration, or the
ability to consider only one aspect of a situation at a time, and animism, or giving life to
inanimate objects because they move, make noise, or have certain other qualities.
 Concrete Operational (7 to 11 Years)
 Transductive reasoning has given way to a more accurate understanding of cause and effect.
The child can reason quite well if concrete objects are used in teaching or experimentation.
The concept of conservation (that matter does not change when its form is altered) is
learned at this age.
 Transitions from perceptual to conceptual thinking
 Masters the concept of conservation:
o Conservation of mass is understood first, followed by weight, and then volume
 Learns to tell time
 Classifies more complex information
 Able to see the perspective of others
 Able to solve problems
 Formal Operational (11 Years to Adulthood)
 Fully mature intellectual thought has now been attained. The adolescent can think
abstractly about objects or concepts and consider different alternatives or outcomes
 Able to think through more than two categories of variables concurrently
 Capable of evaluating the quality of their own thinking
 Able to maintain attention for longer periods of time
 Highly imaginative and idealistic
 Increasingly capable of using formal logic to make decisions
 Think beyond current circumstances
 Able to understand how the actions of an individual influence others
 Able to think in terms of abstract possibilities and hypothetical situations
o Kohlberg
 Preconventional (4 to 7 Years)
 Decisions are based on the desire to please others and to avoid punishment.
 Early preschoolers continue in the good-bad orientation of the toddler years, and actions
are taken based on whether or not it will result in a reward or punishment
 Older preschoolers primarily take actions based on satisfying personal needs, yet are
beginning to understand the concepts of justice and fairness
 Conventional (7 to 12 Years)
 Conscience, or an internal set of standards, becomes important. Rules are important and
must be followed to please other people and “be good.”
 Postconventional (12 Years and Older)
 The individual has internalized ethical standards on which to base decisions. Social
responsibility is recognized. The value in each of two differ- ing moral approaches can be
considered and a decision made
Pain assessment
o Age appropriate assessment tools
 Assessment of pain depends on the child’s cognitive, emotional, and physical development
 FLACC: 2 months to 7 years
o Pain rated on a scale of 0 to 10. Assess behaviors of the child.
o FACE (F)
 0: Smile or no expression
 1: Occasional frown or grimace, withdrawn
 2: Frequent or constant frown, clenched jaw, quivering chin
o LEGS (L)
 0: Relaxed or normal position
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 1: Uneasy, restless, tense
 2: Kicking or legs drawn up
o ACTIVITY (A)
 0: Lying quietly, moves easily, normal position
 1: Squirming, shifting, tense
 2: Arched, ridged, or jerking
o CRY (C)
 0: No cry
 1: moans or whimpers, occasional complaints
 2: Crying, screaming, sobbing, frequent complaints
o CONSOLABILITY (C)
 0: Content or relaxed
 1: Reassured by occasional touching or hugging. Able to distract
 2: Difficult to console or comfort
Numeric scale: 5 years and older
o Pain rated on a scale of 0 to 10.
o Explain to the child that 0 means “no pain” and 10 means “worst pain.”
o Have the child verbally report a number or point to their level of pain on a visual
scale.
FACES: 3 years and older
o Pain rated on a scale of 0 to 5 using a diagram of six faces.
o Substitute 0, 2, 4, 6, 8, 10 for 0 to 5 to convert to the 0 to 10 scale.
o Explain each face to the child; ask the child to choose a face that best describes how
they are feeling.
o 0: No hurt
o 1: Hurts a bit
o 2: Hurts a little more
o 3: Hurts even more
o 4: Hurts a whole
o 5: Hurts worst
Oucher: 3 to 13 years
o Pain rated on a scale of 0 to 5 using six photographs.
o Substitute 0, 2, 4, 6, 8, 10 for 0 to 5 to convert to the 0 to 10 scale.
o Have the child organize the photographs in order of no pain to the worst pain; ask
the child to choose a picture that best describes how they are feeling.
o 0: No hurt
o 1: Hurts a bit
o 2: Hurts a little more lot
o 3: Hurts even more
o 4: Hurts a whole lot
o 5: Hurts worst
Non-communicating children’s pain checklist: 3 years and older
o Behaviors are observed for 10 min.
o Six subcategories are each scored on a scale 0 to 3.
o 0: Not at all
o 1: Just a little
o 2: Fairly often
o 3: Very often
o SUBCATEGORIES
 Vocal
 Facial
 Body and limbs
 Social
 Activity
 Physiological
CUTOFF SCORES
 11 or higher indicates moderate to severe pain.
 6 to 10 indicates mild pain.
Immunizations & communicable diseases
o DTap, MMR
 CDC immunization recommendations for healthy infants less than 12 months of age include:
 2 months: diphtheria and tetanus toxoids and pertussis (DTaP)
 4 months: DTaP
 6 months: DTaP
 CDC immunization recommendations for healthy preschoolers 3 to 6 years of age include:
 4 To 6 Years: Diphtheria and tetanus toxoids and pertussis (DTaP); measles, mumps, and
rubella (MMR)
 CDC immunization recommendations for healthy school-age children 6 to 12 years of age include:
 If not given between 4 and 5 years of age, children should receive the following vaccines by
6 years of age: diphtheria and tetanus toxoids and pertussis (DTaP); measles, mumps, and
rubella (MMR)
o Reactions
 Complications, Contraindications, and Precautions
 A severe allergic reaction (anaphylaxis) can occur in response to any vaccine, and is a
contraindication for receiving further doses of that vaccine or other vaccines containing that
substance
 Moderate or severe illnesses with or without fever are precautions to receiving
immunizations
 The common cold and other minor illnesses are not contraindications to immunizations
 Severe febrile illness is a contraindication to all immunizations
 Do not administer live virus vaccines (varicella or MMR) to a child who is severely
immunocompromised, pregnant, or has received treatment that provide acquired passive
immunity (blood products) within 3 months
 Precautions to immunizations require providers to analyze data and weigh the risks that
come with immunizing or not immunizing
o Vaccine administration documentation
 Document the administration of the vaccine
 Date, route, and site of immunization
 Type, manufacturer, lot number, and expiration date of the vaccine
 Evidence of informed consent from the legal guardian
 Name, address and title of administering nurse
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Respiratory & EENT disorders - pathophysiology, clinical management, diagnosis, treatment, nursing management, and
patient education of:
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Otitis media
o Eustachian tube in children vs adults
 Eustachian tubes in children are shorter and more horizontal than those of adults.
o Care plan for child with OME
 Otitis media with effusion (OME) - a collection of fluid in the middle ear but no infection
 Children generally improve within 3 months
 Most children are not hospitalized so treatment is given at home
 If the child has pain
 Give analgesic such as acetaminophen (ear drops)
 Have the child sit up, raise head on pillows, or life on unaffected ear (decreases pressure
from fluid)
 Apply warmth to ear (increases blood supply and reduces discomfort)
 Have child blow a pinwheel to relieve pressure in ear (attempts to open eustachian tubes)
For risk of infection
 Encourage breast feeding in infants (provides natural immunity)
 Instruct parents to administer antibiotics as directed and complete prescribed course of
medication
 If symptoms have not improved in 36 hours, treatment should be evaluated
 Examine ear 3-4 days after completion of antibiotics or if symptoms worsen (to see if
treatment is effective)
 For developmental risk
 Assess hearing ability frequently (to detect for hearing loss)
 Assess for motor and language development (to detect developmental delays)
Teaching for parents of child with frequent OM / things to avoid
 Avoid exposure to secondhand smoke
 Don’t let infants or toddlers sleep with pacifier
 Avoid exposure to a large number of children (day care)
 Make sure to take full course of antibiotics even if their child starts feeling better
 Breast feeding provides antibodies
Tympanostomy tube teaching
 If infection recurs in spite of antibiotic treatment myringotomy (surgical incision of the tympanic
membrane) may be performed and tympanostomy tubes (pressure equalizing tubes) inserted to
drain fluid from the middle ear
 After Surgery
 Encourage the child to drink generous amounts of fluids
 Reestablish a regular diet as tolerated
 Give pain medication (acetaminophen) as ordered for discomfort and at bedtime
 Place drops in child’s ears if prescribed
 Restrict the child to quiet activities
 After postoperative period
 Follow the care provider’s instructions regarding swimming and water
 Ear plugs can be used to prevent water from getting into ears
 Be alert for tubes becoming dislodged and falling out and alert HCP if they do (they usually
fall out within one year)
 Report purulent discharge from the ear, which may indicate a new ear infection, contact
HCP
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o Fever management
 Treating the fever
 Use a thermometer to check child’s temperature every 4-6 hours
 Use acetaminophen or ibuprofen to lower temperature
 Remove all but a light layer of clothing
 Monitor child’s response to fever medication
 Sponging the child is not recommended, lukewarm water may increase shivering and
discomfort. Do not use alcohol for sponge baths.
 Give the child lots of fluids to drink and allow the child to rest
o Medication amoxicillin
 First line therapy, unless it has been given to the child in the previous 30 days
 Broad spectrum antibiotic
 Do not use if you have an allergy to penicillin
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More about this disorder
o Risk Factors
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Eustachian tubes in children are shorter and more horizontal than those of adults.
Otitis media is most common in the first 24 months of life and again when children enter school
(ages 5 to 6). Otitis media occurs infrequently after age 7
 Otitis media is usually triggered by a bacterial infection (Streptococcus pneumoniae,
Haemophilus influenzae, Moraxella catarrhalis), a viral infection (respiratory syncytial virus or
influenza), allergies, or enlarged adenoids
 There is a lower incidence of otitis media in infants who are breastfed possibly due to the
presence of immunoglobulin A (IgA) in breast, and the semi-vertical feeding position of
breastfed babies
 Incidence is higher in the winter and spring months
 Exposure to large numbers of children (day care)
 Exposure to secondhand smoke
 Cleft lip and/or cleft palate
 Noncompliance with childhood immunizations
 Down syndrome
Pathophysiology
 Specific cause unknown – eustachian tube dysfunction
 Often preceded by upper respiratory infection  causes mucous membrane of the eustachian
tube to become edematous
 Normal air flow of the middle ear is blocked
 Number 1 causative organism: streptococcus pneumoniae
Expected Findings
 Recent history of upper respiratory infection
 Acute onset of changes in behavior
 Frequent crying, irritability, and fussiness
 Inconsolability
 Tugging at ear
 Turning head from side to side
 Reports of ear pain, loss of appetite, nausea, and vomiting
 Fever
 Physical Assessment Findings
 AOM
o Rubbing or pulling on ear
o Crying
o Lethargy
o Bulging yellow or red tympanic membrane
o Purulent material in middle ear or drainage from external canal
o Decreased or no tympanic movement with pneumatic otoscopy
o Lymphadenopathy of the neck and head
o Temperature: can be as high as 40° C (104° F)
o Hearing difficulties and speech delays if otitis media becomes a chronic
condition
 OME
o Feeling of fullness in the ear
o Orange discoloration of the tympanic membrane with decreased movement
o Vague findings including rhinitis, cough, and diarrhea
o Transient hearing loss and balance disturbances
Diagnostic Procedures
 Pneumatic otoscope
 A pneumatic otoscope is used to visualize the tympanic membrane and middle ear
structures and assess tympanic membrane movement
 NURSING ACTIONS: Gently pull the pinna down and back to visualize the tympanic
membrane of a child younger than 3 years old. For a child older than 3 years, gently pull
the pinna up and back

