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Pediatric Exam 1 Study Guide

Pediatric Nursing -Chapter 1 and Chapter 22 Pg 636-658

1. Based on age development what are the major causes of mortality and morbidity
Neonates and postneo- Congenital anomalies, low birth weight, sudden infant death
syndrome, newborn affected by maternal complications during pregnancy, accidents,
affected by complications of placenta, umbilical cord, and membranes; bacterial sepsis of
newborn; respiratory distress of newborn; diseases of circulatory system; neonatal
1-4 years-mobile vehicle accidents, other accidents, congenital anomalies, homicide, cancer,
heart disease
5-9 years- accidents, cancer, congenital anomalies, homicide, influenza and pneumonia
10-14 years- accidents, cancer, suicide, homicide, congenital anomalies
15-19 years- accidents, homicide, suicide, cancer, heart disease
2. What is and how do you apply family centered and atraumatic care
Family centered care- It recognizes the family as the constant in a childs life. When
providing care, the nurse must consider the needs of all the family members in relation to
the care of the child.
Its important for the nurse to enable families by creating opportunities for all
members to display their current abilities and competencies and to acquire new ones
to meet the needs of both the child and family
Empowerment is the interaction b/w the nurse and family, where families have that
sense of control over their family lives and acknowledge positive changes that results
from helping behaviors that foster their own strengths, abilities, and actions.
Atraumatic care- The provision of therapeutic care in settings, by personnel, and through the
use of interventions that eliminate or minimize the psychologic and physical distress
experienced by children and their families health care system.
Therapeutic care includes the prevention, dx, tx, or palliation of acute or chronic
Personnel include anyone directly involved in providing therapeutic care.
Interventions range from psychologic approaches (preparing children for procedures),
to physical interventions (providing space for a parent to room in with child).
GOAL- first, do no harm by:
(1) Prevent or minimize child from being away from family;
(2) promote a sense of control;
(3) prevent or minimize bodily injury and pain.
3. Role of pediatric nurse
Therapeutic relationship
o Essential for providing high-quality nursing care
o Must have meaningful relationships with child and parents BUT also have

Family advocacy and caring

o Work with family members and identify their goals and needs, plan interventions
o Make sure child and family are aware of all health services, tx, procedures, etc
o Nurses must ensure that every child receives optimum care
o Must demonstrate caring, compassion, and empathy for others
Disease prevention and health promotion
o Education and anticipatory guidance
o Anticipatory guidance: hazards or conflicts of each developmental period
o These guidelines enables nurses to guide parents regarding childbearing practices
aimed at preventing potential problems
Health teaching
o Nurses direct goal
o Includes teaching about a dx, tx, etc.
o Must transmit information at the childs and familys level of understanding
Injury prevention
o Safety!!
o Must discuss injury prevention with parents and children routinely
Support and counseling
o Support by listening, touching, and being physically present
Coordination and collaboration
o With other professionals to provide high quality care
Ethical decision making (not in exam)
4. Consent issues of when and how to obtain when a minor is involved
Must be obtained for:
Major surgery
Minor surgery (ex. Cutdown biopsy, dental extraction, suturing a laceration, removal of
cyst, closed reduction of a fracture)
Diagnostic test with an element of risk (bronchoscopy, lumbar puncture, bone marrow
Medical treatments with an element of risk (e.g. blood transfusion, radiotherapy)
Photographs for medical, educational, or public use
Removal of the child from the health care institution against medical advice
Postmortem examination, except in unexplained deaths (SIDS, violent death, or
suspected suicide)
Assent: Child of teen has been informed about the tx, procedure, or research and is willing
to permit a health care provider to perform it.
How to obtain:
Parents or legal guardians required to give informed consent if child is a minor
If parents are married, either one can for non-urgent care.
If divorced, usually from the parent who has legal custody
Parent must be over 18 and competent

5. Developmental considerations in procedure preparations

Psychologic preparation- decrease anxiety and promote cooperation, support coping skills
and teach new ones, facilitate a feeling of mastery in experiencing a stressful event
Establish trust and provide support-easier to gain cooperation
Parental presence and support
Provide an explanation- short, simple, and appropriate
Physical preparation
Performance of procedure
Expect success- approach with confidence
Involve the child
Provide distraction
Allow expression of feelings
Use play in procedures
Infant- Developing trust and sensorimotor thought

Attachment to
-Involve parent in
procedure if desired
-Keep parent in
infants line of vision
-if parent is unable to
be there, place
familiar object such
as a stuffed toy.

Strange anxiety
-Make advances
slowly and in a
-Limit # of strangers
in room

Sensorimotor phase
of learning
-Use sensory
soothing measures
-Use analgesics
-cuddle and hug
infant after stressful

Increased muscle
-Restrain adequately
-Keep harmful objects
out of reach

Memory for past

-Keep frightening
objects out of view
-Use non intrusive
procedures whenever

Imitation of
-Model desire

Toddler Developing autonomy and sensorimotor to preoperational thought

Egocentric though
-Explain to child in
relation to what child
will see, hear, taste,
smell, and feel
-Emphasize aspects
of procedure that
require cooperation

Negative behavior
-Expect tx to be
resisted; child might
try to run away
-use firm, direct
-ignore temper
-use distraction
-restrain adequately

-Keep frightening
objects out of view

Limited language
-communicate using
gestures or
-give child 1 direction
at a time
-Use small replicas of
equipment & let child
handle them
-Use play; use a doll
to demonstrate but
avoid favorite doll

Limited concept of
-Prepare child shortly
or immediately before
-keep teaching short
-have preparations
completing before
involving child in it

Striving for
-Allow choices when
-allow to participate in

Preschooler- Developing initiative and preoperational thought

-Same as toddler plus,
-demonstrate equipment
-allow child to play with doll or equipment
-Use neutral words

Increased language skills

-use verbal explanations
-encourage child to verbalize ideas & feelings

Limited concept of time and frustration

-Same as toddler but may play longer
teaching session

Illness and hospitalization viewed as

-clarify why procedure is done

-Keep equipment out of view until used

Fears of bodily harm, intrusion, and

-point out on doll or child where it will be done
-emphasize that no other body part will be

Striving for initiative

-involve child in care
-Praise child for helping
School-aged child- developing industry and concrete thought

Increased language
skills; interest in
-Explain procedure
using scientific and
medical term
-explain procedure
using pictures
-Discuss why its
being done
-explain function and
operation of

Improved concept
of time
-Plan for longer
-prepare up to 1 day
in advance of

Increased selfcontrol
-Gain childs
-Tell child what is

Striving for industry

-Allow responsibility
for simple task
-include child in
decision making


-encourage active

relationships with
-prepare 2+ children
for same procedure
or encourage to help
each other
-privacy from peers
Adolescent- developing identity and abstract thought

Increasing abstract
thought and
-Discuss why its
being done
-Explain long-term
consequences of
-Realize they might
fear death, disability,

Consciousness and
-Provide privacy
-Discuss how
procedure may affect
-Emphasize physical
benefits of procedure

Concern more with

present than with
-immediate effects of
procedure more
significant than future

Striving for
-involve in decision
making and planning
-explore coping
-have difficulty
accepting new
authority figures

Developing peer
relationships and
group identity
-same as school

aged child


Preparation for procedures and pre-operative procedures (include play related)

For preparation for procedures see tables and information above
Pre-op care
Psychologic and physical preparation
Similar as preparing for procedures (play, tours, videos)
Let children wear underpants under the hospital gown
Include a family centered preop preparation such as a tour of the
perioperative areas, a video to take home, a mark to take home and practice,
pamphlets, phone calls before surgery
Restriction of food and liquids
Different than adults.
Fasting: clear liquids- >2 hours
Breast milk: 4 hours
Infant formula: 6 hrs
Nonhuman milk: 6 hrs (amount ingested must be considered)
Light meal 6 hrs (toast and clear liquids; amount must be considered)
Parental presence
Appropriate education is important for parents to understand the stages of
When parents are not allowed or dont want to be near the child during the
induction of anesthesia, leaving a favorite possession with the child and uniting the
child and parents as soon as possible after surgery are important interventions
PLAY ACTIVITIES for specific procedures
Fluid Intake
Ice pops using favorite juice
Cut gelatin into fun shapes
Tea party
Let child fill a syringe and squirt into mouth
Use crazy straw
Deep breathing
Blow bubbles with bubble blower, straw (no soap)
Blow on a pinwheel, feather, balloon, etc
Blowing contest using balloons, boats, feathers, etc
Straw-blowing painting
Take a deep breath and blow out the candles
Range of motion and use of extremities
Play simon says or twister game
Play pretend and guessing game (imitate a bird, butterfly, horse)
Play kickball or throw ball
Play video games or pinball

Hide and seek

Clay to mold with fingers
Play with small toys
Wash dolls or toys
Read to child during soaks
Sitz bath
Punch holes in bottom of plastic cup, fill with water, and let it rain on child
Let child handle syringe, vial, alcohol swab and give injection to a doll
Use syringes to decorate cookies with frosting
Draw a magic circle on area before injections and smiling face after
Progress poster
Give child something to push (toddler: push pull toy; school aged: wagon or
doll in a stroller; adolescent: decorated iv stand)
Have a parade
Extending environment
Make bed into a pirate ship or airplane with decorations
Put up mirrors so patient can see around room
Move bed frequently to playroom, hallway, or outside

