Pediatric ATI

Chapter 1
Parenting styles
 Dictatorial or authoritarian  not really good parents
 Democratic or authoritative  very good parents
 Passive

Chapter 2
Physical assessment findings
 Everything is going to be higher except for BP
 Infant HR: 80-180 RR: 30-35 BP: 65-80/40-50
 Fontanels – flat and soft
o Posterior closes between 6 & 8 weeks
o Anterior closes between 12 & 18 months
 Teeth – 6 to 8 teeth by 1 year
o 20 baby teeth and 32 permanent teeth
 Reflexes ** chart on pg. 10
o Moro
o Tonic neck reflex
o Babinski
 Cranial nerves ** chart on pg. 11
o Olfactory
o Optic
o Oculomotor
o Trochlear
o Trigeminal
o Abducens
o Facial
o Acoustic
o Glossopharyngeal
o Vagus
o Spinal accessory
o Hypoglossal

Chapter 3
Infants
 Baby’s birth weight will double by 6m and triple by 12m
 Infants will grow 1 inch per month (2.5 cm) for the first 6m of life and at 12m their birth length has increased by 50%
 First teeth erupt between 6 and 10m
 Gross and fine motor skills
o By 3m a baby should only have slight head lag
o 4m should be able to roll from back to side
o 5m roll from front to back
o 6m roll from back to front and hold a bottle
o 7m move object from hand to hand
o 8m sit unsupported
o 9m crude pincer grasp
o 10m prone to sitting position and grasp a rattle by handle
o 11m put objects into a container and have a neater pincer grasp
o 12m try to build a 2-block tower and won’t succeed
 Piaget cognitive developmental stages
o Sensorimotor (birth to 24m)
 Separation
 Object permanence – around 9m
 Mental representation
 3-5 words by 1yr
 Concept of no
  Erikson’s: Trust vs. mistrust birth – 1yr.
o Caretaker meeting the needs of the infant
 Separation anxiety begins to occur around 4-8m of age
 Stranger fear 6-8m of age
 Rattles, Blocks, Brightly colored toys, Mirrors, Patty cake
 Immunizations
o Birth –hep B
o 2m – hep B, IPV, RV, PCV + dtap & HIB
o 4m – all of the 2m – the hep B
o 6m – hep B + all the previous
o Flu shots 6m-1 yr.
 Nutrition
o Breast milk first 6m
o Solids 4-6m & first solid is usually iron fortified rice cereal
o No juice or water is not needed for first year
o Foods introduced one at a time over a 4-7 day period to monitor for allergies
 Choking/aspirating – grapes, coins, candy
 Burns – sunscreen, handles turned away on stove, electrical outlets are covered
 Drowning
 Rear facing car seat until 2yrs.
 Crib slats are no more than 6cm apart, no pillows, and sleep on back

Chapter 4
Toddlers
 4x their birth weight by 30m
 3 inches per year (7.5 cm)
 Head and chest circumference are about equal – compared to when they are born, and their head is wider than their chest
 Gross and fine motor skills
o 15m expect walking without help + should be able to build 2 block tower
o 18m can throw a ball over hand
o 2 yr. can walk up and down stairs by placing feet on each step + 6/7 block tower
o 2.5 yrs. Can jump with both feet + draw circles
 Language
o 1 yr. = 1 word sentences  “hollow phrases”
o 2 yr. = 2-3-word sentences
 Erikson’s stages – autonomy vs shame and doubt
o Independence
o Begin to express selves by saying no a lot
o Thrive on rituals – maintain routines
 Age appropriate activities – blocks, push pull, thick crayons, puzzle
 Toilet training begin when they have recognized the sensation that they need to go potty
 Immunizations
o 12-15m – IPV, PCV + MMR & varicella + HIB
o 12-23m – Hep A 2 doses/6m apart
o 15-18m – dtap + annual flu vaccine
 Nutrition
o Breast milk or formula through 1 year
o 1-2 year whole milk
o After 2 can transition to low fat
o Limit juice consumption – 4-6oz per day
o Prevent choking  nuts, grapes, hot dogs, peanut butter, raw carrots, tough meat and popcorn
 Burns, drowning, falls, aspiration prevention

Chapter 5
Preschoolers
 4.5-6.5 pounds per year
 2.5-3.5 inches per year (6-9 cm)
 Gross motor skills
 o 3yr. can ride tricycle + jump off bottom step on stairs
o 4yr. can skip and hop on q foot + throw ball over head
o 5 can jump rope
 Cognitive development
o Piaget: preoperational phase 4-7 yrs.  Moving from the preconceptual phase to the phase of intuitive thought
 Magical thinking
 Animism
 Centration
 Time
 Psychosocial development – Erikson’s
o Initiative vs guilt
 Another baby in the family can cause the preschooler to regress to bed wetting or thumb sucking – to be expected
 Playing ball. Puzzles, tricycles, dress up, role playing
 Immunizations
o 4-6 years – dtap, MMR, IPV + annual flu
 12 hours of sleep, bedtime routine
 Eruption of primary teeth is finalized by the beginning of the preschool years
 Protective gear with tricycles

Chapter 6
School-age children
 4-6-pound weight gain per year & grow 2 inches (5 cm) per year
 Permanent teeth start to come in
 Piagets cog development – concrete operations
o Perceptual to conceptual thinking
o Learns to tell time, see other perspectives, solve problems
 Erikson’s: industry vs inferiority
o Trying to make meaning contributions to society & cooperative and compete with others
 Peer groups important – competitive and cooperative play
 Board games, hop scotch, bikes, jump rope & organized sports
 Immunizations
o 11-12yr – dtap + HPV vaccine (series of 3 shots)
 9 hours of sleep recommended @ 12 yrs.
 Safety – helmets

