Pediatrics

© USMLE Galaxy LLC

I. Part I
A. Pediatric Assessments
B. Delivery room complications
II. Part II
A. Cardiac
B. Respiratory
III. Part III
A. Neuro
B. GI
IV. Part IV
A. Hematology
B. Immune System
C. Musculoskeletal
D. Integumentary

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 Part I:
Pediatric Assessments +
Delivery Room Complications

Newborn Assessment
1. APGAR
2. Work of breathing
3. Vital signs (including temperature!)
4. Weight
5. Length
6. Head circumference
7. Chest circumference
8. Abdominal girth
9. Head to toe assessment

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APGAR Assessment

Work of Breathing
● Retrations?
○ Note the severity and location
● Respiratory rate and depth
● Secretions?
○ Note the color, odor, consistency, and amount
● Nasal flaring
● Grunting

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Pulse
● Check brachial pulse
● Check for no longer than 10 seconds
○ If you don’t feel it - start resuscitation!
● Count for a full minute when obtaining vital signs

4
Temperature
● Newborns can’t maintain their own temperature very well
● They’re wet!
○ Evaporative heat loss!
● To keep them warm:
○ Dry them off
○ Place them skin to skin
○ Bundle
○ Radiant warmer
○ Incubator

Head to toe Assessment

● Neurological
● Reflexes
● Head, ears, nose, and throat
● Respiratory
● Cardiac
● Musculoskeletal
● Integumentary
● Gastrointestinal
● Genitourinary

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Neurological
● Level of consciousness
● Infant behavior
● Cry
● Tone
● Pupils
○ Size
○ Shape
○ Reaction to light
● Any seizure activity

Reflexes
● Reflexes, or lack thereof, can indicate abnormalities with the nervous system
● Many present as newborns (normal) and diminish at expected ages
● Abnormalities in newborn period:
○ Absent developmental reflexes
○ Asymmetric
○ Persist beyond anticipated age at which they should diminish

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Head, Ears, Eyes, Nose, Throat
(HEENT)
● Eyes
● Ears
● Nose
● Lips
● Mouth
● Throat
● Tongue
● Oral mucous membranes
● Neck
● Cranial sutures
● Anterior and posterior fontanelles

Fontanelles
● Soft/flat
○ Anterior
■ Closes between 6 and 18 mo
○ Posterior
■ Closes by 2 months

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Respiratory
● Airway patency
○ Kids have a large occiput
■ Shoulder roll - ‘sniffing position’
■ Avoid supine position
○ Secretions
■ They can’t get their own boogers out!
■ Have suction ready
○ Swelling can occlude airway quickly
■ Tongue is bigger
■ Airway is smaller and less rigid
● Breathing
○ “Kids compensate until they fall off a cliff”
○ Lower lung capacity
○ Trend their vital signs! If they start to look bad…. Often, they are about to look really bad

Cardiac
● Rate, rhythm, regularity
● Heart sounds
○ S1, S2
○ Murmur
■ Extra ‘whooshing’ heart sound
● Cyanosis
● Pulses
● Cap refill
● Edema
○ Location, severity

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Musculoskeletal
● Weakness
● Any abnormalities
○ Contractures
○ Club foot
● Splints or devices

Integumentary
● Skin color
● Moisture
● Integrity
● Wounds
● Rashes
● Lanugo
● Milia
● Mongolian spots
● Vernix caseosa

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Gastrointestinal
● Bowel sounds
● Abdominal girth
● Palpation
● Hernias
● Emesis
● Stools
● Anus/rectum
● Tone

Genitourinary
● Urine
○ Color
○ Odor
○ Amount
● Genitalia
● Check for sacral dimple (or a tuft of hair)
● Male - circumcised?

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 Newborns:
Complications in the
Delivery Room

Meconium Aspiration
● Meconium is the first stool of the newborn
● When the meconium is passed before delivery, the fetus is at risk for
meconium aspiration
● The aspiration can occur in utero, or just after delivery when the infant
takes their first breath and starts to cry
● Meconium in the lungs causes very serious illness; pneumonia, pulmonary
hypertension, and sepsis are all common
● These infants become critically ill very quickly

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Assessment
If meconium aspiration is suspected, pertinent assessment will include:

● Respiratory status:
○ Accessory muscle use
○ Breath sounds
○ Grunting
○ Nasal flaring

Assessment to determine if meconium has been passed in utero:

● Visible meconium in fluid/on infant

● Discolored or foul smelling amniotic fluid
● Discoloration of the cord
● Discoloration of the nails/tongue on the infant

Interventions
Very quick action is essential to the outcome.

● Suction immediately after birth - before they take their first breath
● Intubation
● IV antibiotics
● IV fluids

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Jaundice
● Jaundice - elevated bilirubin level resulting in yellowing of the sclera, skin,
and mucous membranes
● Bilirubin - waste product produced during breakdown of red blood cells
○ Unconjugated (indirect) - The heme that is released from hemoglobin in the process of red
blood cell breakdown is converted to unconjugated bilirubin; transported to the liver

○ Conjugated (direct) - Unconjugated bilirubin is converted to conjugated bilirubin in the liver;

excreted in the stool.

Physiological Jaundice
● Jaundice that appears on day 2 or 3 of life
● This is expected and not considered pathologic unless other issues arise
● This is simply due to the normal transition from the placenta removing
bilirubin, to the infant's liver doing the work
● Followed up outpatient with pediatrician

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Pathological Jaundice
● Jaundice that occurs within the first 24 hours of life
● Serum bilirubin will be compared to normal value based on hours of life
● Jaundice appearing in the first 24 hours indicates some problem or disease
process that needs addressed
● Could be an issue with the liver, or an ABO incompatibility

Kernicterus
Kernicterus is a type of brain damage that can result from high levels of bilirubin
in the blood.