o Patient‐Centered Care
 Nursing Care
 Provide comfort measures
o Administer pain medication as needed
o Provide diversional activities
 Place child in an upright position
 Management of fevers
 Medications
 Acetaminophen or ibuprofen
o Used to provide analgesia and reduce fever
 Antibiotics
o Amoxicillin, amoxicillin-clavulanate, or azithromycin PO (10 to 14 days)
o Ceftriaxone IM (once)
o Nursing Actions
 Antibiotics are recommended for children over 6 months of age who have
severe manifestations (increased pain or temperature above 39° C [102.2°
F]) for more than 2 days, or for children 6 to 23 months with bilateral AOM
and no manifestations
 In other cases, antibiotic therapy can be withheld. If the child does not
improve or worsens within 48 to 72 hours, antibiotics are started at that
time
 Administer in high doses orally, usually 80 to 90 mg/kg/ day in two divided
doses.
 The usual course of oral treatment is 10 days in children younger than 6
years of age. The course can be shorter for older children
 IM is used for resistant organisms or for client-specific reasons (difficulty
taking oral medications, inability to complete the oral course)
o Client Education
 The child should complete the total course of antibiotic treatment
 Observe for manifestations of allergy to the antibiotic (rash or difficulty
breathing)
 Topical anesthetics
o Benzocaine or lidocaine drops can help relieve pain
 Client Education
 Use comfort measures
 Feed the child in an upright position when bottle-or breastfeeding
 If drainage is present, clean the external ear with sterile cotton swabs. Apply antibiotic
ointment
 Avoid exposure of child to risk factors if possible (secondhand smoke, individuals with
viral/bacterial respiratory infections)
 Seek medical care at initial manifestations of infections (change in behavior, tugging on ear)
 Maintain up-to-date immunizations
o Complications
 Hearing loss and/or speech delays
 Nursing Actions
o Assess and monitor for deficits
o Refer the child for audiology testing if needed
 Client Education
 Speech therapy may be necessary
Tonsillitis
o Tonsillectomy post op nursing care
 Positioning
 Place in position to facilitate drainage
 Elevate head of bed when child is fully awake