Chapter 7
Adolescents (12-20)
 Girls stop growing 2-2.5 years after their period starts
 Boys stop growing around 18-20
 Sexual maturation in girls:
o Breast development
o Pubic hair growth
o Underarm hair
o Period
 Sexual maturation in boys:
o Testicular enlargement
o Pubic hair
o Penile enlargement
o Underarm hair growth
o Facial hair
o Vocal changes
 Piagets cog development – formal operations
 Erikson’s: identity vs role confusion
 Video games, music, sports, pets, reading
 Immunizations
o Flu
o 16-18 – meningitis (before college)
 Injury prevention – helmet use, seat belts, driving, substance abuse
Chapter 8
Safe med admin
 Oral is preferred, smallest measuring device possible, don’t mix oral meds in formula
 Put in side of mouth, hold cheeks, and stroke chin to swallow
 Ear drops <3: pinna down and back
 Injections (IM)
o Preferred route is vastis lateralis  ventral gluteal or in the deltoid
o 22-25g with half inch to 1-inch needle
 IV – procedure room; away from bed – EMLA cream to numb the area is recommended
o Avoid terms like bee sting or stick
o Keep stuff out of site
o Parents can stay
o Swaddle the infant
o Non-nutritive sucking is offered before, during, and after to infants

Chapter 9
Pain management
 Self-report is only used for children 4 and older
 FLACC scale: 2m – 7 years
o Pain rate on a scale of 0-10 & assessing behaviors of the child
 FACES: 3 years and older
 Oucher scale: 3-13 years
 Numeric scale: 5 and older
 Use play therapy to explain procedures
 Give medications to kids routinely vs prn
 Combining opioid and non-opioid meds
 EMLA cream  1 hour prior to small stick or 2.5 hours for a big stick
o Occlusive dressing over

Chapter 10
Hospitalization, illness, and play
 Infant
o Stanger anxiety 6-18m
 Toddler
o Behavior may regress
o Separation anxiety
o Intense reaction to procedures
o Parallel play
 Preschooler
o Magical thinking  may think they caused an illness to happen
o Still experience separation anxiety
o Explain the procedure in very simple clear language, give them a choice if possible (cup or spoon)
o Associative play – play together without much organization
 School age child
o Describe pain and increased ability to understand cause and effect
o Give factual info, tell the truth, encourage contact with peer group, and express feelings
o Cooperative play; play in groups/more organized
 Adolescent
o Body image disturbance
o Feel isolated from peers
o Give factual info, tell the truth, encourage contact with peer group, and express feelings
o Friends can come visit

Chapter 11
Death and dying
 Anticipatory grief – when death is expected or a possible outcome
 Complicated grief – extends for more than 1 year following the loss
  Parental grief – intense, long lasting, and complex
 Sibling grief – differs from adult/parental; depend on age and developmental stage

Infants/toddlers
 No concept of death
Preschooler (3-6)
 Magical thinking  may feel guilt or shame
 View dying as temporary *
School-age (6-12)
 Adult concept of death, express fear through uncooperative behavior
Adolescents (12-20)
 Adult concept of death
 Rely on peer’s vs parents
 Stressed out by changes in physical appearance

Physical manifestations of death

 Sensation of heat when the body feels cool
 ↓sensation, loss of senses, ↓ LOC, swallowing issues, bradycardia, hypotension, Cheyne stokes respirations

After death
 Allow family to stay with body
 Rock infant/toddler
 Assist in post-mortem care

Chapter 12: Acute neuro disorders

Meningitis
 Viral often resolves with supportive care
 Bacterial more dangerous
o 2 vaccines that help prevent  PCV and Hib
 s/s: photophobia, n/v, irritability, h/a
 newborns: poor muscle tone, weak cry, refusal to eat, vomiting, diarrhea, poor sucking, possible fever or hypothermia, neck
is supple without nuchal rigidity
o bulging fontanels are a late sign
 3m-2years
o Seizures with a high pitch cry
o Fever and irritability, bulging fontanels, nuchal rigidity, poor feeding & vomiting
o The signs B & K are not reliable
 2 years – adolescence
o Seizures, nuchal rigidity, fever & chills, ha, n/v, irritability, petechiae
o + brudzinski’s sign  pull head forward – extremities will also flex (bro why are you pulling on my neck)
o + kernigs sign  leg is flexed, and you try to extend – it causes a lot of pain
 Labs
o CSF analysis through lumbar puncture  empty bladder before, EMLA cream, side lying position; after procedure –
remain in bed 4-8 hours in a flat position
 Bacterial = cloudy, ↑ WBC, ↑ protein, ↓ glucose, + gram stain
 Viral = clear, slightly elevated WBC, normal or slightly elevated protein, normal glucose, - gram stain
 If meningitis is suspected, put them on droplet precautions; ↓ LOC = NPO, provide quiet environment, dim the lights,
seizure precautions
 Bacterial will need IV abx
 Maintain contact precautions for bacterial for 24 hours after abx treatment has started
 Monitor for ↑ ICP ***
o Infants: bulging fontanels, ↑ head circumference, high pitch cry, bradycardia, and resp. changes
o Children: irritability, ha, n/v, seizures, bradycardia, and resp. changes

Reyes syndrome
 Liver dysfunction and cerebral edema
  Associated with giving children aspirin for a fever
 Follows a viral illness like the flu, gastroenteritis, or varicella
 Lab tests: liver enzymes (AST/ALT↑), ammonia levels ↑, liver biopsy for diagnosis + CSF analysis
 s/s: lethargy, irritability, confusion, delirium, vomiting, LOC