Complications of kernicterus:

● Cerebral palsy
● Hearing loss
● Problems with vision
● Problems with teeth
● Intellectual disabilities

Kernicterus is completely preventable! We must monitor for signs and symptoms

of jaundice early and treat promptly.

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Treatment - phototherapy
● Helps break down bilirubin so it may
be excreted in the feces
● Must ensure the eyes and genitals are
covered
● Monitor the level and distance from
the light if overhead therapy being
used
● Double, triple, and quadruple therapy
depending on severity

Part II: Cardiac + Respiratory

Pediatrics

15
 Cardiac
Pediatrics

Development of the
Cardiovascular System

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Fetal Circulation
● Fetal circulation bypasses the lungs
○ Mom is doing the oxygenation
■ No need for blood to to the lungs
○ Uses three shunts
■ Foramen ovale - opening between the atria
■ Ductus arteriosus - opening between the pulmonary artery and the aorta
■ Ductus venosus - Vessel connecting the inferior vena cava to the umbilical
vein
● Umbilical vein
○ Carries oxygenated, nutrient-rich blood from the placenta to the fetus
● Umbilical arteries
○ Carry deoxygenated, nutrient-depleted blood from the fetus to the placenta

Foramen ovale
An opening between the right and left atrium present in fetal circulation

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Ductus arteriosus
An opening between the pulmonary artery and aorta present in fetal circulation

Defects
● Abnormalities in the structure of the heart
● Risk factors:
○ Maternal viral infections
○ Maternal diabetes
○ Drug and alcohol use
○ Advanced maternal age
● Commonly occur with chromosomal abnormalities and syndromes such as:
○ Trisomy 21
○ Trisomy 18
○ Turners syndrome
○ DiGeorge syndrome

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Terminology
● Stenosis: stiffening or thickening
● Atresia: does not develop
● Hypoplasia: underdeveloped
● Hyperplasia: overdeveloped/grown
● Coarctation: narrowing or stricture
● Mixing: deoxygenated and oxygenated blood mixing together
○ “Purple blood”
● Ductal dependent: dependent on the ductus arteriosus for mixing of blood
● Shunting: the movement of blood from one area to another

Shunting
Blood will ALWAYS move from areas of high pressure,
to areas of low pressure
● Right to left shunt
○ Blood from the right side of the heart moves to the left side of the heart
○ Blood on the right side is deoxygenated
○ Blood in the left side of the heart moves out to the body
○ Deoxygenated blood is getting out to the body!
○ This shunt therefore causes cyanosis
● Left to right shunt
○ Blood from the left side of the heart moves to the right side of the heart
○ Blood on the left side is oxygenated
○ Blood in the left side of the heart moves out to the lungs
○ MORE oxygenated blood is going to the lungs
○ This shunts causes pulmonary overcirculation - but NO cyanosis

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Congenital Heart Defects
Acyanotic Cyanotic
Increase pulmonary blood flow Decrease pulmonary blood flow
L→ R shunt R→L shunt
1. Patent Ductus Arteriosus (PDA) 1. Tetralogy of Fallot
2. Atrial Septal Defect (ASD) 2. Tricuspid atresia
3. Ventricular Septal Defect (VSD)
4. Atrioventricular canal
Ductal Dependent: mixed
Obstructive 1. Transposition of the great arteries (TGA)
1. Coarctation of the aorta 2. Hypoplastic Left Heart Syndrome (HLHS)
2. Aortic stenosis
3. Pulmonic stenosis

Acyanotic

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Patent Ductus Arteriosus
● Defect
○ Failure of the ductus arteriosus to close
○ Should close 12 to 72 hours after birth
● Specific assessment findings
○ Machine-like murmur
● Treatment:
○ Small: often close spontaneously
○ Indomethacin or ibuprofen
○ Surgically closed

● Alprostadil (Prostaglandins/PGE)
○ Medication that can be administered to keep the PDA open in certain heart defects
○ This can allow blood to get out to the body when it otherwise couldn’t

Atrial Septal Defect

● Defect:
○ Opening between the atria
● Shunt:
○ Left to Right - acyanotic
● History:
○ Is often asymptomatic until later in childhood
○ Child fatigues easily, DOE, poor weight gain
● Assessment findings:
○ Murmur
● Treatment
○ Small - often close spontaneously
○ Large - surgical closure

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Ventricular Septal Defect
● Defect:
○ Opening between the ventricles
● Shunt:
○ Left to right - acyanotic
● History:
○ Typical for s/s of HF to begin at 2-8 weeks
● Assessment findings:
○ Loud murmur
○ CHF
● Treatment
○ CHF management: Diuretics, ACE inhibitors, β-blockers
○ Nutrition
○ Surgical closure
■ Bacterial endocarditis prophylaxis

Atrioventricular Canal Defect

● Defect:
○ Opening between the atria AND the ventricles
○ ASD + VSD + Single AV Valve
● Shunt:
○ Left to right - acyanotic
● History:
○ Heart failure s/s and failure to thrive
● Assessment findings:
○ Murmur
○ *High risk for heart failure
● Treatment
○ CHF management: Digoxin, diuretics, ACE inhibitors,
and β-blockers
○ Nutrition
○ Complete surgical repair at 3-6 months
■ Bacterial endocarditis prophylaxis

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 Cyanotic

Tetralogy of Fallot
● Four defects:
○ Large VSD
○ Pulmonary stenosis
○ Right ventricular hypertrophy
○ Overriding aorta
● History
○ Cyanosis
○ Dyspnea
○ Poor feeding and inability to adequately gain
weight
● Specific assessment findings:
○ Tet spells

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Tet Spells
● Hypoxic spells that occur in TOF
● Begins with irritability
● Prolonged period of intense cyanosis
leading to syncope
● An increased pulmonary vascular resistance
increases the right to left shunt
● More right to left shunting → more
deoxygenated blood out to the body

