Pain Scales

● CRIES scale (infant under 6 months)

○ Crying
○ Requires O2
○ Increased vitals
○ Expression
○ Sleepless
● FLACC Scale (2 months-7yrs)
○ Face
○ Legs
○ Activity
○ Cry
○ Consolability
● Faces Scale (ages 3+)
○ Uses diagram of 6 faces to rate pain from 0-5
● Oucher Scale (3-13 yrs)
○ Used 6 photos to rate pain on scale from 0-5
● Numeric Scale (ages 5+)
○ Rate pain from scale of 0-10
● Non-Communicating Child Pain Checklist (ages 3+)
○ Observe behaviors for 10m minutes to gauge level f pain
Newborn (Birth to 1 month)
● Transitioning to extrauterine life
○ Immediate adjustments include respirations that are facilitated by chemical and thermal factors.
Low oxygen, high CO2, and chilling of the infant excite the respiratory center. Surfactant helps
with breathing too. Closing of the fetal shunts helps the newborn transition to postnatal blood
circulation. Intercostal retractions are normal.
○ BAT (brown adipose tissue) = generates heat
○ Newborn is 70% entirely water and total blood volume after birth averages 300mL.
○ Stomach capacity varies in the first few days; MMC= propel nutrients forward.
○ Sebaceous glands produce vernix caseosa; plugging these causes milia.
○ Skeletal system is soft and not joined; muscular system is complete
● Stooling
○ Meconium: first stool passed in first 48 hours
○ Transitional: 3rd day; greenish-brown
○ Milk stools: 4th day; yellow to golden/brown with odor
● Sensory Functions
○ Vision- eye is incomplete. Newborns can fixate on a bright or moving object 8 inches away. Acuity is
20/100→ 20/400. Prefer medium colors over dim or bright colors, as well as black and white patterns, large
objects, geometric shapes, and reflecting objects.
○ Hearing- can detect sounds similar to adults. Moro reflex. Can differentiate between the mother's
voice from others.
○ Smell- can react to strong odors and recognize the smell of mother’s breast milk.
○ Taste & Touch- can distinguish tastes and perceive sensations.
Infancy (1 month to 1 year)
● Physical Development
○ Birth weight doubles by 5 months
○ Some newborn reflexes disappear
 ● Cognitive
○ Sensorimotor period: explore through senses and learn by trial and error
○ Object permanence develops (7-9 months)
○ Language develops from sounds, imitation, repetition, and can comprehend simple commands
● Psychosocial
○ Erikson’s trust vs mistrust
○ Begin to separate self from others and by 8 months recognize familiar faces from strangers
○ By 9 months, can play simple games such as peek-a-boo
● Health Risks
○ Injuries: suffocation, aspiration, falls, MVA, poisoning
○ Physical/emotional/sexual abuse and neglect
● Nutrition
○ Breastfeeding is the best nutrition or alternatively, iron-fortified formula
○ Adequate iron and fluoride intake
○ No solid foods until 6 months→ introduce one at a time to assess for allergies
● Immunizations
○ Hep B is the first vaccine (PARENT CAN REFUSE)
● Interventions
○ Stimulation strategies to promote develop while conserving energy during hospitalizations
○ Limit negative experiences and number of caregivers
○ Encourage parents to provide care during hospitalization and provide anticipatory guidance
Chapter 4: Communication and Assessment
Pg. 94 Blocks to Communication
● Communication barriers can be on the nurse’s end as well as the patient’s (information overload).
Nurses may give unasked for advice, prejudged conclusions, stereotyping, and premature/over
encouragement. Information overload can cause anxiety and decrease attention.
Pg. 94 Using an Interpreter
● Do not use family members as interpreters
● Ask single questions and direct them to the patient; avoid medical jargon
Pg. 95 Communicating with Children
● Allow child time to feel comfortable and address parents initially if the child is shy
● Avoid sudden advances and prolonged eye contact
● Speak clearly in short sentences and in a quiet voice
● Allow older children to talk in the absence of parents
● Be honest and allow children to express their thoughts
● Do not avoid questions or change the topic
Pg. 97 Communicating with Adolescents
● Build a foundation by allowing them to express ideas, respect their views and tolerate differences,
allowing privacy, and praising good points.
● Communicate by giving undivided attention, listening, keeping an open-mind, avoid judgment and
overreacting, and choose important issues when taking a stand.
Pg. 98 Creative Communication
● Verbal techniques include “I” messages, third-person, storytelling, books, dreams, 3 wishes, rating, word
association, sentence completion, and pros/cons.
● Nonverbal methods include writing, drawing, magic, and play.
Pg. 103 Anticipatory Guidance- Sexuality (adolescents)
● (12-14) Have adolescent identify adult to talk with; responsible decisions regarding sex: STIs;
contraceptives; drugs/alcohol; peer pressure/media; sexual identity; and genitalia exam.
 ● (15-18) Support delaying sex; alternatives to intercourse; clarify values/thoughts; STIs, contraceptives,
pregnancy; sex should be safe and pleasurable for both partners.
Anticipatory guidance provides parents information on normal growth and development and nurturing
childrearing practices.
Nutritional assessment
● Food diary and 24hr recall
● Height and HC reflect PAST nutrition
● Weight, skinfold thickness, and arm circumference reflect PRESENT nutrition
Physical assessment
● Growth chart
○ Denver II, ASQ
○ BMI > 2 years of age
○ Tanner staging
● Age specifics- pg. 112
● Vital signs
○ Measure apical pulse for 1 full minute for infants under 2
○ Compare radial and femoral pulses in infancy
○ BP is taken annually after 3 years of age; automated devices for newborns/infants
■ The width of the cuff bladder ideally covers 40% of the arm circumference at the
midpoint of the upper arm.
○ Breathing is irregular; diminished needs further investigation
○ Count respirations first, apical pulse 2nd, BP 3rd, and temperature last
○ CCHD with pulse oximetry for newborns
● Vision testing
● Cranial nerves
● Reflexes

