pediatrics exam 1

common childhood injuries

• suffocation

• drowning

• motor vehicle injury

major child stressors during hospitalization

• separation

• loss of control

• bodily injury

• pain

separation anxiety

major stress from mid-infancy to preschool
 (Esp 6 – 30 mos)

 3 stages of separation anxiety Protest
 Despair
 Detachment/Denial
 Greatest stress imposed by hospitalization
during early childhood

nursing interventions for hospitalized child

Promoting freedom of movement when applicable
 Maintaining routine
 Encourage independence
 Promote understanding
 Provide developmentally appropriate activities
 Provide opportunities to PLAY
 Provide socialization
 Foster parent-child relationships
 Provide educational opportunities

atraumatic care meaning

to provide therapeutic care through the use of
interventions that eliminate or minimize the psychologic and physical distress experienced by children and their families in the health care system

atraumatic care goal

do no harm

Benefits of Atraumatic Care

• ​​​​​Reduces stress

• Supports client’s feeling of control

• Reduces fear and anxiety

• Promotes faster healing

Providing Atraumatic Care for the Hospitalized Client

Anticipate, recognize, and address pain using pain assessment tools. Use analgesic/numbing medication prior to injections or IV starts. Have a parent hold the child. Use age-appropriate distraction techniques (blowing bubbles, interactive game). Use skin-to-skin contact with parent or administer a sucrose solution for infants.

Family-Centered Care concepts

• ​​​Respect and Dignity

• information sharing

• paticipation

• collaboration

Primary Care Clinics 

provide care by performing physical exams and collecting and recording measurements (height, weight, head circumference) and vital signs. They may also complete developmental screenings, administer immunizations and medications, and teach parents ongoing aspects of caring for children. 

Pediatric Specialty Day Care Facilities

provide additional support and care where children who have complex medical needs attend while their parents work. At these day care facilities, children who are medically fragile are closely monitored by a nurse on a regular basis, which can aid in identifying any problems quickly.

Pediatric Emergency Room

focusing on abnormal vital signs, administering medications, drawing blood and interpreting lab values, starting IVs, administering blood products, and managing acute and life-threatening conditions.

school nurse

work in schools optimize student health, safety, and learning. They provide first aid, ensure up-to-date immunizations of students, manage outbreaks of contagious diseases, and administer medications to students who are on routine medicines

Specialty Hospitals

specialize in chronic or terminal diseases—such as cancer, heart conditions, and orthopedic needs—that focus on the differing treatments that come into play with pediatric clients.

Role of the Pediatric Nurse

• advocacy

• therapeutic relationships

• health promotion

• injury prevention

steps to make therapeutic communication

1. Establishing rapport
    Foster a nurse-client relationship
    Therapeutic communication

2. Interviewing the client and support system
    Age-appropriate communication strategies
    Open-ended questions

3. Communicating with the pediatric client across the life span
    Social/emotional milestones
    Language/communication milestones

communication techniques Birth to 2 years old

Make eye contact
 Engage the client
 Use toys and comfort items
 Allow infants to be held by their parent
 Include the client as much as possible

communication techniques 2 to 7 years old

 Focus on the client
 Allow adequate time
 Provide praise and encouragement
 Provide simple explanations:
 Reduce anxiety
 Familiarize with equipment
 Encourage questions

communication techniques 7 to 11 years old

Focus on communication
 More awareness, more involvement
 Provide detailed explanations
 Reduce anxiety

communication techniques 11 years and older

Encourage participation
 Focus on privacy and self-concept
 Provide detailed explanations

Health Promotion: The nurse's role in immunizations

Review individual immunization records at every
clinic visit
-Avoid missing opportunities to vaccinate
-Encourage parents to keep immunizations
current
-Keep up with changes in immunization
schedules, recommendations, and research
related to childhood vaccines
- series vs yearly vaccinations
- combination vs single

How to treat mild reactions from vaccines

 Encourage fluids to stay hydrated
 Use a cool, damp cloth to help reduce
redness, soreness, and/or swelling at the injection site
 Reduce fever with a cool sponge bath
 Ask if you can give a non-aspirin pain reliever

Common Pediatric Vaccines

Haemophilus influenzae Type B (Hib)
Hepatitis A
Hepatitis B
Inactivated poliovirus vaccine (IPV)
Pneumococcal
Rotavirus (live, attenuated oral vaccine)

Varicella
Diphtheria, tetanus, and pertussis (DTaP or Tdap)
Measles, mumps, and rubella (MMR)
Human papillomavirus (HPV)
Meningococcal
Influenza
COVID-19

Vaccine Considerations

1. Contraindication: conditions that permanently exclude the client from receiving further doses of the
   vaccination due to significant risk for poor outcomes.
    Severe allergic reaction is only standard contraindication.