Tet Spell Interventions

Comfort and calm

Knee-to-chest position

Supplemental oxygen

Sedation - morphine

Volume

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Management
● If mild - can go home and grow until ready for surgery
● If critically ill with severe hypoxia - surgery is required in the neonatal period
● Ideally, complete repair around 6 months of age
● Can be earlier depending on signs and symptoms
● Surgery - “Tet repair”
○ BT shunt
○ Repair of pulmonary valve
○ Patch VSD
● Bacterial endocarditis prophylaxis

Tricuspid Atresia
● Defect:
○ Tricuspid valve does not grow
○ Leaves no communication between the right atrium
and the right ventricle
○ VSD/ASD
○ Hypoplastic right ventricle
○ Enlarged mitral valve and left ventricle
● Specific assessment findings:
○ Cyanosis
● Treatment
○ Prostaglandins
○ Surgical repair - BT shunt, Rashkind procedure

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 Ductal Dependent/Mixed

Transposition of the Great Arteries

● Defect:
○ The aorta and the pulmonary artery are switched
○ Two parallel circuits
■ Oxygenated blood continuously circulating through
the pulmonary circuit
■ Deoxygenated blood continuously circulating
through the systemic circuit
● Specific assessment findings:
○ Cyanosis within 1 hour of birth
● Treatment
○ Prostaglandins
○ Balloon atrial septostomy
○ Surgical repair: arterial switch
○ Bacterial endocarditis prophylaxis for life

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Hypoplastic Left Heart Syndrome
(HLHS)
● Defect:
○ Left-sided structures don’t develop normally
○ Aorta is small
○ Left atria/ventricle are hypoplastic
○ Mitral valve is atretic
○ When the ductus arteriosus closes, very little blood
will be able to get out to the body
● History:
○ Cyanosis when DA closes
○ Increased RR, fatigue - can lead to obstructive
cardiogenic shock
● Specific assessment findings:
○ Hepatomegaly
○ Murmur

Management
● Immediate treatment:
○ Prostaglandins
○ Correct acidemia
○ Inotropes
○ Plan for surgery
● Palliative Surgery:
○ Norwood at birth
○ Glenn at 2 months old
○ Fontan at 2 years old
● Possible cardiac transplantation

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 Obstructive

Aortic Stenosis
● Defect:
○ Narrowing of the aorta
○ Harder for the left ventricle to eject blood
● History:
○ Activity intolerance, fatigue, chest pain
○ Sudden death due to ventricular arrhythmias
● Specific assessment findings:
○ Exercise intolerance and syncopal episodes
○ Narrow pulse pressure
○ Pronounced apical impulse
○ Thrill
● Treatment
○ Critical
■ Balloon valvuloplasty asap! Prevent shock!
○ Ross procedure
○ Surgical valve replacement; if mechanical valve - will need anticoagulated!
○ Severe: needs to avoid contact sports

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Pulmonary Stenosis
● Defect:
○ Narrowing of the pulmonary artery
○ Makes it harder for the RV to pump, causes hypertrophy
● History:
○ Often asymptomatic; as progressed DOE and fatigue develop
● Specific assessment findings
○ Dyspnea on exertion
○ Murmur
● Treatment
○ Pulmonary valvotomy
○ Moderate to severe stenosis: child should avoid high intensity
activities

Coarctation of the Aorta

● Defect:
○ Narrowing of the aorta
○ Impedes blood flow to the lower half of the body
● History:
○ Symptoms appear quickly
■ When ductus arteriosus closes, can rapidly
progress to hypotension, acidosis, shock, and
death

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Specific findings
● Upper extremities ● Lower extremities
○ Bounding pulses ○ Weak or absent pulses
○ Hypertensive ○ Hypotensive
○ Warm ○ Pale
○ Pink ○ Cool

● Management
○ Critical coarctation - think shock!!
■ Prostaglandins
■ Surgical repair
○ Lifelong follow up
■ High risk for recoractation or aortic aneurysm

NCLEX Question
Which of the following assessment findings would lead the nurse to believe their
client could have a coarctation of the aorta? Select all that apply.

a. +1 radial pulses and +3 femoral pulses

b. Pale, cool feet and legs with warm pink hands and arms
c. Hypertensive brachial blood pressure
d. >4 second capillary refill on the hands
e. Hypotensive popliteal blood pressure

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Answer: B, C, and E
A is incorrect. In coarctation of the aorta, there is a stricture in the aorta preventing blood flow out of the left ventricle. It usually
occurs beyond the blood vessels that branch off to your upper body and before the blood vessels that lead to your lower body. So
blood flow to the upper body is abundant, but hardly any can make it to the lower part of the body. Therefore, there are decreased
lower extremity pulses, and increased upper extremity pulses. So, the nurse would expect to palpate bounding +3 or +4 pulses in the
radial pulse, but weak +1 or even absent femoral pulses. This is all due to the stricture in the aorta preventing blood flow from
getting to the lower extremities.

B is correct. Pale, cool feet and legs with warm pink hands and arms would be expected in a client with coarctation of the aorta due
to the stricture in the aorta preventing blood flow from getting to the lower extremities.

C is correct. A hypertensive brachial blood pressure would be expected in a client with coarctation of the aorta due to the stricture in
the aorta preventing blood flow from getting to the lower extremities.

D is incorrect. A normal capillary refill time is <2 seconds. A >4 second capillary refill is considered delayed and is a sign of
decreased perfusion. This would be expected in the lower half of the body if the client had a coarctation of the aorta, but not in the
hands.

E is correct. A hypotensive popliteal blood pressure would be expected in a client with coarctation of the aorta due to the stricture in
the aorta preventing blood flow from getting to the lower extremities.
NCSBN Client Need:
Topic: Physiological Integrity Subtopic: Physiological adaptation

Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited.