Chapter 6: Communicable and Infectious Diseases

Precautions
● Hand hygiene, cough etiquette, safe injection practices, barrier from blood/body fluids
● Airborne, Droplet, Contact (page 169-170, Box 6.1)
○ Airborne - transmission occurs by dissemination of either airborne droplet nuclei (small
particle residue <5mm of evaporated droplets that may remain suspended in the for long periods)
or dust particles containing the infectious agents.
■ Special air handling and ventilation are required to prevent airborne transmission.
(AIIR - Airborne Infection Isolation Room)
■ Disease include - Measles, Varicella and TB
○ Droplet - involves contact of the conjunctivae or the mucous membranes of the nose or mouth of
a susceptible person with a large particle droplet (>5mm); droplets are generated during
coughing, sneezing, or talking and during procedures such as suctioning and bronchoscopy.
■ Diseases include - Hib (meningitis, pneumonia, epiglottis, and sepsis), Neisseria
meningitidis (meningitis, pneumonia, and sepsis),
● Other serious bacterial respiratory tract infections: diphtheria (pharyngeal),
mycoplasma pneumonia, pertussis, pneumonic plague, streptococcal pharyngitis,
pneumonia, or scarlet fever in infants and young children
● Serious viral infections: adenovirus, influenza, mumps, human parvovirus B19
(Fifth Disease), and rubella.
○ Contact - direct contact transmission involves skin to skin and physical transfer such as in
 turning or bathing patients and hand contact, indirect contact is contact with a susceptible host
with a contaminated intermediate object, usually inanimate, in the patient’s environment
(stethoscope is the most common)
■ GI, Respiratory, skin or wound infections or colonization with multidrug-resistant bacteria
■ Enteric infections with low infectious dose or prolonged environmental survival including;
C-diff (Clostridium difficile; for diapered on incontinent patients; enterohemorrhagic,
Escherichia coli 0157:H7, Shigella organisms, hepatitis A, or rotavirus
■ Respiratory syncytial virus, parainfluenza virus, or enteroviral infections in infants and
young children
■ Skin infections that are highly contagious or that may occur on dry skin including
diphtheria (cutaneous), herpes simplex virus (neonatal or mucocutaneous), impetigo,
major
(noncontained) abscess, cellulitis or decubitis, pediculosis (head lice), scabies,
staphylococcal in
infants and young children, zoster (disseminated or in the immunocompromised host)
■ Viral or hemorrhagic conjunctivitis
■ Viral hemorrhagic infections (Ebola, Lassa, or Marbug)

Schedule of immunizations

Cathy Parkes (Flashcard #12)