Feeding the sick child

Loss of appetite is a common sx to most childhood illnesses
Refusing food can also be one way children can exert power and control
Encourage parents to relax any pressure during an acute illness- dont force them to eat
Dehydration is always a risk
Nurses should present food in the usual order, such as soup first followed by small
portions of meat, potatoes, and vegetables and ending with dessert
When child is hungry, take advantage by serving high quality foods and snacks
Parents can bring food items from home (esp. if cultural eating habits differ from the
hospital food)
Charting amount of food/liquid consumed is important
Nursing care guidelines
Take dietary hx and make eating time as similar to eating at home as possible
Encourage parents to feed child
Make mealtimes pleasant; avoid any procedures before or after eating
Serve small, frequent meals rather than 3 large meals
Provide finger foods for young children
Involve children in food selection when possible
Serve each course of food separately, not all plates at the same time
Provide food and fluid selections that are favorites of most children
Avoid food thats highly seasoned, have strong odors, or are mixed

Offer nutritious snacks

Make food attractive and different (serve picnic lunch in a paper bag, put a face or
flower on a hamburger with pieces of veggies, use cookie cutter to shape a sandwich,
add food coloring to milk or water, etc)
DONT punish children for not eating by removing their dessert
Praise children for what they do eat

During febrile, shivering and vasoconstriction generate and conserve heat during the chill
phase of fever, raising central temperatures
Fever has physiologic benefits which include increased in wbc activity, interferon
production and effectiveness, and antibody production and enhancement of some
antibiotic effects
Important terms
Set point- Temp. around which body temp is regulated by a thermpstat-like
mechanism in the hypothalamus
Fever (hyperpyrexia)- an elevation in set point. Above 38 C
Hyperthermia- body tempt exceeding the set point
Therapeutic management
To relieve discomfort
Acetaminophen is the preferred drug
Aspirin should not be used
Ibuprofen should be 5mg/kg of body wt for temp less than 39.2C or 10mg/kg for
greater than 39.2C
Acetaminophen dosage should never be exceeded
Cooling measures such as wearing minimal clothing, exposing skin to air, reducing
room temp, increasing air circulation, and applying cool moist compresses to the
Sponging or tepid baths are ineffective
Antipyretics are no value bc the set point is already normal
Cooling measures are used such as applications to the skin
Cooling devices and cooling blankets can reduce body temp
Tepid baths are effective to reduce body temp. Water should be 1C less than childs
body temp and left in there for 15-20 mins while water is gently squeezed from
washcloth over the back and chest of body


Responsibility of everyone who comes into contact with small children to maintain
protective measures throughout their hospital stay
Each age level and how each child is operating is important in guiding a safety plan
Identification bands are important for children
Infants and unconscious parties are unable to respond to their names

Toddlers might only answer to nicknames or will respond to any name

Older children may exchange places, give an erroneous name, or choose not to
Environmental Factors
All safety measures applied to adults are used with children
Windows secured, electronic equipment in good order, practice proper disposal
of syringes, and other small medical devices
Check bathwater before placing child in bathtub and never leaving child in
bathtub alone
Furniture scaled to childs height
Danger of entrapment when electronically controlled bed when they are
activated and descended
Baby walkers should not be used
Safest sleeping position is wholly supineno pillows placed in a young infants
crib when infant is sleeping
Nurses must assess the safety of toys when brining them from home to
the hospital setting
Toys should be appropriate to the childs age, condition, and tx
Toys should also be non allergic and have nonbreakable/removable small
Pass the choke tube test
Toy should not fit into the cylinder of a toilet paper roll
Latex balloons are never permitted in the hospital setting
Preventing Falls
Identify which children are at most risk by using a fall risk assessment
Risk Factors for Falls
Medication effects: post anesthesia or sedation
Altered mental Status
Altered or limited mobility: reduced skill at ambulation, new
assistive walking devices
Postoperative children: risk for hypotension, extended bed
History of Falls
Side rails down when family members are present
Once identified alert staff by posting signs on the door, bedside, and chart
Alter the environment
Bed in lowest position
Call bell within reach
All necessary items (toiletries, snacks, glasses, tissues, water ,etc)
are within reach
Offer toileting on regular basis
Lock wheelchairs before transferring pts
Keep lights on at all times

Keep room free of clutter

Educate parents and patients with age appropriate teachings about
Call the nursing staff if assistance is necessary and do not allow
patient up independently
Keep side rails up
Do not leave infants on day bed
When all family members leave the bedside notify the staff and
ensure the patients is in bed with all rails up
Transporting Infants and Children
Infants and small children can be carried for short distances but for extended
trips, child should be securely transported in a suitable conveyance
Horizontal position with the back supported and the thigh grasped firmly
by the carrying arm which leave one arm free for activity
Football hold is when the infant carried on the nurses arm with the head
supported by the hand and the body held securely between the nurses
body and elbow which leaves one arm free for activity
Upright position with the buttocks on the nurses forearm and the front of
the body resting against the nurses chest infants head and shoulders
supported by the nurses other arms in case the infant moves suddenly
Method of transporting depends on the childs age, condition, and destination
Younger children= crib
Older children= wheelchair with safety belt
Critically ill children= Stretchers/bed equipped with high sides and a
safety belt
Two staff members with monitoring continue during transport
Airway equipment and medication should accompany the patient
10. Appropriate restraining
Therapeutic holdings: use of a secure, comfortable, temporary holding position that
provides close physical contact with the parent or caregiver for 30 minutes or less
Use of restraints avoided with the adequate preparation of the child, staff supervision of
the child, adequate protection of the vulnerable site
Medical Surgical Restraints
Used for children with an artificial airway or adjunct airway for oxygen, indwelling
catheters, tubes, drains, lines, pacemaker wires, or suture sites
Ensure safe care is given to the patient
Risks of the restraint are offset by the potential benefit of providing safer care
Can be initiated by an individual order or by protocol
Protocol must be authorized by an individual order
Order for continued use must be renewed each day
Patients monitored at least every 2 hours
Behavioral Restraints

Limited to situations with a significant risk of patient physically harming

themselves or other behavior reasons where non physical interventions not
Assess patients mental, physical, and behavioral status
Collaborative approach used when implementing restraints with the help of the
medical staff and family
Order must be obtained as soon as possible but no longer than 1 hour after
Must be renewed every 1 to 2 hours
Licensed independent practitioner must conduct an in person evaluation within 1
hour and again every 4 hours until restraints discontinued
Children must be assessed every 15 minutes for signs of injury, nutrition,
hydration, circulation, and ROM exercises, vital signs, hygiene, and readiness for
Restraints with ties must be secured to bed or crib frame not the side rails
One finger space between the skin and the restraint device
Should be tied with slip knots that can easily be quick released
Types of Restraints
Mummy Restraint/Swaddle
Short term restraint for examination or tx that involves the head and neck
A pappose board with straps or a mummy board controls the childs
Child is placed on a blanket opened in the bed or crib with one corner
folded to the center so the childs shoulder lines up with the fold and the
feet are toward the opposite corner
Infants right arm is straight down against the body with the right side of
the blanket beneath the left side of the body
Left arm placed straight against the shoulder and chest locked beneath
the body on the right side
Safety pins secure the blanket
To modify the mummy restraint for chest examination bring the folded
edge of the blanked over each arm and under the back and then fold the
loose edge over and secure it at a point below the chest
Jacket Restraint
Used to keep a child safe in various chairs
Put on the child with the ties in back so the ties cannot be manipulated
Help maintain the child in a desired horizontal position
Long tapes, secured to the understructure of the crib, keep the child
inside the crib
Arm and Leg Restraint
Restrain one or more extremities to limit movement
Must be right size and padded to prevent undue pressure, constriction, or
tissue injury

Extremity must be observed frequently for signs of irritation or impaired

Ends of restraints never tied to the side rails because lowering the rail can
injure the child
Elbow Restraint
Prevents child from reaching head or face
Fits from just below the axilla to wrist with a number of vertical pockets
into which tongue depressors are inserted
Restraint wrapped around the arm and secured with tapes or pins
Legal issues, family centered care and role of family on child health - Chapter 3 and 21
1. Family general concepts, theories
Family General Concepts:
No universal definition of family
Biology: perpetuation of the species
Psychology: intrapersonal aspects of the family and its responsibility for
personality development
Economics: productive unit providing for material needs
Sociology: social unit interactions with the larger society, creating the
context within which cultural values and identity are formed
Family structure and dynamics have a huge influence on the child that affects the childs
health and well being
Nursing care of infants and children is involved with the care of the child and the
Family defined by the relationship of the persons who make up the family unit
Consanguineous= blood relationships
Affinal=marital relationships
Family of origin=family unit a person born into
Newer Concepts of family household
Single parent
Homosexual families
Theories: describes families and how the family unit responds to events both within and
outside the family
Family Systems
Family viewed as system that continually interacts with its members and
the environment with emphasis on the interactions between the family
A change in one part of the system affects all other parts of the family
where there are periods of rapid growth and change and then periods of
Strengths and Limitations
Applicable for family in normal everyday lifefamily dysfunction

