Children & Adolescent • Newborn-2 month: Grasp reflex,

L2 – Growth Involuntary, instinctual grasping

• Directional trends • 3 month: Palmar grasping

Ø Cephalocaudal (head-to-toe) direction • 4-6 months: grasps feet & pulls to mouth

Ø Proximodistal (near-to-far) direction • 6-8 mths: Pincer crude grasp, transfer

• Sequential trend (crawl >> walk) object

• Infancy (Neonate Birth-1mth) (Infancy 1- • 10 mths: Uses thumb & index finger in

12 mths of age) pincer grasp, pick up small objects

• Early Childhood (Toddler 1-3 yrs old) • 9-10 mths: creeps on hands and knees

(Preschool 3-6 yrs) • Bladder & Bowel: at least four wet

diapers a day à average is around 6-12
• Head & Chest circumference (top of the
times a day
eyebrows & pinna of the ear to occipital • Bowel control before bladder control
prominence of skull) (Around chest at • Gross Motor skills:
nipple line) • Fine Motor skills:
• Sensory:
• Apical impulse > more reliable in
• Attachment:
infants younger than 2 yrs. old Separation anxiety:
Stranger fear:
• Risk of fall, aspiration, drowning, burn,
injury
• HR, RR, BP in Toddler
HR 90-130
RR 22-36/ mins
BP 86-106/ 42-63
• BP:
Neonatal 66-84/34-54 • In preschool
Infant 72-104/38-56 HR 80-120
RR 20-28
BP 89-112/ 46-72
• Weight: 4-6months 150-210gm/wk; 1 yr.
old Triples • In schooler
HR 75-120
• Hight: 1.25cm/mon; 50% longer than at
RR 18-26
birth BP 96-116 / 58-76
• Head: 1-6 mth: 1.5cm/mth; 6-8mth:
posterior fontanel fusing; 12-18mth: • In adolescents
HR 60-100
Anterior fontanel fusing RR 12-20
• Coordinated suck-swallowing: 32-34 wks BP 100-120/60-80
• Breastfeeding (0-6 mths); Transitional
feeding (6-24 mths)
L3 – GI disorders
• Cleft lip and palate
• Consequences
Ø Difficulties in feeding
Ø Speech problems
Ø Prone to ear infection (otitis media)
Ø Dental & facial problems
• Found around 20 wks
• Cleft lip: 2-6 months depend on child’s
health.
• Cleft palate: 9-18 months
• Pre-op: NAM (Nonalveolar molding) >>
Change the tape and rubber band daily
• Priority: Feeding
Ø Compressible plastic sides
Ø A wide base of the nipple
Ø Slightly longer nipple
Ø Upright positioning
Ø Hard surface on palate
• Support for family’s acceptance
Ø Family’s reaction toward defect
Ø Praise the effort of breastfeeding
• Post-op: Fluid & nutrition, Wound care
(splint), Oral care, Pain management, Skin
care, Family coping
Ø Level of acceptance, degree of anxiety,
social support, encourage parents’
participant in care
• Esophageal atresia (EA)
• VACTERL
Ø Vertebral, Anal, Cardiac, Tracheal,
L4 – Motility Disorder of GI
Esophageal, Renal, Limb dysplasia
• Coughing, choking, Excessive saliva,
Aspiration pneumonia
• Gastric detention (Type C, D, E)
• Airless, scaphoid abdomen (Type A & B)
• Prevention of pneumonia (upright, suction)
• Thoracotomy with chest drain
• Pyloric stenosis
• 3-6 wks of life; Projectile vomiting;
movable, palpable, olive-shaped mass
approximately 2 cm in length
• Metabolic alkalosis
• Monitor I & O
• Biliary atresia
• Jaundice, Dark brown colored urine,
Acholic stool, Poor growth
• Supplementation with fat-soluble vitamins
(A, D, E, & K)
• Kasai procedure
• Trimethoprim (prevent Ascending
cholangitis)
• Skin care (Colloidal oatmeal bath,