● Birth
○ Heb B
● 2 months - Hint: “B DR. HIP”
 ○ Hep B, DTaP, Rotavirus, Hib, IPV, PCV
● 4 months - HINT: “DR. HIP”
○ DTaP, Rotavirus, Hib, IPV, PCV
● 6 months - HINT: “B DR. HIP”
○ Hep B (3rd dose;given at 6-12mths), DTaP, Rotavirus (3rd dose; 6-12 mths), Hib, IPV, PCV.
Yearly Influenza may be started at 6 months of age.
● 12-15 months - Live vaccines- caution w/ immunocompromised children!
○ Hep A, MMR (live vaccine), Varicella (live vaccine), PCV (4th dose), Hib (4th dose)
Diphtheria
● Agent: Corynebacterium diphtheriae
● Source: Discharged from mucous membranes of nose and nasopharynx, skin, and other lesions of
infected person
● Transmission: direct contact
● Manifestations: URI-like symptoms, cough, fever, nonpurulent nasal discharge, “bulls neck”,
white-gray MM
● Tx: antibiotics, bedrest, suction as needed, humidified oxygen if prescribed
● Precautions: immunization, droplet
● Complications: toxic cardiomyopathy & neuropathy
MMR
● Measles (Rubeola)
○ Agent: Virus
○ Source: Respiratory tract secretions, blood and urine of infected person
○ Transmission: direct contact from respiratory secretions, blood, and urine
○ Manifestations: fever, malaise, cough, conjunctivitis, coryza, “koplick spots”, rash appears on
day 3-4 and spreads downward, anorexia, abdominal pain
○ Tx: antibiotics, bedrest, antipyretics
○ Precautions: immunization; airborne if in hospital until day 5 of rash
○ Complications: otitis media, PNA, obstructive laryngitis/laryngotracheitis, encephalitis (rare)
● Mumps
○ Agent: Paramyxovirus
○ Source: saliva of infected person
○ Transmission: direct contact with or without droplet spread from an infected person
○ Manifestations: Prodromal stage: fever, headache, malaise, and anorexia for 24 hrs, followed by
“earache”, that is aggravated by chewing. Parotitis: by the 3rd day, parotid gland(s) (either
unilateral or bilateral) enlarges and reaches maximum size in 1-3 days; accompanied by pain and
tenderness; other exocrine glands (submandibular) may also be swollen
○ Tx: Analgesics for pain and antipyretics for fever, IV fluids for child who refuses to drink or vomits
because of meningoencephalitis , rest, apply hot or cold compresses to neck, hot or cold packs
for analgesia and scrotal elevation
○ Precautions: childhood immunization; maintain isolation during period of communicability
(immediately before and after swelling begins), institute Droplet and Contact Precautions
○ Complications: sensorineural deafness, postinfectious encephalitis, myocarditis, arthritis,
hepatitis, epididymo-orchitis, oophoritis, pancreatitis, sterility (extremely rare in adult men),
meningitis
● Rubella
○ Agent: Rubella virus
○ Source: Primarily nasopharyngeal secretions, also present in stool, blood and urine
○ Transmission: contact with droplets
 ○ Manifestations: fever, HA, sore throat, malaise, lymphadenopathy, rash
○ Tx: antipyretics and analgesics
○ Precautions: immunization; droplet; avoid pregnant women
○ Complications: rare (encephalitis, arthritis); most benign however possible teratogenic effect on
fetus
Varicella
● Agent: Varicella zoster virus (VZV)
● Source: primary secretions of respiratory tract, to a lesser degree skin lesions (scabs not infectious)
● Transmission: direct contact or respiratory secretions
● Manifestations: Prodromal stage—slight fever, malaise. Pruritic rash begins a macule → vesicle then erupts.
Rash is typically centripetal: extremities, face
● Tx: lessen itching, keep child cool, apply calamine/skin care, bathe and change linens daily,
remove crust from skin
● Precautions: immunization; standard; child is contagious from day before rash
appears to until vesicles are crusted.
● Complications: secondary skin infections, encephalitis, PNA, hemorrhagic varicella
Poliomyelitis
● Agent: Enterovirus (3 types)
○ Type 1, most frequent cause of paralysis, both epidemic and endemic
○ Type 2 least frequently associated with paralysis
○ Type 3, second most associated with paralysis
● Source: feces and oropharyngeal secretions of infected persons, especially young children
● Transmission: Direct contact, spread via fecal-oral and pharyngeal oropharyngeal routes; vaccine
acquired
as a result of live vaccine (no longer available in the U.S.)
● Manifestations: In three different forms:
○ Abortive or inapparent - fever, uneasiness, sore throat, headache, anorexia, vomiting, abdominal
pain; lasts a few hours to a few days
○ Nonparalytic - same manifestation as above but more severe, with pain and stiffness in neck,
back and legs
○ Paralytic - Initial course similar to nonparalytic type, followed by recovery and then signs of
central nervous system paralysis.
● Tx: Complete bed rest during acute phase, mechanical or assisted ventilation in case of respiratory
paralysis, physical therapy for muscle after acute phase
● Precautions: childhood immunization, Contact Precautions
● Complications: permanent paralysis, respiratory arrest, HTN, kidney stones (from demineralization of
bone during prolonged immobility)
Pertussis
● Agent: Bordetella pertussis
● Source: Discharge from respiratory tract
● Transmission: direct contact or droplet
● Manifestations: URI symptoms 1-2 weeks, short, rapid cough→ high-pitched crowing, “whoop”/gasp
4-6 weeks (cyanosis may occur)
● Tx: suction, humidification, hydration, oxygenation, antimicrobial therapy
● Precautions: immunization; droplet
● Complications: PNA, otitis media, seizures, dehydration/weight loss, hemorrhage, hernia, prolapsed
rectum; in adolescents: syncope/sleep disturbances, rib fractures, and incontinence
HepA
● Agent: HAV
● Source: fecal oral route, contaminated food & water
 ● Transmission: fecal-oral route, person to person contact, ingestion of contaminated food and water,
rarely by blood
● Manifestations: abrupt onset, with fever, malaise, anorexia, abdominal discomfort, dark urine, and
jaundice
● Tx: clears on its own in 1-2 months, rest and adequate hydration