Subject: Pediatrics
Lesson: Cardiac

Respiratory
Pediatrics

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Epiglottitis
● Inflammation of the epiglottis
● Epiglottis
○ A leaf-shaped flap in the throat that prevents food from entering the windpipe and
the lungs. It stands open during breathing, allowing air into the larynx
● Inflammation restricts the airway
● Caused by an infection
○ Bacterial
● Haemophilus influenzae type b
● Medical emergency

Assessment
● Fever
● Difficulty swallowing
● Drooling melvil, Vocal folds-201611, CC BY-SA 4.0 藤澤孝志 , Epiglottitis endoscopy, CC BY-SA 3.0

● Stridor The 4 D’s of epiglottitis

● Tripoding
● No cough ● Dysphagia
● Change in LOC ● Dysphonia
● Cherry red epiglottis ● Drooling
● Distress

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 NCLEX Question
The nurse is assessing a 4 year old who was sent to the ED from urgent care. Assessment reveals
tripod positioning, blue lips, mottled skin, inspiratory stridor, and excessive drooling. Vital signs
are: Temp: 39 C
HR: 188
RR: 46
O2: 82 %
Which of the following should the nurse do first?

a. Keep the child calm and call for emergency airway equipment
b. Obtain IV access
c. Assess the throat for a cherry red epiglottis
d. Place the child on a high flow nasal cannula at 100% FiO2
e. Administer a dose of oral antipyretic medication to reduce the child's fever

Answer: A
A is correct. Based on the presenting symptoms, the nurse suspects that this child has epiglottitis. Any child presenting with excessive drooling,
distress, and stridor is highly suspicious for this medical emergency. In addition, this client is already showing signs of circulatory compromise
including circumoral cyanosis and mottling. The priority nursing action in this emergency is keeping the child calm and calling for emergency
airway equipment. The child is at risk of losing their airway, and airway is always the priority!

B is incorrect. It is inappropriate to attempt to obtain IV access on a child suspected of epiglottitis before emergency airway equipment is available.
The priority action at this time is keeping the child calm and calling for emergency airway equipment.

C is incorrect. It is inappropriate to assess the throat for a cherry red epiglottis at this time. Although presence of a cherry red epiglottis would
confirm the diagnosis of epiglottitis, this child is at risk of losing their airway. The priority action will be to protect that airway before assessing the
throat. .

D is incorrect. Placing the child on a high flow nasal cannula at 100% FiO2 is not the priority at this time. This answer probably sounded right,
because you see the O2 is 82% and they have circumoral cyanosis. Oxygen sounds like the right answer! But this intervention addresses the ‘C’ in
your ABC’s - circulation. And the priority is always ‘A’, airway! This child is at risk of losing their airway, so all interventions need to wait until there
is emergency airway equipment close by. If anything upsets the child their airway could spams and obstruct completely making it impossible to
intubate them. That is why keeping the child calm and calling for emergency airway equipment is the priority in epiglottitis clients.

E is incorrect: choice is incorrect because it does not address the immediate life-threatening condition presented by the child's symptoms. The
child's tripod positioning, blue lips, mottled skin, inspiratory stridor, excessive drooling, and low oxygen saturation (82%) indicate a potential
airway obstruction or respiratory distress. The priority in this situation is to secure the child's airway and provide adequate oxygenation
NCSBN Client Need:
Topic: Physiological Integrity Subtopic: Risk potential reduction

Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited.

Subject: Pediatric
Lesson: Respiratory

33
Interventions
● Tripod position
● IV antibiotics
● Avoid supine
● Humidified oxygen
● Hib vaccine has reduced incidence
● Intubation and mechanical
● Encourage parents to vaccinate to
ventilation
prevent
● Keep the child calm
● No interventions until airway is
secure
● Do not irritate the throat
○ NO tongue depressor
○ NO oral thermometer
○ NO assessing the throat
● NPO

Bronchiolitis
● Inflammation of the bronchioles
● Bronchioles
○ Smallest branches of the airway
○ Lead to alveoli
● Alveoli
○ Air sacs
○ Location of gas exchange in the lungs
● Thick mucus clogs up the
bronchioles
● Leads to decreased gas exchange
in alveoli
○ Air trapping
○ Collapsed alveoli

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Overview
● Most common in children under 2 years old
● Seasonal illness
○ Most common in winter
● Causative agent usually viral
○ Respiratory Syncytial Virus (RSV)
● Very contagious
● Worst on days 4-6

James Heilman, MD, RSV, CC BY-SA 3.0

Assessment
● Cough
● Hypoxia
● Fever ○ Circumoral cyanosis
● Increased work of breathing ○ Mottling
○ Retractions ○ Delayed capillary refill
■ Subcostal ○ Decreased SpO2
■ Intracostal ● Changes in behavior
■ Tracheal tug ○ Irritability
○ Nasal flaring ○ Lethargy
○ Head bobbing ○ Poor feeding
○ Tachypnea
● Lung sounds
○ Crackles
○ Wheezing

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Interventions
Supportive treatment

● Oxygenation
○ Nasal cannula - high flow nasal cannula
○ Always humidified
● Fluid & Nutrition
○ NGT
○ Enteral feedings
○ IVF
● Antipyretics
● Analgesics

Croup
● Laryngotracheobronchitis (LTB)
● Viral respiratory tract illness
○ Results in inflammation and
edema of the larynx and/or
trachea
● Commonly affects pediatric
population

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Assessment
● Hoarse, “bark-like” (or seal-like) cough
● Stridor
● Chest wall retractions
● Runny nose, fever
● Symptoms often worsen at night

Treatment
● Corticosteroids
● Epinephrine via nebulizer
○ “Racemic epi”
● Keep client calm and decrease anxiety levels
○ Agitation can lead to respiratory distress

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Cystic Fibrosis
● Autosomal recessive disorder
● Mutation leads to a buildup of excessive mucus in the airways
● Mucus leads to airway obstruction

Pathophysiology
● Mucus is both excessive and very thick
● Causes mechanical obstructions throughout the body
○ Bronchi
○ Small intestines
○ Pancreatic ducts
○ Bile ducts