Chapter 13: Seizures

 risk factors: cerebral edema, fever, trauma, bleeding, tumor, toxins in body (lead poisoning), hypoglycemia, electrolyte
imbalances, infection
 tonic-clonic seizure – 3 phases
o tonic – arms and legs flex up and head and neck extend; stiff; loss of consciousness
o clonic – jerking movements
o postictal – awake and confused
 absence seizure – school age children (4-12)
o loss of consciousness 5-10 seconds, daydreaming look, drop whats in hands, lip smacking or twitching of face
 myoclonic – no posticical
 atonic – no tone; fall
 diagnosis: EEG to find cause, prior to EEG  no caffeine and wash hair

 medications: antiepileptics
o carbamazepine, valporic acid, phenytoin, and diazepam
 complications – status epilepticus: seizure lasting longer than 30 min  medical emergency

Chapter 14: Head injury

 Minor head injury – confusion, vomiting, pallor, irritability or drowsiness
 Irritability is usually one of the first signs of ↑ ICP
 INFANTS – bulging fontanels, high pitched cry, poor feeding, increased sleeping, restlessness, setting-sun sign, distended
scalp veins
 CHILDREN – nausea, vomiting, ha, seizures, blurred vision
 Late signs: delayed or impaired pupillary responses, posturing, ↓ response to painful stimuli, Cheyne-stokes respirations,
optic disc swelling, ↓ LOC coma
 Stabilize the spine first – then vital signs, GCS, etc.
 Keep HOB 30, maintain head in midline/neutral position, minimize oral or endotracheal suctioning, avoid coughing or
blowing their nose, foley catheter, stool softeners, implement seizure precautions
 Medications:
o Corticosteroids
o Mannitol (diuretic)
o Anti-epileptics
 Surgically:
o Craniotomy
 Complications: hemorrhages, brain herniation
 s/s of hernia: loss of blinking, loss of gag reflex, unreactive pupils, coma or resp. arrest

Chapter 15: cognitive and sensory impairments

 Snelling test: stand 10 feet away
 myopia – near sightedness
 hyperopia – far sightedness
 strabismus – inward or outward deviation of one of the eyes
o treatment is to patch the good eye
 acute otitis media – middle ear infections
o common under 7  their tubes are shorter and more horizontal than adults
o give pain meds, abx, and if surgery is needed – tube is put in the middle ear myringotomy and the placement of
tympanoplasty tubes
o tubes will fall out on their own in 6-2 months & tell HCP when they come out
o don’t get their ears wet

Chapter 16: O2 therapy

 Sao2 95-100%
  Meter dose inhalers
o Shake 5-6x
o Spacers make them more effective
o Take a deep breath then exhale
o Hold inhaler up, while pressing in, take a slow deep breath
o And hold breath for 10 sec before exhaling
 Dry powder inhaler – don’t shake
 Chest physiotherapy
o Schedule 1 hour before or 2 hours after meals to prevent vomiting
o Give bronchiodilator or nep treatment prior
 Hypoxemia s/s: tachypnea, tachycardia, restlessness, accessory muscles, nasal flaring
 O2 toxicity  hypoventilation and maybe LOC
 Suctioning – clean technique for nasal and oral
 ET tube and trach tube suctioning
o High fowlers or fowlers
o Catheter one half of the diameter
o Hyperoxygenate and hyperventilate with 100%
o Surgical aseptic technique
o Limit suctioning to 5 seconds for infants and 10 seconds for children
o Rest for 30-60 seconds in-between passes

Chapter 17: acute and infectious respiratory illnesses

 Tonsillitis
o Fever meds, abx to cure the infection, culture to test for strep
o Tonsillectomy  side lying position initially, assess for bleeding, frequent swallowing and clearing of the throat,
clear fluids after gag reflex has returned, no citrus juices, no milk products, discourage coughing or nose blowing,
warn parents that there may be some blood clots, limit strenuous activity, full recovery in bout 2 weeks
o Group a beta blah blah of strep can lead to kidney infection or rheumatic fever
 Bacterial epiglottitis **
o Drooling, hoarseness, difficulty speaking and swallowing, and high fever
o Most important: DO NOT put anything in their throat; no throat culture; or tongue blades, etc.
 Cause airway to close up
o Abx therapy, intubation supplies ready
 Influenza
o Fever, body aches, congestion
o Anti-viral (usually only within first 48 hours)
 Complications
o Pneumothorax and pleural effusion

Chapter 18: Asthma

 Bronchodilators: albuterol  s/e is tachycardia and tremors
 Anticholinergic like ipotropium  s/e cant see, cant see, cant pee, cant spit, cant shit
 Steroid – prednisone  rinse mouth after steroid inhaler bc they can get a fungal infection
 Peak flow meters
o Stand up
o 0 out machine
o Lips around device
o Blow out hard
o 3x
o Highest reading
 Complications – status asthmaticus  not relieved by medications; intubation

Chapter 19: Cystic Fibrosis

 Caused by a genetic mutation – both parents have to carry recessive traits
 Increased thick tenacious mucous – pancreas, lungs, liver, small intestines, and reproductive organs
 Carrel chest, finger clubbing, large loose fatty foul-smelling stools (steatorrhea), not gain weight, delayed growth, failure to
thrive, deficiency of fat-soluble vitamins (ADEK), sweat and tears are salty
 Diagnosis: sweat chloride test & dna testing
  Chest physiotherapy
o Schedule 1 hour before or 2 hours after meals to prevent vomiting
o Give bronchiodilator or nep treatment prior
 IV abx, and O2 therapy
 Diet high in calories and protein
 Pancreatic enzymes with their meals to help with digestion – pancrelipase
 And vitamin supplements
 Albuterol, anticholinergics, dornase alfa (↓ viscosity to the mucous)
 Chronic illness, difficulty managing, parents find a support group. Etc.