● Complications: Are rare; Acute renal failure, interstitial nephritis, pancreatitis, red blood cell aplasia,
agranulocytosis, bone marrow aplasia, transient heart block, Guillain-Barré syndrome, acute arthritis, Still
disease, lupus-like syndrome, and Sjögren syndrome have been reported in association with HAV.
● Precautions: Immunization at 12-23 months (2 doses), hand hygiene
HepB
● Agent: HBV
● Source: blood, semen, body fluids that are contaminated
● Transmission: sex with infected person, birth from a positive mother, contact with blood or open sores
from infected person, exposure to needle sticks or sharp instruments, injection drug use (needle sharing)
● Manifestations: fever, fatigue, loss of appetite, nausea, vomiting, abdominal pain, dark urine, clay-colored
stool, joint pain and jaundice
● Tx: supportive treatment for symptoms, antivirals may be given for chronic HBV with close monitoring of
liver damage/carcinoma
● Complications: cirrhosis, liver cancer
● Precautions: Immunization (first dose given at birth), standard precautions, safe sex practice, lab tests,
not sharing needles, avoiding needle sticks
Tetanus
● Agent: Clostridium tetani
● Source: broken skin, injury from contaminated object (such as a nail)
● Transmission: contaminated object that breaks the skin, burns, crush injuries, injuries with dead tissue,
puncture wounds, wounds contaminated with dirt, poop or spit
● Manifestations: ”lockjaw” (spasms of the jaw muscles), trouble swallowing, painful muscle stiffness all
over the body, jerking or staring (seizures), headaches, fever and sweating, tachycardia,
● Tx: tetanus immune globulin (TIG), antibiotics, hospitalization, drugs to control muscle spasms, tetanus
vaccine
● Complications: can be fatal, PE, broken bones
● Precautions: vaccination, hand hygiene, good wound care,
Hib
● Source: Respiratory droplets
● Transmission: coughing or sneezing, mucus
● Manifestations: fever, chills, excessive tiredness, pain in abdomen, nausea with or without vomiting
● Tx: breathing support, antihypertensives, wound care if damaged skin
● Complications: bacterial meningitis (brain damage/hearing loss), epiglottis (breathing problems), bacterial
pneumonia, septic arthritis, sepsis
● Precautions: immunizations
Meningococcal
● Agent: Neiserria meningitidis
● Source: saliva
● Transmission: coughing, kissing (droplet precaution, until first 24 hours of treatment are completed)
● Manifestations: fever, chills, fatigue, vomiting, cold hands and feet, severe aches or pain in muscles,
joints, chest, abdomen, tachypnea, diarrhea, in the late stages a dark purple rash
● Tx: surgery to remove dead tissue, wound care, antihypertensive, breathing support (CDC)
 ● Complications: significant morbidities, limb or digit amputation, skin scarring, hearing loss, neurologic
disabilities, septicemia, meningitis, cranial nerve dysfunction (6, 7, 8), seizures, adrenal hemorrhage &
insufficiency, vasomotor collapse and shock, DIC, brain damage
● Precautions: MCV immunization
Scarlet Fever
● Agent: Group A B-hemolytic streptococci (“GABHS”)
● Source: usually from nasopharyngeal secretions
● Transmission: Direct contact or droplet spread, indirectly contact with contaminated (ex. Cup, spoon)
● Manifestations:
○ Prodromal stage: abrupt high fever, pulse increased, vomiting, h/a, chills, malaise, abdominal
pain, halitosis
○ Enanthema: tonsils enlarged, edematous, reddened, covered with exudate patches, white
strawberry tongue (1-2days) and then by 4-5th days red strawberry tongue, palate is covered
w/ erythematous punctuate lesions
○ Exanthema: Rash appears within 12 hours after prodromal signs, red pinched-sized rash but
is absent in face which becomes flushed with striking circumoral pallor; rash more intense in
skin folds of joints, by end of first week desquamation begins and may be complete by 3
weeks
○ Tx: PCN (or erythromycin if allergy to PCN) oral cephalosporin, abx therapy for newly
diagnosed carriers (nose or throat cx positive for streptococci), rest during febrile period,
analgesics for sore throat, antipruritic for rash
○ Complications: Peritonsillar and retropharyngeal abscess, sinusitis, otitis media, acute
glomerulonephritis, Acute rheumatic fever, polyarthritis (uncommon)
○ Precautions: Standard and Droplet precautions, precaution until 24 hours after starting
treatment, ensure Abx compliance, IM benzathine PCN G (Bicillin) may be given, relieve
discomfort of sore throat with Lozenges, gargles, analgesics, antiseptic sprays, inhalation of
cool mist, encourage fluids, avoiding irritants such as citrus juices, chips, discard
toothbrush, avoid sharing drinks and eating utensils
Pneumococcal
● Agent: streptococcal pneumococci
● Source: Droplet Precautions
● Transmission: respiratory secretions; saliva, mucus; person to person
● Manifestations: confusion, SOB, tachycardia, fever, shivering, feeling cold, extreme pain or discomfort,
clammy or sweaty skin, cough
● Tx: antibiotics, immunization
● Complications: pneumonia, pericarditis, respiratory failure
● Precautions: immunization, droplet precaution
Influenza
● Transmission: droplet, cough, sneeze, talking
● Manifestations: fever, body aches, cough, sore throat, runny/stuff nose, muscle or body aches,
headaches, fatigue, vomiting, diarrhea
● Tx: Tamiflu (antivirals), hydration, antipyretics, rest,
● Complications: pneumonia, dehydration, worsening of long-term health conditions (heart, lung, DM),
hospitalization
● Precautions: yearly vaccine, droplet precaution
Fifth Disease
● Transmission: droplet or direct contact
● Manifestations: persistent fever 3-7 days, “slapped cheek”, mild URI symptoms, cough
 ● Tx: antipyretics, analgesics, antiinflammatory drugs, possible blood transfusion
● Precautions: standard
● Complications: arthritis, arthralgia, anemia, fetal death, hydrops, aplastic crisis, myocarditis
Bacterial, viral, and skin infections **Strep*