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Diagnosis
● Meconium ileus
○ Meconium is thicker and stickier than normal, creates a blockage and first stool doesn’t pass
● Sweat chloride test
○ Sweat is collected and analyzed for increased levels of chloride
○ Sweat tastes salty

Assessment
● Respiratory
○ Excessive mucus ● Endocrine
○ Frequent respiratory infections ○ Diabetes
○ Hypoxemia ● Integumentary
■ Clubbing ○ Salty tasting sweat
■ Cyanosis
○ Elevated chloride in sweat
■ Barrel chest
● Gastrointestinal
● Reproductive
○ Males are infertile
○ Intestinal obstruction
○ Meconium ileus
○ Large, bulky, frothy, foul smelling stool
○ Fat soluble vitamin deficiency
■ ADEK
■ Malnutrition
■ Failure to thrive

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Treatment
● Airway clearance
○ Chest physiotherapy
○ Vest therapy
● Respiratory infections
○ Monitor for
○ Treat with IV antibiotics
○ Prevent!
● Respiratory support
○ Monitor work of breathing
○ Oxygen as needed
● Bronchodilators
Part III: Neuro + GI
● Promote nutrition and growth
○ High calorie, high protein diet
○ Increased fluid intake
○ Monitor serial weights
○ Pancreatic enzymes
■ Give within 30 min of eating every
meal and snack
■ Sprinkle capsules on food
■ Fat soluble vitamin replacement
Neuro + GI
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 Neurology
Pediatrics

Hydrocephalus
● Increased accumulation of cerebrospinal fluid
● Increases ICP
● Causes:
○ Tumor
○ Hemorrhage
○ Infection
○ Congenital

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External Ventricular Drain (EVD)

VP Shunt

○ Ventricle - Space in the brain

○ Peritoneum - Serous membrane
lining the abdominal
compartment
○ Shunt that drains extra CSF
from brain to the abdomen,
where it can then be excreted
as urine

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Cerebral Palsy
● Damage to immature brain- most often before birth
○ Pre/perinatal hypoxia or trauma
● Causes disorder in movement, muscle tone, and posture

Assessment Findings
● Movement/Coordination ● Development
○ Stiff muscles ○ Delayed motor skills
○ Spasticity ○ Intellectual disabilities
○ Ataxia ○ Delayed growth
○ Tremors
● Speech and Eating
○ Speech delays
○ Dysphagia
○ Difficulty speaking
○ Excessive drooling

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Treatment
● No cure- focus is on symptom management
● Seizures
○ Anticonvulsants
● Spasticity
○ Muscle relaxants
● Growth + Development
○ PT
○ OT
○ SLP

Defects in neural tube closure

● Development of the nervous system occurs early on in gestation
○ Develops from the neural tube
○ Low folic acid intake can impair neural tube development
● Spina Bifida
○ Failure of the vertebrae to close with protrusion of neural tube contents
○ Meningocele (closed spina bifida)
■ Protrusion of spinal fluid–filled meninges through a vertebral defect
○ Myelomeningocele (open spina bifida)
■ Protrusion of spinal fluid–filled meninges AND the spinal cord
through a vertebral defect

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 Open Closed

Image Source: CDC.gov Image Source: CDC.gov

Assessment findings
● Paralysis possible
○ More likely the higher the defect is located on the spine
● Developmental delay
● Speech delay
● Intellectual disability
● Impaired coordination
● Sacral dimple or tuft of hair

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Treatment
● Pre-op
○ Cover the sac with a moist, warm, sterile dressing
○ No diapering if defect is low- keep the sac clean with a protective barrier
○ Prophylactic antibiotics
○ Prone positioning
● Post-op
○ Remain prone until surgical site is healed
○ Family teaching

Microcephaly
● Head circumference is smaller than normal
○ Brain did not develop properly or stopped growing
● Causes
○ Genetic abnormalities
○ Drug or alcohol use during pregnancy
○ Virus during pregnancy
■ Cytomegalovirus
■ Rubella
■ Varicella
■ Zika

46
Assessment Findings
● Impaired cognitive development
● Delayed motor function
● Delayed speech development
● Facial distortion
● Dwarfism
● Hyperactivity
● Seizures

Treatment
● Nothing will return the child’s head to normal size
● Focus: decrease impact of neurological complications
○ Physical therapy
○ Occupational therapy
○ Speech therapy
○ Control seizures with medications

47
 Gastrointestinal
Pediatrics

Cleft Lip
A congenital abnormality where
there is a slip, or gap, in the upper
lip on one or both sides

48
Cleft Palate
A congenital abnormality where there is a split, or gap, in the hard palate (the
roof of the mouth)

Assessment
● Visible defect
● Monitor respiratory status
● Airway patency
● Nutritional status
● Weight gain
● Hydration

49
Management
● Surgically corrected
○ Cleft lip first at 3-6 months of age
○ Cleft palate second at 6-24 months of age
● Pre-operative care
○ Monitor for aspiration
○ Assess airway patency frequently
● Post-operative care
○ Positioning:
■ Position upright for feedings
■ Cleft palate - can be prone post op to help drain secretions
■ Cleft lip should NOT be prone as this could disturb the suture line
○ Protect suture line
○ Elbow restraints to avoid toddler putting things in the mouth that would compromise the sutures
○ No hard foods, straws, pacifiers, etc.
○ No oral or nasal suctioning

Feedings
● Specialized bottle to facilitate a good suction/latch
● Small, frequent feedings
● Upright position
● Burp frequently - will swallow a lot of air
● May take longer to feed than other children
● Monitor for aspiration
○ At risk for feeding to go out of their nose

50
 NCLEX Question
While assisting the intra-disciplinary team with interventions for a toddler who has just had
a cleft palate repair, the nurse knows which of the following are appropriate? Select all
that apply.

a. Pacifier with oral sucrose to reduce postoperative pain

b. Elbow restraints
c. Specialized bottle for feedings
d. Prone positioning
e. Oral suctioning

Answer: B, C, and D
A is incorrect. It is not appropriate to offer a toddler who is postoperative from a cleft palate repair a pacifier. This is
because there is an incision with sutures in the palate of the mouth, and placing an object there could compromise the site.
If the sutures break, the surgical site could open back up.