Chapter 20: Cardiovascular Disorders

Congenital heart defects – usually result in 2 things:
 Hypoxemia and heart failure
o s/s: tachypnea, dyspnea, tachycardia, peripheral edema, cyanosis, exercise intolerance, and polycythemia (↑ in
rbc’s)

 Increasing pulmonary blood flow defects:

1. ventricular septal defect (VSD) *
a. creates a harsh murmur that can be heard at the left sternal border
2. atrial septal defect (ASD)
a. loud hard murmur; split sound
3. patent ductus arteriosus (PDA) *
a. creates bounding pulses + a machine hum murmur
b. give indomethacin

 Obstructive blood flow defects

1. pulmonary stenosis
a. systolic ejection murmur
2. aortic stenosis
3. coarctication of the aorta *
a. upper body: bounding pulses and high pressure, flushed warm skin
b. lower body: low pressure, faint pulses, cool skin

 Decreasing pulmonary blood flow defects

1. tricuspid atresia
a. complete closure of the tricuspid valve  also have to have an ASD
2. tet of fallot * PROV
a. pulmonary stenosis, VSD, overriding aorta, and right ventricular hypertrophy

 mixed blood flow defects

1. transposition of the great arteries
a. sx within first 2 weeks of life – major cyanosis
2. truncus arteriosus
a. no spetum between the ventricles
b. requires sx after birth
3. hypoplastic left heart syndrome

 EKG, echo, cardiac catherization

o Allergies to shellfish or iodine
o NPO 4-6 hours prior to procedure
o Both pedal pulses located
o Assess insertion site for bleeding
o Flat position 4-8 hours post-op
 Nursing care
o Frequent rest periods; cluster care
o Small frequent meals
o Crying kept to a minimum
o Encourage semi-fowlers or fowlers
 o Car seat at 45-degree angle vs flat
o Feed Q3 hours
o Enlarged opening on bottle nipple
 Medications
o Digoxin – help improve contractility of the heart
 Toxicity – n/v, halo. Decreased HR and appetite
o ACE (Aprils) – help provide vasodilation
o Beta blockers – helps decrease HR, BP, and causes vasodilation
o Lasix – K levels
 High potassium foods *** look in nutrition
 Severe hypoxemia episode  knee to chest to calm them down
 High risk for bacterial endocarditis – abx prior to dental and surgical procedures

Rheumatic fever
 Inflammation of the heart, blood vessels, and joints
 Caused by a strep throat infection  untreated or partially treated
o 2-6 weeks following
 Lab tests – throat culture, serum ASO titer, EKG, diagnosis based on the jones criteria (pt. needs to have 2 major criteria or
1 major and 2 minor)
o Major criteria: carditis, subcutaneous nodules (non-tender), polyarthritis, rash (pink-non pruritic on the trunk and
the inner surfaces of the extremities), Chorea – involuntary muscle movements
o Minor: fever + pain in one joint

Kawasaki Disease
 Acute systemic vasculitis – inflammation of the blood vessels
 Acute phase
o Onset of high fever that is unresponsive to meds, with development of other cm’s
o Irritability, red eyes without drainage, bright red chapped lips, strawberry tongue, red oral mucosa, red palms and
feet, joint pain, enlarged lymph nodes, etc,
 Subacute phase
o Resolution of fever and gradual subsiding of other cm’s
o Peeling skin
 Convalescent phase
o No cm’s seen except abnormal labs
o Resolution 6-8 weeks from onset
 Treatment – IV Igg ** (gamma globulin)
o + aspirin
o Avoid live immunizations for 11 months after the onset of the disease

Chapter 21: Hematologic Disorders

Epistaxis – nose bleeding
 Sit upright and lean forward, pinch the nose for 10 min until bleeding stops, ice on the nose, or cotton or tissue in the nare
 After the bleeding stop – Vaseline in the nose to help prevent re-bleeding + recommend parent uses cool mist humidifier

Iron deficiency anemia

 Poor diet, drink a lot of cow milk (low in iron)
 Lab work – RBC, hbg & hct low
 Diet in iron, protein, and vitamin C
 Iron supplement  1 hour before or 2 hours after milk or antacids, vitamin C, straw, IM injection use z track method, stool
is expected to turn tarry green color if dose is adequate, brush teeth after
 Prevent overdosing of iron – locked in cabinet

Sickle cell anemia

 Autosomal recessive genetic disorder
 HbS is produced
 Increased blood viscosity, obstruction of blood flow, tissue hypoxia
 Painful af
 Crisis – exacerbation
  African American highest risks
 Fam history, reports of pain, SOB, pallor, jaundice (destruction of RBC’s)
 Vasoclusive crisis 4-6 days painful ischemia in the tissue
 Treatment: fluids *** and pain control
o Blood products
 Complications  CVA and any reactions to the blood products

Hemophilia
 Prolonged bleeding time due to lack of a specific factor that’s needed to clot properly
 A = lack of factor 8
 B = lack of factor 9
 Excessive bleeding, joint pain and stiffness, bruising
 Labs: prolonged PTT, platelets and prothrombin will be normal
 No rectal temps, avoid skin punctures when necessary, hold pressure 5 min, painful joints = elevate and apply ice to that
area
 Replace the factors that are missing
 Minimize the risk of bleeding
o RICE
 Complications: joint deformity