Can be used for family in varying structures and stage of the life
Difficult to determine cause and effect relationships due to
circular causality
Mate selection, courtship processes, family communication, power
and control within family, parent-child relationships, teenage
pregnancy and parenthood
Family Stress
Explains how families react to stressful events and suggests factors that
promote adaptation to stress
Family encounters both normative (parenthood) and unexpected ( illness,
unemployment, etc.) stressors throughout the life cycle
Too many stressors in a short time (1 year) can overwhelm the family and
its ability to cope causing breakdown or additional stressors that can lead
to a family crisis
Strengths and Limitations
Explain and predict how a family will react to stressors and
develop into effective interventions to promote family
Focuses on positive coping, resources, and social support
Not yet known if there are certain resources and coping
strategies are applicable to all stressful events
Transition to parenthood hood, single parent families, families with
work related issues, acute or chronic childhood
illnesses/disabilities, infertility, death of child, divorce, teenage
pregnancy and parenthood
Addresses family change over time using Duvalls eight developmental
tasks of the family based on predictable changes in the familys structure,
function, and roles with the age of the oldest child as the marker for stage
Each family member must achieve individual developmental tasks as part
of each family life cycle stage within the family and broader society
Family role performance at one stage of the family life cycle influences
familys behavioral options at the next stage
Family is in a stage of equilibrium when entering a new life cycle stage
and strives towards homeostasis within stages
Strengths and Limitations

Provides a dynamic view of the family

Addresses both changes within the family and the family
as a social system over its life history
Anticipates potential stressors with transitions over various
stages in life and when the problems may peak because of
lack of resources
Geared towards two parent families with children
Uses age of oldest child and marital duration as marker of
stage transition sometimes problematic with step families
and single parent families
Anticipatory guidance, education for developing or strengthening
family resources for management of transition to parenthood,
family adjustment to children entering school, becoming
adolescents, leaving home, managing empty nest and retirement


Family nursing intervention

Nurses choice of intervention depends on the theoretic family model that is used
Family system: group dynamics, anticipatory guidance
Family stress: crisis intervention
Developmental: anticipatory guidance
Family involvement is essential to be included in the care of children
General Nursing Interventions
Behavior modification
Case management and coordination
Collaborative strategies
Counseling, including support, cognitive reappraisal, and reframing
Empowering families through active participation
Environmental modification
Family advocacy
Family crisis intervention
Networking, including use of self helps groups, and social support
Providing information and technical expertise
Role modeling
Role supplementation
Teaching strategies (including stress management, lifestyle modification, and
anticipatory guidance)


Family roles
Each individual has a position in each family structure with a culturally and socially
defined interactions and roles in the family

Conflicts arise when members do not fulfill their roles according to other family members
expectations or because they choose not to fulfill them
Parental Roles
Socially recognized mother and father with socially sanctioned roles that
define the sexual behavior and childrearing responsibilities in a family
structureall based upon parents social experience
Roles have evolved immensely with changing times fathers are more active in
child rearing and household tasks
More conflicts arise in families due to cultural lag and persisting of
traditional role definitions
Narrower the spacing between siblings, the more the children influence one
Wider spacing between siblings, the greater the influence from parents
Siblings exert power, exchange services, and express feelings in a reciprocal
Family Size
Small families emphasize individual development of the children
Children have a say in the family
Adolescents indentify more strongly with their parents and rely on them
for advice
Large Families emphasis on the group and less than the individuals
All members learn to cooperate
Dominant member either the parent or an older sibling emerges
Children adopt specialized roles to gain recognition in the family
Older children administer discipline and assumes responsibility for the
security of the other children when a parent is either ill or dies
Ordinal Position/Birth Order
Affects personalities and how parents treat their children as well as how sibling
interact with one another
Achievement oriented, dominant, self discipline
Identify with parents more than peer group
Begin to speak earlier in life
Plan better and experience fewer frustrations
Subject to greater parental expectations
Middle children
More demands made on them to help with the household
Praised less often and receive less of parents attention
Good at compromising and adapting to new situations
Difficult to characterize due to variety of positions it assumes in the family
Less dependent and less intense than the firstborn
Identify more with peer group than parentspopular among classmates


Fewer demands to help household

Flexible with thinking
Only children
Similar to firstborn child
More mature
Experience greater parental pressure for mature behavior and
Rarely develop into the sterotype of spoiled, selfish child
Enjoy a rich fantasy life as a result of isolation
Multiple Births
Develop a capacity for cooperative play and considerable loyalty and
generosity between each other
One member tends to be more dominant, outgoing, and assertive than
the other
The more passive twin tends to accomplish as much and get his or her
way more frequently than the assertive twin
Fraternal vs Identical
Identical or near unison in the actions of twinsalternate between
Differ in response to treating twins like some thrive best when in
each others company or when separated
Early years of togetherness is basis of the childrens
security and separating to early can be a stressor
Should foster differences when they become evident to
ease separation
Fraternal have no real unison in actions, sibling rivalry often found

Transition to parenting
No amount of preparation can fully prepare prospective parents for an infants constant
and immediate needs
Factors affecting transition
Parental age
Physiological standpoint best age for childbearing 18-35 years old
Childbearing age increased to 30-44 years old
Father involvement
Fathers with little initial contact with newborns will become involved with
them over the next few months
Fathers engage in more physically stimulating activities, successful at
soothing infants
Secure attachment to the father can help offset the consequences of an
insecure attachment to the mother
Parenting education

Programs are designed to take place near the time of birth or soon after
can be more helpful in easing transitional stress than earlier programs
Nurses offer suggestions and education in helping become a better
Support systems
Need to have at least two types of family resources
Internal Resources
Adaptability: learning to be patient, becoming better
organized, and becoming more flexible
Integration: couples attempt to continue some activities
they engaged in before they becoming parents
Time away from the child is essential
Coping Strategies
Use of social support systems and community resources
Interpersonal supportrelationship with family, friends, and
the community
Provides opportunities to be away from the child
Brings reassurance that others experience the
same fears of parenthood as you
5. Discipline and limits
Discipline: the action taken to enforce the rules of noncompliance
Types of Discipline
Explaining why an act is wrong
Appropriate for older children especially with moral issues
Does not work well for children because of egocentrism or they cannot
see the other side
Used by children to gain attention
Often combined with reasoning
A form of shame or criticism
Believe that they are bad not necessarily that their action is bad
Behavior Modification
Consistency and timing are essential
Positive and negative reinforcement
Rewarded for positive behavior to minimize the tendency to want to
Older Children use a token system
Certain number of stars or points add up to a special reward
Parents need to plan and explain expected behavior to the child and
establish a reward system that is reinforcing
Verbal approval should accompany extrinsic rewards
Extinguish or minimize the act

Difficult to implement consistently

Behavior actually reinforced because the child learns that persistence
gains parental attention
In order to be effective
Understand the process
Record the undesired behavior before ignoring to determine
whether a problem exists and to compare results after ignoring
Determine whether parental action acts as a reinforce
Be aware of response burst
Response burst is when the undesired behavior increased
after ignoring the child because the child is testing the
parents to see if they are serious
Involves allowing the child to experience the results of their misbehavior
Three Types
Occur without any intervention
Being late to the table and having to clean up the
dinner table
Preferred type and most effective
Directly related to the rule
Not being allowed to the play with another toy until the
used ones are put away
Preferred type and effective
Imposed deliberately
No playing until homework is completed
Using time out
Withdrawing privileges
After a child experience the consequence, parents should
not say anything since the child will try to place blame for
imposing the rule
Time Out
Refinement of the common practice of sending the child to his or her
Type of unrelated consequence
If done in an un stimulating environment, child will become bored and try
to behave in order to renter the family group
Avoids many of the problems of other disciplinary approaches
Allows both child and parents to have a cooling off period
Corporal or Physical Punishment
Most often takes the form of spanking


Inflicting pain causes a dramatic short term decrease in behavior

Serious Flaws
Teaches violence is acceptable
Physical harm the child if it results in parental rage
Children become used to spanking and require more severe punishment
over time
Can result in severe physical and psychological injury
Interfere with the childs developmental theory of moral reasoning
When parents not around children are likely to misbehave because they have not
learned to behave well for their own sake
Limit Setting: establishing rules or guidance for behavior the clearer the limits, the
more consistently they will be enforced, and then the less need for discipline to be used
Minimizing Behavior
Reasons for misbehavior attention, power, defiance, and a display of
inadequacy, rules not clearly established
Set realistic goals
Praise children for desirable behavior
Teach desirable behavior by own example
Call attention to unacceptable behavior as soon as it appears
Off sympathetic explanations for not granting a request
Keep all promises made to children
Avoid outright conflict
Provide children with opportunity for power and control
Nurses help parents establish concrete and realistic rules
Test their limits of control
Children learn how they can manipulate their environment and gain reassurance
knowing that there are others to protect them from potential harm
Achieve in area appropriate mastery at their level
Channel undesirable feelings into constructive activity
Protect themselves from damage
Learn socially acceptable behavior
Children need limits and unrestricted freedom is a threat to their safety and security

Parenting and divorce

Function of parenthood is to provide for the security and the emotional wellfar of children
Disruption of the family structure often leads to guilt on the childs part for the divorcing
Stages of the Divorce Process
Decision to separate made
Legal steps for filing divorce and most likely departure of father from the
New caregiver put in place, new home environment, possibly new school
Lasts from several months to more than 1 year