2. Precaution: place the client at an elevated risk for adverse reaction.
    Example: personal or family history of seizures for MMRV vaccination

3. Mild illnesses, such as ear infections, do not require delay of vaccinations.

4. Vaccines should be delayed to a future date if current moderate or severe illness

infant-18 months psycho social crisis

Trust vs mistrust

18 months to 3 years psycho social crisis

Autonomy vs Shame & doubt

Children learn to do things on their own without the help of their parents: Going to the bathroom on their own, learn to dress themselves

Toddlers learn to control their environment by using their words (“No, me do!”), start to become more independent.
If criticized for showing autonomy, may develop shame and doubt.
Play: Parallel play

3-5 years psycho social crisis

initiative vs guilt

Child expresses desire to take initiative in activities
Child learns about environment through play

“Magical thinking”: Children believe that inanimate objects (toys, chairs, etc.) are able to think and act. (Tricycle is bad if child fell from the trike). Also, children believe that they can cause things to happen by thinking them.

Examples: Allow them to clean up their toys, make their bed, sweep the floor
Play: Associative

5-13 years psycho social crisis

industry vs inferiority

• Industry: Stage of accomplishment
• Seeking to gain competence
• Acquisition of new skills, assuming new responsibilities, developing a sense of confidence in new skills
• Projects are enjoyable, child follows rules and order

13-21 psycho social crisis

identity vs role confusion

“Who am I?”
• Depends on past experiences in childhood and future goals
• Develops personal values, wants to be an adult but needs support of adult or caregiver
• Interested in sexuality and gender roles
• Self image is dependent on what others think
• Tests limits and rules
• Believes he or she is special or unique

Infant Development: Physical

Gain aprox 5-7oz/week for the first 6 months of life
• Grow 2.5cm (1in)/monthly for first 6 months of life
• Head circumference increased by 1.5cm
(0.6in)/month for first 6 months of life
• Posterior fontanelle closes at 2 months
• At 5-6 months first tooth may start to erupt
• At 5-6 months birth weight doubles. By 1 year
birth weight triples
• At 12 months birth length increases by 50%
• At 12 months anterior fontanel almost closed

Infant Development: Fine motor skills

Grasp reflex (until 2-3 months) progresses to pincer grasp (starts 8-9 months) and

transferring objects from hand to hand (6-8 months)

Infant gross motor development

• 2 months: Start to gain head control
• 4 months: Turns from abdomen to back
• 6 months: Turns from back to abdomen,
Sits unattended by 7 months
• 8 months: Locomotion, crawling and creeping
• 10 months: Cruising, starts deliberate steps
• 12 months: Walking

Infant sensory development

1 mo able to fix on moving object
• 2 mos searches to locate sounds
• 4 mos beginning of hand-eye coordination
• 7 mos responds to own name

Infant vocalization development

3 mos starts babbling
• 4 mos begins consonant sounds
• 9 mos responds to simple commands and comprehends "no”
• 10 mos says dada or mama and understandings meaning;
may say one word
• 12 mos 3-5 words besides mama or dada

socialization/cognition infant development

2 mo social smile
• 6-7 mo stranger anxiety
• 10 mos develops object permanence

birth to 1 year basic needs Eriskon

Nourishment, attachment, attention

Infants learn whether or not people are reliable

Anticipatory Guidance for Parents of Infants

• Anticipatory guidance should be provided at every interaction between medical professionals and families
• Promoting optimum nutrition
• First 6 months: Breast milk vs formula is primary source of nutrition
• Age 6-12 months: introduction of solid foods

• Sleep: By age 3 months, most babies sleep cumulatively 15
hours
• SIDs prevention – Back to Sleep, in separate sleep space, flat surface, snug clothing, no loose blankets or pillows or toys

Injury Prevention for Infants

• Injury prevention (Infants Box 10-5; p. 365) " SAFE PAD:
• S: suffocation, sleep position
• A: asphyxia, animal bites
• F: falls
• E: Electrical burns or burns
• P: Poisoning, ingestion
• A: Automobile safety
• Drowning