Chapter 22: acute infectious GI disorders

 Rotavirus – most common cause of diarrhea in kids <5
o Vaccine available
o s/s: watery diarrhea, vomiting, and fever
 Pin worm (Enterobius vermicularis) – cause perianal itching
o Tape test for diagnosis while sleeping
 When a kid has diarrhea, you need to know what foods/drinks they should and shouldn’t have *
o Should have oral rehydration therapy drink (ORT)
o Shouldn’t give fruit juices, carbonated drinks, jello, caffeine, chicken or beef broth & no BRAT diet
 Dehydration
o Mild – slight thirst and capillary refill is a little longer
o Moderate – cap refill between 2-4 seconds, thirst and irritability, dry mucous membranes, tears and skin turgor are
decreased
o Severe – cap refill >4 seconds, tachycardia, extreme thirst, mm very dry, tented skin, no tearing, sunken eyes,
sunken anterior fontanel, oliguria or anuria

Chapter 23
 Cleft lip  repaired in 2-3m
o Before sx: use a wide based nipple for feeding, encourage breastfeeding, squeeze cheeks together to decrease gap
o After sx: back and upright, elbow restraints, ns water or diluted hydrogen peroxide to clean the suture line,
antibiotic ointment if prescribed
 Cleft palate  repaired in 6-1m
o Before sx: upright for feeing, one-way valve bottle with specially cut nipple for feeding, burp frequently
o After sx: prone position, IV fluids then clear liquid for first 24 hours, nothing in mouth that could mess up the
sutures, elbow restraints
 Complications: ear infections and hearing loss – seen by specialists
o Speech therapists
o Dental problems – teeth may not erupt normally

GERD – gastrointestinal reflex disease

 Usually self resolves by 1 year of age
 s/s with infants – spitting up, irritability, excessive crying, blood in the vomit, arching of back, stiffening, resp. problems,
FTT, apnea
 s/s with children – heartburn, abd pain, difficulty swallowing, chronic cough, noncardiac chest pain
 nursing care  small frequent meals, thicken infant’s formula with rice cereal, avoid foods that can make it worse, head
elevated for 30 at least 1 hour after eating
o meds: PPI (omeprazole, pantoprazole); H2-receptor antagonists (famotidine or ranitidine)
 Sx – nissen fundoplication
Pyloric stenosis – thickening of the pyloric sphincter = obstruction
 Projectile vomiting, dehydration and constant hunger, olive shaped mass in the RUQ
 Sx – pylorotomy

Hirschsprung’s Disease – congenital aganglionic megacolon  structural anomaly of the GI tract caused by lack of ganglion cells in
the segments of the colon resulting in decreased motility and mechanical obstruction
 Ribbon like stool, vomiting bile, abd distention
 Risk factor  infant fails to pass meconium in 24-48 hours of life
 Nursing interventions – high calorie, protein & low fiber diet
o Surgery  remove bad portion of the colon & may need a colostomy for a while

Intussusception – proximal segment of the bowel telescopes into a more distal segment, resulting in lymphatic and venous
obstruction causing edema in the area  with progression, ischemia and increase mucous into the intestine will occur
 Common in infants and children 3m-6 years
 Red currant jelly stool, sausage shaped abd mass
 CF at risk
 Air enema is therapeutic procedure

Appendicitis
 Avg age is around 10 years
 Abd pain in the RLQ, ↓ or absent bowel sounds, fever, WBC ↑and inflammatory markers
 Diagnosis with CT
 Avoid heat to the abd
 Fluids, abx prior to the stomach
 Suddenly feeling better – ruptured appendix  medical emergency

Chapter 24: Enuresis and UTI’s

Enuresis – uncontrolled or unintentional urination after the age of 5 years for at least 3m’s
 Primary – never had control of bladder
 Secondary – have been potty trained and now they are wetting their bed
o Regression from stress of emotional trauma
 Self-esteem and coping strategies
 Restrict fluids in the evenings, avoid constipation, etc.

UTI’s
 Frequent urination, foul smelling urine, fever, pallor, poor appetite, vomiting, increase in thirst, swelling of the face, and
seizures
 Diagnosis – urinalysis  nitrates and leukocytes elevation
 Educations – females wipe front to back, cotton underwear, avoid bubble baths, void more, empty bladder fully
 Important constipation – high fiber diet

Chapter 25
Bladder exstrophy – the bladder/urethra/ureteral orifices are coming through the suprapubic area – medical emergency; requires
immediate surgery
 Sterile gauze over that area and prepare for sx

Hypospadias
 Urethral opening is on the underside (ventral) side of the penis
 No circumcision

Epispadias
 Urethral opening on the upper part of the penis (dorsal) side
 No circumcision

Phimosis – narrowing of the opening of the foreskin  can’t retract the foreskin

Cryptorchidism – undescended testes

 Sx at 6 and 24m’s
Hydrocele – fluid in the scrotal sac

Testicular torsion – medical emergency

 Enlargement of the effected testical and severe and sudden onset of pain

Chapter 26 – renal disorders

Acute glomerulonephritis [AGN]
 Associated with a strep infection
 Cloudy tea colored urine, dec urine output, periorbital edema, facial edema that’s worse in the am and then spreads down
over the day, mild -severe HTN, oliguria
 Proteinuria and Smokey or tea colored urine, hematuria, increased specific gravity, ASO titer – for strep infection
 Nursing care
o Restrict sodium and fluid
o Edema  risk for skin breakdown
o Diuretics, anti-hypertensives, abx for strep infection

Nephrotic syndrome – alteration in the glomerular membrane that allows proteins [esp. albumin] to pass through to the urine 
resulting in decreased serum osmotic pressure
 Facial and periorbital edema, dec urine, frothy urine, norm BP, >2+ protein, hypoalbuminemia, hyperlipidemia,
hemoconcentrion, hyponatremia maybe
 Daily weights – same scale, same time, same amount of clothing on everyday
 Monitor edema – measure abd girth @ the level of the umbilicus
 Restrict fluids and salt
 Skin breakdown
 Meds – steroids  monitor for GI bleeding, hyperglycemia, etc
o Albumin and diuretics  help increase the plasma volume and decrease edema in the pt.