Ursodeoxycholic acid)
• Malrotation & Volvulus
• Abdominal distention, Lower GI bleeding
(blood in stool), intermittent bilious
vomiting
• Surgery >> may cause SBS (short bowel
syndrome
• Imperforate anus
• Failure to pass meconium (within 24 hrs)
• Keep fasting
• IV therapy
• Temporary colostomy
• Diarrhea
Ø Acute Diarrhea
- Associated with Otitis media, URI/ URTI,
antibiotics or laxative use; new food/
 allergy, caused by virus, bacteria, fungus
(shigella, E coli)
Ø Chronic diarrhea
- Malabsorption disorder, inflammatory,
bowel diseases, irritable bowel syndrome
• Dehydration, Acid-base imbalance, Shock,
Electrolyte imbalance
• Dehydration: Vital signs, skin sugor, urine
output > even lead to > nuchal rigidity,
sunken fontanel
• Rehydration, Antibiotics for bacteria,
parasites fungi
• Oral rehydration therapy: early
reintroduction of nutrients
• Oral rehydration solution: recommended
for acute diarrhea & dehydration
• Contact precaution (explain to parent);
Assess & monitor severity of symptoms,
Perianal skin care (clean with bland, non-
alkaline soap & water; Vaseline)
• Reassurance to parent
• Hirschsprung disease
Ø Fail to pass meconium stool, bile-stain
vomitus, abdominal distention, refusal
to suck
Ø Perform Rectal wash out
Ø NPO, IVF
Ø Ostomy surgery
Pre-op:
1. Signs of shock (enterocolitis), bowel
perforation (abd. Distention, vomiting,
increase tenderness)
2. Insert gastric tube for decompression
Post-op: I & O, abd. Distention, bowel opening,
stoma condition, gastric deainage (decrease)
• Intussusception
Ø Colicky abdominal pain, jelly-like
stool with blood, bile-stain fecal
emesis, Screaming and drawing the
knee onto the chest, Emptying lower
right quadrant, Fever (peritonitis)
Ø *** Abdominal pain, abdominal mass,
bloody stool
Ø Pediatric emergency > prevent bowel
ischemia and necrosis
Ø Pneumatic reduction/ Hydrostatic
enemea
Ø Pre/ post -op
• Constipation
Ø Develop encopresis
• Caused: Hirschsprung disease,
hypothyroidism/ Hyper. ; Spinal cord
lesion
• Establish regular bowl routine (sitting on
the toilet, regular toilet time for one or two
per day
• Diet: dietary change, increase fluid intake,
Bean added to soup, corn, cereal, buts,
dried fruit
L5 – Neurological system
• Neural tube defect
Ø Anencephaly
Ø Encephalocele
Ø Myelodysplasia
• Spina Bifida
Ø Lumbosacral area
Ø Spina bifida occulta (5th lumbar or 1st
sacral vertebrae) > not visible >
abnormal gait & bowel & bladder
sphincter disturbances
 Ø Spina bifida cystica (defect in closure
of posterior vertebral arch with
protrusion through the bony spine)
Meningocele (without nerve)
Myelomeningocele 脊髓脊膜膨出 (with nerve)
Ø Contains a portion of themeninges,
spinal cord or nerve roots protrude
Ø Folic acid deficiency, medications,
Radication, excessive use of alchhol
Ø Other complication: Chiari II
malformation, meningitis, UTI
Ø Myelomeningocele repair: w/I 24-48
hours
Ø Impaired skin integrity: Cover the
sac with sterile NS dressing, silicone
based dressing pad, Prone position
avoid direct pressure, renew padding
Q2-4 hours
Post-op
Complication: hydrocephalus, increase ICP,
meningitis, wound infection
Ø Measure head circumference daily
Ø Prone or side-lying position
