Pediatric exam 1 outline
Week 1 Content
● Newborns- 1-3 months
o Communication
o The basic reason for crying is unmet needs.
▪ 1- to 3-month-old baby coos, makes other vocalizations, and
demonstrates differentiated crying.
● Infants 3-6 month
o Communication
o
o
o
o
o
4 to 5 months of age, the infant makes simple vowel sounds, laughs aloud, performs
“raspberries,” and vocalizes in response to voices. The infant also responds to his or her
own name and begins to respond to “no.”
Between 4 and 7 months, the infant begins to distinguish emotions based on the tone of
voice. Squealing and yelling begin around 6 months of age; these may be used to express
joy or displeasure.
ASSESSMENT- We need to move slowly, and talk softly. Don’t come in quickly
Think about who your patient is going in- Baby talk is good- they’re babies
Establish relationship, be calm to be able to do PE, rely a lot on facial expression
▪
o
Look happy and smile, keep it soft. Talk to the baby, because that’s the patient
and parents will respond better to you
Don’t tell them something WONT hurt, some may hurt even if you think it wouldn’t
6 months, develop stranger anxiety, get down to eye level- give toys
▪
infants in daycare tend to have less stranger anxiety than infants who stay home
(bc less exposure to other people)
▪
The nurse becomes concerned if the infant does not move slowly through six
states of consciousness, which begin with deep sleep. The infant should then
progress as follows: light sleep, drowsiness, quiet alert state, active alert state,
and finally crying.
● Older infants 6-8 months
o Communication
o
o
o
o
o
7 to 10 months, babbling begins and progresses to strings (e.g., mamama, dadada)
without meaning. The infant at this age is also able to respond to simple commands.
9 to 12 months- the infant begins to attach meaning to “mama” and “dada” and starts to
imitate other speech sounds.
The average 12-month-old uses two or three recognizable words with meaning,
recognizes objects by name, and starts to imitate animal sounds.
At this age, the infant pays increasing attention to speech and tries to imitate words; he
or she may also say “uh-oh.” The 12-month-old also babbles with inflection (this
babbling has the rhythm and timing of spoken language, but few of the “words” make
sense)
ASSESSMENT- Peekaboo to allow trust with us, so we can start assessment.
▪ Teach Safe things only around house
● Toddlers 2-3 yrs
o
o
ASSESSMENT- Head-to-toe is done backwards, always touch hurting spot last.
Curious and busy- they are all over the place. Safety is a priority.
Let parent hold them, baby will feel less nervous
Toddlers need rituals. Ex. Bedtime includes bath and story time.
Needs 12 hours of sleep a day including 1 nap.
o
o
o
● Preschoolers- 3-5 yrs
o
o
o
o
o
o
Take everything at face value.
What you say is exactly what they hear. Always think about what you’re going to say.
o We don’t TAKE blood pressure, were measuring, or counting.
Don’t lie, but don’t give more info than they need at the time.
They do not understand time. Instead, use terms such as “after lunch”
People pleasing stage.
Regression is common from stress in an acute hospitalization - bed wetting while in the
hospital. May also happen during abuse/ trauma/change.
▪
o
May also regress in speech, thumb sucking, etc.
Only tell them right before any assessment is going to happen, and don’t give choices
where there’s not choices.
▪
It helps autonomy to give choices.
o
o
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Don’t ask permission, only give options when you can. (ex. L or R arm?)
Play with your patients, helps build relationships and trust. (Watching SpongeBob
together)
o Use pictures, books for communication/explanation
Adolescent- 12-18 yrs:
o Concerned with appearance, perception/approval
o Want connection with peers
▪
o
Self-conscious
▪
o
These two things will remain their priority throughout their hospitalization
We must address concerns even if superficial, it is important to them
They may share info with us that they don’t want to with parents
▪
Keep confidential unless a threat to self or others
You are there to advocate for your patient
If PT can’t say anything to parents, we can recommend therapy or pull in another adult they feel
connected too.
Parents can be crazy, but they are usually scared, so when someone is being crazy try to think about where it is coming
from.
REMINDER- If the conversation isn’t appropriate, you can tell them it’s not ok.
Number 1 type of abuse: neglect (not going to school, not showering, malnourished, etc)
- May result from a family not having the resources.
- The abuser is usually the parent at the bedside (the mother)
- Low income and single mothers inc these chances of abuse occurring
Reported to CPS
Memorize- Erikson’s Psychosocial (TAG-IR) vs. Piaget (SPICF)
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Erikson’s- Psychosocial
Piaget- Cognitive
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Trust vs mistrust BIRTH TO 1 YEARS- Feeding
(NEWBORNS)
Trust you’ll take care- Caregivers respond to the
infant’s basic needs by feeding, changing diapers,
cleaning, touching, holding, and talking to the infant.
Getting their needs met, infant must develop trust.
Parents should be the one developing trust.
Holding baby is important, they need warmth- it’s
the consistency (establishes the greatest bond)
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Autonomy vs. Shame and Doubt 2-3 YEARSToilet training
Let them do things self- and give choices when we
can. E.g., Band-Aid, Get dressed, eat, toileting,
walking around. Let’s them foster independence.
Success= autonomy, failure= shame + doubt
3 yr old ask “what” & “why” a lot to facts
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Initiative vs Guilt 3-5yrs- Exploration
Questions, direction, purpose, don’t shut them
down= guilt! Let them do things, press buttons, let
them answer the questions
Physical ability to explore things.
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Industry vs Inferiority 6-11 yrs- SchoolAccomplishment
School work/accomplished tasks; Independence,
bounce around. Let them build toys, and do school
work. Need to learn to cope with new social and
school responsibilities.
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Identity vs Role Confusion- 12-18 – Social
relationships- identity
Independence and Identity. Help them through
confusing times- Teens need to develop a sense of
self and personal identity.
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Sensorimotor Period, Birth- 2 yrs.
Most action is reflexive. Perception of events is
centered on the body. Objects are extensions of
self. Acknowledges the external environment.
Developmental Phenomena:
See the world through senses
Object permanence and stranger anxiety.
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Preoperational – Preconceptual, 1.5-3 yr
Self-centered. Asks many questions. Explores the
environment. Language development rapid.