Causes familial stress and chaotic atmosphere

parents preoccupied with own feelings and needs leaving them
unavailable to help support the children through this process
sometimes parents begin to feel frightened and alone and starts
depending on the child to substitute for the absent parent causing a huge
burden to be placed on the child
Adults and children assume unfamiliar roles and relationships within the
new family structure
Inflammable tempers in both parents and children
Reduced parental competence
Greater sense of parental helplessness
Poorly enforced discipline
Diminished regularity in household routines
Noncustodial parents become the role of the visitor or the fun
Change of residence, a reduced standard of living and lifestyle, larger
share of economic responsibility by the mother, radically altered parent
child relationships
Post divorce family reestablished a stable, functioning family unit
Remarriage frequently occurs with concomitant change is all areas of
family life
Impact of Divorce on Children
Causes poor mental health outcomes
Possible relationship between child abuse, parental divorce, and
psychiatric disorder, and suicide attempts
Children recall parental separation with the same emotional felt by victims of
natural disasters
Impact depends on age, gender, outcome of the divorce, and quality of parentchild relationship
Children feel like they are caught in the middle
Feel a sense of shame and embarrassed concerning the family situation
A successful post divorce family can improve the quality of life for both the adults
and children
Greater stability in the home system
Conflict resolved= a better relationship with one or both the parents
Have less contact with a disturbed parent
Telling the Children
Hesitant to tell children
Initial discussion should include both parents and siblings followed with individual
discussions with each child


Discussion should include the reason for the divorce and reassurance that the
divorce is not the fault of the children a
Acknowledge feelings of fear and abandonment
Need love and reassurance that their lives will try and remain as consistent and
orderly as possible
Physically comfort the children can help provide them with warmth and
Custody and Parenting Partnerships
Past belief is mother gets custody with visitation agreements for the father
Current belief is neither mother nor father should be awarded custody
automaticallyshould be awarded to the parent who is best able to provide for the
childrens welfare
Grandparents on the side of the parent with custody are increasingly involved in
the care of young children of divorced parents
Non custodial grandparents are kept away from their grandchildren
Divided/Split Custody
Each parent is awarded custody of one or more of the childrenseparated
Sons live with the father and daughters with the mother
Joint Physical Custody
Parents alternate the physical care and control of the children on an
agreed on basis while maintain shared parenting responsibilities legally
Works well with families who live close to each other and whose
occupations permit an active role in the care and rearing the children
Joint Legal Custody
The children reside with one parent but both parents are the childrens
legal guardians and both participate in childrearing
Co parenting allows children to be close to both parents and life with each parent
can be more normal
For a successful co parenting relationship, parents have to be committed
to providing normal parenting and to separate their marital conflicts from
their parenting roles
Primary consideration is welfare of the children

Major hospital stressors

Separation from caregiver*: inability to go home, to be separated from family
If parents stay with child sleep issues, work concerns
Dont want pt too separated but consider caregivers need time to address
personal issues
Separation anxiety: major stressor middle infancy throughout pre-school years
Protest* stage: pt with be in flight/fight mode physically try to get out
and find parents
Despair: regression (may regress toilet training need diapers; refuse
food), withdrawal, may refuse food


Detachment: us. after prolonged separation (long hospitalizations),

appear happy ignore parents when they visit (hurtful to parents) but
may be so detached that theyre not really happy can make separation
even worse
Stranger anxiety: level varies depending on developmental level of child
Fear of unknown: for parent and child; important to address parent fears b/c children can
sense parent anxiety, worry feelings transfer to child unintentionally
Fantasy thinking: child might hear/observe something and think about it in ways adults
wouldnt consider; sometimes kids live in cartoon worlds where anything is possible;
maybe I am here because my parents are trying to get rid of me or being punished for
having done something wrong
Need to be aware of common fantasies to help kids dealing with anxiety
Loss of control: children get routine set by hospital; e.g. IV, cant run around like normal
For parents: need to negotiate scheduling things to give them back some control
and give kid control back e.g. do so by giving children limited* choices [having
a procedure, like receiving oral meds, ask with frequency]
Painful past experiences
Fear of death
Invasion of privacy: younger roommate, hospital gown
Parental anxiety transferred to patient
Isolated: isolating both child and family; PPE can frighten/intimidate patients; so
encourage pt and family to put on isolation gown and experience it, understand it a little
better to decrease anxiety
Waiting times
Procedures involving pain
Rectal/Genital exams: e.g. vaginal exam go to general anesthesia rather than
explaining procedure/traumatizing
Large number of adults: young boys having to show genitals to adults, nurses
Explain circumstances as far as examinations its ok for nurses, doctors but not
Explain rounds
Unfamiliar equipment, sounds and settings: allow pts to feel stethoscope to better
understand what were doing

Nursing interventions to decrease stressors

Admission Assessment address
Address needs, concerns, routines, transitional objects: e.g. childs fave blanket,
animal; continue routines e.g. nighttime prayer
Environment safety: rails up, help pt/family understand about IV/maintain
Physical: e.g. explain NPO, addressing concerns
Hospital/Unit regulations: smoking, amount of ppl in rooms conserve quiet
Unit Orientation: let family know specifics nutrition room, playroom


Minimize Separation
Rooming In: parents/family stays with child
Telephone: communication with family
Nursing Presence: play with patient
Parent Education
How to leave*: leave without saying goodbye is difficult; encourage
parents to have discussion with child (I may leave when you fall asleep,
the nurses can call me at home)
Explaining time: frequent short visit are good- quality*
Limit Physical Restriction/Changed Routines
Help parent maintain routine
Take out of room: noisy room
Provide visual, auditory, tactile diversion: games, videos, books, cards
Maintain certain routines: e.g. pray before bed
Familiar food
Promote self-care if appropriate: wagon instead of wheelchair
Help child understand
Carefully consider how much information: little tube in your hand to give your
body medicine
Timing of information varies: 3 yo will normally be combative regarding a Foley
tell them a new min before
Prevent Fear of Bodily Injury
Pre-procedure preparation
Parental presence: encourage pts to be present for most things even
anesthesia in OR; can be relief to parents who think its worse than it is
Clear communication: IV stick (not a stick like found in woods), CAT-SCAN
(cat? big camera thats taking a lot of pictures its going to get loud but it will be
ok; headphones), Stretcher (bed on wheels), Flush (explain not bathroom)
Explain wording!

Providing developmentally appropriate diversion

School: 14+ days in hospital before schools provide schooling; go on computer/on
phone to attend classes and continue
Play*: appropriate time and types of play
Peer interaction* and developmentally appropriate play: unless C/I like isolation,
encourage interaction
Many young pts on unit arent patients to encourage socialization (siblings,
friends from school, etc); play room on unit with infantile games
Adolescents: separate teen room appropriate for their age (video games, etc)
Volunteers: story telling, playing games with pts, perform e.g. Halloween, Christmas
Safety considerations
Play is a childs work provide with age appropriate, safe toys

Infection control: e.g. soft, plush toy becomes pts permanently (cant
wash for another kid)
10. Dealing with Isolated patients
Isolated: isolating both child and family; PPE can frighten/intimidate patients; so
encourage pt and family to put on isolation gown and experience it, understand it a little
better to decrease anxiety
Communication and Physical Assessment- Chapter 6
1. Concentrate on content pp 99-131
2. Appropriate ways to obtain vitals (equipment, size, method)
Order is important!
Look, listen, than feel*
Look: RR (chest, nasal flare) can count, color
Listen: apical heart rate, lung sounds for FULL minute
Lung sounds are loud can overbear heart rate
Feel: BP, thermometer, cap refill
Vary by age: ranges via table*
Birth to 2 years: axillary, rectal
2-5 Years: axillary, tympanic, oral, rectal
5+ years: oral, axillary, tympanic
Radially: 2+ years old
Apical impulse: under 2; heard with stethoscope; count for full minute
Grading: 0 not palpable; +1 difficult to palpate, thready, weak; +2
difficult to palpate, may ne obliterated with pressure; +3 easy to palpate,
normal; +4 strong, bounding, not obliterated with pressure
Compare with femoral pulse at least once during infancy to detect presence
of circulatory impairment e.g. aorta coarctation
Count like you would for adult
Observe* abdominal movements since they are primarily diaphragmatic
Movements are irregular so count for a full minute
Breath Sounds: R/T low fat and because it is such a small area and most you
dont even need a stethoscope for (wheezing, stridor can be loud)
Can hear referred sounds (bowel, heart)
Almost always uncooperative: do before child get active/upset, while
parents hold
Can us. hear when patients cry
Blood Pressure
Annually in children 3+ years of age with sx of HTN, in the ER or ICU, and highrisk infants
Compare in upper and lower extremities to detect abnormalities

Use appropriately sized cuff OR a larger one if appropriate size if not available:
cuff bladder should be about 40% of circumference of arm measured at a point
midway between olecranon and acromion (shoulder, elbow); cuff bladder should
cover 80-100% of arm circumference; measure at the level of the heart with arm
supported; stethoscope bell placed over brachial artery pulse