B is correct. Applying elbow restraints is an appropriate intervention for a toddler who has just had a cleft palate repair.
Toddlers are often putting things in their mouths, and pulling on things. It is a priority to protect their sutures, and we do
not want the toddler to be able to pull out the sutures or put anything in their mouth that would compromise the suture
line. Therefore, elbow restraints are often needed and an appropriate intervention.

C is correct. Providing specialized bottles to the toddler who has completed their cleft palate repair will be very important
for helping them establish feedings. It will be difficult for them to get good suction on a normal bottle, so specialized ones
are needed.

D is correct. Prone positioning is appropriate for the infant with cleft palate repair post-operatively to aid in drainage of
secretions and maintenance of a patent airway.

E is incorrect. Oral suctioning should be avoided after a cleft palate repair as this could disturb the suture line.
NCSBN Client Need:
Topic: Physiological Integrity Subtopic: Physiological adaptation

Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited.

Subject: Pediatric
Lesson: Endocrine

51
Tracheoesophageal fistula (TEF)
● A congenital abnormality in which there is an opening between the trachea
and the esophagus

Esophageal atresia
● Part of the esophagus does not form

Normal anatomy

52
Assessment
● Choking
● Coughing
● Cyanosis

53
Treatment
● Pre-operative
○ NPO
● Surgery
○ Repairs the opening
● Post-operative
○ Gradual oral nutrition

Pyloric stenosis
● Hypertrophy of the circular muscle fibers of the pylorus, with a severe
narrowing of the lumen

54
Assessment
● Vomiting
○ Non-bilious
○ Projectile
○ Right after feeding
○ Infant is still hungry
● Dehydration
● Malnutrition
● Palpable pylorus

Treatment
● Correct dehydration
● Pyloromyotomy
● Nutrition after surgery

55
Omphalocele
● Congenital abnormality where
the abdominal contents
protrude through the umbilicus
while remaining in the
peritoneal sac
● Occurs during weeks 9-10 of
gestation
● Usually diagnosed on a
prenatal ultrasound
Image source: cdc.gov

Assessment
● Visible defect
● Some infants have only the omphalocele
● Some also have cardiac defects
● Lung size can be affected

56
Complications

Surgical repair

57
Management
Pre-op Post-op
● Keep exposed intestines moist ● Parenteral feeds
● Cover with sterile gauze soaked ● Trophic feeds started enterally
in saline very gradually
● IV fluids ● Monitor weight
● IV antibiotics ● Very long hospital stay
● Thermoregulation

Gastroschisis
vs.
Omphalocele

58
 NCLEX Question
The nurse observes a parent swaddling their infant with an unrepaired omphalocele. Which
of the following statements would be appropriate?

a. “Stop, you’ll kill your baby!!”

b. “That is a nice, tight swaddle. It will really help sooth your new baby”
c. “May I help you? We will need to be careful with their intestines, we do not want
the swaddle to push them back inside.”
d. “Swaddling is not allowed for these babies, please stop.”
e. "Swaddling the baby with an unrepaired omphalocele is perfectly fine. It won't
cause any harm."

Answer: C
A is incorrect. This is inappropriate to say to a parent as it would cause panic and upset them. The nurse wants to promote the parent
bonding with their infant, and phrases like this will scare the parent and make them afraid to touch the baby, which is not therapeutic.

B is incorrect. It is not appropriate to tightly swaddle an infant with an omphalocele. This would place pressure on their exposed
intestines and could push them back inside of the baby, which we do not want.

C is correct. This is a therapeutic statement. It educates the parent about the need to swaddle the baby only very loosely, and avoid
any pressure on the exposed intestines so that they do not get pushed back inside of the baby. It also promotes bonding with the
infant, as it encourages the parent to touch and care for their baby.

D is incorrect. This is not appropriate. Swaddling is not ideal for an infant with an omphalocele due to the exposed intestines, but if it
is done loosely and avoids placing pressure on the defect it can certainly be done. Telling the parent to stop will not promote bonding
and decrease their interaction with the baby. The nurse should educate the parent on the necessary precautions when traveling and
help them develop a positive relationship with their new baby.

E is incorrect. Swaddling involves wrapping the baby tightly in a blanket, which may exert pressure on the omphalocele, potentially
causing injury or complications. The appropriate response in this scenario would be to prioritize the safety and well-being of the
infant by addressing the issue with the parent. Swaddling may need to be modified or avoided altogether to ensure the omphalocele
remains protected and does not experience any undue pressure.
NCSBN Client Need:
○ Topic: Physiological Integrity Subtopic: Physiological adaptation
●
○ Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited.
Subject: Pediatric
○ Lesson: Gastrointestinal

59
Intussusception
● Occurs when one part of the
intestine slips inside the
other intestine
● “Telescoping”
● Often occurs where the
small intestine and large
intestine meet

Assessment
● Red currant jelly
stools
● Cyclical abdominal
pain
● Nausea
● Vomiting
● Green, bilious emesis
● Sausage-shaped mass
in abdomen

60
Treatment
● Enema to attempt to push the intestine back out
○ Air enema
○ Hydrostatic enema
○ Barium enema
● If unsuccessful, a surgical repair is needed

Management
Pre-op Post-op
● Monitor stool ● Monitor bowel function
● NPO ● Infection is common
● IV fluids complication
● IV antibiotics ○ Monitor temps, WBCs, CRP
● Slowly advance diet

61
Hirschsprung's
● Congenital aganglionic
megacolon
● Absence of enteric
neurons within the
myenteric and submucosal
plexus of the rectum
and/or colon
● No neurons? No peristalsis
● Stool builds up and causes
a megacolon

Assessment
● Delayed passage of meconium
● Ribbon-like stool
● Swollen belly
● Vomiting, including vomiting a green or brown substance
● Constipation
● Gas
● Irritation

62
Treatment
● Surgical removal of the portion of the colon lacking innervation
○ The main surgical procedure performed for Hirschsprung's disease is called a "pull-through" or "Soave
procedure."