Associates’ words with objects. (symbols)
“ Beginning to question parents values”
Developmental Phenomena:
Pretend play
Egocentrism
Language development
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age
Preoperational- Intuitive, 2-7 yrs- Preschool
Symbolic thought- Egocentric thinking diminishes.
Includes others in environment. Enjoys repeating
words, may count to 10. Words express thoughts.
Developmental Phenomena:
Further Language Development
Concrete operations, 7-11 yrs
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Logical thinking, “it is what it is,” no sarcasm; math;
relationships; left vs. right.
Solves concrete problems. Begins to understand
relationships such as size. Understands right and
left. Cognizant of viewpoints
Developmental Phenomena:
Conservation
Mathematical Transformation
Formal Operations- 11+
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Abstract thinking, question & learn more scientific
reasoning
Uses rational thinking. Reasoning is deductive and
futuristic.
Developmental Phenomena:
Abstract logic
Potential for mature reasoning
If you never develop trust, you can’t become autonomous, from there how do you move on?
Think about what stage of development this child is in at the time, were always
modeling and role modeling for parents.
Milestones - IMPORTANT
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2 months Baby will smile with purpose.
3 months- smiles widely and gurgles with caregiver. Mimics facial movements- sticking out
tongue.
4 months, Rolls over back to front, “prone to supine” Always put side rail up. Begins to play
6 months, sit with support “tripod” (supported)
o Stranger anxiety starts; 4-7m “Maintain the same nursing staff during each shift” (6 m
in class) Object permanence starts
8 months, will sit unsupported- If not babbling by 8 months, then there is a problem.
o 8-9m Object permanence is solidified- Peek-a-boo
9 months- Crawling with abdomen off floor
10- 11 months, Will pull up to stand supported
12 months- Walking unsupported
o Separation anxiety start
One year- Stop drinking milk and gets regular milk- 3- 8 oz of milk a day
o Must take in other nutrients now have to come from what they’re eating because
they’re not in cow/alt. milk.
o African Americas more prone to Lactose Intolerance- need Calcium other ways.
If not hitting milestones, ask parents, “what ARE they doing?” and keep an eye on it (some do
not develop simply because they do not “need” to i.e.e someone is speaking for them, someone
walks and gets them what they want for them)
Reflex
Root
If reflexes don’t disappear it may be neurological,
Observe responsiveness, behavior, most of our assessment is what we observe
Reflexes
Description
Age Appears
Age Disappears
When infant’s cheek Birth
3 months
is stroked, the infant
turns to that side,
searching with
mouth.
Reflexive sucking
when nipple or
finger is placed in
infant’s mouth.
Birth
2-5 months
With sudden
extension of the
head, the arms
abduct and move
upward and the
hands form a “C.”
Birth
4 months
Asymmetrical Tonic Neck
While lying supine,
extremities are
extended on the side
of the body to which
the head is turned
and opposite
extremities are
flexed (also called
the “fencing”
position).
Birth
4 months
Palmer Grasp
Infant reflexively
grasps when palm is
touched.
Birth
4-6 months
Suck
Moro
Plantar Grasp
Infant reflexively
grasps with bottom
of foot when
pressure is applied
to the plantar
surface.
Birth
9 months
Babinski
Stroking along the
lateral aspect of the
sole and across the
plantar surface
results in fanning
and hyperextension
of the toes.
With one foot on a
flat surface, the
infant puts the other
foot down as if to
“step.”
Birth
12 months
Birth
4-8 weeks
Step
What of the history is different in PEDS?
Go through pregnancy HX
○ Premature babies more prone to respiratory infections as they grow
○ A history of significant problems related to labor and delivery is also important: stress or
asphyxia at birth may be related to cardiac dysfunction and pulmonary hypertension in
the newborn.
○ Assess for additional risk factors such as:
Family history of heart disease or CHD (investigate the history further if heart disease
occurred in a first-degree relative) Hyperlipidemia, Diabetes mellitus, Obesity, Inactivity, Stress,
High-cholesterol diet
- Social HX
- Occupation of the parents - who is home? Is there financial stability?
● Maternal part
○ How was the pregnancy? Ask about
smoking, drugs, alcohol?
○ Vaginal vs. C-section. What was their
APGAR?
○ Traumatic birth? Pre-Term?
● Developmental history- sleeping patterns,
socialization, school, etc.
○ were they potty trained around 2
● Immunization Status: be familiar with this, and
know if a child is up to date with this record
depending on their age
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Diet
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How were they fed? How long, how much? What do they eat? Diligent first few years
Infants: Breastfed or bottle fed, or a combo of the two
■ Bottle fed: ounces, type of formula, how often
■ Breast fed: how often are you feeding them? Check weight, and count wet
diapers.
■ Ideally, we want 6-9 wet diapers per day. In an acute setting, we would weigh
these diapers (checking for I&O)
○ When do we introduce baby food? 6 months. If a child can sit upright (no flopping over),
they are ready for normal baby food. We begin baby food to introduce new textures and
flavors.
○ Switch from breastmilk/bottle milk to Whole Milk at 1 y/o
■ Once switching to Whole Milk, their stool changes with this transition.
■ All nutrients now are derived from regular food, once this switch has been made
■ Ounces of Whole Milk/Day: 18 oz (too much milk can lead to milk anemia reason why we screen for anemia at 12 mo)
Physical Assessment: Begin at the feet and work up to the head. This is based on trust and personal space
● Obesity- educate to do things in moderation
○ bring awareness to risks (diabetes risks)
○ Baby has to be able to sit up to eat **small airway=choking/aspiration risk**
● VS are different - pediatric patients will continue to compensate until they crash, meaning that
vital signs may not always be a reliable source
○ Under 2yrs take BP on leg, pulse ox on toe- bc babies like to put fingers in mouth
○ Count Respirations for one full minute (infants normally breathe irregularly)
○ Apical pulse up to 2 years old
○ Temp - depends on the equipment
Height and Weight: Use of a growth chart to determine if they are in adequate range. Looking for trends
to make sure they are maintaining their growth rate. A large dip or rise in their growth chart is not good.
- Sudden Weight Gain: may come from a hormonal imbalance, diabetes, malnutrition, etc.