Order of assessment
Do full exam: patient may not be able verbalize problems and some dont want to tell
Prior to exam, look at general appearance: appear well, sick, or very sick?
Observation: kids associate nurses with shots
First thing to do*: once touch child, assessment may change e.g. crying
increases RR; start with least invasive assessment first
General appearance
Assessment order: usually cannot go in order go as body part becomes available
Listen when child is calmest: hate BP (do at end)
Toe to head
Infant: listen to heart, lungs, and abdomen if quiet; palpate and percuss the
areas; head to toe direction; traumatic procedures last e.g. ears, eyes, mouth
(while crying); elicit reflexes as body part is examined; elicit moro last
Toddler: use play to inspect areas (tickle toes); minimum physical contact
initially; introduce equipment slowly; auscultate, percuss, palpare whenever
quiet; perform traumatic procedures last
Pre-school child and up: if cooperative, head-to-toe fashion and genitalia last
Assessment Tips
Play with kids
Inspect the entire body
Parent assist: good!
Listen to history


How to communicate with the child and family

Interview: parent/caregiver be open minded with or without patient (R/T age)
Assume truth of parent usually dont question parent
Communication: many meanings for one word utilize parents
Injury booboo, ouchie
Bottle baba
Difficult neuro assessment R/T it being so dependent on verbal
Not necessarily A&Ox3
Alert: eye movement
Oriented: time of day, know who mom or cartoon character is
Family dependency
Listen to familys story

5. Steps in general assessment of various systems (i.e capillary refill time, apical pulse)
Go from toe to head
General appearance- if a significant finding sticks out, it may direct how assessment is
Facial expressions, posture, position, body movements, hygiene, behavior
Growth measurements
Length- fully extend the body of the infant, children can stand upright
Skin fold thickness and/or arm circumference may be used to distinguish
between fat and muscle
Head circumference-up to 36 months or if childs head size is questionable
Apical pulse-listen for 1 minute
RR-count for 1 minute
Blood Pressure (mean averages)- Newborn-> 65/41, 1month-2years -> 95/58, 25years-> 101/57
Temperature- for children a value of 37-37.5 C (97.7-99.7 F), for neonates 36.537.6 C (97.7-99.7 F)
Skin-texture, color, hair distribution, nail quality
Lymph nodes-palpate for enlargement and/or tenderness
Head and neck-shape, symmetry, head control, palpate skull for patent sutures,
depressed fontanels, fractures, and swelling
Eyes-PERRLA, inspect conjunctiva, vision testing
Ears- inspect external structures and see if ears are level with eyes, inspect internal ear
with otoscope, auditory testing
Nose/throat/mouth-inspect mucous membranes, internal and external structures
Chest-inspect for barrel or pigeon chest
Lungs- note breathing mechanism (nose breather?), assess
rate/rhythm/depth/quality/breath sounds
Heart- S1 and S2 present, S3 may be normal in some children but S4 is abnormal
Abdomen- inspect contour (distension, respiratory involvement), umbilicus for
abnormalities, check for hernias (umbilical, inguinal, femoral), auscultate for BS, palpate
for abnormal masses, tenderness, muscle tone, internal organs
Boys-note the external appearance of the glans and shaft of the penis, inspect
urethral meatus, note location and size of scrotum and identify two testes
Girls- limited to inspection and palpation of external structures (prepuce, clitoris,
labias, urethral meatus, vaginal orifice)
Anus-inspect skin, gluteal folds, anal reflex (assess tone of anal sphincter)
Back and Extremities- Curvature of spine, assess mobility, shape of bones (Bowleg
(knees outward) or Knock knee (knees inward)), pigeon toe, plantar/grasp reflex,
babinski reflex, assess range of motion, tone/strength of muscles
Neuro- assess cranial nerves, reflexes, cerebellar function (balance and coordination)

Health Promotion of Infants- Chapter 9.10 and 11

1. Injury prevention for infants
The top leading causes for injury to infants were falls, ingestion, injuries, and burns
The three leading causes of accidental death injury in infants were suffocation, motor
vehicle-related injuries, and drowning
Box 10-1 on pages 345-346 of textbook has all the safety promotion and injury
prevention during infancy

Play during infancy r/t development

Play during infancy represents the various social modalities observed during cognitive
The activity of infants is primarily narcissistic and revolves around their own bodies
Infants responses to the environment are global and largely undifferentiated
Pleasure is demonstrated by a quieting attitude (1 month), a smile (2 months), or
a squeal (3 months)
infants show more discriminate interest in stimuli and begin to play alone with
rattles or soft stuffed toys
by 4 months, infants laugh a loud, show preference for certain toys, and become
excited when their favorite toy is brought to them
6 months-1 year
play involves sensorimotor skills
peek-a-boo and pat-a-cake are played
at 6-8months, infants refuse to play with strngers
at 6 months, they extend their arms to be picked up
at 7 months, they cough to make their presence known
at 10 months, they pull their parents clothing
at 12 months, they call their parents by name
stimulation is as important for psychosocial growth as food is for physical growth
infants need to be played with, not merely allowed to play


Infant growth and physical development, gross and fine motor

Table 10-1 on pages 310-314 of textbook (it literally has everything laid out in the


Nutrition and feeding promotion

Birth to 6 months: Breastfeeding or bottle feeding
Breastfeeding more desirable
Iron-fortified commercial formula is a complete food for the first 6 months
4-12 months:
may begin to add solids
first foods are strained, pureed, or finely mashed

introduce one food at a time, usually at intervals of 4 to 7 days, to identify

introduce solids when the infant is hungry
never introduce foods by mixing them with formula in the bottle
4-6 months: cereal (low allergenic potential)
6-8 months: fruit and vegetables
8-10 months: meat, fish, and poultry (avoid fatty meats)
12 months: eggs and cheese
feeding is a learning process--- taste and chewing experience
weaning- relinquishing the breast or bottle for a cup
regarded as a major task
infants are required to give up a major source of oral pleasure and gratification


Feeding difficulty and sensitivity

Infants are highly prone to aspiration and its attendant dangers
The amount and method of feeding are determined by the infants size and condition
Infants who are ELBW, VLBW, or critically ill often obtain the majority of their nutrients
by the parental route because of their inability to digest and absorb enteral nutrition
Preterm infants should be carefully evaluated for their readiness to breastfeed
Time , patience, and dedication on the part of the mom and nursing staff are needed to
help infants with breastfeeding
Feeding readiness is determined by each infants medical status, energy level, ability to
sustain a brief quiet alert state, gag reflex, spontaneous rooting and sucking behaviors,
and hand-to-mouth behaviors
A preterm infant may have difficulty coordinating sucking, swallowing, and breathing
When infants are unable to tolerate bottle feedings, intermittent feedings by gavage are
instituted until they gain enough strength and coordination
Gavage feedings may be provided by continuous drip regulated via infusion pump or by
intermittent bolus feeding
Nonnutritive sucking on a pacifier may help bring the infant to a quiet alert state in
preparation for feeding
The longer the period of nonoral feeding, the more severe the feeding problem
Infants identified as being at risk for feeding resistance should be provided with regular
oral stimulation


Vegetarian diets
Lacto-ovo-vegetarian: exclude meat from diet but consume dairy products and rarely fish
Lactovegetarian: exclude meat and eggs but drink milk
Pure vegetarians (vegans): eliminate all foods of animal origin, including milk and eggs
Macrobiotics: allowing only a few types of fruits, vegetables, and legumes (more strict
than vegans)
Semi vegetarians: consume lacto-ovo-vegetarian diet with some fish and poultry

The major deficiencies that may occur are inadequate protein for growth, inadequate
calories, poor digestibility of many of the bulky natural, unprocessed foods (especially for
infants), and deficiencies in vitamins and minerals
May need supplementation of vitamins and minerals
Achieving a nutritionally adequate vegetarian diet is not difficult but requires careful
planning and knowledge of nutrient sources (especially to ensure sufficient protein in the


Primary cause is not always lack of food
Diarrhea is a major factor
Additional factors are bottle feeding in poor sanitary conditions, inadequate knowledge,
economic and political factors
Poverty is leading cause of malnutrition
Most extreme form of malnutrition is protein-energy malnutrition (PEM)
Causes of PEM in U.S. are cystic fibrosis, renal dialysis, cancer, and GI malabsorption
Treatment of PEM includes providing a diet with high-quality proteins, carbohydrates,
vitamins, and minerals
If malnutrition is due to underlying disease and/or infection, must treat that as well


Nutrition problems such as kwashiorkor, failure to thrive

Kwashikor: A deficiency of protein with an adequate supply of calories.
Often occurs in children who are weaned off of breast milk after a younger sibling is
Thin wasted extremities, prominent abdomen because of ascites (edema).
Edema masks severe muscular atrophy.
Skin is scaly and dry. Mineral deficiencies, diarrhea, infection.
Failure to Thrive (FTT): Also known as growth failure, pediatric undernutrition.
Inability to maintain or use calories for growth.
Diagnosed with a pattern of persistent deviation from established growth parameters,
usually the weight and/or height is below the 5th percentile.
Categories includes organic, non-organic, or idiopathic. (More specifically, from
inadequate caloric intake, inadequate absorption, increased metabolism, or an
inability to use the calories they take in.)
Lots of factors can contribute, goal is to get child to have correct nutritional intake and
to catch up with growth.


Problems such as SIDS, ALTE, Plagiocephaly

SIDS: Sudden infant death syndrome. Unexplained sudden death of an infant younger
than 1 year of age.
Happens during sleep.
Put babies on their back to sleep!!!
Other risk factors include maternal smoking, co-sleeping, and soft-bedding.