• Hydrocephalus (Butterfly MRI)
Imbalance between production & absorption of
CSF & Blockage in the flow of CSF
S/S: Sunset-setting sign, Increase ICP, bulging or
tense anterior fontanel, Dilated scalp vein, wide
palpable suture line, Macewen’s sign, Sluggish &
unequal pupils, abnormal reflexes
Ø Surgical: Shunt Placement (relieve
pressure)
Ø Ventriculo-peritoneal shunt (to the
body’s abdomen)
Ø Vetriculo-atrial shunt (to the atrium of
the heart)
Ø Ventriculo-pleural shunt (to the pleural
space)
• Pre/ Post-shunting care
Ø Pre-shunting diagnoses
- Imbalanced nutrition: vomiting
- Excessive fluid volume: alternation in CSF
flow
- Risk of injury to neck muscle
- Risk of impaired skin integrity
- Support head & neck in midline or in
neutral position support
• Post- care
- Monitor vital sign, Measure head
circumference, perform neurological
assessment
- Position: Lie flat immediately post-op on
un-operated side
- Head up to avoid too rapid CSF drainage
- Monitor IV site closely
• Shunt Malfunction/ Infection
Ø Headache, Drowsiness, Vomiting,
Personality, Vomiting, Personality
changes, Fever, Redness
• Cerebral palsy 腦性麻痺
Related to the motor dysfunction > permanent
disability of childhood
Ø Spastic CP
Motor cortex damage
Ø Dyskinetic/ Anthetoid CP
Basal ganglia damage (Constant involuntary)
Ø Ataxic CP
Cerebellum damage
Ø Mixed/ dystonic CP
Combination demage
• Botox injection, Hyperbaric oxygen
therapy (HBOT)
 • Ankle-foot orthosis, braces, mobilization Ø Both hemispheres of the brain à
devices cortex à brainstem
Ø Tonic-clonic (Three phares) + S/S
L6- Seizure Tonic – Unconsciousness, uprolling eyeball, tonic
Ø Preictal muscle contraction, cyanosis, legs, head & neck
- Visual extended
- Auditory (Hallucination, buzzing) Clonic – Limb undergo rhythmic contraction and
- Olfactory (Burning rubber) relaxation, violent jerking movements, incontinent
- Tactile (Numbness, weakness) of urine & faeces
Ø Ictal Postictal – Appears to relax, poor coordination,
Ø Postictal visual & speech difficult, vomit
- Memory loss, confusion Ø Absence
- Headache, nausea, pain - Stare blankly & not responsive (4-8 yrs
old) (5-20s, > 20 attacks/day)
- Weakness - Maintain postural control
- exhaustion
Causes: Ø Myoclonic
Vascular (stroke, hypertension) - Sudden, brief contraction of muscle or
Infection (meningitis, encephalitis) group of muscle in the whole body (1-2s)
Toxin (alcohol, Med: antidepressant/physchotic) Ø Akinetic or Atonic
AV malformation - Sudden loss of tone (between 2-5 years
old) (<15 s)
Metabolic (hypoglycemia, hypo/hypernatremia)
Idiopathic 特發性
Neoplasms 腫瘤 Ø Infantile spasm
- Infant 4-8 month (1-2 second)
Stress
- Sudden head flexed, arms extended & legs
Types of Seizures
drawn up
• Focal onset seizures
Ø Febrile
Abnormal electrical activity in one hemisphere
1. Simple Febrile seizure
or in a specific area of the cerebral cortex
- Generalized onset
Ø Aware
- Last < 15 mins, One episode within a 24
LOC: Fully awake, alert, able to recall
hour period
Motor: Jerking movement, Eyes & head turn to
2. Complex febrile seizure
opposite direction
- Focal onset
Sensory: Paresthesia, Decrease auditory or visual
- > one episode in a 24 hour period
Ø Impaired aware