Possibly r/t endocrine
- Head Circumference is measured up until 2 y/o
● Breath sounds, the most important, need to take shirt off.
○ If you can hear/ see the kid breathing when you come into the room, call for help.
○ Sit them up to open their airway, depending on the age of the child
○ Supplemental Oxygen
○ Suctioning
○ Chest PT
● Most common cause of respiratory distress: trauma or shock.
● Palpation: if a patient is experiencing pain in the abdominal area, assess all other areas first and
leave that for last!
○ If using other muscles to breathe must check- usually pressure, asthma, obstruction.
Most common cause of Cardiac arrest= respiratory failure.
If child in respiratory distress, ABCs always.
If parent isn’t able to console child, this is a very serious situation
Child abuse
o
Neglect
o
Not enough food, clothes, shelter, medical attention when necessary.
▪
o
o
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Poverty is different situation- evaluate circumstances
See something, say something
o We will report to CPS- mandatory
Bruises
o If they’re withdrawn, they might tell you or show you, if afraid of parents.
o SOME bruising is normal- NO BRUISING means the child isn’t doing anything- SUS
We get hx from parents but ask the child why they’re there- fosters autonomy
o If parent doesn’t allow child to answer anything- SUS.
STUDY- Go through growth and development, the table
Concept mapping
Age-appropriate toys
Infants- 0-12 m Solitary play
Rattles
Older Infants- Mobile with contrasting colors or
patterns
Soft, brightly colored toys
Play peek-a-boo with baby
Toddlers- Parallel Play (with another child)
Push/pull toys, block stacking
Preschool age
Imagination- tea house/tea party, dolls etc.
School Age
3 C’s- cooperative play- Puzzles, games with rules,
art, legos
Adolescents
Socialization and technology
Tips for Communicating with Parents
When communicating with parents, be honest. Parents want to feel valued and should be equal partners
in the health care team. Allow the parent to express concerns and ask questions.
Explain equipment and procedures thoroughly. Help the parents to understand the long-term as well as
short-term effects of the treatment.
Teach the parents what the child will feel like and how he or she will look during a procedure. Teach and
encourage the parent to perform as much of the child’s care as is reasonable and permitted.
Ask the parent about his or her perception of the child’s progress.
Allowing the parents to be involved in the care of their child gives them a sense of control and lets them
know they are valued by the health care team. Provide parents with positive reinforcement, reassurance,
guidance, and support
Week 3 Content
Cardiac
Detecting cardiac problems
● S/S- Poor feeding, high HR/RR, pulse ox <94 in quiet baby, failure to thrive, poor weight
gain, developmental delay, positive prenatal hx/ family hx of cardiac dx.
Diagnostics
● Do any PE/assessment in parents’ lap.
o Ultra sound- prenatal, Echo cardio gram to see areas of heart- more frequent,
and cardiac catheterization.
Cardiac Cath● Get baseline V/S, mark pedal pulses Lets us see where defect is- Pressure, structure,
O2 sats, repair PDA, Intra Arterial balloon
Post Cardiac Cath● if bleeding, compress 1 inch above site- NO baths.
o Force fluids. Check dressing, color, temp of leg and s/s fever, pulse may be weak
immed. After but should pick up quickly.
Digoxin● IS good for kids. Checked by 2 nurses. Has short half-life- clears the body sooner. Less
chance of toxic but Narrow therapeutic levels. K must be in range (3.5-5.5) or dig toxicity
if K is low. High K- Low Dig. Low K- High Dig. MUST BE IN THERP. RANGE.
toxicity= halos/vision changes, check apical pulse.
Congestive Heart Failure● Diuretics and Digoxin to remove fluids and increase force of contractions
Cyanotic vs Acyanotic heart defects
Cyanosis- FOUR T’S
● The patient appears cyanotic due to deoxygenated blood bypassing the lungs and
entering the systemic circulation. SKIPS LUNGS
o This can be caused by right to left shunt or malposition of the great arteries.
o -tetralogy of fallout, tricuspid atresia, Truncus arteriosus, transport of great
vessels.
o Tetralogy of Fallot- Most common cyanotic- Must minimize stimuli in room/cluster
care.
o S/S- Easily fatigued tachycardia, tachypnea, murmur, heart failure, respiratory
infections
Mixed Blood flow● transposition of great arteries, total anomalous pulmonary venous return. Truancy’s
arteriosclerotic, hypoplastic left heart syndrome.
High BP, RR, HR, respiratory infection, polycythemia- HF Knee to chest position- they’re trying
to bring blood back up.
Acyanotic● Blood shunting left to right- skipping the body. Acyanotic heart defects have normal
levels of oxyhemoglobin saturation in systemic circulation.
Blood from the lungs reenters the right side of the heart to be re oxygenated.
PDA● bounding/machine like murmur. Left shunt to the right. Increase pressure in the lung. Small
hole loud, big hole quieter. Younger than 6 months is better.
Aortic Stenosis- Valve only has 2 instead of 3- valve is thick and rigid. L ventricular Hypertrophy,
decreased CO- weak pulse, hypotension, clubbing, can be deadly bc blood can’t move from L
ventricle to aorta. Balloon helps.
Atrial Septal Defect● Left to right- they tire easily, and failure to thrive. If large hole may need cardiac cath
closure.
Ventricular Septal Defect
● Most common- open in ventricular septum, left to right. Medium/large hole S/S of CHF, freq
resp infections, failure to thrive. Don’t fluid restrict, but need to manage so they don’t
overload or dehydrate.
Signs of CHF● Tachycardia (early), fatigue, weakness, restlessness, pale, cool extremities, decreased
blood pressure, decreased urinary output; diaphoresis
Hyper cyanotic spell- blue lips and crying-knee to chest helps calm and breathe- give 100%
blow by O2,
Coarction of the Aorta● narrowing of the aorta, high BP in arms, low in lower extremities. SX opens up narrowing
portion. “Epitaxis, decreased pulse, and in LE
o S/S- Diminished pulses, poor color, decreased cap refill, exercise intolerance, chest
pain, dizziness when standing for long periods; CHF. Radial pulses full/bounding and
femoral or popliteal pulses weak or absent. Leg pains, fatigue, Epistaxis
Hypoplastic L heart● Left side doesn’t develop- need heart transplant after birth.