o
o
Assessment
 Assess for evidence of bleeding, which includes frequent swallowing, clearing the throat,
restlessness, bright red emesis, tachycardia, and/or pallor
 Assess the airway and vital signs
 Monitor for difficulty breathing related to oral secretions, edema, and/or bleeding
 Comfort measures
 Administer liquid analgesics or tetracaine lollipops as prescribed
 Provide an ice collar
 Offer ice chips or sips of water to keep throat moist
 Administer pain medication on a regular schedule
 Diet
 Encourage clear liquids and fluids after a return of the gag reflex, avoiding red-colored
liquids, citrus juice, and milk-based foods initially
 Advance the diet with soft, bland foods
 Instruction
 Discourage coughing, throat clearing, and nose blowing in order to protect the surgical site
 Avoid straws as they can damage the surgical site
 Alert guardians that there can be clots or blood-tinged mucus in vomitus
 Client Education
 Notify the provider if bright red bleeding occurs
 Get plenty of rest
Normal assessment findings
 Expected Findings
 Report of sore throat with difficulty swallowing
 History of otitis media and hearing difficulties
 Physical Assessment Findings
 Mouth odor
 Mouth breathing
 Snoring
 Nasal qualities in the voice
 Fever
 Tonsil inflammation with redness and edema
 Difficulty swallowing or eating
 Laboratory Tests
 Throat culture for group A beta-hemolytic streptococci (GABHS)
More about this disorder
 Risk Factors
 Exposure to a viral or bacterial agent
 Immature immune systems (younger children)
 Patient‐Centered Care
 Nursing Care
o Tonsillitis
 Provide treatment for manifestations of viral tonsillitis (rest, warm fluids,
warm salt-water gargles)
 Administer antibiotic therapy as prescribed for bacterial tonsillitis
 Medications
 Antipyretics/analgesics: acetaminophen
 Hydrocodone is indicated for the child having difficulty drinking
fluids
 Antipyretics
o Decrease fever and manage pain
o Nursing Actions: Be aware of allergies
o

Client Education: Teach appropriate dosing for
acetaminophen and ibuprofen
Antibiotics
o For treatment of GABHS infection
o Nursing Actions: Be aware of allergies
o Client Education: Teach guardians to administer antibiotics
for the full course of treatment