Treatment:
• Generalized onset 1. Antiepileptic drug (AED)
 - Drowsiness, headache, dizziness, nausea &
vomiting
- Sodium Valproate (tremor Steven-Johnson
rash) ! Sodium Valproate (SR) Vs
Sodium Valproate !
- Monitor serum drug level
- No episodes of seizure for at least 2 yrs
with normal EEG > could consider stop
medication
2. Surgery
- Vital sign
- ICP (Q1H till stable)
- Fluid & electrolyte status
- Any CSF leaking
- Could return to normal activities in 4-6
wks after the surgery
3. Vagus nerve stimulation
S/S: voice change, Headache, Throat pain,
Tingling of the skin
4. Ketogentic diet
Ø Increase Ketone à suppress seizures
(Continue the diet for 2 yrs)
Ø High fat, adequate protein, very little
carbohydrate
S/S: Kidney stones, high cholesterol level in
blood, dehydration, bone future, constipation
Interventions: (Breathing + Cyanosis)
Diagnosis à
1. Ineffective breathing pattern (due to
decrease respiratory effort during tonic
phase)
2. Ineffective airway clearance (seizure
activity & inability to control secretion)
3. Risk of aspiration (decrease level of
consciousness & possible vomiting)
Management
1. Ensure all necessary equipment in place
2. Position the child on his side
3. Perform suction if necessary
4. Administer oxygen, monitor child’s vital
signs, colour, seizure duration
5. IV or PR diazepam or phenobarbital
6. Perform a jaw thrust maneuver if the
airway is obstructed
• Tonic-clonic seizure last >5 mins à
respiratory distress
• Tonic & clonic seizure last > 30 minutes =
Status Epilepticus
• Anticonvulsive drug cause gingivitis (teeth
problems)
• DON’T restrain child, place anything
between child’s teeth during seizure, give
any food
• Anti-pyrexia for Febrile seizure
• Diazepam suppository (DDA) à Anus
route
L8 – Infectious Disease of neurological
• Glasgow Coma Scale (Appropriate
stimuli, Irritable stimuli)
• Meningitis
• *** Place the client on droplet precaution !!!
(Isolation precaution***)
- Acute inflammation of meninges & the
CNS
- Associate with otitis media, sinusitis,
pharyngitis or pneumonia
- Thick pus, fibrin à obstruct the flow of
CNS
Ø Bacterial Meningitis (CSF Cloudy)
Person-to-person via droplets
Children < 2 months: Group B strepto.
 Children > 2 months: H. Influenza
Type B
S/S: Fever, seizure, Increase ICP
Ø 3 Hs (Headache, Photophobia; Hard
stiff neck – Nuchal rigidity; High temp
– Fever)
Ø Positive Kernig sign
Ø Positive Brudzinski sign
Ø Baby S/S: High pitch Cry & Bulging
fontanelle 囟門凸出
Ø Viral Meningitis (CSF clear)
- MRI before Lumbar puncture
Ø Increase WBC
Ø Decrease glucose & increase protein
(bacteria use up glucose, bacteria
increase)
• Encephalitis 腦炎
Ø Meningeal signs: Photophobia, neck
stiffness, Kernig sign, Brudzinski
sign, Opisthotonic position
Ø Severe headache
Prevention:
• Meningococcal vaccination
à 1 bivalent (serogroup A & C) & 2 Quadrivalent
(Serogroup A,C,Y & W135)
• Pneumococcal vaccination
à Prevenar 13
Treatment:
Antibiotics (IVI):
• Aminoglycoside (Must dilute!! > inject
medicine slowly)
• Corticosteroid: reduce edema in the brain
• Viral meningitis: Acyclovir* (not to all
patients)
• Hydration
• Ventilation (Inability to sustain
spontaneous ventilation; ineffective airway
clearance)
• Reduction of increased ICP
• Bacterial shock
• Seizures
• Risk of ineffective thermoregulation
• Risk of fluid volume deficit
Intervention:
• Isolate from possible infection
• Vital signs monitoring
• Measures head circumference
• Positioning – the head of the bed slightly
elevated with no pillow; Side-lying
position if nuchal rigidity
(DON’T life the children’s head)
• Maintain hydration, Document intake &
output
• Prevent complication: seizure
• Psychological care to parents & patient,
Encourage parents to participate in care
(remind parents put on mask)
• Reorienting the child to the hospital
(+bring some favorite toys – washable)
• Lumbar puncture (LP):
Ø Neonates & infants: L4 & L5 or L5-S1
Ø Children: L3-L4
• Contraindication of LP:
Ø Active bleeding
Ø Increase ICP, Lumbar skin infection
Ø Hypotension
Ø Spinal hematoma
Ø Superficial infection at LP site
 - Children <1 yr old – ear straight back
L9 – Care of Children for Surgery - Children >1 yr old – ear back and up
• Pre-op Condition:
Pain assessment tools, wound care, pain Increase RR: Respiratory distress or pain
management Decrease RR: anesthetics, opioids
Check baseline: Vital sign, body weight, body Increase BP: Increase ICP
height Decrease BP: Vasodilating anesthetic agents
• Informed consent (surgeon & Increase Temp.: Malignant hyperthermia
anaesthetist) Ø Apex of heart
• Correct operation site & side - Before 4 yrs old: at 4th Lt intercostal
• Type & Screen space, b/t midclavicular line & anterior