Bacterial endocarditis
● Infection of valves and lining of heart. If had transplant and murmur disappears then
reappears, this is the problem
Kawasaki disease- damages vessels- can lead to heart cell death if not caught early- causing
MI- or heart attack.
● Acute: sudden high fever, unresponsive to antipyretics and antibiotics (lasts 1-2 weeks)
Sub-acute: end of fever through end of all KD clinical signs (lasts 2-4 weeks)
Convalescent: clinical signs resolved, but laboratory values not returned to normal;
completed with normal values (6-8 weeks)
● Red, rash, and fever > 5 days, and high HR- in child under 5 is Kawasaki.
Rheumatic fever
Is a complication of an untreated strep throat infection.
S/S- strawberry tongue, red rash, fever, NO RASH on palms/soles
● Inflammatory reaction after a streptococcal throat infection, Leukocytes accumulate on
the affected tissues, infrequently seen in United States bc we treat with ABX early in
strep infection; big problem in Third World
● joint pain, fever, chest pain or palpitations caused by heart inflammation
(carditis), jerky uncontrollable movements (Sydenham's chorea), a rash, and
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small bumps (nodules) under the skin. A child may have one symptom or
several.
Tx- : eliminating any residual strep infection; reducing inflammation, particularly
in the joints and heart, and thus relieving symptoms; and limiting physical activity
that might aggravate the inflamed structures.
When the heart is inflamed, strict bed rest (getting up only to go to the bathroom)
is generally suggested.
If the heart valves become damaged, the risk of developing a valve infection
(endocarditis) remains throughout life- People who have heart valve damage
must always take an antibiotic before any surgery, including dental surgery,
throughout life.
Prolonged PR interval.
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Hypertension● take BP a few times before dx- monitor BP and weight.
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Respiratory:
Respiratory Assessment- chest wall is smaller, will get larger as they grow. The
bifurcation of the airway is smaller= aspiration,
Trouble with breathing- position for airway access. Extremely narrow bronchial lumen
until 5yrs. About diameter of their finger
Infants have less cartilage. Chest walls are more flexible- More prone to collapse. Tonsils
in children are larger.
Acidosis, shock, anxiety can cause high RR.
Color- assess lips, nails, skin. Clubbing- chronic hypoxemia
Indications of Respiratory Distress- Might hear absent/diminished breath sounds.
Nasal flaring, Cyanosis, Expiratory grunting, mottling (can be from the cold air)
Postural drainage
Oxygen selection- based on compliance, concentration they will need.
Nasal Canula- need to make sure their nares are patent, may need to suction nostrils.
Can use tents if non-compliant.
Mask- needs to fit snug around face.
Blow-by method- blow oxygen towards pt. Aerosol- nebulizer tx- meds go directly into
airway. Not for emergency
Retractions- More prone to retractions in respiratory distress. Trying to get more oxygen
because of resistance. We see retractions in the ribs, neck, nasal flaring.
Kids use Abdominal breathing until 7
Assess- Look at RR, prolonged expiratory rate- asthma
Prolonged Inspiratory rate- obstruction
Look for depth, effort, regularity, sounds, laterality.
Trach Care
If can’t clear mucus from cough, postural drainage uses gravity help to loosen
secretions. LOOOK AT POSITIONS- first thing in morning, before they eat, or 1 hr after.
May not need to suction if use aerosolized tx to loosen up secretions. Should hear
popping hallow sound when loosening secretions.
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If on vent- still look at pt● Oral airway is preferred if is emergency
Tube in nose can still do good oral hygiene, suck on pacifier, less oral/feeding issues.
● Size of ET tube should be size of pinky finger,
Uncuffed ET tube under 8 yrs old
Adverse effects of being intubatedo hypoxia, bradycardia, can have aspirations, trauma to mouth/teeth/trachea/sore
throat
Trach can be long term or acute.
Suction infants less than 5 seconds, and less than 10 seconds for an older child.
o Only suction when it needs to be done. Only insert catheter just beyond throat.
Trach ties- keep area clean/dry prevent infection/breakdown. Change daily or when
soiled. Fingertip loose. When change keep head flexed when securing.
o Tonsillectomy po care
Tonsillitis- can have difficulty breathing. Usually do culture, most common is strep. ABX
for 10 days. But if resp status is compromised, we can remove.
Tonsillectomy
Place on abdomen or side until fully awake- aspiration precaution.
Manage airway
Check for bleeding, esp. new bleeding. Constant swallow, is bleeding.
Croup- 3 S’s- Stridor, Subglottic swelling, and Seal-bark cough. Inspirator stridor, and
worse at night. 3 months to 2 years. Take them outside in the cool air, usually viral, no
abx, just supportive care.
Listen to lung sounds, O2 sat. Must be able to take in fluids, health literacy of parents
must know how to bring the baby back
Croup
Fever
Cough
Dysphagia
Cause
Emergency
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VS.
Fluctuating
Yes
No
Viral
Not Typically
Epiglottitis
High
No
Yes
Bacterial
Yes
Epiglottis- DDDD- Dysphagia, Drooling, Dysphonia, Distressed Inspirators efforts.
True emergency. Inflammation of epiglottis and all folds. Usually in tripod position, high
fever and may follow a cold. S/S drooling, agitated (can’t breathe) head drooping
forward, don’t look, can occlude airway. May need to sedate bc anxious. IV abx
Pneumonia- if RR rate is high, keep NPO to prev. Aspiration. Chest PT, suctioning,
Cough and deep breathe. Teach how to splint, lay in affected side can help. Tylenol for
fever, abx and pneumonia isolation.
RSV is Bronchiolitis- Inflamation of small airways in the lungs. - Higher incidence for
malesWheezing, crackles, Respiratory distress,
o Starts as mild URI and gets worse.
If admitted bc they’re not tolerating fluids or diff breathing.
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Cluster care so you’re not bothering sleep.
Contact and droplet precaution- isolation.
Parents must be gowned and masked If coming in/out or need to stay in the room.
o Hand washing!!
Asthma- Children should be taught how to use spacer bc it traps the med so its effective.
o Inflammation from any triggers. Dander, dust, pollen, smoke.