Chapter 7: Newborn (Birth-1m)

Physiological changes
● Lose up to 10% birth weight by day 3-4; regained by days 10-14
● HC is 33-35cm and crown-rump is comparable. If unequal, abnormalities can be present.
● Length is 19-21 inches and weight is between 6-9 lbs.
Assessments
● Sleep and Activity pg. 249
○ There are six sleep-wake states and the ability to transition between states is called state
modulation.
○ Newborns sleep for up to 16-18 hours a day and do not follow a diurnal rhythm.
● Gestational age charts pg. 251
● Fontanels- when do they close?
○ Anterior closes between 12-18 months
○ Posterior closes between 6-8 weeks
● Red reflex
○ Vision fixates on object and follows movement
○ Absence of pupillary reflex by 3 weeks suggests blindness
● Newborn screening
○ Ophthalmia neonatorum (conjunctivitis) prophylaxis eye drops
○ Vitamin K administered to prevent hemorrhage
○ HepB administered birth-2 months
○ PKU screening (PKU can cause brain damage without the enzyme to break it down)
○ Universal hearing screen
● Review bathing, umbilicus care, circumcision care
○ Bathe from head-toe with genitals last; cover baby if washing head
○ Let umbilical stump shrivel on its own; don’t get it wet; apply vaseline to base
○ Apply gauze with gentle pressure if circumcision site is bleeding
● General breastfeeding & bottle feeding
○ Breastfeed q2-3hr; Bottlefed q3-4hr
○ Check formula temperature on wrist
○ 6-8 wet diapers per day
*Inspect spine for tufts (spina bifida)

Chapter 10: Infant (1m-1y)

Physiological changes pg. 414
● Key measurement indicating developmental growth is head circumference
● Birth weight doubles by 5 months; 3x by one year
● Height increases by 2.5cm during first six months, then 1.2cm till 12 months
Gross and Fine motor skills pg. 430
Play pg. 428
Erikson- Trust vs. Mistrust
● Delayed gratification builds trust. Mistrust can also occur if needs are met before being vocalized.
Piaget- Sensorimotor
 ● Separation (themselves and others)
● Object permanence (still exists even if not in view) develops between 7-9 months
● Mental representation (recognize and use symbols)
Language & Behavior
● Crying decreases by 12 weeks→ cooing noises 3-4 months
● 3-5 words by age of one
● Comprehends to “no” by 9-10 months and obeys single commands
Separation anxiety and stranger fear (4-8 months of age)
Nutrition pg. 440
● Vitamin D supplements to prevent rickets and deficiency; iron supplements for breastfed infants after 4
months
● Non-nutritive sucking (thumb, pacifier)
● Dental health
○ 6-8 teeth by 12 months
○ Dental caries can occur due to night time feeding and falling asleep or too much juice
● Solid foods
○ Iron-fortified cereals first
○ New foods every 5-7 days to assess for allergies
○ Vegetables and fruits first then meat and eggs (after 6 months)
○ Weaning occurs when infants are able to drink from a cup→ replace one feeding with a sippy cup; bedtime
feedings are the last to be stopped.
Sleep & activity
● Hands and feet are objects of play; mouth is pleasurable
● Objects of play: noisy, reflective, large (BW initially), soft, nesting, teething, balls, blocks, and books
● Nocturnal sleep pattern by 3-4 months; sleep 9-11 hrs through the night with 1-2 naps; 15 hours total
Injuries chart pg. 443/ ATI pg. 18
● Car seat should be rear-facing and retainer clip at the level of armpits
● Ibuprofen/Acetaminophen over 6 months of age but not more than 3 days

Chapter 12: Toddler (1-3)

Physiological changes
● Grows about 3 inches in height and 4-6 pounds in weight each year.
● Starts to participate in self-care such as eating, dressing, and toileting.
● Gross motor skills develop from walking to running, jumping, climbing, and
● riding a tricycle.
● Fine motor skills develop in drawing, stacking blocks, and feeding self.
Gross & Fine Motor Skills pg. 499
Erikson - Autonomy vs Shame and doubt
● Temper tantrums, negativism, ritualism, sibling rivalry, and striving for independence
● Solitary play develops into parallel play
● Good and Bad behavior results in reward and punishment
Piaget - Preoperational stage (2-7)
● Egocentric
● Imitate others
● Memories of events
**Gender identity develops by 3 years of age**
Play
● Parallel play
● Filling/emptying containers, blocks, thick crayons, push-pull, balls.
Language & Behavior
● Vocabulary is up to 300 words by 2 years
● Reading to toddler helps develop language
Nutrition
● Childhood obesity
● Limit milk 2-3cups/day→ causes anemia
● Picky eaters
● Dental health
○ Flossing and brushing should be performed by caregiver
○ Fluoride supplement
Sleep & Activity
● Toilet training; nighttime control might develop last
● Sleep 11-12 hours per day including one nap; bedtime fears are common
Injuries ATI pg. 22