Client Education
o Contact the provider if the child experiences difficulty breathing, lack of oral intake,
increase in pain, and/or indications of infection
o Ensure that the child does not put objects in the mouth
o Administer pain medications for discomfort
o Intake plenty of fluids, advance to a soft diet, and avoid foods that are irritating or
highly seasoned
o Limit activity to decrease the potential for bleeding
o Full recovery usually occurs in approximately 14 days
o Observe for manifestations of hemorrhage, dehydration, and infection, and notify
the provider if necessary
Complications
 Hemorrhage
o Nursing Actions
 Use a good light source and possibly a tongue depressor to directly observe
the throat
 Assess for findings of bleeding (tachycardia, repeated swallowing and
clearing of throat, hemoptysis). Hypotension is a late manifestation of shock
 Contact the provider immediately if there is any indication of bleeding
o Client Education
 Instruct family to report indications of bleeding (frequent swallowing,
clearing the throat, restlessness, bright red emesis, tachycardia, pallor).
 Dehydration
o Nursing Actions
 Encourage oral fluids
 Monitor I&O
o Client Education
 Increase intake of oral fluids
 Observe for manifestations of dehydration
 Chronic infection
o Chronically infected tonsils with GABHS can pose a potential threat to other parts of
the body. Some children who frequently have tonsillitis can develop other diseases
(rheumatic fever and kidney infection)
 Client Education
o Seek medical attention when the child presents with manifestations of tonsillitis
Laryngotracheobronchitis (LTB)
o Assessment findings
 Low-grade fever
 Restlessness
 Hoarseness
 barky cough – sounds like a seal
 dyspnea
 inspiratory stridor
 retractions
 Infants and Toddlers
 nasal flaring
o
o

 intercostal retractions
 Tachypnea
 continuous stridor
Symptoms of impending resp failure
 Dyspnea
 Mood changes
 Disorientation
 Pallor
 Fatigue
 Restlessness
 Tachypnea
 Tachycardia
 diaphoresis
More information about this disorder
 Usually, a viral cause
 Most common in children 6 months to 6 years (peak around 2-3 years)
 Airway tissue become inflamed and swollen
 Clinical therapy and diagnosis
 Diagnosis is made by clinical signs
 AP and lateral x-ray of upper airway is ordered is diagnosis is in question
o Positive x-ray shows “steeple sign”
 Use pulse oximetry to detect hypoxemia  can lead to altered mental status
 Clinical therapy treatment
 Usually can be treated at home with cool mist and PO steroids
 For moderate to severe:
o Supplemental oxygen
o Medications
 Racemic epinephrine
 Albuterol
 Corticosteroids
o Hydration and nutrition
o Observe for difficulty swallowing or drooling which may be signs of epiglottitis
which is a medical emergency
Foreign body aspiration
o Parent teaching
 Prevention of future aspirations
 Child’s development characteristics and how to identify potential safety hazards
 Food should be cut in small pieces
 Check toys for small or broken parts and remove from young children
 Store small objects (e.g. batteries, screws, buttons, earrings, and coins) out of child’s reach
 Encourage parents to learn rescue breathing, back blows, chest thrusts, or abdominal thrusts
 If it is smaller than the inside of a toilet paper roll it is too small for children and they could
potentially choke
o More information about this
 Physiologic assessment
 Observe for signs of respiratory distress
o Altered vital signs
o Altered mental status
o Audible wheezing
Attach child to cardiorespiratory monitor and pulse ox
o Under 95% shows hypoxia
Psychosocial assessment
 This can create anxiety for both the parents and child
 Child will be fearful because of difficulty breathing
 Assess family’s level of distress and coping ability
Developmental assessment
 Once child’s condition stabilizes, match parent’s understanding of age-appropriate
behaviors




RSV Bronchiolitis
o Nursing diagnosis
 Test nasopharyngeal secretions using either rapid immunofluorescent antibody-direct fluorescent
antibody staining or enzyme-linked immunosorbent assay (ELISA) techniques for RSV antigen
detection
 Chest x-ray that shows hyperinflation, atelectasis of lower respiratory system
o More about this disorder
 Mostly caused by Respiratory Syncytial Virus (RSV)
 Primarily affects the bronchi and bronchioles
 Occurs at the bronchiolar level
 Assessment
o Expected Findings
 Initially
 Rhinorrhea, intermittent fever, pharyngitis, coughing, sneezing, wheezing,
possible ear or eye infection
 With Illness Progression
 Increased coughing and sneezing, fever, tachypnea and retractions, refusal to
nurse or bottle feed, copious secretions
 Severe Illness
 Tachypnea (greater than 70/min), listlessness, apneic spells, poor air exchange,
poor breath sounds, cyanosis
 Patient‐Centered Care
o Nursing Care
 Supplemental oxygen to maintain oxygen saturation equal to or greater than 90%
 Encourage fluid intake if able to tolerate oral fluids. Otherwise, IV fluids until acute
phase has passed
 Maintain airway
 Medications as prescribed
 Corticosteroid use is controversial
 Bronchodilators are not recommended
 Antibiotics if a coexisting bacterial infection is present
 CPT not recommended
 Nasopharyngeal or nasal suctioning as needed
 Encourage breastfeeding
 Place with other RSV positive children
 Prevention
o Synagis (plivizumab) IM injections monthly during RSV season (November – April with peak in
January to February) for those at highest risk
 Decreases incidence of hospitalizations