Attack- Mucosal edema- airway tissues, Bronchospasm- constriction, Mucus pluggingthicker
Position upright, Albuterol, O2, oral steroids. Cardiac monitoring with constant pulmonary
assessment.
Teach how to use peak flow meter, shows what direction they’re going in. Blow out as
hard and fast as you can. Do it regularly and can see when they’re headed to attack.
Bronchodilators- albuterol - relax muscle while steroid kicks in
If have chronic cough, or infection during Inspiratory phase then ASTHMA.
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Cystic Fibrosis- recessive disorder. Mutation disrupts chloride ions. Mucus builds up in
lungs/liver/pancreas ducts/ take pancreatic enzyme daily. They will grow slowly. Early
signs are meconium illuis- difficult passage of meconium stool in the newborn periodreoccurring respiratory infections, skin taste salty bc of chloride.
Chest PT helps loosen mucus, helps with deep breathing, Builds strength and
endurance or resp muscles. Don’t multiples times a day between 1-2 hr increments,
NOT done right before/after meals.
Sweat test- Positive sweat sodium chloride test- shows high chloride levels > 60
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Choking child- can’t speak, cyanosis, do Heimlich. Back blows.
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Flu- give tamiflu within 48 hrs
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1 oz= 16 oz
https://www.youtube.com/watch?v=Pv7kfk3TyKQ IV fluid maintenance
PEDS EXAM 2
GI
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Make note of the suck- swallow reflex- develops at 34-36 wks
Stomach capacity is 10-20 mLs and then increases until adolescence
Stages of GI Development
● Starts at 3rd week of gestation
● Emptying time is faster in smaller stomach
● Liver edge is palpable 1-2 cm in infant
● Abdominal distention can easily become respiratory issue
Focused hx for Gi● Congenital, feeding trouble, traveling, socioeconomic status (food, resources) Hygiene,
family hx of allergies
Most common consequences of Gi disease in children
● Malnutrition (absorption issues), FTT, dehydration) fluid and electrolyte disturbances)
o Ask duration, onset, if causing weight +/-, if they have pain, what’s their normal
bowel habits, d+/constipation, diff in appetite or thirst lvl, any intol to certain types
of food, what/when/how are they eating and how are they tolerating.
▪ Most common complaint is V+, reflexive- in response to infection/allergy
or CNS- head trauma, meningitis, tumors.
● Ask about V+. Color, how often, blood, what does it look like, is anything else in it.
● Green V+, what may be going on?
o Green is bile- obstruction.
o Curdled looking- in stomach too long and is trying to empty.
o Coffee ground- Gi bleed. V+
o Fever- infections
● Constipated and V+- obstruction
● V+, headache, change in LOC- CNS or metabolic
● V+ can be from stress- investigate if nothing else works
● Abdominal paino Access last- if you touch pain first- won’t let you touch anything else
▪ May be guarding, but can take bell of stethoscope, and can gently palpate
and get a sense of pain
● Pyloric stenosis- Projectile vomiting
o Narrowing of outlet of stomach, at pyloric sphincter, will give you feeding
problems and projectile V+, can start s/s at 1 wk- 5 m.
▪ Can lead to obstruction.
o Assessment findings- Baby will look like- weight loss, dehydration, olive shape
mass in RUQ- right of midline, and failure to thrive. Baby is hungry but can’t eat
●
Can see a parasystolic wave across abd before V+, and V+ will occur shortly after
feedings.
*Priorities for babies- IV fluids and correct electrolyte imbalance, support to the family.
*Weigh baby bc of weight loss from V+*
● Surgery- will keep them on IV fluids, then slowly feed. 4-6 hrs after of pedialyte then
advance within first 24 hrs.
Focus on full feeding tolerance, check feedings, I&os
Inter-conception, telescoping of one part of the intestine into the lower part of intestine. Will
block the intestine- causing obstruction. Nothing can pass through and can cut blood supply,
causing ischemia, and mucus from the intestine.
● Stool with bloody/mucus looking stool.
● They have intermittent colicky pain, comes and goes.
o Every 15-20 min they bring knees up to chest and cry. Between episodes they
are fine, V+ is common.
● Can see it on X-ray- how confirmed.
● Contrast enema for Dx to see obstruction- Barium enema and how it works= visualized
obstruction and sometimes fixes it.
75% contrast enema solves, if not they need to go in and fix it. If not caught early, that piece of
bowel necrosis. Colicky pain is key
Hirschsprung's disease- large intestine, mobility, obstruction, and can’t evacuate stool.
Congenital anomaly.
● Part of colon is missing ganglia cells, so no nerve intervention to that part- so no mobility,
and will result in obstruction.
● In infancy, no stool in 1st and 2nd day of life, illness V+, abdominal distention, no feeding
so failure to thrive
● Older infant lack of weight gain, V+ with episodes of D+ because it just leaks out
● Ribbon like stools- bc that’s all that can come out. Usually Dx in first first weeks of life,
biopsy will see missing the cells, can go in and remove that portion of the bowel and
reconnect to healthy portion. May need colostomy if can’t do Sx in 1 go● Baby with colostomy- monitor stoma, bleeding/infection/stool will be loose- NPO then is
baby eating? Check bowel sounds. Tape things behind them or onesies to keep them
from pulling at it. Check/manage pain after major SXClinical manifestations- infantsOlder child need to update
Appendicitis- most common in childhood. 10yr is average age.
● Inflammation and obstruction (fecal, food) will block outflow of mucus, and pressure
builds up
● RLQ for older kids, for younger it’ll be more diffused, anywhere on belly.
o S/S- Rebound tenderness. High fever, n/v, loss of appetite, Abd distention, pain
around umbilical, Murres point.
● Ideally want to take it out before ruptures ( manifests as spontaneous relief)
● They will guard area, confirm by ultrasound (less invasive and no radiation) or cat scan.
● Post op- Vitals, pain meds, possibly Abx- esp. if perforated, check site for infection, IV
fluids and electrolytes
● NPO then once gag reflex, flatulence and bowel sounds can eat, and ambulationprevent DVT, and lung expansion (cough and deep breathe) or incentive spirometer,
Reflux in infants- peak usually around 4m and most grow out of it.