○ This surgical intervention aims to remove the affected portion of the colon (large intestine) that lacks the
nerve cells responsible for peristalsis

● Nutrition after surgery

Key Pediatric GI Symptoms

63
Part IV: Remaining Systems
Pediatrics

Hematology/Immunology
Pediatrics

64
Sickle Cell Anemia
● A disorder that causes the red blood cells to ‘sickle’ and break down
● Autosomal recessive

Pathophysiology
● Autosomal recessive
● Those with the trait have ‘sickled’ RBCs
● The sickled cells are not able to carry
oxygen like they should
○ Decreased perfusion
● Due to their shape, they can get caught
in vessels and cause obstruction

65
Sickle Cell Crisis
● The decreased blood flow to the tissues leads to hypoxia, ischemia, and
infarction
● There is severe joint pain
● Sequestration
○ Blood pools
○ Often in the spleen
○ Splenomegaly and tenderness
● Acute exacerbation can be caused by hypoxia, exercise, high altitude (due
to low oxygen), and fever

Assessment
● Pallor
● Pain
● Fatigue
● Arthralgia
● Chest pain
● Respiratory distress

66
Treatment
● IV Fluids
○ This helps dilute the blood so that the sickled cells are not so concentrated
○ Provides hydration
● Blood transfusion
○ Provides normal RBCs
○ Helps optimize oxygenation and better perfusion
● Oxygen
○ Increase oxygen to the tissues if the client is hypoxic
● Medications
○ Pain management - analgesics often necessary
○ Hydroxyurea
■ Increases production of fetal hemoglobin to reduce crises

NCLEX Question
You are providing education to your 8 year old client diagnosed with sickle cell
anemia. He has had three crisis events this year. Which of the following points do
you enforce with him and his parents to help prevent more sickle cell crises?
Select all that apply.

a. Drink lots of water

b. Perform vigorous exercise for 60 minutes a day
c. Avoid flying on airplanes
d. Call the PCP if he becomes febrile
e. Encourage a diet high in calcium

67
Answer: A, C, and D
A is correct. Hydration is an essential component of preventing a sickle cell crisis, so this is very important education. By
drinking lots of water, the boy will increase the volume in his vascular space with fluid, essentially “thinning out” the
sickled cells. In other words, they will not be as concentrated anymore. This will help to prevent the sickled cells from
snagging on vessels, creating occlusions, and causing a crisis.

B is incorrect. While promoting a healthy lifestyle is always important, vigorous exercise is a specific trigger for a sickle
cell crisis. This is because during vigorous exercise the tissues have a high demand for oxygen and the sickled cells are
unable to deliver a sufficient amount. This results in a crisis. So for this client, 60 minutes of vigorous exercise every day
would not be a good recommendation.

C is correct. Avoiding flying on airplanes is good education. In airplanes, you are at a very high altitude where there is
much less oxygen. This can be a trigger for a sickle cell crisis because it leads to a high oxygen demand state.

D is correct. It is important for the parents to know to call the child’s primary care doctor if he is ill with a fever. Because
the body demands more oxygen when it is febrile, fevers are a trigger for sickle cell crises, and must be treated promptly.

E is incorrect. Encouraging a high calcium diet will not prevent the client from having sickle cell crises.

NCSBN Client Need:

Topic: Physiological Integrity Subtopic: Risk potential reduction

Reference: Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited.

Subject: Pediatrics
Lesson: Hematology

Kawasaki Disease
● Acute systemic vasculitis
● Infectious agent triggers T-Cells → overproduction of cytokines → activation
of macrophages and monocytes
● Leukocytes adhere to vascular walls and damage the lining of blood vessels
● Can result in coronary artery aneurysms and thrombosis

68
Assessment
● Strawberry tongue - red and swollen
● Inflammation!! Elevated:
● Rash ○ CRP
● Bilateral conjunctivitis ○ ESR
● Red cracked lips/mucous membranes ○ WBC
○ Platelets
● Red, swollen hands and feet
● Anemia
● Lymphadenopathy
● Arthralgia
● High fever
● Abdominal pain/diarrhea/vomiting

Treatment
● Aspirin
○ Reduces the fever, swelling, pain and rash
○ Prevents blood clots

● IVIG (Intravenous Immunoglobulin)

○ Reduces risk of complications
○ Must be given early

69
Reye Syndrome
● Acute encephalopathy following viral illness
● Diagnosed by liver biopsy
● Characterized by cerebral edema and fatty changes in liver
● Most commonly follows influenza or varicella
● Associated with aspirin use in pediatrics during viral illness!

Assessment findings
● Viral illness
● Nausea, vomiting
● Fever
● Signs of liver dysfunction: lethargy, jaundice
● High ammonia levels in blood
● Altered mental status

70
Treatments and interventions
● Monitor neuro status and signs of increased ICP!!
● Monitor liver function
● Monitor I&O
● Monitor for impaired coagulopathy
● Rest and low stimulation

** Acetaminophen and ibuprofen are the medications of choice for fever in viral
illness due to risk of Reye Syndrome!**

Phenylketonuria (PKU)
● Phenylketonuria, or PKU, is a rare, inherited disorder where the body is
unable to break down phenylalanine, an amino acid
● Normal levels of phenylalanine: 0-2 mg/dL
● PKU: >20 mg/dL
● High levels can cause damage to central nervous system if toxic levels if
phenylalanine are not treated