ALTE: Apparent life-threatening event. Infant exhibits a combination of apnea, change

in color, change in muscle tone, choking, gagging, or coughing.
Require significant intervention.
Needs diagnostic evaluation and sleep monitoring at home.
Plagiocephly: Misshapen head. When babies are put on their back to sleep, the back of
their head (posterior occiput) flattens over time.
This can lead to a bald spot that goes away, can also lead to mild facial asymmetry.
Prevention includes changing babys head position frequently and giving them
tummy time when they are awake.
In more severe cases a specialized helmet can be worn during sleep, or they can
have surgery.
10. Newborn rash, thrush, herpes
Newborn rash: ERYTHEMA TOXICUM. Benign, self limiting.
Usually appears within first 2 days of life.
Lesions are firm, small, and white or yellow. Look like flea bites.
Can be located everywhere on the body except for the hands and soles.
Usually lasts 5-7 days.
Thrush: Oral candidiasis. It is due to a yeast-like fungus.
White patches on the tongue that can hurt when the infant feeds.
When scraped with a tongue blade it will cause bleeding.
Can apply anti-fungal to the mouth and diaper area. (There can be transmission
when babies put their hand in their diaper and then their mouth.)
Herpes: Neonatal herpes is a serious viral infection.
Usually transmission occurs during birth.
Manifests itself in either 1. skin, eye, mouth infection, 2. as a CNS disease, or 3. as
a disseminated disease involving multiple organs.

11. What is a high risk newborn what are major nursing concerns-temp, infection,
nutrition, feeding methods
A high risk newborn is a newborn who has a greater-than-average chance of morbidity
or mortality. A newborn can be considered high-risk regardless of their gestational age
or weight.
Primary objective for high-risk newborns is to establish and maintain respiration.
Thermoregulation is important to control in newborns. It is important to make sure that
they stay warm. In healthy term infants, axillary temps should be 36.5-37.5.
A fever in a newborn warrants immediate attention.
Less than 3 months old, a fever is 100.4 (38)
3-36 months, fever is 102 (38.9)
For children of any age, immediate attention for anything over 104
Watch BEHAVIOR though. (Restlessness and refusal to feed are two red

Infection: High-risk newborns are particularly susceptible to infection. Use standard

Nutrition: Best way to determine nutrition is through their growth and physical
Breastmilk is best source of nutrition, but some preterm infants need extra nutrients in
addition to breast milk.
Breastfeeding, Nipple/bottle feeding. Best to have oral feedings

12. Hyperbili, RDS

Hyperbili: Excessive bilirubin in the blood, characterized by jaundice.
Common, usually benign, but can also be pathologic.
Treated with breastfeeding and with phototherapy.Can lead to bilirubin
encephalopathy, you see CNS effects.
Lethargy, irritability, hypotonia, seizures, deafness.
Delayed motor skills.
RDS: Respiratory distress syndrome.
It is a severe lung disorder, results in many deaths.
Self-limiting, but requires respiratory support to get through it.
Often in preterm infants who are born before lungs are fully developed.
Signs include tachypnea, dyspnea, retractions, crackles, grunting, flaring, cyanosis,
Treatment: surfactant, respiratory equipment,
13. Necrotizing Enterocolitis
NEC: Necrotizing Enterocolitis. Acute inflammatory disease of the bowel.
Prematurity is the highest risk factor.
Diminished blood supply to intestines, cell damage and death.
Signs: distention, blood in stool, gastric retention, abdominal redness, vomit, lethargy,
poor feeding, unstable temp, jaundice.
Treatment: Prevention! It is infectious so hand wash. Breastmilk can help to treat it,
surgery may be necessary sometimes.
14. Role of nurse in genetic counseling
Be alert for situations where a family may benefit from genetic counseling
Suggest it at an appropriate time.
Maintain contact with the family or refer them to an agency that can provide a sustained
GI Dysfunction - Chapter 24, Chapter 22 694-703; GI Medications on Pediatric Pharm List
1. Dehydration signs for different types (mild, moderate, severe)
Weight loss is most important determinant of total body fluid loss.
Mild dehydration:
3-5% or 50 ml/kg weight loss over 48 hours.
HR 10-20% higher than baseline

Dry mucus membranes

Concentrated urine
Poor tear production.
Moderate dehydration:
6-9% or 75 ml/kg weight loss over 48 hours.
Increased severity of above signs.
Oliguria (low amounts of urine)
Sunken eyes
Sunken anterior fontanel
Severe dehydration
Decreased BP
Delayed capillary refill ltime

2. Motility disorders
- Diarrhea:
Caused by abnormal intestinal water and electrolyte transport
Involves digestive, absorptive, and secretory functions
Involves stomach and intestines, small intestine, colon, colon and intestines
Classified as acute or chronic
Acute: leading cause of illness in children younger than 5
Sudden increase in frequency and change in consistency of stools, often
caused by infectious agent in GI
May be associated with upper respiratory, antibiotic therapy or laxative use
Self limiting (<14 days)
Acute Infectious Diarrhea: caused by viral, bacterial and parasitic pathogens
Chronic: increase in stool frequency and increased water content with a duration of
more than 14 days.
Often caused by chronic conditions (IBD, malabsorption syndrome, food
allergy, etc.)
Intractable diarrhea of infancy: first few months of life, longer than 2 weeks
Difficult to treat
Chronic nonspecific diarrhea: irritable colon of childhood
Children 6-54 months
Loose stool, undigested food particles, diarrhea lasting longer than 2 weeks
Children grow normally and have no evidence of malnutrition, no blood in stool, no
Excessive intake of sugar substances, sweeteners could be a factor
Fecal-oral through contaminated food/water or person to person
Rotavirus is most important cause of serious gastroenteritis
Most severe in 3-24 months
Salmonella, shigella, and campylobacter are top causes of bacterial diarrhea
Giardia and shigella have highest incidence among toddlers

Salmonella among infants

Invasion = increased intestinal secretion
Most serious issues for severe diarrhea
Acid-base imbalance with acidosis
Shock when dehydration progresses
Careful history recent travel, etc.
Presence absence of vomit, fever, freq./character of stool
Lab tests only for severely dehydrated
Neutrophils/RBC in stool indicate bacterial gastroenteritis or IBD
pH<6 indicates carb malabsorption or secondary lactose deficiency
Assessment of fluid and electrolyte imbalance
Maintenance fluid therapy
Reintroduction of an adequate diet
Oral rehydration therapy for infants and children with acute diarrhea and
Enhance and promote reabsorption of sodium and water
After rehydration, ORS can be used during maintenance by altering solution
with low sodium solution
Should consist of 75-90 mEq/L of sodium
40-50 ml/kg of rehydration solution over 4 hours
Replacement and maintenance: 40-60 mEq/L of sodium
Dont exceed 150 mL daily volume
Vomiting child SHOULD be given ORS at frequent intervals and in small
5-10 mL every 1-5 minutes
can be given via NG or GT
Vaccine: for rotavirus
RotaTeq: infants should receive at 2,4,6 months
Rotarix: infants should receive at 2,4 months
Breastfeeding during first 6 months helps prevent
Early reintroduction of nutrients is desirable
Nursing Care
Monitor for signs of dehydration: intake/output
Education on ORT
ORS in small and frequent amounts
Obtain accurate weights
Check correct rate and fluid for IV fluids
Skin care

Avoid taking temperature to avoid bowel stimulation

3. Rehydration how much, methods
information is above
4. - Hirschsprung Disease Congenital anomaly results in mechanical obstruction from
inadequate motility of part of the intestine
Familial pattern
Males and females
Absence of ganglion cells
Decreases internal sphincters ability to relax
Neonate with distended abdomen, feeding intolerance and bilious vomiting, delay in
passage of meconium
Radiographs, unprepped barium enema, and anorectal manometric exams
Most require surgery - stabilize first with fluid and electrolyte replacement
Transanal Soave endorectal pull through
Constipation and fecal incontinence are chronic problems in most patients
Perioperative care
Low fiber, high protein diet sometimes TPN for malnourished patients
Empty bowels with saline enemas and decrease bacterial flora with antibiotics
Enterocolitis is most serious complication
Monitor vitals and BP, fluid and electrolyte
Watch for symptoms of bowel perforation: fever, abdominal distention, vomit,
Measure abdominal distension with tape measure
Explain to preschool age with visual age
Colostomy is temporary
Postoperative care
Stoma care: diaper placed below dressing
Nursing Care
Help parents adjust
Foster infant parent bonding
Prepare them for medical surgical intervention
Assist them in colostomy care
- Vomiting
Well-defined, complex, coordinated process under CNS control
Nausea and retching
Nonbilious vs. bilious
Nonbilious: if obstruction present suggests a more proximal obstruction