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Gi contents regurgitates in esophagus.
S/S- weight loss, pain, screaming/crying bc hurts and hungry. Freq resp infections from
aspirations, coughing stridor, wheeze from this.
Will eat a lot but wont gain weight.
Tx: Barium swallow, thicken their feeding, sit up right after feedings, if severe need to be
upright for 2-3hrs. Meds like antacids
If severe like constant resp infections, FTT, need the Nissen SX.
Kids in wheelchair has higher incidence of resp infections because not expanding or
moving.
Spit up VS true Reflux; Babies spit up bc they over eat, only can come back out.
o Happy baby- GAINING weight- is just a piggy ☺
IBD- group by inflammation of GI tract- autoimmune
Both very similar
Weight loss, pain, bloody (UC) n/v, fever. Has periods of remission. Control inflammation,
nutrition to promote normal development- not taking in enough nutrients and body image
disturbances for adolescence- psychosocial portion in adolescent population.
Crohn’s- More often effects small intestine, and possibly parts of large intestine. Inflammation
extends deeper into layers. Occurs more at night.
Ulcerative colitis- large intestine inner lining becomes inflamed, swells,
● bloody D+- lower end of intestine; Can cause failure to thrive
Celiac- gluten intolerance causing malabsorption issues.
● Triggered by gluten, in bread, cookies, pasta, wheat, barley, rye.
● Microvilli get destroyed decreasing surface area causing malabsorption.
o Small intestine starts attacking itself● Not dx until about 2yrs of age bc still eating different kinds of foods.
● Weight loss or slowed growth, can check for positive markers abt 18m of age, and then
in early adulthood in college- drinking beer.
● Can also become lactose intolerance- absorption is damaged.
Lactose doesn’t break down, causes abd distention, bloating, n+,
GU/Renal
Differences- Kidneys are for filtration of blood and balance.
o Responds to solutes, volume, and intake in general. While maintaining
equilibrium. When born all nephrons are present, but are immature and less
efficient.
During first 2 yrs, aren’t functioning efficiently, so they don’t maintain equilibrium.
o Over or under hydrated very quickly.
● Kidney function in utero starts within first few weeks but still goes until 2 yrs.
● Bladder capacity increases with age. Birth: 20-50 mL, Adult up to 700 mL
● Potty training- must have words for it. Have to comm. they need to go. Have to have
control (dry for 2+ hrs) or stay dry at night.
o Age 2-3, but all above must be happening.
● Normal for trained child to regress when stressed (in hospital, don’t shame or it’ll
continue); Communicate empathy & teach normality.
UTI- causes kidney infection, diabetes (check urine first, sugar, protein, ketones) stress, trauma,
always rule out medical before psychosocial
● Most common- bacterial inf in infants and children.
o More common in girls, age 2-6
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Causes- neurogenic bladder (doesn’t fully empty)
▪ UTI can be cause of reflux/VUR; presents as UTI. Retrograde flow of
urine into ureter; more of an Upper UTI but can cause UTI & it’s the most
common cause of pyelonephritis.
o Anatomic; Not voiding enough
o Adolescents- sexual intercourse
o Educate girls; wipe front to back, no tight clothes, cotton clothes, avoid baths
Investigate if a little boy comes in w frequent UTI; w/ the exception of young boys who
aren’t circumcised.
o Uncircum= increase risk of uti if not cleaning properly. Educate: retract foreskin to
clean
S/s of uti depends on age
o Infant- Jaundice, fever, irritability v, poor feeding
o Older child; v, abd pain, flank pain, fever, enuresis w/ urgency, frequency, strong
odor to urine.
o Adolescents; flank pain, fever, chills, pain w/ urination
o Under 2- more GI s/s & more nonspecific, classic s/s in kids above 2
Dx: depend on degree of suspicion &What they complain of; check urinalysis& culture.
o How to collect urinalysis: clean catch urine if potty trained & can understand;
Infant- more challenging. Most accurate is w Cath but can attempt other ways,
but won’t be as accurate. (Urine collection bag on infant; Attempt to take a
recently wet diaper & pull-out urine w syringe.
▪ If sending culture, you want cleanest/most accurate- Catheterization.
▪ Collection bags are less invasive, you put bag over genital area and it
seals. Wait for urination, and take bag off quickly and send out. If sits for >
1 hr will be contaminated and results will be inaccurate.
Tx- Abx for 7-10 days
o Once culture comes back; may change to narrow spec abx
o Increase fluid intake & void frequently.
Assessments for Kidneys- I&O’s, daily weight (retention) and BP
If freq can be reflux, means urine in bladder will back up into urethra causing upper UTI, then
may have to go for ultrasound to check
Acute renal failure- not able to appropriately regulate fluid intake or maintain equilibrium.
Happens suddenly, not able to concentrate urine. Fluid in face, jugular vein distention, high BP,
possible respiratory issues- SOB. Electrolyte imbalance- hyponatremia- seizures.
Acute renal failure from dehydration secondary to d/v
How to prevent? Teach caregivers when they’re still little bc kidneys not functioning until 2.
Want 6-7 diapers per day, if no wet diaper in a few hours, that’s a problem
-Don’t get a lot of leewayCan also go into ARF from shock, trauma, burns. Not primary reasons.
Most effective management of ARF is prevention.
Can give diuretics, check in BP, HTN is common but serious, check fluid and electrolytes. Must
check for Hyperkalemia and water intoxications
When kidneys can’t maintain equilibrium, may be chronic. GFR drops below 10-15% normal
may need dialysis or transplant.
Progressive Renal injury is greatest when a UTI occurs in which age group? Infant (+ toddler)
Peritoneal Dialysis
● is preferred in smaller baby- Quick & doesn’t have as much fluid shift/change.
●
Can be done at home. Filters blood. Insert catheter in abdominal wall, and use high
dextrose solution.
o Cath inserted through abd wall; fills abd w high dextrose solution; Dextrose pulls
the waste and extra fluid into abd cavity and is then drained; Is more natural and
slower.
● Complications- Assess for peritonitis; pain; leakage around cath; resp s/s
o Can cause infection, could leak into chest- respiratory assessment- listen and
count (Check lung sounds (no sound is good) and check for resp difficulty.)
o Abd is closer to lungs of small infants/toddlers. If any leakage could easily go to
lungs.