Asthma
o
o
o
Environmental control teaching
 Reduce allergens
 Focus on reducing molds in the home with lowered humidity and removal of house plants
 When possible, remove pets from the home (especially the child’s bedroom)
 Vacuum carpets and upholstered furniture frequently as dust mites live here
 Buy soft toys that can be washed regularly
 Encase child’s mattress and pillow in plastic covers
 Bathe pets regularly to reduce pet dander
 Initiate cockroach eradication
 Eliminate smoke from cigarettes, wood stoves, and fireplaces
Oxygen use safety ( ie: flammable toys/stuffed animals)
 No smoking should be allowed in the house or car with a child on oxygen
 No open flames are allowed within 10 feet of a child on oxygen
 Keep oxygen tanks at least 10 feet away from heaters and radiators
 Do not leave oxygen tanks in hot car
 Keep toys with electric motors away from oxygen
 Do not use products containing oils (Vaseline) can cause burns
More information about this disorder
 Asthma - chronic childhood inflammatory disorder of the airways that results in intermittent and
reversible airflow obstruction of the bronchioles
 It causes school absences and is considered one of the leading causes of hospitalizations among
children
 The obstruction occurs because the mast cells release histamines and leukotrienes which causes
inflammation or airway hyper-responsiveness
 Asthma diagnoses are classified into one of four categories based on effects on the child:
intermittent, mild persistent, moderate persistent, and severe persistent
 Assessment
o Risk Factors
 Family history of asthma or allergies
 Sex (boys affected more than girls until adolescence, then the incidence is greater
among girls)
 Exposure to tobacco smoke
 Low birth weight
 Being overweight
o Triggers to Asthma
 Allergens
 Indoor: mold, cockroach antigen, dust, dust mites
 Outdoor: grasses, pollen, trees, shrubs, molds, spores, air pollution, weeds
 Irritants: Tobacco smoke, wood smoke, odors, sprays
 Exercise
 Cold air or changes in weather or temperature
 Environmental change (new home or school)
 Infections/viruses (colds)
 Animal hair or dander
 Medications: Aspirin, nonsteroidal anti-inflammatory drugs, antibiotics, beta
blockers
 Strong emotions: Fear, anger, laughing, crying
 Conditions: Gastroesophageal reflux, tracheoesophageal fistula
 Food allergies or additives (sulfites)
 Endocrine factors: Menses, pregnancy, thyroid disease
o Expected Findings
 Chest tightness
 History regarding current and previous asthma exacerbations

o

 Onset and duration
 Precipitating factors
 Changes in medication regimen
 Medications that relieve manifestations
 Other medications
 Self-care methods used to relieve manifestations
 Home/school environment
 Heating/cooling source in the home
Physical Assessment Findings
 Dyspnea
 Cough
 Audible wheezing
 Coarse lung sounds, wheezing throughout possible crackles
 Mucus production
 Restlessness, irritability
 Anxiety
 Sweating
 Use of accessory muscles
 Decreased oxygen saturation (low SaO2)
 Tripod positioning
 Sitting retractions
 Inaudible breath sounds or crackles (severe obstruction)
Laboratory Tests
 CBC (increased WBC, eosinophils)S
o Diagnostic Procedures
 Pulmonary function tests
 The most accurate tests for diagnosing asthma and its severity
 Baseline test at time of diagnosis
 Repeat testing after treatment is initiated and child is stabilized
 Test every 1 to 2 years
 Peak expiratory flow rates (PEFR)
 Uses a flow meter to measure the amount of air that can be forcefully
exhaled in 1 second
 Each child needs to establish personal best
 Bronchoprovocation testing
 Exposure to methacholine, cold air, or histamine
 Exercise challenge
 Skin prick testing: Identify allergens that trigger asthma
 Chest x-ray: Showing hyperexpansion and infiltrates
Patient‐Centered Care
o Nursing Care

o
Assess airway patency, respiratory rate, symmetry, effort, and use of accessory
muscles.
 Assess breath sounds in all lung fields
 Monitor for shortness of breath, dyspnea, and audible wheezing. An absence of
wheezing can indicate severe constriction of the alveoli
 Monitor vital signs and oxygen saturation
 Check CBC and chest x-ray results, possible ABGs
 Position the child to maximize ventilation
 Administer oxygen therapy as prescribed
 Keep endotracheal intubation equipment nearby
 Initiate and maintain IV access as prescribed
 Maintain a calm and reassuring demeanor
 Encourage appropriate vaccinations and prompt medical attention for infections
 Administer medications
 The provider can prescribe antibiotics if a bacterial infection is confirmed
 Teach the family and the child about when to use each of the prescribed
medications (rescue medications vs. maintenance medications)
Medications
 A stepwise approach is used for treatment based upon the severity
 Bronchodilators (inhalers)
 Short-acting beta2 agonists (SABA) (albuterol, levalbuterol, terbutaline)
o Used for acute exacerbations
o Prevention of exercised-induced asthma
 Long-acting beta2 agonists (LABA) (formoterol, salmeterol)
o Used to prevent exacerbations, especially at night, and reduce use
of SABA
o Must be used along with anti-inflammatory therapy
o Cannot be used to treat acute exacerbations
 Cholinergic antagonists (anticholinergic medications; atropine, ipratropium)
o block the parasympathetic nervous system, providing relief of acute
bronchospasms
o Nursing Actions
 Instruct child and family in the proper use of metered-dose
inhaler or nebulizer
 Observe the child for dry mouth when taking ipratropium
o Client Education
 Older children taking ipratropium can suck on hard candies
to help with dry mouth
 Administer prior to exercise or activity
 Monitor for irritably, tremors, insomnia, and nervousness
while taking this medication
 Anti-inflammatory agents
 Decrease airway inflammation
 Corticosteroids can be given parenterally (methylprednisolone), orally
(prednisone), or by inhalation (fluticasone)
o Oral systemic steroids can be given for short periods (3 or 10 days)
o Inhaled corticosteroids are administered daily as a preventive
measure
o Monitor child’s growth
 Leukotriene modifiers (zafirlukast, montelukast)
o Decrease in airway resistance
 Mast cell stabilizers (cromolyn)
o Long term control