Chapter 13: Preschooler (3-5)

Physiological changes
● Gain 5lbs each year and grow 2.5-3 inches per year
● By age 5, able to jump rope, skate, swim, and skip on one foot.
● Graceful, posturally erect body
Gross & Fine Motor Skills pg. 529
Erikson - Initiative vs. Guilt
● Energetic learners
● Good and Bad behavior results in reward and punishment; older preschoolers begin to understand
concept of justice and fairness
● Master skills that allow independence; can regress to previous immature behaviors if ill or in stress
● Compare self to others by age 5→ recognize difference in appearances
Piaget - Preoperational→ intuitive thought
● Social awareness lets them consider viewpoints of others
● Make judgements based on visual appearances
○ Magical thinking (thoughts cause events to happen), Animism (lifelike qualities to inanimate
objects), centration (focus on one aspect), and time (understand sequence of daily events).
Freud (Oedipal Stage)- want to marry father/mother; notice sexual differences
Play
● Pretend play
● Associative play; cooperation exists between children
● Playing ball, sand boxes, tricycles, role-playing, skating, electronic games, etc.
Language & Behavior
● Increases more than 2100 words by end of age 5
● Speak in sentences of 3-5 words; enjoy talking
Nutrition
● Consume half the amount of energy that adults do
● More willing to try new foods
● Need 13-19g/day protein, 5 servings of fruits and vegetables and less than 10% total caloric intake of
saturated fats
● Dental Health
○ Eruption of primary teeth→ trauma to teeth is common
Sleep & Activity
● 2 hours or less of screen time and 1 hour of physical activity (reduce childhood obesity)
● 12 hours of sleep per day→ can include night terrors
Injuries ATI pg. 26
● Protective equipment while playing (helmet, pads, etc.)
● Pedestrian safety
● Booster seat until 145cm or ages 8-12

Chapter 15: School-age (6-12)

Physiological Changes
● Gain 4-7lbs per year and grow 2 inches per year
● Prepubescence changes occur at age 9 in girls
● Permanent teeth erupt
● Minimal sexual changes in boys
● Immune system improves and bones continue to ossify
Erikson - Industry vs. Inferiority
● Accomplishment is gained through cooperation with others and completion of task; if incomplete=
inferiority
● Do not understand reasoning behind rules
● Think what others tell them is right and what they think is wrong
● Later ages, able to judge intentions of an act rather than just consequences
● Golden rule!
Piaget - Concrete operations
○ Conservation of mass, weight, and volume
○ Learns to tell time
○ Able to see others’ perspective and solve problems
Play
● Peer groups→ peer pressure
● Clubs and bestfriends become popular
● Like to hang out with same gender but later school ages develop interest in opposite gender
● Competitive and cooperative play
○ 6-9 years of age: board games, hopscotch, jump rope, collect stuff, bicycles, build models, skill-
building sports
○ 9-12 years of age: crafts, models, hobbies, jigsaw puzzles, games, competitive sports
Language & Behavior
● Understand personal values, abilities, and physical characteristics
● Confidence gained through positive self-concept
● By middle school, opinions of peers and teachers become more valuable
● Solidification of body image; curiosity about sexuality; hold emphasis on privacy issues
Nutrition
● Screen for scoliosis
● Eat adult size portions→ obesity is an issue!
● Dental health
○ First permanent teeth erupt at 6 years
Sleep & Activity
● Sleep is variant to age, activity, and health status: 9 hours needed
● Resistance ages 8-12 years
Injuries ATI pg. 30
Chapter 17: Adolescent
Physiological Changes
● Girls height increases 2-8 inches and 15-55 lbs
○ Reach puberty before boys
○ Stop growing 2-2.5 years after menarche
● Boys height increases 4-12 inches and 15-65 lbs
● Primary and secondary sexual characteristics develop and mature
○ Acne can appear
Erikson - Identity vs. Role Confusion
○ Personal identity and group identity
○ Same-sex relationships into sexual experimentation→ transition to intimate relationships
● Develop own values, ethics, and emotions→ separate from family
● Make choices in career, education, and lifestyle
○ Underestimate consequences of actions (i.e. smoking)
Piaget - Formal operations
● Abstract thinking and problem solving
○ Able to maintain attention
○ Highly imaginative and idealistic
● Risky behavior→ feeling invincible
● Question moral values of society
Play
● Nonviolent games and music, sports, pets, career-training, social events
Language & Behavior
Nutrition
● Dental health
○ Corrective appliances (braces)
Sleep & Activity
● Changes occur due to rapid growth and increased metabolism
● Sleep later, sleep in, and sleep more
● Provide information on STI, pregnancy, safe-sex or abstinence
Injuries ATI pg. 34
● Homicide, suicide, substance abuse, STI, MVCs, eating disorders, and human trafficking.