Hemodialysis- machine functions as kidneys. “Treatment removing fluid from the body”
● Difficult in child that weights less than 20kg bc of cardiovascular shift (change in blood
volume)
● Lots of Cons- takes a long time, have to stay still, and happens 3X wk;
o Dietary restrictions- Fluid and NA restricted, Make sure all kids in CRF are getting
high protein.
o Physical limitations; pt will not be up and moving while hooked to machine. Makes
them very tired.
o Causes; Slowed growth, not going through puberty at same time, Stuck to a machine 3X
week for 3-5 hrs.
o Body change/image changes
o Disturbed bc/ hemodialysis causes slowed growth, skin changes, and delay/lack of
sexual maturation (Will appear much smaller than peers & Mature @ slower rate)
Transplant only other option- or death. If kid opts out of dialysis- must support them.
Nephrotic syndrome- usually idiopathic
● Toddlers and preschool age kids, having massive proteinuria, hypoalbuminemia,
hyperlipidemia, and edema.
o Albumin keeps fluid inside cells- if not enough- fluid shifts and causes edema.
● Happens slowly with dramatic weight gain(fluid)
● S/s- Weight gain, puffy face/eyes, pale, fatigue, decreased urinary O; Urine looks foamy and
frothy from protein,
● Tx- Give albumin, then give Lasix.
● Tx- I&O’s, weights, BP. Diuretics, IV albumin to restore,
o Don’t fluid restrict- just monitor
● Tx: Increased steroids (pred for 6 wks), once protein decrease can taper
o S/s of steroids; moon face, weight gain, mood swings, increased hunger, decreased
sleep. ( @ risk for imb. Fluid, infection, impaired skin integrity.)
▪ Educate- its temporary and normal. Support parents
o Teach- Give as RX’d, don’t miss a dose, and taper. Take with food, can cause gi
upset.
● Considerations- weight, I&O’s want to see Decreased the Abdominal girth, lung
sounds, & s/s dehydrated
● Primary goal: decrease excretion of urinary protein, we want protein free urine and to
decrease edema
● Pt Is taking prednisone- what priority to watch for? Infection
Glomerulonephritis- 1-2 wks post strep infection.
▪ Preschool/school age kid at most risk bc they are at high risk of getting strep
▪ Body holds onto NA and H2O- causes edema, and Oliguria.
▪ Urine looks dark/brown/tea color- RBC
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Latent for about 10 days after being sick
S/S; hematuria, facial edema, periorbital edema in the morning, low urine vol, mild
proteinurea, low appetite, HTN from NA and H2O retention.
▪ If HTN- they have severe edema, may use low NA diet, high protein.
▪ May need abx if throat culture is still strep +
o Monitor- I&os, BP and weight. May restrict fluids+NA. Increase rest and quiet
activity/room
▪ No contact sports to protect kidney
o UA shows hematuria, proteinuria, and increased specific gravity.
▪ Tx- No specific tx, recovery is spontaneous. Supportive care.
Supportive care until resolves. Prevent contact sports so no further injury to kidneys.
Baby needs to be cath. Bc off suspicion of UTI- explain to the parents that it gives best
results
Hematological
● Differences
● Assessment
IDA- problem when kid stops breastfeeding; screen for anemia usually @ 1 yr & is @ risk for
anemia bc poor diet.
● Iron def. anemia is common in toddlers and adolescents (menstruation) bc of poor diet.
o Make sure IDA isn’t from bleeding
o Looking for HGB below 8 and look at iron& serum iron lvls.
● S/s depend on iron level. Pallor, fatigue, activity intolerance
o Determine if they need iron supplement. Take in the morning and on empty
stomach
● If liquid- make sure pt uses straw to prevent teeth staining.
● Teach- will cause dark stools. “Which needs further teaching about iron supplements?
“I’ll call if my child has black tarry stools””
● Best way to deal w/ iron def. anemia is to prevent it by making sure infants have iron
fortified formula, and are eating a diet w high iron when solid food introduced.
o Food w high iron- meat, green leafy veg, yogurt, cheese, cereal, iron fortified
food.
● Monitor teen diets bc they are at risk
SCA- Sickle cell priority oxygen; SCD- if have chest pain go to nearest ER; Unknown Questionmove child carefully and gently to minimize pain; Pt with vaso-occlusive crisis- what will you
see? Swelling and pain in the hands and feet (bc of pooling blood)
● 3 types- A.B& C
● Autosomal recessive disorder, defect causes sickling of cells, and decreased blood flow.
o Stress and infection are triggers
o Decreased o2 to blood= sickling of cells and causes decreased BF (to capillaries
and increased congestion) to tissues= hypoxia= Sickle cell crisis= VERY painful.
ALL systems- Resp/circulatory, cardiac, spleen, liver, and brain are all effected.
● Pain depends on location of crisis- Make sure to check pts pain properly.
o Acute chest syndrome- #1 mortality.
▪ Chest pain from SCA- is emergency.
● Splenic enlargement; ULQ pain, blood pools in spleen and abd distention. Primary
concern is hypovolemic shock.
o Labs; decreased H&H; increased reticulate site count shows amount of RBC
destroyed.
o
Aplastic destruction; very low hemoglobin, Increased destruct of RBC leads to
decrease prod of RBC. Infection/stress can lead to this. We see pale, s/s of
anemia
● Unlikely to see Sickle crisis in Newborn bc they have high HGF circulating, then turns
into high HGS (symptomatic)
o DX- teach parents evaluate for enlarged spleen; s/s of sepsis, infection
● PRIORITIES HOP to it- Oxygen, hydration, pain (narcotics) Morphine=gold.
o ALWAYS ABC’s, No one dies from pain but its important.
● Pain management- distract with play (non-pharm) or meds(pharm)
● Pts pain depends on how long they haven dx bc their baseline pain is lower than
expected bc pain tolerance- they’re use to pain meds and have a high tolerance.
o Dependent on meds NOT addicted to meds
▪ Pain is subjective, help control (and advocate) pain- believe them always
● Max morphine for meds pt- no # bc of titration monitoring and tolerance. Titrate
appropriately.
o Ask the right Q’s- OPQRST; if pain in mult. areas you need a diff assessment and
reassess in each area
o Education- Triggers. Infection, stress, dehydrated, extreme temp change (hot to
cold, or cold to hot) ex winter.