Causes: infectious, inflammatory, metabolic, or endocrinology, neurolic and

psychological causes, pyloric stenosis
Bilious: implies disorder of motility or distal physical blockage
Causes: intestinal atresia, stenosis, malrotation, ileus, intussusception, intestinal
duplication, appendicitis
Also associated with infectious disease
Watch for
Acute volume loss (dehydration)
Electrolyte disturbances
Mallory-Weiss syndrome (small tears in distal esophageal mucosa
Administer fluids
Antiemetic (Zofran)
For vomiting related to obstruction, withhold food
Ad libitum administration of a glucose electrolyte solution to an alert child to restore
water and electrolytes
Small frequent feedings of fluids and foods
For infant or child: position on side or semi reclining
Have child brush teeth or rinse mouth after vomiting
GER: Transfer of gastric contents into the esophagus: physiologic
Physiologic GER resolves by 1 year of age
Predisposition: neurologic impairment, hiatal hernia, morbid obesity, premature infant
Infants: Spitting up, vomit, excessive crying, weight loss, silent, respiratory
problems, apnea
Children: heartburn, abdominal pain, noncardiac chest pain, chronic cough,
dysphagia, nocturnal asthma
GERD: symptoms of tissue damage as a result of GER
24 hour intra esophageal pH monitoring study is gold standard for diagnosis
No therapy needed for thriving infants (could fix itself by 1 year)
Avoidance of certain foods (citrus, tomatoes, caffeine)
Small, more frequent meals
Thickened feeding, upright positioning
For severe: NG tube
Elevate HOB 30 degrees for 1 hour after feedings
Drugs: H2 receptor antagonists, proton pump inhibitors
Surgery: Nissen fundoplication

Nursing Care
Identifying children with symptoms
Educate parents regarding home care
Care for children undergoing surgery
Supine positioning for feeding
Avoid vigorous play after feeding
PPIs are most effective when administered 30 minutes before breakfast
- Acute Appendicitis Inflammation of the vermiform appendix
Periumbilical pain followed by nausea, right lower quadrant pain, and later vomiting with
Perforation of appendix can occur within 48 hours
Phlegmon: acute supportive inflammation of subcutaneous connective tissue that
Cause: obstruction of the lumen of the appendix
Fever, vomiting, abdominal pain, and elevated WBC counts (greater than 10,000)
Lower right quadrant
McBurney point
Referred pain, elicited by light percussion
CBC, urinalysis (to rule out UTI)
Peritonitis: sudden relief from pain after perforation, subsequent increase in pain, progressive
abdominal distention, tachy, rapid shallow breathing, pallor, chills, and irritability
Rehydration, antibiotics, surgical removal of appendix (laparoscopic normally)
IV fluids, NPO, NG tube
Listen for bowel sounds
Meticulous skin care
Ruptured: preoperative IV administration of fluid and electrolytes, continued administration of
antibiotics, NG abdominal, Penrose drain post op
Nursing Care
If appendicitis suspected avoid laxatives or exams and applying heat to the site
Meckel Diverticulum Remnant of the fetal omphalomesenteric duct
Failure of obliteration may result in an omphalomesenteric fistula
Complication: bleeding (due to peptic ulceration), obstruction or inflammation
History, physical exam, radiographic studies, often hard to diagnose
Painless rectal bleeding in children, abdominal pain, signs of intestinal obstruction, dark
red or jelly stool
Surgical removal of diverticulum

Reverse electrolyte imbalances and prevent abdominal distention
Nursing Care
Frequent monitoring of vital signs including BP
Keeping the child on bed rest
Recording the approximate amount of blood lost in stools
- Cirrhosis
End stage of many chronic liver diseases
Irreversibly damaged
Jaundice, poor growth, anorexia, muscle weakness, and lethargy, ascites, edema, GI bleed,
anemia, and abdominal pain
Monitoring liver function
Combination of immunosuppressive medication
Nutritional support: supplements of fat-soluble vitamins
Sodium restriction and diuretics for ascites
Drugs to reduce ammonia formation (neomycin and lactulose)
- Biliary Atresia Progressive inflammatory process that causes both intrahepatic and
extrahepatic bile duct fibrosis
If untreated usually leads to cirrhosis, liver failure and death if first 2 years of life
Acquired late in gestation or in perinatal period and is manifested a few weeks after birth
Jaundice, manifesting with yellow discoloration of skin and sclera, pale stool, dark urine
Direct bilirubin greater than 1 ml/dl with total bilirubin less than 5 mg/dl
Early diagnosis is key (surgery within first 60 days)
Hepatic portoenterostomy: segment of intestine is anastomosed
Progressive cirrhosis still occurs in many children
Support is important
Supplication of fat soluble vitamins
Aggressive nutritional support
- Cleft Lip and Cleft Palate
Occur during embryonic development and most common congenital deformities
CL: failure of maxillary and median nasal processes to fuse
Can be unilateral or bilateral
CP: midline fissure of palate that results from failure of the two palatal processes to fuse
CL/P and CP are distinct from isolated CP
Multifactorial inheritance, exposure to tetragons, foliate deficiency and show up between
4th and 10th week of embryonic development
Impact on the feeding is biggest complication
Surgical correction
Cleft Lip

Usually 2-3 months

Rule is 10 weeks old, 10 pound, and have hemoglobin of 10
Tennison-Randall triangular flap and Millard rotational advancement technique
Cleft Palate
6-12 months
Speech impairment
Pressure-equalization tubes placed
Extensive orthodontics
Growth failure in infants
CL typically have no difficulty breast feeding
CP and CL/P often unable to feed using conventional methods
Position an infant with CP in an upright position with head supported
Help with suctioning (Pigeon bottle)
Burping is important due to swallowing of excessive air
- Hypertrophic Pyloric Stenosis Circumferential muscles of the pyloric sphincter becomes
thickened elongation and narrowing of pyloric channel
First 2-5 weeks of life, causing projectile nonbilious vomiting, dehydration, metabolic
alkalosis, and growth failure
More common in full term infants
Olive like mass palpable when stomach is empty
Vomiting usually occurs 30-60 minutes after feeding and becomes projectile
Become dehydrated and appear malnourished
Hungry, avid feeder, distended upper abdomen
Surgical relief
Preop: infant needs rehydrated and metabolic alkalosis corrected with parenteral
fluid and electrolyte administration, decompress stomach with NG tube
Feeding usually 4-6 hours postoperatively, start small and frequent of an
electrolyte solution or sterile water
- Intussusception
Most common obstruction in children between 3 months-3years
Segment of bowel telescopes into another segment, pulling mesentery with it
Children initially seen with screaming, irritability, lethargy, vomit, diarrhea, fever,
dehydration, and shock
Radiologist guided pneumonia with or without water soluble contrast
IV fluids, NG decompression, and antibiotic drug
Nurse monitors all stools before surgery
Passage of normal brown stools normally indicates intussusception has reduced itself

- Malabsorption syndromes Chronic diarrhea and malabsorption of nutrients

Complication: growth failure
Celiac disease:
The Four Signs: steatorrhea, general malnutrition, abdominal distention, secondary
vitamin deficiencies
Normally between the ages of 6 months and 2 years
Hypotonic, poor appetite
In ages 5-7: abdominal pain, nausea, vomiting, bloating, constipation, dental
enamel defects, anemia, short stature, pubertal delay
Intolerance to dietary wheat and related proteins
Wheat, barley, rye, and oat grains
Damages mucosa of small intestine and leads to villous atrophy
Genetically predisposed
Celiac Crisis: acute, severe episodes or profuse watery diarrhea and vomiting
Infections, prolonged fluid and electrolyte depletion, and emotional disturbance
are causes
Biopsy of small intestine
Institute new diet: good response in 1-2 days (weight gain improved appetite)
and no diarrhea within a few weeks
Serologic tests: antigliadin antibodies
Associated with type 1 diabetes, thyroiditis, arthritis, primary biliary cirrhosis,
Down, Turner, Williams
Primarily dietary: gluten free
Avoid wheat, rye, barley and oats
Chronic disease : Lymphoma is most serious complication
Nursing Care
Explaining disease to family and helping with diet changes
Gluten is often added to foods with hydrolyzed vegetable protein: read labels!
Some need lactose free diet as well and avoid high fiber foods like nuts, raisins,
ray vegetables and fruits
Consult with registered dietician
Digestive defects: enzymes necessary for digestion are diminished or absent
Cystic fibrosis (pancreatic)
Biliary or liver (bile flow)
Lactase deficiency (lactose intolerance)
Absorptive defects: intestinal mucosal transport system is impaired
Anatomic Defects: extensive resection of bowel or short-bowel syndrome
-Short-bowel syndrome Malabsorptive disorder that occurs as a result of decreased
mucosal surface area, usually because of extensive resection of the small intestine
Causes: necrotizing enterocolitis, volvulus, jejunal atresia, and gastroschisis

Definition: Decreased intestinal surface area for absorption of fluid, electrolytes, and
A need for PN (feeding)
Preserve as much length of bowel as possible during surgery
Maintain optimum nutritional status, growth, and development while intestinal
adaptation occurs
Stimulate intestinal adaptation with enteral feeding
Minimize complications related to disease process and therapy
Nutritional support is long term focus
Initial phase: PN as primary source
Secondary phase: introduction of enteral feeding (after surgery)
Decrease PN solution in terms of calories, amount, and total hours infused per
Final phase: sustained exclusively by enteral feedings
Risk for nutritional deficiency secondary to malabsorption of fat soluble vitamins
(A, D, E, K) and trace minerals
Use of H2 blockers, PPIs
Bacterial overgrowth is often a problem: altering cycles of broad spectrum antibiotics
Also watch for metabolic acidosis and gastric hyper secretion
Surgical interventions: intestinal valves, tapering enteroplasty, intestinal lengthening
Nursing Care
Most important: monitoring and administration of nutritional therapy
Avoid infection, occlusions, dislodgement or accidental removal of lines
Routine ostomy care
5. Abdominal trauma
- Gastroschisis Protrusion of intra abdominal contents through defect in abdominal wall
lateral to umbilical ring; there is no peritoneal sac covering the exposed bowel
Symptoms: defect obvious at delivery if not detected prenatally by ultrasonography
Nursing Management
Surgical repair of defect
Use of Siloh pouch
Keep sac covered with bowel bag
BG decompression
Maintain thermoregulation
Monitor electrolyte status
IV fluids
Observe exposed bowel for necrosis
Monitor vitals, especially BP
Bowel decompression with NG tube