Chapter 27 – musculoskeletal
Fractures
 Open or compound – bone is sticking out of the skin
 Closed or simple – bone not sticking out
 Complicated – organ or tissue is also damaged
 ABC’s + elevated the extremity, apply ice, stabilize the injured area & a complete neurovascular check
o Sensation
o Skin temp.
o Skin color
o Cap refill
o Pulses
o Movement
 Casting – elevate the cast above the level of the heart for the first 24-48 hours, apply ice for 24 hours to dec swelling & turn
and position the pt. every 2 hours to help dry the cast, assess for inc warmth or hot spots on the cast – hot spot indicated
infection
 Plaster casts  use the palms of your hands to avoid denting
 Expose all surfaces to promote drying
 Don’t put anything in the cast to itch

Traction care
 Align, mobilize, and reduce muscle spasms in patients who have fractures
 Maintain body alignment, give meds to help prevent muscle spasms and pain, neurovascular checks, pin sites for s/s of
infection, make sure the weights hang freely & not on the bed or floor, do not lift or remove weights unless ordered
 Halo tractions – wrench attached to the vest if needed for CPR

Complications of fractures:
Compartment syndrome  compression of the nerves, blood vessels, and muscle within a confined space
 Tissue necrosis can occur
 Very intense pain unrelieved with meds, numbness, pulselessness, inability to move digits, pallor, cool extremities
 Fasciotomy  muscle compartment is cut open to allow tissue to swell, decrease pressure, and restore blood flow
 5 P’s – pain, paresthesia, pulselessness, paralysis, and paleness
Osteomyelitis – open/compound fractures – infection of the bone
 Fever, pain, tachycardia, edema
 Bone biopsy
 Abx therapy to treat

Chapter 28 – congenital musculoskeletal disorders

Clubfoot
 Treatment is serial casting

Legg-calve-perthes disease – aseptic necrosis of the femoral head (uni or bi)

 Intermittent painless limp, hip stiffness, shortening of the effected leg, limited ROM
 Bracing, casting, or traction or replacement of the hip joint

Developmental dysplasia of the hip [DDH] *

 Infants – asymmetry of the gluteal and thigh folds, limited hip abduction
o + ortolani test  hip is reduced by abduction
o + barlow test  hip is dislocated by adduction
 Children – one leg is shorted than the other, walk with a limp, + tendelenberg sign [while bearing weight on the effected
side, the pelvis tilts down], walks on tippy toes on one foot
 Newborn to 6 months = Pavlik harness
o 12 weeks
o Check straps every 1-2 weeks for adjustments by HCP
o Preform neurovascular and skin checks
o Use an undershirt and wear knee socks
o Gently massage under the straps
o No lotion or powders
o Put diaper on under the straps
 Over 6 months
o Bryant harness
 Hips flexed at a 90-degree angle with the butt raised off the bed
 Maintain traction & assure alignment
 Skin care
o Hip spica cast
 Neurovascular checks
 Position casts on the pillow & keep elevated until dry
 Frequent position changes to promote even drying
 Handle casts with palm of hands to prevents dents until dry
 Give sponge baths to avoid wetting the cast
 Use waterproof barrier around the genital opening so nothing gets in there
 Complications from casts and harnesses – bowel and bladder eliminations
 Fiber to help pooping and fluids

Osteogenesis imperfecta – an inherited condition that results in bone fractures and deformity along with restricted growth
 Heterogeneous autosom dominant
 Brittle bone disease
 Multiple bone fracture, blue sclera, early hearing loss, small discolored teeth
 No cure – treatment is supportive
 Medication  pamidronate: can be used to increase bone density
o s/e: hypocalcemia, hypomagnesia, low phosphate, low K, thrombocytopenia, dysrhythmias, kidney failure
 encourage the child to do low impact exercises – braces and splints for support

scoliosis – lateral curvature of the spine and spinal rotation that causes rib asymmetry
 diagnosis – bend at the waist with arms hanging while assessing for asymmetry of the rubs and flank
 treatment – bracing or spinal fusion with rod placement

Chapter 29: chronic neuromuscular disorders

Cerebral palsy – impairment of motor function, coordination, and posture
  Abnormal perception and sensation, visual, hearing, and speech impairments; seizures, and cognitive disabilities
 Cause is unknown – correlated with prenatal risk factors
 Assessment findings:
o Spastic hypertonicity
o Dyskinetic (non-spastic, extrapyramidal) – jerking movements that appear slow and wormlike of the trunk neck
face and tongue
o Ataxic s/s – wide based gait and difficulty with coordination, difficulty with precise movements, and low muscle
tone
 Treatments – skeletal muscle relaxants [Baclofen] + valium [diazepam]
 Complications – aspiration *, elevated HOB, handle secretions, risk for injury

Spina bifida – failure of the osseous spine to close

 Neural tube defects are present at birth and effect the CNS and osseous spine
 Occulta – not visible
 Cystica – protrusion of the sac is visible
 Meningocele – contains spinal fluid and the meninges
 Myelomeningocele – contains spinal fluid, meninges, and nerves
 Associated with a lack of folate acid during pregnancy

 s/s:
o cystica – protruding sac midline of the spine
o occulta – dimpling of the lumbosacral area + port wine angioma + dark hair tufts, subcutaneous lipoma

 interventions – close asap

o sterile moist non-adherent dressing and change Q2 hours
o prone position with hips flexed and legs abducted
o no pressure on the sac

 complications – skin ulceration, latex allergies *, increased ICP, bladder issues, and orthopedic issues

down syndrome
 chromosomal abnormality
 small round head, flattened forehead, small nose with depressed nasal bridge, small ears with short pinna, protruding abd,
hypotonia and hyper flexibility
 manage secretions and help prevent respiratory infections
 cardiac defects and strabismus
 rinse mouth after feeding and throughout the day
 cool mist humidification and use bulb syringe prn

juvenile idiopathic arthritis – chronic autoimmune inflammatory disease affecting the joints and other tissues
 joint swelling, stiffness, redness and warmth
 worse in morning or after naps
 apply a splint for sleeping
 encourage use of a firm mattress and discourage use of pillows
 apply heat or warm moist packs to the affected joints
 encourage warm baths
 NSAIDS, methotrexate, steroids