• Car seats: All infants should be in a rear facing car seat in
back seat of car

Toddler development: 12-36 months of age biological development

Height and weight trends
• Head circumference

toddlers gross motor development

Pulls self up to stand and takes 2-3 steps independently
by 1 year
• Jumps, kicks a ball and pedals a tricycle around 2-3
years

toddlers fine motor development

• Can hold a crayon by 1 year
• Can draw simple shapes by 2-3 years

Toddler Health Promotion

• Transitional objects for security
• Ritualism helpful in setting routines and expectations
• Learning through play: Parallel play with peers
• Temper tantrums common opinions exceed verbal ability
• May show interest in toilet training
• Needs 11-12 hr of sleep a night
• Children should remain in a 5 point car seat in back of
car; can move forward facing once at least 2 years old

Preschool development: 3-5 years of age
• Biologic development

Become more graceful no longer squat and potbellied,
height and weight growth slow a bit

Preschool development: 3-5 years of age gross motor skills

• Rides a tricycle around 3 years
• Hops on one foot around 4-5 years

Preschool development: 3-5 years fine motor development

• Can draw discernable pictures and use scissors at 4-5 years

Preschool Health Promotion

Sleep: ◦10-12 hours a day, ? 1 nap a day
◦Nightmares or Night terrors
Encourage enrollment in nursery school
Assess school readiness
Pedestrian, drowning, fire and fire arms
Motor vehicle safety
Dental Health
immunizations

HEALTH PROMOTION in YOUTH: DENTAL CARE

• Dental caries (tooth decay): Single most common chronic disease in childhood
• Dental caries are preventable with early dental preventive care
• Dental hygiene beginning with first tooth eruption @ 4- 7 months
• Dental care disparities
• Role of fluoridated water and fluoride varnish at PCP

SCHOOL AGE DEVELOPMENT

AGES 5-12 YEARS biological development

• Slow and steady pace of height and weight growth
• Beginning of school age: Boys weight/height > girls
• End of school age: Girls > boys

School age: Social development

• Play: Strong identification with peers
• Tend to associate with same sex for play
• Group activities, clubs and peer groups: Conformity and rules to be “in” or “out”
• Social relationships are very important.
• Peer pressure present
• Bullying can be an issue around this time (cyber or in person)

Health Promotion in School-Age Children

• Encourage personal responsibility for hygiene,
nutrition, exercise, recreation, sleep and safety

• Injury prevention includes:
• Safety helmets
• Protective eye and mouth wear in sports
• Protective padding

Tanner Stages girls

Puberty begins between ages 8 and 13 and is completed in about 4 years

First signs are breast buds (thelarche), then pubic hair and
beginning of menstruation (menarche)

Tanner Stages boys

Puberty begins between 9 and 14 and is completed in about 3.5 years

First signs testicular enlargement

School-Age Children: 6 to 12 Years

physical development

 Grow and develop at varied paces influenced by genetics,
nutrition, and activity levels
 Loss of deciduous (baby) teeth and eruption of permanent teeth
 Become more aware of their bodies
 Puberty begins

School age Psychosocial Development

1. Self-esteem
    Influenced by academic achievements and parental support.
    High self-esteem correlates with better adaptation skills, satisfying relationships, improved academic performance, and better mental and physical health.

2. Body Image
    Children experience significant physical and psychological development, making body image crucial for overall well-being..
    Positive body image experiences in childhood contribute to lifelong habits like balanced diet and exercise, promoting overall well-being.

3. Sexual Identity
    Sexuality encompasses sexual orientation, gender identity, and ideals about relationships and intimacy.
    Sexual orientation typically forms between ages 10 to 17.

4. Discipline
    Crucial for fostering positive behavior and character development in school-age children, providing accountability.
    Effective discipline significantly impacts children's cognitive and mental health

School age: Social development

 Play: Strong identification with peers
 Tend to associate with same sex for play
 Group activities, clubs and peer groups: Conformity and rules to be “in” or “out”
 Social relationships are very important.
 Peer pressure present
 Bullying can be an issue around this time (cyber or in person)

Bullying

 Prevalent in middle school
 One in three report being bullied
 Can cause physical injury, depression, anxiety, sleep disturbances, poor academic performance, and poor school attendance
 Can lead to decreased sense of belonging, increased self-harm, and psychosomatic symptoms like tiredness, poor appetite, stomach pains, difficulty sleeping, headaches, back pain, and dizziness

Health Promotion in School-Age Children

 Encourage personal responsibility for hygiene, nutrition,
exercise, recreation, sleep and safety
 Educate about Safe internet use & social media

 Injury prevention includes:
 Safety helmets
 Protective eye and mouth wear in sports
 Protective padding
 Bus safety
 Firearms