o
o
Monoclonal antibodies (omalizumab) are used to treat moderate to severe
persistent allergic asthma uncontrolled by inhaled corticosteroids in
children 12-years-old and older
 Combination medications contain an inhaled corticosteroid and a LABA
(fluticasone/salmeterol)
o Nursing Actions
 Observe the oral mucosa for infection secondary to use of
inhaled medication
 Assess weight, blood pressure, electrolytes, glucose, and
growth with oral corticosteroid use
o Client Education
 Drink plenty of fluids to promote hydration
 Take oral corticosteroids with food
 Rinse the mouth after the use of a corticosteroid inhaler
 Watch for redness, sores, or white patches in the mouth,
and report them to the provider
 Follow prescription for medication administration (dosage,
tapering off medication, length of time to take)
 Theophylline: Used in the Pediatric Intensive Care Unit (PICU) when the
child is not responding to therapy because of increased risk for toxicity and
frequent monitoring of blood levels
 Magnesium sulfate: Potent medication used for moderate to severe
attacks. Administered IV (Emergency Department/ICU)
Interprofessional Care
 Consult respiratory services for inhalers and breathing treatments
 Contact nutritional services for weight loss or gain related to medications or
diagnosis
 Consult rehabilitation if the child has prolonged weakness and needs assistance with
increasing level of activity
Client Education
 Identify personal triggering agents
 Avoid triggering agents
 Provide the family and child with an asthma action plan
 Properly self-administer medications (nebulizers, inhalers, and spacer)
 Use a peak flow meter. (Use at the same time each day.)
 Ensure the marker is zeroed
 Have the child stand up straight
 Remove gum or food from mouth
 Close lips tightly around the mouthpiece (ensure the tongue is not
occluding)
 Blow out as hard and as quickly as possible
 Read the number on the meter
 Repeat these steps two more times for a total of three attempts (wait at
least 30 seconds between attempts.)
 Record highest number
 Keep a record of PEFR results. Readings over time show the child’s “best” efforts,
and provide a warning of increased airway impairment
 Learn how to interpret PEFR results and what measures to take for their zone
 Learn how to recognize an asthma exacerbation (decreased PEFR, increased use of
SABA, difficulty speaking or eating)
 Perform infection prevention techniques
 Promote good nutrition
 Reinforce importance of good hand hygiene
 Reduce allergens in the child’s environment






Perform prompt medical attention for infections.
Keep immunizations, including seasonal influenza and pneumonia vaccines, up to
date
Perform regular exercise as part of asthma therapy
 Promotes ventilation and perfusion
 Maintains cardiac health
 Enhances skeletal muscle strength
Children can require medication before exercise to prevent induced spasms of the
bronchus
Complications
o Status asthmaticus
 A life-threatening episode of airway obstruction that is often unresponsive to
common treatment
 It is considered a prolonged severe asthma attack
 Manifestations include wheezing, labored breathing, nasal flaring, lack of air
movement in lungs, use of accessory muscles, distended neck veins, tachycardia,
tachypnea, hypoxia, diaphoresis, and risk for cardiac and respiratory arrest
 Nursing Actions
 Monitor oxygen saturations continuously
 Place on continuous cardiorespiratory monitoring
 Position the child sitting upright, standing, or leaning slightly forward
 Administer humidified oxygen
 Administer three nebulizer treatments of a beta2 agonist, 20 to 30 min
apart or continuously. Ipratropium bromide can be added to the nebulizer
to increase bronchodilation
 Obtain IV access
 Monitor ABGs and blood electrolytes
 Administer corticosteroid
 Prepare for emergency intubation
 Magnesium sulfate IV decreases inflammation and improves pulmonary
function and peak flow rate among children who have moderate to severe
asthma when treated in the emergency department or pediatric ICU
 Heliox (a mixture of helium and oxygen) can be administered via a nonrebreathing mask to decrease airway resistance and work of breathing
 Ketamine: Smooth muscle relaxant that decreases airway resistance
o Respiratory failure
 Persistent hypoxemia related to asthma can lead to respiratory failure
 Nursing Actions
 Monitor oxygenation levels and acid-base balance
 Prepare for intubation and mechanical ventilation as indicated
Cystic fibrosis
o Newborn assessment requiring further testing for CF
 Assessment
 Risk Factors
 Both biological parents carry the recessive trait for cystic fibrosis
 Caucasian ethnicity