▪ Hard for kids to understand to stay warm and comply to tx plan
● Adolescents stress themselves out and go into crisis- recover and repeat the cycle
Hemophilia- Hemophilia most common internal bleeding space- Into the joints● Clotting disorder, factor 8 Hemophilia A
● Goal: provide factor 8 to aid in clotting.
o Worry abt reaction from blood transmission
o DX: new born screen, prolonged bleeding from circumcision
● Have mild and severe cases.
● Most common pt bleeds into joint spaces- hemarthrosis
● Most dangerous- intracranial bleed- Be aware of head/brain trauma
o Labs- prolonged activated PTT; decreased factor 8
o Do genetic testing on fam to see who is carriers
o Tx- admin. Factor 8 in hospital. Can also be done at home w pt teaching
(depends on situation)
o Adm fresh frozen plasma as ordered to increase clotting
o Fibrin glue can be applied topically to seal the wounds and stop bleed
● Prioritieso Replacing factor 8
o Managing pain bc bleeding
o Mobilize bleeding areas.
● Promote strengthen muscles; No contact sports- parents keep kids in a bubble from
G&D stages.
● Med ID bracelet; Injury prevention education
● Aim: teach s/s of internal bleeding and hemarthrosis; Mot kids are part of a heme
program team w/ doctors. *Multidisciplinary care*
● 20% of kids will develop lung neutralizing antibodies that are less effective over time;
(antibodies are compensatory from multi transfusions) risk of getting many blood
transfusions. And transfusions are less effective over time.
ITP- Blood doesn’t have enough platelets- thrombocytopenia
● S/s bruising, freq nose bleeds, gum bleeding, heavy period, excessive bleed/bruise,
petechia.
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Most common age @ 3-7 yrs. But can be any age
Labs will show less than 150k, antiplatelet antibodies in blood smear under microscope.
cause is unknown but can be from viral infect.
Eliminates platelets bc body thinks they’re bacteria (Autoimmune, body is attacking
platelets)
TX- IVIG for a few days, sometimes SE and steroids used
Self-limiting for a few wks after tx; usually feel better but sometimes pt has chronic
conditions. Some kids don’t feel sick, become frequent flyers
#1 priority- Safety. Fall risk. Room close to nurse station. Fall can lead to very serious
trauma and bleeding. Especially if below 20k
Any disorder w/ below 150k platelets= high fall risk and high priority pt. Move pt to top of
list.
Endocrine disorders
Type 1 Diabetes
Type 2 Diabetes
Hypoglycemia
Ketoacidosis
Diabetes Insipidus
SIADH
Precocious Puberty
Diabetes sick management
DKA- priority = ineffective breathing patterns.
Growth Hormone deficiency
Hypothyroidism
Neurological disorders● Febrile seizures- increased temp give antipyretics.
● Febrile seizures- occur bc of how quick the temp elevates and OTC antipyretics are
given to decrease fever
● Sign of increased ICP in a 10 yr old pt that has meningitis- what would be concerning?
Mood swings
● What do you do when child has tonic-clonic seizure? Put a pillow under head
● A child had a sz in school and has no hx of previous sz. The dad says I can’t believe my
son has epilepsy- how do you respond? This sz may or may not be indicative of
epilepsy.
● What is normal behavior post sz? Lethargy and confusion
● If a pt flexes his hips and knees when you flex the neck- whaat is this a positive
indication of? Brudzinski’s sign ( B- Both neck and knees, Kernigs- knees only)
● Meningitis pt what do you make sure to teach to prevent infection? Pneumococcal vaxx.
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Important intervention for when child is having sz? Record behaviors, don’t place
anything in mount, don’t suction, don’t place young blade, and don’t restrain.
Pt collapse on floor with sz- stay w pt & call for help and keep close to NUR station
Mobility● 12 year old dx w/ muscular dystrophy and hospitalized bc of a fall- surgery and skeletal
traction needed; what complication is greatest concern? Respiratory infection bc they
aren’t moving around= increased secretions.
● Unknown Qustion- answer is Describe and record seizure activity observed
● Unknown Question- answer is aim or physical activity each day
● Keep environment stimuli to a minimum for increased ICP
● Muscular dystrophy has these signs- waddling gait, gowers sign
● Cerebral palsy- trauma from birth- non progressive
● Mother asks about difference between Pavik harness and spica cast? Pavik harness is
for babies under 6 months
● Priority for pt with skeletal traction? Pin care
● What finding is a characteristic of fractures in children? Rapidity of healing is inversely
related to the child’s age
● Pt w osteomyelitis- what is priority intervention? IV abx therapy
● Parent brings 7yr old to the clinic for eval of injured wrist after a bike accident. Parents
upset, child refuses exam, priority intervention? Calmly ask child to point to where the
pain is the worst, and wiggle fingers.
● 6 p’s Pain, Pallor, pliothermic (cold), pulselessness, parathesia, patalysis/pressure and
cap refill. Important for fractures. Signs of decreased BF
● The nurse uses the 6 p’s to assess ischemia in a child w a fracture. Which is considered
a late ominous sign? Parathesia.
● Gowers sign is a- Transfer technique.
● Which pt is closest to the NUR station? Sz pt- and decreased platelet pt
● Osteomylitis- how to clean wound. Soap and water
● How do you get osteomyelitis- infection/exposure to the bone ( enterance wound/cut
● Compound fracture- complete break
● Osteomyelitis tx- PICC line w/ abx for 6 wks.
● How to prevent osteomyelitis? Keep wounds clean
● LOTS OF EPILEPSY- STUDY IT
● Bryant- Butt off bed and legs cant come down
● Spica cast- turn and position the pt= don’t use bar to t+p.
● Unknown eriksons question- give HW
● Irrirated Skin cast- these make a smooth edge on the cast so the skin is better protecteddon’t stick anything into the cast
● Diaper under cast
● Femur fracture: traction on bed ( weights)
● + types of traction + pulleys ( acronym)
● Lots of neuro q’s.
● Study Sickle cell HOP to it.
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