 Physical Activity
 Essential for health, reducing risks such as high blood pressure, obesity, and diabetes.
 Lowers the risk of depression, enhances academic performance, and improves memory and attention.
 60 minutes of physical activity daily recommended daily.
 Sleep
 Adequate sleep reduces the risk of obesity, diabetes, attention and behavior problems, poor mental health,
and injuries.
 Recommended sleep duration is 9 to 12 hours per night.
 Obesity
 Major public health challenge with increasing pediatric cases

Attention Deficit Hyperactivity Disorder

 Manifestations include hyperactivity, impulsive behavior, and difficulty maintaining attention.
 Symptoms typically begin before age 12 and as early as age 3.
 Symptoms range from mild to severe and can resemble other conditions.
 Many challenges to diagnosis
 Multi-modal treatment options
 Challenges to diagnosis
 Must persist over a long period
 Interfere with daily functioning
 Be present in multiple settings (e.g., school and home)
 Treatments include
 Medication
 Behavior therapy
 Counseling
 Educational services

Adolescents: 12 to 20 Years behaviors

 Self-Esteem
 Sexuality
 Social Interactions
 Perspective on Health
 High-Risk Behaviors

Newborn and Young Infant Behavioral Responses to Pain

Crying; facial expressions; generalized body responses

Older infant Behavioral Responses to Pain

Crying; withdrawal of area with pain; physical struggle

young child Behavioral Responses to Pain

crying, screaming, “pain words”, begging for end, clinging

school age child behavioral responses to pain

Time wasting behaviors; muscle rigidity

adolescent behavioral responses to pain

More verbal expressions; less resistance; muscle tension

Premature Infant Pain Scale
(PIPP-R) age

Preterm and term infants

Face, Legs, Activity, Cry, Consolability (r-FLACC, FLACC)

2 months to 7 years old OR Nonverbal/Cognitively
impaired at any age

Faces Pain Scale age

5 to 12 years old

management of mild dehydration

Oral rehydration includes replacement over 4-6hrs,
plus account for ongoing loss + need for maintenance fluids
(generally 50ml/kg of PO solution)

management of moderate dehydration

May need ~100ml/kg fluids PO

If child cannot take in oral solutions to meet needs and provide replacements for losses, consider IV hydration

management of severe dehydration

IV:
1. Isotonic solution 20ml/kg over 5-20 minutes; repeat per exam
2. Replace deficits and meet maintenance needs
3. Return to normal by introducing orals

Morphine dose for toddlers

0.1-0.2 mg/kg

signs of respiratory distress

tachypnea

nasal flaring

retractions

grunting

see saw breathing 

head bobbing

croup interventions

cool mist, nebulized epinephrine, oral steroids (Decadron), quick relief in 6 hours, and close monitoring.

acute epiglottitis symptoms

dyspnea, dysphagia( difficulty swallowing), dysphonia( hoarse voice; frog-like voice), drooling. Often sitting in a tripod position. Caused by hemophilis hepatitis B. 

bronchiolitis

RSV is bronchiolitis. Pre-term babies, cardiac conditions babies, second-hand smoke, low SEC are at risk. Seasonal illness. Happens after a URI. thick sticky secretions in the bronchioles. Caused by a virus

how cystic fibrosis affects the organs

• Intestinal obstruction in small intestine.

• Bronchi: pneumonia, inflammation in lungs

• Pancreatic ducts: leads to malabsorptive syndromes

• Salivary glands: excrete more NACL

• Reproductive system: can take longer to conceive because of cervical mucus thickness, men are infertile: no sperm canal

Management of CF

• Good pulmonary hygiene, use broncho dilators

• Hypertonic saline nebulizers, dornaze to thin out mucus

• Chest PT

• Tricafta medication

• IV antibiotics for pulmonary infection

• nutritional enzymes, vitamins

Risk Factors for Respiratory Distress

 Infectious agents—viruses like RSV, Covid 19, influenza
 Age- size
 Resistance
 Seasonal variations
 Excessive or Thick Secretions
 Stasis of Secretions
 CNS Depression or Immobility D/T sedation, surgery, trauma, pain, anxiety or cognitive impairment
 Extreme high or low humidity
 Sleeping positions of infants

adventitious breath sounds

stridor

wheezing

rhonchi

Postural drainage

 Removal of excessive fluid or mucous
 Position with gravity
 Every 4-6 hours, 20-30 minute intervals
 Deep breathing – be creative

alert for epiglottitis

If the back of the throat is examined, it may result in total tracheal occlusion. The nurse should never assess the child’s throat if epiglottitis is suspected

initial symptoms of bronchiolitis

 Rhinorrhea
 Pharyngitis
 Coughing, sneezing
 Wheezing
 Possible ear or eye drainage
 Intermittent fever

progressive symptoms of bronchiolitis

 Increased coughing and wheezing
 Fever
 Tachypnea and retractions
 Refusal to nurse or bottle-feed
 Copious secretion

severe symptoms of bronchiolitis

Tachypnea, greater than 70 breaths/min
• Listlessness
• Apneic spells
• Altered air exchange (e.g., retractions, crackles)
• Diminished breath sounds