o
o
Expected Findings
 Family history of cystic fibrosis
 Medical history of respiratory infections, growth failure
 Meconium ileus at birth manifested as distention of the abdomen, vomiting, and inability to
pass stool. Meconium ileus is the earliest indication of cystic fibrosis in the newborn
 Respiratory Findings
o Stasis of mucus increases the risk for respiratory infections
o Early manifestations
 Wheezing, rhonchi
 Dry, nonproductive cough
o Increased involvement
 Dyspnea
 Paroxysmal cough
 Obstructive emphysema and atelectasis on chest x-ray
o Advanced involvement
 Cyanosis
 Barrel-shaped chest
 Clubbing of fingers and toes
 Multiple episodes of bronchitis or bronchopneumonia
 Gastrointestinal Findings
o Large, frothy, bulky, greasy, foul-smelling stools (steatorrhea)
o Voracious appetite (early), loss of appetite (late)
o Failure to gain weight or weight loss
o Delayed growth patterns
o Distended abdomen (infant)
o Thin arms and legs (infant)
o Deficiency of fat-soluble vitamins
o Anemia
o Reflux
o Prolapse rectum (infant, child)
 Integumentary Findings
o Sweat, tears, and saliva have an excessively high content of sodium and chloride
 Endocrine and Reproductive System Findings
o Viscous cervical mucus
o Decreased or absent sperm
o Decreased insulin production
Pancreatic enzyme administration
 Assists in digestion of nutrients decreasing fat and bulk
 Administer pancreatic enzymes within 30 min of eating a meal or snack
 Cotazym-s
 Pancrease
 Viokase
 Pancreatic enzymes
 Pancrelipase treats pancreatic insufficiency associated with cystic fibrosis
o Nursing Actions
 Monitor stools for adequate dosing (1 to 2 stools/day)
 Monitor weight
 Administer capsules with all meals and snacks.
 Child can swallow or sprinkle capsules on food. Do not sprinkle on hot foods
or add to bottles or formula
 Increase dosage of enzymes when eating high‐fat foods
Nursing diagnosis
 Ineffective airway clearance
 Risk for infection
o
o
o
o
o
 Imbalanced nutrition: Less than body requirements
 Parental role conflict
Cystic fibrosis is a respiratory disorder that results from inheriting a mutated gene. It is characterized by
mucus glands that secrete
an increase in the quantity of thick, tenacious mucus, which leads to mechanical obstruction of organs
(pancreas, lungs, liver, small intestine, and reproductive system); an increase in organic and enzymatic
constituents in the saliva; an increase in the sodium and chloride content of sweat; and autonomic nervous
system abnormalities
Laboratory Tests
 Blood specimen: Nutritional panel to detect a deficiency of fat-soluble vitamins (A, D, E, and K)
 Sputum culture for detection of infection: Pseudomonas aeruginosa, Haemophilus influenzae,
Burkholderia cepacia, Staphlococcus aureus, Escherichia coli, or Klebsiella pneumoniae
Diagnostic Procedures
 DNA testing: To isolate the mutation
 Pulmonary function tests (PFTs): evaluate the small airways
 Chest x-ray: Can indicate diffuse atelectasis and obstructive emphysema
 Abdominal x-ray: Detect meconium ileus
 Stool analysis: For presence of fat and enzymes
 Duodenal analysis: Analyze pancreatic trypsin levels (NG tube)
 Sweat chloride test
 The child must be well hydrated to ensure accurate test results.
 A device that uses an electrical current stimulates sweat production
 Collection of sweat from two different sites for adequate sample
 Expected reference range is chloride content less than 40 mEq/L and sodium content less
than 70 mEq/L
 Diagnostic confirmation of cystic fibrosis: Chloride greater than 40 mEq/L for infants less than 3
months of age and greater than 60 mEq/L for all others; sodium greater than 90 mEq/L
Patient‐Centered Care
o Nursing Care
 Assess lung sounds and respiratory status
 Vital signs with oxygen saturation
 Obtain IV access. Use of a peripherally inserted central catheter or IV port allows for home IV
antibiotic therapy
 Obtain sputum for culture and sensitivity
 Provide support to the child and family
 Pulmonary management
 Assist in providing airway clearance therapy (ACT) to promote expectoration of
pulmonary secretions. Usually prescribed twice a day in the morning and evening. Avoid
ACT immediately before or after meals. Several methods of ACT are available:
o Chest physiotherapy (CPT) with postural drainage as prescribed (manual or
mechanical percussion)
o Positive expiratory therapy (PEP) uses a device (a flutter mucus clearance
device) to encourage the client to breathe with forceful exhalations
o Active‐cycle‐of‐breathing techniques (“huffing” or forced expiration) are
encouraged
o Autogenic drainage uses an electronic chest vibrator or handheld percussor
along with breathing techniques
o High‐frequency chest compression uses a mechanical chest device combined
with nebulization therapy
 Administer aerosol therapy as prescribed (bronchodilator, human deoxyribonuclease).
Often recommended prior to ACT
 Administer IV or aerosolized antibiotics
 Encourage physical aerobic exercise
 Provide oxygen as prescribed (assess for carbon dioxide retention)
 Monitor for hemoptysis or pneumothorax
Gastrointestinal management
 Provide a well‐balanced diet high in protein and calories
 Give three meals a day with snacks
 Encourage oral fluid intake
 Administer pancreatic enzymes within 30 min of eating a meal or snack
 Administer vitamin supplements: multivitamin; vitamins A, D, E, and K.
 Administer laxatives or stool softeners for constipation
 Polyethylene‐glycol electrolyte solution is administered
 orally or via nasogastric tube.
 Administer histamine‐receptor antagonist and motility medications for GERD.
 Administer possible formula supplements in addition to breastfeedings or via gastric
tube
 Encourage to add salt to food during hot weather‐ (dehydration)
 Consult a dietitian. Child should receive regular nutritional evaluations
 Endocrine management
 Cystic fibrosis related diabetes (CFRD) necessitates monitoring of blood glucose levels
 Administer insulin. Oral glycemic medications are not effective for CFRD
 Interprofessional Care
 Respiratory and physical therapy, social services, pulmonologist, pharmacist,
pediatrician, infectious disease specialists, and dietitians may be involved in the care of
the child who has cystic fibrosis
 Transplantation of heart, lung, pancreas, and liver for adolescents who have advanced
disease can be a consideration
 Client Education
 Utilize information provided regarding access to medical equipment and medications
 Understand equipment and medications prior to discharge
 Utilize ways to provide CPT and breathing exercises
 Visit the provider regularly
 Stay up-to-date on immunizations, including a yearly influenza vaccine and
pneumococcal vaccine
 Practice regular dental hygiene
 Understand the importance of diet and ways to increase calorie intake
 Observe for indications of infection and notify the provider if necessary
 Know methods to manage chronic illness in children.
 Change diapers frequently.
 Monitor for impairments of skin integrity.
 Perform regular physical activity. Encourage the child to rest prior to meals and before
physiotherapy
 Participate in a support group and use community resources
 Identify specific needs based on the client’s developmental level. For example, older
adolescents are at a higher risk for depression due to the emotional and physical effects
of cystic fibrosis
 Provide home palliative care for the child or adolescent in the terminal stages of CF
 Complications
 Respiratory: Respiratory infections, respiratory colonizations, bronchial cysts,
emphysema, pneumothorax, nasal polyps
 Gastrointestinal: Meconium ileus, prolapse of the rectum, intestinal obstruction, GERD
 Endocrine: Diabetes mellitus
Medications
 Respiratory medications
 Short‐acting beta2 agonists (albuterol)
 Cholinergic antagonists (anticholinergics [ipratropium bromide])