 Muscular dystrophy – group of inherited disorders with progressive degeneration of symmetric skeletal muscle groups
causing progressive muscle weakness and wasting
 Most common  Duchenne’s MD – onset within 3-7years
 s/s: muscle weakness, unsteady gait, waddling, lordosis, and delayed motor skills development
o frequent falling, learning difficulties, progressive muscle atrophy
 resp. and cardiac difficulties around age 20
 corticosteroids
 complications: resp. compromise  progressive weakening of the resp. muscles

Chapter 30: skin infections + infestations

Impetigo
 Caused by staph
 Reddish macule that becomes vascular and can erupt forming dry crusty’s + itchy
 Direct contact
 Abx ointment, burow’s solution

Cellulitis
 Firm swollen red area of the skin and subcutaneous tissue
 Fever
 Abx and warm moist compresses

Tinea – fungal
 Round red scaley patches, itchy in warm and moist areas
 Head – selenium sulfide shampoo
 Topical antifungal
 Treat infected pets as well

Lyme disease
 Bit by a tick carrying borrelia burgdorferi
 Stage 1 - 3-31 days: flu like s/s * bullseye rash at the bite area
 Stage 2 – after 31 days  more systemic issues – paralysis, swelling in joints, weakness
 Stage 3 – deaf, encephalopathy, arthritis, weakness, numbness and tingling, and speech issues

Scabies
 Itchiness, rash, thin pencil mark lines, pimples on trunk, blisters on palms and soles
 Apply 5% permethrin cream everywhere + family + wash everything in hot water

Pediculosis capitits (lice)

 Small red bumps on the scalp, nits (white specks) on the hair shaft
 Shampoo containing 1% permethrin + remove nits with special comb + wash everything in hot water

 Can’t wash? Bag for 14 days

 Boil hair products for 1 hour in lice killing solution

Chapter 31: dermatitis and acne

Dermatitis – diaper rash
 Washing with warm water and mild soap
 Expose to air
 Encourage parents to use good diapers + frequent changes
 No bubble baths
 Skin barrier – zinc oxide containing
 Corn starch to reduce friction NOT TALCUM POWDER

Poison ivy
 Plant exposure – treat area with alcohol followed by water then mild soap and water
 Then apply a calamine lotion
 Or a burrow solution
 Steroid gel

Seborrheic dermatitis – cradle cap

 Scaly and greasy thick flakes
 Not contagious
 Gently scrub the scalp with mild shampoo or special treatment
 Fine tooth comb

 Keep nails trimmed short for skin issue kids + gloves or socks over hands for sleeping
 Cotton clothing
 Avoid excessive heat
  Avoid irritants

Atopic dermatitis – eczema

 Intense itchy
 Damage from so much itching
 Antihistamines + topical steroids

Acne
 Good diet, exercise, mild cleanser, don’t pick
 Meds

Chapter 32: Burns

Thermal
Chemical
Electrical

First degree Seconds degree Third degree Fourth degree

Superficial Superficial Deep partial Full thickness Deep full thickness
partial thickness
thickness
Damage to the epidermis Damage to Epidermis + Epidermis + dermis + possible Damage to all layers and
the entire some of the subcutaneous damage extends to the muscle, fascia,
epidermis dermis and bones
Nerve endings, hair follicles,
and sweat glands are
destroyed
Pink to red Painful, Mottled, red Red to tan, black, or brown, or Color variable
No blisters moist, red, to white, waxy white in color Dull and dry
Blanches with pressure blisters, mild blisters. Mod Dry, leathery appearance Charring
to moderate edema No blanching Possible visible ligaments,
swelling, no Blanches with bone or tendons
eschar pressure
Blanches with
pressure
Painful Painful Painful As it heals – painful sensation No pain is present
Heals in 3-7 days Heals in <21 Sensitive to returns, and severity Heals in weeks to months
No scarring days temp increases Scarring
Possible changes Heals in weeks-months Grafting required
scarring Healing >21 Scarring Possible amputation
Sensitive to days Grafting is required
temp Scaring is
changes likely

Rule of nines:

Nursing interventions for burns:

ABC’s
IV access with lg bore catheters
Immunization status – tetanus in last 5 years = they are going to get one
Advise family nothing greasy on burn

Fluids based on urine output

Kids <30 kg (66 pounds)  1-2ml/kg/hour
>30 kg  30ml/hour

LR and NS sometimes
Manage pain – IV opioid’s
Nutrition – increase protein and calories + vitamin A, C, and Zinc
Restoring mobility – active and passive ROM
Silver sulfadiazine – 2nd and 3rd degree  transient neutropenia

Allograft – cavader
Xenograft – animals
Autograft – own skin

Chapter 33: diabetes mellitus

Type 1: beta cells in the pancreas are destroyed and the pt. then becomes dependent on insulin
Type 2: body fails to use insulin properly

Hypoglycemia s/s: cold and clammy need some candy <60 blood sugar
 Hunger
 Shakiness
 Diaphoresis
 Irritability
 Pale cool skin
 Possible in LOC
 Slurred speech, HA, seizures
 Tachycardia and palpitations
 Normal to shallow respirations