Chapter 26: Respiratory

Respiratory Distress → Pg. 1133/35 (pg. 884-885)
● Retractions - sinking in soft tissues
○ Subcostal retraction indicates flattened diaphragm
● Nasal Flaring - enlargement of nostrils helps reduce nasal resistance and maintains airway patency
○ May be intermittent or continuous; should be described as minimum or marked
● Head Bobbing - head bobs forward with each inspiration
○ Sign of dyspnea
● Noisy Breathing - “snoring”
○ Associated w/ hypertrophied adenoid tissue, choanal obstruction, polyps, or foreign body in nasal
passages
● Stridor - high-pitched, noisy respiration; can be inspiratory or expiratory
 ○ Indication of narrowing of upper airway either as result of edema/inflammation or associated w/
upper airway obstruction from mucus secretion or foreign objects
○ Common causes → croup, epiglottitis, foreign body, or tracheitis
● Grunting - the body’s attempt at more frequent respirations
○ Frequently a sign of pain in older kids
○ Suggests pneumonia or pleural involvement; also observed in pulmonary edema
○ It serves to increase end-respiratory pressure
● Wheezing - continuous musical sound originating from vibrations in narrowed airways
○ Primarily heard on EXPIRATION
○ Infants → may be due to increased airway resistance and compliant chest wall
○ Older kids → wheezing w/ lower respiratory tract infection as result of inflammation, bronchospasms, and
accumulated secretions
● Color Changes of Skin - mottling, pallor, cyanosis
○ Mottling (brick-like skin) and Cyanosis usually indicate cardiopulmonary disease
○ Acrocyanosis (peripheral bluish discoloration) results from circulatory stasis in newborn
○ Mottling results from cool environment
● Chest Pain - usually in older kids; most pleural pain related to respiration
○ Respiratory movements are shallow and rapid and may be accompanied by grunting
○ Respiratory movement
● Clubbing - proliferation of tissue about terminal phalanges; due to chronic hypoxia
○ Degree of clubbing depends on extent to which nail base is lifted on dorsal surface of phalanx by
tissue proliferation
○ The greater the angle formed above the finger or toe at the skin-nail junction, the more
pronounced the clubbing
● Cough - serves as protective mechanism and indicator of irritation
○ Severe Cough → associated with measles and CF
○ Paroxysmal Cough w/ Inspiratory “Whoop” → associated w/ pertussis in infants & small children
○ Brassy/Productive Cough → associated w/ croup and foreign body aspiration
○ Pneumonia → Cough may be absent in child w/ pneumonia in early stages but appears in active pneumonia
and recovery
Urine Box - Nursing Alert (pg. 891)
● Counting # of wet diapers in 24-hour period is good output method
● 0.5 - 1 mL/kg/hr in child who weight less than 30 kg (66 lbs)
● 30 mL/h for children weighing > 30kg
Respiratory Failure → Pg. 1157 (pg. 954)
 Chest PT→ do BEFORE meals or ONE HOUR
AFTER to avoid vomiting and aspiration
Albuterol (SABA - rescue inhaler)
● Use of inhaler (bronchodilator or nebulizer -
usually Albuterol) → Schedule treatment
before meals or 1-hour after meals
● Risk for vomit
Strep Throat
● Antistreptolysin O → tells you if child has had
strep IN THE PAST
● Rapid test only tells you if they have strep
NOW
● Use penicillin to treat or amoxicillin
Otitis Media - presence of fluid in middle ear along w/ acute signs of illness & symptoms of middle ear
inflammation
● Acute Otitis Media
○ Inflammation of middle ear space with rapid onset of S/S of acute infection - namely, fever and
otalgia (ear pain)
● Otitis Media with Effusion
○ Fluid in the middle ear space without symptoms of acute infection
○ S/S → severe pain & fever is usually ABSENT and child may NOT appear ill; feeling of fullness in ear,
popping sensation during swallowing, and feeling of “motion” in ear if air present above level of fluid;
deficient hearing
○ Therapeutic Mgmt. → observation, antibiotics alone, or combo of antibiotic & corticosteroids
○ Hearing test in children who have OME for 3+ months
■ Frequently associated w/mild/moderate ear impairment
○ Placement of tympanostomy tube recommended after 3-6 months of bilateral effusion
 ■ Mechanical drainage of fluid, promoting healing of membrane and prevents scar formation
and loss of elasticity
● As result of rupture, there is immediate relief of pain, gradual decrease in temp,, and presence of
purulent discharge in external auditory canal
● Amoxicillin to treat
● Prevention → routine immunization w/ pneumococcal vaccine
Croup → pg. 1184 (pg. 902-906)