o


Fluticasone propionate/salmeterol
o Nursing Actions
 Monitor for tremors and tachycardia when the child is taking albuterol
 Observe for dry mouth when the child is taking ipratropium
o Client Education
 Understand how to properly use an MDI, PEP, or nebulizer
 Rinse mouth after fluticasone propionate/salmeterol
 Dornase alfa (aerosol)
o Decreases the viscosity of mucus and improves lung function
 Nursing Actions
 Monitor sputum thickness and ability of client to expectorate
 Monitor the child for improvement in PFTs
 Client Education
 Understand how to use a nebulizer
 Administer once or twice a day
 This medication can cause laryngitis
 Antibiotics
 Administer through IV or aerosol
 Specific to treat pulmonary infection
 Common medications include tobramycin, ticarcillin, or gentamicin
o Nursing Actions
 Assess for allergies
 High doses may be prescribed. Collect blood specimens before and after
some IV antibiotics to maintain therapeutic levels
Hearing / Visually impairment
o Socialization skills
 Help parents plan early, regular social activities with other children
 Visual impairment
 Stroke, rock, and hug infants and children who have a visual impairment. Sing and talk to
them. These infants do not make eye contact and have rather blank expressions.
 Call the child’s name and speak before touching the child. Tell the child when the nurse and
others are leaving the room. Describe locations of food on the plate and tray to orient the
child.
 Teach parents to read body language and vocalization as expressions of emotion. Facial
expressions give a great deal of information, but infants and children with poor vision do not
have the ability to learn by visual imitation. Show parents how to use tactile means to teach
appropriate facial expressions. For example: a touch on the arm can be soft and stroking to
indicate a smile, but firmer to indicate dismay or frown.
 Describe procedures such as blood pressure, ear examinations or cast application so the
child knows what they will feel like. Let the child touch the equipment.
 Explain to the parents that disciple and rewards for children with poor vision should be the
same as those for other children in the family. The child should be given age-appropriate
tasks.
 Encourage contact with peers as the child grows older. Teach children to look directly at
persons who are talking to them. Play, sports, and other activities can be modified to give
the child with visual impairment the same social experiences as a sighted child.
 Hearing impairment
 If hearing loss is mild, temporary or the child reads lips, first obtain the child’s visual
attention by lightly touching the child or saying the child’s name
 Position your face 1 to 2 m (3 to 6 feet) from the child’s face and make sure the child’s eyes
are focused on your face and lips

o
Place hearing aids in ear with volume off, slowly turn up to half volume and adjust as
needed
Interventions for hospital admission
 Visual impairment
 Maintain normal to bright lighting for the child when reading, writing, or participating in any
activity that requires close vision
 Assess infants and children for visual impairments, and identify children that are high-risk
 Observe for behaviors that suggest a decrease or loss of vision
 Promote child’s optimal development and parent-child attachment
 Identify safety hazards, and prevent injury to the eyes (helmets, safety glasses)
 Provide information regarding laser surgery for clients who have myopia, hyperopia, or
astigmatism
 Reassure the child and family.
 Orient the child to the surroundings and provide a safe environment
 Promote independence and meeting developmental milestones while assisting with play
and socialization
 Refer to educational services for visual impairment (Braille, audio tapes, special computers)
 Hearing impairments
 Assess children for hearing impairment
 Promote speech development, lip reading, and use of cued speech (hand gestures with
verbal communication)
 Encourage socialization and use of aids to promote independence (flashing light when the
doorbell or phone rings, telecommunication devices, closed captioning on the television)
 Refer child and family to community support groups
 Use sign language or an interpreter if appropriate when working with a child who has
hearing loss. Always talk to the child, not the interpreter
 Assess gait/balance for instability.
 Identify safety hazards and adjust environment as needed
 Assist with the use of hearing aids
o Store batteries in safe place
o If whistling sound present, turn down the volume or readjust the hearing aid in ear
 Instruct families on methods to prevent further damage to hearing