71
Assessment
● Newborn Screening in all 50 states!!

○ Infant must be eating breastmilk or formula before sample collection

○ Heel stick around 24-48 hours old

○ Repeated test if screening is positive

● GI problems and vomiting

● Growth failure

● Behaviour difficulties

● Seizures

Treatments
● Avoid foods high in protein and phenylalanine - meats, dairy products, and
aspartame

● Special preparation formulas

● EDUCATION!! Parents and children need education on the importance of

follow-up appointments and treatments, adhering to safe diet, and risks for
future children

72
 Musculoskeletal
Pediatrics

Fractures common in pediatrics

Bowing Torus; “Buckle” Greenstick

James Heilman, MD, Tibfracture, CC BY-SA 3.0 Apaul291003, Buckle Fracture, CC BY-SA 4.0 Hellerhoff, Gruenholzfraktur - Unterarmfraktur, CC BY-SA 3.0

73
Rickets
● A softening and weakening of bones
● Extreme or prolonged lack of vitamin D
● Vitamin D promotes absorption of calcium
● Bones can’t absorb calcium
● Become soft and weak

Assessment
● Delayed growth
● Bow legs
● Weakness
● Pain
○ Spine
○ Pelvis
○ Legs

Oxfordian Kissuth, Male legs 01, CC BY-SA 3.0

74
Treatment
● Vitamin D and calcium!
○ Diet
○ Supplementation
● Surgery
○ Correct bow legs

Developmental dysplasia of the hip

● An abnormality in the development of the femoral head, acetabulum,
or both
● Causes the femur to become displaced from the hip
● Can occur in one or both hips
● Catching it early is key to treatment!

75
Assessment
● Infant Barlow Ortolani
○ Ortolani & Barlow Tests
● Toddler
○ Limb length inequality (legs with
different lengths)
○ Abnormal walking or gait

Treatment
Goal = promote proper formation of the hip

● Brace
○ Pavlik harness
● Cast
○ Spica body cast
● Surgery Thiemo Schuff, Saeugling mit angelegter spreizhose, CC BY-SA 3.0

○ Usually followed by a cast!

BruceBlaus, Hip Spica Casts, CC BY-SA 4.0

76
Osteogenesis Imperfecta
● Brittle bone disease
● Inherited defect in the gene that makes collagen
● Body can’t make enough collagen, and bones are therefore weak
● Bones fracture easily, often with no obvious cause
● Symptoms can range from a few fractures to many medical complications

Assessment
● Easily broken bones
● Deformities
○ Barrel-shaped chest
○ Bow legs
○ Curved spine
○ Triangle-shaped face
● Loose joints
● Weak muscles
● Soft, discolored teeth

77
Treatment
● Lifelong condition
● Prevent fractures
○ Fall precautions
● Fracture care
○ Light casts
● Bisphosphonates
○ Decrease calcium reabsorption to keep more calcium in the bones and make them stronger
● Prevent deformities
○ Braces or splints
● Surgery
● PT / OT
● Assistive devices

Muscular dystrophy
● Inherited lack of specific protein needed for muscle function
● Progressive atrophy of symmetrical groups of skeletal muscles
● Loss of strength
● Progressive disability and deformity
● *No degeneration of neural tissue*
● Two most common types:
○ Duchenne (DMD)
○ Becker
● More common in males

78
Assessment
● Trouble standing unsupported
● Poor posture
● Dysphagia
● Trouble walking
● Scoliosis
● Loss of reflexes
● Lungs are weak
○ Trouble breathing
● Heart is weak
○ Cardiac complications

Treatment
● No cure
● Median life expectancy
○ DMD - Early 20s
○ Beckers - Middle age
● PT
● OT
● Assistive devices
○ Typically need a wheelchair in late childhood

79
Nonaccidental Trauma
● Any traumatic injury occurring intentionally
● Nurses are mandatory reporters
○ Be aware of what to look for
○ When in doubt, say something
● Work up:
○ X-rays for:
■ Other fractures
■ Head trauma
■ Retinal hemorrhage

Suspicious injuries
● Long-bone fracture in a child who cannot walk
● Fractures in different stages of healing
○ Bruises in different stages of healing
● Soft tissue injury accompanying fracture
● Story doesn’t match pattern of injury
● Story is not possible for the child’s developmental stage

80
 Integumentary
Pediatrics

Diaper Dermatitis
● Irritant contact dermatitis
● Caused by prolonged exposure to a dirty diaper
● Can become infected
○ Most common - candida albicans
● Treatment:
○ Remove diaper
○ Keep area clean and dry
○ Zinc oxide cream

81
Impetigo
● Contagious bacterial disease
● Cause
○ Staphylococcus aureus
● Toxins from this bacteria produce a weeping lesion with a ‘honey colored
crust”
● Treatment
○ Topical antibiotics
○ Oral antibiotics

Image source: CDC.gov

Pediatric Burn Injuries

● Degree of depth - same as adults
○ 1st - 4th
● Non-Accidental Trauma (NAT)

82
Non-Accidental Burn Examples

Total Body Surface Area

● Used to describe the extent of a burn based on the percent of the body
surface area that has been burned
● Children are at much greater risk for severe burns and complications due to
their relatively thin skin and large BSA
● To assess TBSA in pediatrics, you must use an appropriate chart
○ Lund and Browder Chart
○ Rule of nines not applicable in pediatrics

● >10% TBSA needs emergency treatment for fluid replacement

83
Lund & Browder’s
Chart
● The smaller the kiddo - the
bigger the head! https://pharmaceutical-journal.com/learning/cpd-article/burns-assessment-and-treatment/20068363.article

● Accounts for this difference in

TBSA

Fluid Replacement
● Calculated based on client’s body weight
● Parkland burn formula
○ 3ml x %TBSA x kg = LR to be administered over 24 hours
● Monitor UOP to assess if adequate
○ At least 0.5 mL/kg/hr

Pediatric differences:
- Lund Browder Chart to calculate TBSA
- >10% TBSA needs treatment
- Parkland formula = 3 ml x TBSA x kg

84