IV fluids
Pain management
Monitor surgical closure site
Monitor lower extremities for pulses
Monitor for return of bowel function

- Omphalocele Protrusion of intraadbominal viscera into base of umbilical cord; sac covered
with peritoneum without skin
Symptoms: obvious on inspection
However might look like hematoma in umbilical cord
Nursing Management
Surgical repair
Protect defect from trauma
Keep sac or viscera moist with saline soaked dressings
Maintain thermoregulation
Carry out routine IV fluid infusion
Prophylactic antibiotics
Keep patient NPO
Assess for associated birth defects (CL or CP)
Monitor vital signs and BP
Pain management
Bowel decompression with NG tube
Iv fluids
Monitor return of bowel function
- Hernias Protrusion of an organ or organs through an abnormal opening
Danger when circulation is impaired
Congenital Diaphragmatic
Abdominal organs through opening in the diaphragm, commonly left side
Severe respiratory compromise and inability to adequately expand lungs
Seen within a few hours after birth, tachy, cyanosis, dyspnea, impaired cardiac
Avoid bag and mask ventilation because fill stomach with air
Provide supportive treatment
Administration of inhaled nitric oxide
Monitor respiratory status, provide oxygen supplementation
Monitor cardiovascular status, reduce stimulation
Maintain NG suction, oxygen, and IV fluids
Medication: sedation, muscular paralysis, inotropes

Carry out routine care

Relieve pain, support family
Sliding: protrusion of abdominal structure through esophageal hiatus
Dysphagia, growth failure, vomiting, neck contortions, bleeding, respiratory
problem, GER
Diagnosed by fluoroscopy
Manage GER, patient positioning, surgical treatment
Abdominal: Umbilical: weakness in abdominal wall around umbilicus
Noted by inspection and palpating of abdomen
High incidence in preterm and AA infants
Usually closes spontaneously by 1-2 years of age
No treatment is necessary for small defects
Operative repair if persists to 4-6 years
6. GI pharm list
H2 receptor antagonist
Treats ulcers, GER
Duodenal, Gastric Ulcers: PO
Esophagitis: PO
Hyper secretory conditions: PO
Acid Indigestion: PO
Nursing Considerations
Assess epigastria and abdominal pain
Monitor daily pattern of bowel activity and stool consistency
Monitor for diarrhea, constipation, headache
May take without regards to meals, antacids, family should report headache, avoid
excessive amounts of coffee, aspirin
H2 receptor antagonist
Duodenal Ulcer, Gastric Ulcer, GERD: PO
Nursing Considerations
Obtain history of epigastria/abdominal pain
Obtain baseline hepatic/renal function tests
Monitor AST, ALT levels, creatinine, BUN
Question present abdominal pain/ GI stress
Smoking decreases effectiveness of medication
Do not take within 1 hour of magnesium or aluminum containing antacids

Transient burning/purities may occur with IV administration

Report headache
Avoid alcohol or aspirin
Dopamine receptor antagonist
Nausea/vomiting, postop op, facilitate small bowel intubation: IV
Nursing Considerations
Assess for dehydration
Assess for nausea, vomiting, abdominal distention and bowel sounds
Monitor for anxiety, restlessness, extrapyramidal symptoms during IV administration
Monitor daily pattern of bowel activity and stool consistency
Assess skin for rash
Monitor renal function, BP, HR
Avoid tasks that require alertness, motor skill until drug response is established
Report involuntary eye, flaccid limb movement
Avoid alcohol
ammonia detoxicant, lactose derivative
Constipation: PO
Prevention of portal-systemic encephalopathy
Nursing Considerations
Encourage adequate fluid intake
Assess bowel sounds for peristalsis
Monitor daily pattern of bowel activity, stool consistency, record time of evacuation
Assess for abdominal disturbances
Monitor serum electrolytes
Evacuation in 24-48 hours of initial dose
Institute measure to promote defecation; increase fluid intake, exercise, high fiber diet
Black Box: respiratory depression in children 2yrs. and younger
Antihistamine, phenothiazine, sedative-hypnotic
Contraindicated in children 2 years or younger
Allergic symptoms, motion sickness: PO
Prevention of nausea/vomiting, Sedative: PO, IV, IM, rectal
Preop/Postop sedation: IV, IM
Nursing Considerations
Assess allergy symptoms

Assess BP, pulse, for brady, tachy

Assess for dehydration
Monitor serum electrolytes
Assist with ambulation
Monitor for relief of symptoms
Drowsiness, dry mouth may be expected
Avoid tasks that require alertness
Coffee, tea may help reduce drowsiness
Report visual disturbances
Avoid alcohol and other CNS depressants
Avoid prolonged exposure to sunlight

selective receptor antagonist, antiemetic
Chemotherapy induced emesis: PO, IV
Prevention of post op nausea/vomiting: IV
Nursing Consideration
Assess degree of nausea and vomiting
Assess for dehydration
Provide emotional support
Monitor patient in environment
Assess bowel sounds
Provide supportive measures
Assess mental status
Monitor daily patterns of bowel activity and stool consistency
Record time of evacuation
Relief occurs shortly after drug administration
Avoid alcohol and barbiturates
Avoid tasks that require alertness
Acute or chronic diarrhea: PO
Nursing Considerations
Do not administer in presence of bloody diarrhea or temperature greater than 101
Encourage adequate fluid intake
Assess bowel sounds
Monitor daily patterns of bowel activity and stool consistency
Withhold drug and notify physician for abdominal pain, distention, and fever
Do not exceed prescribed dose
May cause dry mouth
Avoid alcohol

Notify physician if diarrhea doesnt stop within 3 days

Meperidine derivative, antidiarrheal
Diarrhea: PO
Nursing Considerations
Check baseline hydration status
Encourage adequate fluid intake
Assess bowel sounds
Monitor daily bowel activity and stool consistency
Record time of evacuation
Assess for abdominal disturbances
Discontinue med is distention occurs
Avoid tasks that require alertness
Avoid alcohol
Activated charcoal
Treat poisonings, reduce intestinal gas, lower cholesterol levels
Nursing Considerations
Duodenal ulcers: PO
Nursing Considerations
Monitor daily pattern of bowel activity
Take medication on empty stomach
Antacids should not be taken 30 min before or after sucralfate
Dry mouth may be relieved by sour hard candy, sips of tepid water
Medication Lab
Higher risk for medication errors than adults
Calculation errors
Administration errors
Pharmacokinetic differences
Neonates & Infants prolonged gastric emptying and irregular peristalsis
Neonates have enhanced skin permeability
IM absorption variable and delayed
Higher in children

Liver metabolism lower

Total body water is higher in neonates, infants and children than in adults
Body fat content is lower in infants than in adults
Renal excretion lower than adults
Patient age
Premature infants have most total body water %, and extracellular volume
Children have highest fat %
1 teaspoon = 5ml or cc
1 tablespoon = 15 ml or cc
1 ounce = 30 ml or cc
16 oz = 1 pound
2.2 pounds = 1 kilograms
Rounding Rules
Weights ARE NOT rounded, the weight is recorded up to the 2nd decimal place
If a weight is converted to 3.5582 kg the weight recorded is 3.55 kg (not rounded)
FINAL medication doses ARE rounded to the 2nd decimal place at the end of the
3.2765ml are rounded to 3.28mls
Body Surface Are (BSA) is rounded to the 2nd decimal place like med doses
Pounds to Kilograms
Pounds are converted to kilograms by dividing pounds by 2.2
You must carry out the FINAL calculation to the hundredth (2 decimal places) to
ensure accuracy of medication administration
Refer to the simulations tab on blackboard
Open the Pediatric Medication Lab Instructions and then open the document called
Instructions to Access Med Lab On-Line Materials
You must memorize the formula for BSA
IV Fluids
IV fluids to run over a specified period in hours
Total Number of milliliters ordered divided by number of hours to run equals ml/hour
1000 ml to run over 5 hours
1000 / 5 = 200 ml/hour
A per hour rate ml/hr must be used on the infusion device
If the device calculates the rate for administration of a particular volume the nurse
must still double check that the rate is correct.
Dose limits must be set on the infusion device
Pediatric Medication Dosing
For a medication dose to be safe the dose must fall within the ranges listed in a drug
handbook, PDR or other reliable medication reference

Most pediatric medication doses are based on a mg/kg of body weight

Usually these ranges are provided over a 24 hour period, but may vary
Determining Safe Dose
Total daily dose ordered (based on order)
Requires dividing 24 hours by number of doses for the day (I.e. Q8 hours = 3 doses in
24 hours)
Then multiply the ordered dose by number of doses in the day
Based on the patients weight use the medication guidelines for children from your
drug reference source to determine the parameters for the dose
Total maximum and minimum daily dose
Compare the patients daily dose to determine if it falls within the safe range
Parenteral Medications
Start by converting weight to kg
Determine if the ordered dose is within the safe range for medication
Calculate the dose to be given
Check reference for medication dilution requirements and duration of administration