● Acute Epiglottitis → NEVER examine the pharynx or larynx with tongue blade
○ Three clinical observations of epiglottitis:
■ Absence of cough
■ Presence of drooling
■ Agitation
○ Assessment Findings include:
■ High fever, sore red and inflamed throat (large, cherry, red edematous epiglottis) and pain
on swallowing
■ Dysphonia (muffled voice), dysphagia, dyspnea
■ Retractions as the child struggles to breathe
■ Inspiratory stridor aggravated by supine position
■ Tachycardia
■ Tachypnea progressing to more severe respiratory distress (hypoxia, hypercapnia,
respiratory acidosis, decreased level of consciousness)
■ Tripod positioning; while supporting the body with hands, the child leans forward, thrusts
the chin forward, and opens the mouth in an attempt to widen the airway
■ A fiberoptic nasal laryngectomy may be necessary to assist in diagnosis
○ Interventions:
■ Maintain a patent airway
■ Assess respiratory status and breath sounds, noting nasal flaring, the use of accessory
muscles, retractions, and the presence of stridor
 ■ Do not measure temperature by oral route
■ Monitor pulse ox
■ Maintain NPO
■ Do not leave child unattended
■ Prepare for lateral neck films to confirm diagnosis
■ Avoid supine position (affects respiratory)
■ Administer IV fluids PRN
■ Administer analgesics and antipyretics, corticosteroids (decrease inflammation), heliox
(helium & oxygen), provide cool mist oxygen
■ Have resuscitation, endotracheal and tracheostomy equipment readily available
■ Ensure up to date immunizations including Hib
Tonsillectomy Post-Care (pg. 895)
● Until fully awake, position to facilitate drainage of secretions
● Suctioning performed carefully to prevent trauma to oropharynx
● When alert, children may prefer to sit up although they should remain in bed for rest of the day
● Discouraged from coughing frequently, clearing their throat, blowing nose, or activities to aggravate site
● Some secretions like dried blood are common
● Dark brown (old) blood usually present in emesis, in the nose, and between teeth
● Ice collar may provide relief
● Pain Mgmt. → Opioids; Analgesics may be given IV to avoid oral route but liquid may also be given as tolerated
● Restrict food and fluids until able to swallow and are alert without signs of hemorrhage
● Cool water, crushed ice, flavored ice pops, or diluted fruit juice given
● AVOID fluids w/ red or brown color to distinguish between blood
● AVOID straws, high seasoned foods, vigorous tooth brushing, coughing/clearing throat
● Citrus juice may cause discomfort
● Milk, ice cream, or pudding not offered until clear liquids retained due to coating of mouth & throat by
these foods
● May begin soft foods (gelatin, cooked fruits, sherbet, soup, mashed potatoes) on 1st or 2nd post-op day
● HEMORRHAGE SIGNS → Restlessness/Irritability are early signs; continuous swallowing of trickling blood
Cystic Fibrosis
● A chronic multisystem disorder (autosomal recessive trait) characterized by exocrine gland dysfunction. A
progressive and incurable disorder, respiratory failure is a common cause of death, organ transplant may
be an option to increase survival rates. Abnormally thick production of mucus.
● Diagnosed:
○ Meconium ileus in the newborn is the earliest manifestation
○ Quantitative sweat chloride test
■ Normal range is <40mmol/L
■ Children positive test
● Result greater than 60 meq/L (60mmol/L)
■ Infants - 3mths positive test
● Result greater than 40 meq/L (40mmol/L)
○ Newborn screening
■ May be done in some states
○ Chest x ray
■ Reveals atelectasis and obstructive emphysema
○ PFT
■ Reveals abnormal small airway function
○ Stool
 ■ Fat enzyme analysis, a 72 hour collection of stool
● Respiratory system:
○ Symptoms are produced by the stagnation of mucus in the airway, leading to bacterial
colonization and destruction of lung tissue.
○ Emphysema and atelectasis occur as airway becomes obstructed
○ Chronic hypoxemia; leading to pulmonary HTN and eventual cor pulmonale
○ Pneumothorax
○ Wheezing and coughing
○ Dyspnea
○ Cyanosis
○ Clubbing of the fingers and toes
○ Barrel chest
○ Repeated episodes of bronchitis and pneumonia
○ Interventions include:
■ CPT
■ Suction of mucus
■ Bronchodilator
■ Oxygen
■ Lung transplant
● GI system:
○ Intestinal obstruction (distal intestinal obstructive syndrome) causes a thick intestinal secretions
can occur, signs include pain, abdominal distention, nausea, and vomiting
○ Stools are frothy and foul smelling
○ Malnutrition and failure to thrive is a concern
○ Pancreatic fibrosis placing the child at risk for DM
○ Rectal prolapse
○ Deficiency of fat soluble vitamins (A,D,E,K), which can results in easy bruising, bleeding and
anemia
○ Hypoalbuminemia results from diminished absorption of protein, resulting in generalized edema
○ Interventions:
■ High calorie, high protein diet, supplemental of fat vitamins
■ Monitor weight
■ Monitor stools/constipation
■ Pancrelipase; may be sprinkled over food, administered with all meals and snacks
■ Monitor for GERD
● Reproductive:
○ Males are usually sterile
○ Delayed puberty in girls
■ Fertility can be inhibited by the highly viscous cervical secretions, which act as a plug and
block sperm entry
● Integumentary:
○ Parents often complain of a salty taste when they kiss the infant/child
○ Abnormally high concentrations of sodium and chloride in sweat
○ Dehydration and electrolyte imbalances can occur

Chapter 32: Integumentary

Pediculosis Capitis (Head Lice)
● Infestation that can be occur in multiple areas of the body
● High degree of transmission
● Isolation and completion of treatment
● Pediculicides and removal of nit
● Prevention:
○ Continued inspection
○ Isolation of self-care products for the individual
○ Machine wash hot water and hot dryer for involved contact products (sheets, pillow cases, and
blankets)
○ Removal of non-washable items or sealing in plastic bag for at least 14 days
○ Follow through with medication therapy
○ Family education