Bronchiolitis care is aimed at

◦ Monitoring oxygenation with pulse oximetry as clinically indicated
◦ Monitoring IV fluids or NG fluids
◦ Monitoring for fever
◦ Administering prescribed medications
◦ Family support & education
◦ Prevention

bronchiolitis meaning

Illness that occurs after and upper respiratory infection that causes inflammation and obstruction of the small airways (bronchioles)

Asthma meaning

A chronic, reversible, inflammatory disorder of the airways that causes episodic airway obstruction and hyperresponsiveness in the airway to multiple stimuli

asthma consists of 

◦ BRONCHOCONSTRICTION
◦ INFLAMMATION in the airways
◦ Expiratory airflow decreases, trapping gas in the airways causing alveolar hyperinflation

Asthma Diagnosis

 Clinical signs and clinical history
 Peak expiratory flow assessment (assessment of how much child can exhale air in his or her lungs)
◦ Used to determine optimal peak flows (in primary care usually)
◦ Will help to determine “Green, Yellow or Red” Zone and educate family on early signs
 Blood gases and pulse oximetry
 RAST testing (radio-allegro-sorbent test) to assess for allergens/triggers

what to do during acute asthma attack

Check peak flow, if in “Yellow Zone”, administer SABA. If in “Red” go to ER immediately for emergent care (Inhaled SABAs q 20 minutes, IV steroids and intubation/ventilator support if needed)

Long term asthma meds

• Inhaled corticosteroids: Fluticasone (Flovent) and Pulmicort
  (budesonide) common
  ○ Long-acting β2-agonists (LABAS): Severent (salmeterol) via MDI
  ○ Leukotriene modifiers: Singulair (montelukast) PO

Quick-relief (“rescue”) medications asthma

○ Short-acting β2-agonists (SABAs): Albuterol or Xopenex
○ Anticholinergics: Atrovent (may be combined with SABAs)
○ Systemic corticosteroids (prednisone) are given orally for 3-5 days and are faster acting, however take 3-8 hours to take effect

CF meaning

chronic, autosomal- recessive, inherited disorder of the exocrine glands that affects multiple organ systems

A CFTR (cystic fibrosis transmembrane conductance regulator) gene mutation

○ Screening can be done via blood or saliva
○ Metabolic screenings performed during pregnancy to
identify risk to fetus

CF diagnostic evaluation

Family history of disease or prenatal DNA testing can be done
○ Newborn screening done in all 50 states
○ Sweat chloride test: Most reliable diagnostic procedure

CF Respiratory Manifestations

Lung congestion
○ Wheezing or rhonchi
○ Dyspnea
○ Dry, non-productive cough
○ Nasal congestion
○ Sinus infections
○ Atelectasis and generalized obstructive emphysema due to
mucoid obstruction Bronchitis
○ Bronchopneumonia (inflammation of the alveoli)

CF GI Manifestations

○ Newborn: not passing meconium stool manifestation of GI involvement
○ Weight loss despite increased appetite
○ Malnourishment and vitamin deficiency
○ Malabsorptive syndrome with chronic diarrhea and large frothy smelling stools
○ Long term GI complications

Cystic Fibrosis : GI Management

Pancreatic enzymes
High-protein, high-calorie diet as much as 150% RDA
Prevention/early management of intestinal obstruction
Reduction of rectal prolapse
Regular nutritional monitoring

Streptococcal Pharyngitis Pathophysiology

Streptococcal pharyngitis occurs when group A streptococcal bacteria enter the nasopharyngeal passages and attack and invade the epithelium of the mucosal lining in the pharynx, causing inflammation and secretions

Streptococcal Pharyngitis Clinical Presentation

• sever sore throat

• The throat will often be red in appearance with the presence of petechiae and

• white patchy exudate on the pharynx.

• red tongue that resembles a strawberry and a rough, red “sandpaper-like” rash on the trunk of the body, which is known as a scarlatina rash.

• Cervical lymphadenopathy is often more prominent in clients who have streptococcal pharyngitis

Treatment for pharyngitis

penicillin family