Hyperglycemia s/s: hot and dry, sugar is high

 Polyuria
 Polydipsia
 Polyphagia
 Dehydration
 Tired/fatigued
 Weak
 Nausea, vomiting, abd pain
 Weak pulse and diminished reflexes
 Warm, dry, and flushed skin
 Rapid, deep respiration – kussmauls respirations – fruity smelling breath

Diagnostic criteria:
 8-hour fasting blood glucose of 126 or higher
o No antidiabetic meds until after the procedure
 A random blood glucose of 200 or more + classic s/s of diabetes
 Oral glucose tolerance test of 200 or more in a 2-hour sample
o Balanced diet for 3 days prior
o Fast for 8 hours
o A fasting level is drawn at the start of the test
o Then instructed to consume a specific amount of glucose – and blood levels are drawn every 30 minutes for 2
hours
o Assess for hypoglycemia throughout the procedure
 HbA1c [glycosylated hemoglobin]
o Expected range is 4-5.9% but an acceptable range for a child with diabetes can be 6-5-8% with a goal of <7%
 Less than 7% indicates that DM is being well managed
 Self-monitored blood glucose – before meals and at bedtime

Foot care of DM
 Pt. inspects feet daily for wounds
 Dry feet completely after showers
 Mild foot powder – corn starch
 Never use commercial remedies for removing calluses or corns
 Cut toenails straight across
  Separate overlapping toes with cotton or lamb’s wool to avoid injury
 Avoid open toe and heel shoes
 Leather is preferred to plastic
 Wear slippers with soles and never go barefoot
 Check shoes and shake them out
 Clean absorbent socks made of cotton or wool
 Not use hot water bottles or heating pads
 Check water temps with hands, not feet

Management of DM when a pt. is sick

 Monitor BG every 3 hours
 Continue to take insulin or oral meds
 Encourage sugar free non-caffeinated liquids to prevent dehydration
 Test urine for ketones Q3 hours
 Rest
 Call HCP if BG >240 or with a fever 102 & if ketones are in urine, rapid breathing, or confusion

Hypoglycemic patients [<60]

 Treat with 10-15-gram simple carbohydrates [1 table spoon of sugar]
o 4 oz. of orange juice, 8 oz. of milk, 3-4 glucose tablets, 4 oz. regular soft drink
 Unconscious patients  glucagon IM or subq + give a simple carb once they wake up

Types of insulin:
Type Onset Peak Duration
Rapid-acting Lispro/Humalog 15 – 30m 30m – 2 hours 3 – 6 hours
Short-acting Regular 30m – 1 hour 1 – 5 hours 6 – 10 hours
Intermediate-acting NPH 1 – 2 hours 6 – 14 hours 16 – 24 hours
Long-acting Glargine/Lantus 70 min None 24 hours

Never mix anything with Lantus *

Mixing NPH with rapid or short  draw up short or rapid first THEN the NPH [clear before cloudy]

Complications:
 DKA  life threatening condition when BG is over 330 & usually due to an acute illness, non-compliance, or stress
o Ketonemia + glycosuria + ketonuria + acidosis [pH 7.30 and bicarb 15]  resulting in the breakdown of body fat for
energy and an accumulation of ketones in the blood, urine, and lungs
o Rapid onset
o Fruity breath, deep breathing, kussmauls, confusion, dyspnea, n/v, dehydration, and electrolyte imbalances
o Metabolic acidosis – hyperkalemia
o Treatment – as we are bringing the glucose levels down, the potassium levels may switch from hyper to hypo
 Cardiac monitor
 Sodium bicarb for metabolic acidosis  slow IV infusion
 When BG levels get around 250 – add glucose to IV fluids in order to maintain 120-240 BG
 Give IV insulin continuously
 Monitor levels hourly

Chapter 34: growth hormone deficiency

 Deficiency = short stature, delayed bone closure, and delayed sex development
 Treatment – somatropin  subcutaneous injections until the bones have closed

Chapter 35: Immunizations

 Common cold or minor illness – not contraindications for getting vaccinated
 Severe acute illness – contraindicated
 Immunosuppression – contraindicated from a few
 Flu vaccine – hypersensitivity to eggs = c/a
 Varicella – corticosteroids = c/a
 IPV – allergy to neomycin = c/a
 MMR – allergy to gelatin & neomycin = c/a
  DTAP – occurrence of encephalopy, seizures, or inconsolable crying that lasted a long time previously = c/a

 VL or ventral gluteal for smaller children

 Older children – deltoid muscle
 Charting  include date, route, site, type, manufacture lot number, and expiration
 Low grade fever (common s/e) – don’t give aspirin = Reyes syndrome
 Babies vaccine  can give concentrated oral sucrose solution on a pacifier 2 min before and for 3 min after the injection

Chapter 36: communicable disease

Risk factors – lack of vaccination, poor sanitation and nutrition, chronic illness, and crowded living conditions

Type Spread Remember

Conjunctivitis Direct contact
Epstein-Barr virus Saliva Kissing disease
[EBV]/mononucleosis Fever, sore throat, swollen
lymph glands, splenomegaly
and hepatomegaly

Encourage no contact sports

Fifths Droplet Red rash across the cheek;
disease/parvovirus B19 Blood slapped cheek
Mumps Direct contact Painful swollen salivary glands
Droplet
Pertussis [whopping Direct contact Cold s/s
cough] Droplet Violent & rapid coughing that
Indirect contact with freshly sounds like a seal
contaminated articles
Rubella [German Direct contact Red rash that starts on face Can cause birth defects in
measles] Droplet then spreads every where women who are infected
during pregnancy
Rubeola [measles] Direct contact Fever, cough, runny nose
Droplet Kopliks spots in the mouth
Varicella Airborne + direct Starts off as macules then
vesicular then crusts form