Children < 4 months, take mother’s blood together axillary line

- Age 4 – 6: at 5th Lt intercostal space,

1. Fasting for elective surgery along midclavicular line

Ø 2 hours for clear non-particulate fluid • Blood pressure

Ø 4 hours for breast milk
Ø 6 hours for solid food, infant formula 2. Fluid & electrolyte
2. Bowel preparation Ø Monitor urine output to maintain at 1-
2ml/ kg/ hour
Ø Klean prep
Ø Check post Na+ & K+
Ø NG tube insertion for administration 3. Pain management
Ø Rectal washout with warm saline Ø FLACC Score (for patient <4 yrs old)
Ø Wong-Baker FACES Pain Rating
3. Skin
Scale (for patient >= 6 yrs old)
Ø Antiseptics (Hibiscrub)
Ø PCA (Patient-controlled analgesia) –
Ø Mark the laterality of lesion
For children > 5 yrs; Educate parent
4. Pre-medication
not to press button for children
Ø Midazolam (for highly agitated child)
Ø Continuous IV infusion – For
children < 5 yrs old
Ø EMLA (eutectic mixture of local
Ø Epidural infusion: for older children
anesthetics) cream à must applied 60
Ø Monitor pain score, sedation score,
minutes before the procedure
pulse rate, RR, SpO2 & dose
• Post-op care delivered
1. Vital signs monitoring
Ø RR first (abdominal movement, 1 full 4. Wound care

minute, Monitor SpO2 & oxygen) - Stoma: Note the color and usually not
functioning in the first 24-48 hrs
Ø Tympanic temp (Axillary in neonates) - Regularly aspirate (GI surgery)
 5. Respiratory care - (N): Describe the spread to lymph nodes
Ø Reposition Q2H - (M): Describe if the cancer has spread
Ø Adequate analgesics before deep Intervention for solid tumor:
breathing exercise - Vital signs, Head circumference,
Behavioral change, Pin
- Provide support to family: Explain to
L10 – Oncology child, attend to emotional support, Involve
Solid Tumor both family and child
Ø Brain & Spinal tumor - Facilitate replacement of VAD and care for
• Typical flexion posturing Ø PICC
• Extension posturing Ø CVC
• Morphine à pinpoint pupil Function of CVAD = Central venous access
• Atropine à Dilate pupil devices

• Increase ICP à Headache, vomiting, 1. Enable easily blood sampling

personality changes, irritability

• Tumor in Cerebrum: Vision, hearing, Complication of CVAD:

speech problem; weakness on one side of

body Principal care of CVAD:

• Tumor in brain stem: Diabetes, Paralysis

of nerves of face, change in respiration
• Tumor in cerebellum: Uncoordinated
muscle; Loss of balance
• Corticosteroid therapy
• Diuretic therapy & VP shunt
(ventriculoperitoneal shunt)
• Anticonvulsants
• PICU care
Ø NO Trendelenburg position

Ø Neuroblastoma 神经母细胞瘤
• Arise from the adrenal gland or in the
neck, chest, or spinal cord
• INSS (Stage 1, 2a, 2b, 3,4,4s)
Ø Osteosarcoma
• TNM staging
- (T): Describes the size of original tumor