Pediatrics ATI CMS

Chapter 1: Family Centered Nursing Care

Parenting styles
- Dictatorial or authoritarian; Parents try to control the child’s behaviors and attitudes through
unquestioned rules and expectations
- Ex: The child is never allowed to watch television on school nights
- Permissive: Parents exert little or no control over the child’s behaviors, and consult the child when making
decisions
- Ex: The child assists with deciding whether he will watch television
- Democratic or authoritative: Parents direct the child’s behavior by setting rules and explaining the reason for
S each rule setting; Parents negatively reinforce deviations from the rules
-considered
- Ex: The child can watch television for 1 hr. on school nights after completing all
best form of his homework and chores
ofparenting
- Ex: The privilege is taken away but later reinstated based on new guidelines

Family Theories
- Family Systems: Family viewed as whole system instead of individual family members; change w/ 1
member affects whole family
- Family Stress: Stress is inevitable
- Developmental: Views families as small groups that interact with larger social system; emphasizes
similarities and consistencies in how families change

Chapter 2: Physical Assessment Findings

Vital signs: Usually all high except for BP

Temperature:
3 – 6 months 99.5 7 years 98.2
1 year 99.9 9– 11 years 98.1
3 year 99.0 13 years 97.9
5 years 98.6
Pulse:
NEWBORN (birth-2 days) 110 – 160/min
INFANT (2 days– 1 yr. ) 90 – 160/min
TODDLER (1- 3 years) 80 – 140/min
PRESCHOOLER (3 - 5 years) 70 – 120/min
SCHOOL AGE (6 - 12 years) 60 – 110/min
ADOLECENT (13 - 18 years) 50 – 100/min

Respirations:
NEWBORN (birth-2 days) 30 – 60/min
INFANT (2 days– 1 yr. ) 25 – 30/min
TODDLER (1- 3 years) 25 – 30/min
PRESCHOOLER (3 - 5 years) 20 – 25/min
SCHOOL AGE (6 - 12 years) 20 – 25/min
ADOLECENT (13 - 18 years) 16 – 20/min
Blood pressure:
 in infants but  the older they get
-INFANT: 65-78 / 41-52
- 1 year
-Female: 83 -114 / 38 - 67
-Male: 80 – 114 / 34 – 66
- 3 years
-Female: 86 -117 / 47 - 76
-Male: 86 – 20 / 44 - 75
- 6 years
-Female: 91 -122 / 54 - 83
-Male: 91 – 125 / 53 - 84
- 10 years
-Female: 98 -129 / 59 - 88
-Male: 97 – 130 / 58 - 90
- 16 years
-Female: 108 -138 / 64 - 93
-Male: 111 – 145 / 63 - 94

Head
- Erect head posture expected after 4 months
- Fontanels should be flat; Post: Closes by 8 weeks; Ant: Closes by 12 - 18 months
Teeth
-Infants should have 6 - 8 teeth by 1 year old
-Children and adolescents should have teeth that are white and smooth, and begin replacing the 20 deciduous
teeth with 32 permanent teeth

Infant Reflexes
Stepping Birth to 4 weeks
Palmar Grasp Birth to 3 months
Tonic Neck Reflex (Fencer Position) Birth to 3 – 4 months
Sucking and Rooting Reflex Birth to 4 months
Moro Reflex (Fall backward) Birth to 4 months
Startle Reflex (Loud Noise) Birth to 4 months
Plantar Reflex Birth to 8 months

Babinski Reflex Birth to 1 year

Chapter 3: Health Promotion of Infants (2 days to 1 year)

Physical Development
Weight: gain 1.5 lb./month for 1st 5 months Doubled by 5 months; Tripled by 12 months
Height: 2.5 cm (1 in)/ month for the first 6 months
Length: Increases by 50% by 12 months
Head Circumference: Increases 2 cm/month for 1st 3 months; 1 cm/month from 4-6 months
& 0.5 cm/month during 6 months- 1 yr.
Dentition: First teeth erupt between 6-10 months; 6-8 teeth should erupt by end of year 1
Motor skill development
- 1 Month; Demonstrates head lag; Has strong grasp reflex
- 2 Months; Lifts head when prone; Holds hand in open position; Grasp reflex fades
- 3 Months; Raises head and shoulders when prone; Slight head lag; No grasp reflex; Keeps hands loosely open
- 4 Months; Rolls from back to side; Grasp objects with both hands
- 5 Months; Rolls from front to back; Uses palmar grasp dominantly
- 6 Months; Rolls from back to front; Holds bottle
- 7 Months; Bears full weight on feet; Sits, leaning forward on both hands; Moves objects from hand to hand
- 8 Months; Sits unsupported; Pincer grasp
- 9 Months; Pulls to standing; Creeps on hands/knees instead of crawling; Crude pincer grasp; Dominant hand evident
- 10 Months; Prone to sitting position; Grasps rattle by its handle
- 11 Months; Walks while holding something; Walks w/ 1 handheld; Places objects in container; Neat pincer grasp
- 12 Months; Stands w/o support briefly; Sits from standing w/o assistance; Tries to build 2 block tower w/o
success; Can turn pages in a book

Cognitive development
-Piaget: sensorimotor (birth to 24 months)
Object Permanence: objects still exists when it is out of view
-Occurs at 9-10 months
Language development
-3-5 words by the age of 1 year
Psychosocial development Erikson: Trust vs. Mistrust
- Learn delayed gratification
- Trust is developed by meeting comfort, feeding, simulation, and caring needs
- Mistrust develops if needs are inadequately or inconsistently met or if needs are continuously met before
being vocalized by the infant
Social development
- Separation Anxiety: protest when separated from parents; Begins around 4-8 months
- Stranger Fear: ability to discriminate between familiar and unfamiliar people; Begins 6-8 months
Age appropriate activities; Rattles, Playing pat-a cake, Brightly colored toys, Playing with blocks

Immunizations
- Birth: hepatitis B (Hep B)
- 2 months: diphtheria and tetanus toxoids and pertussis (DTaP), rotavirus vaccine (RV), inactivated poliovirus
(IPV), Haemophilus influenzae type B (Hib), pneumococcal vaccine (PCV), and Hep B
- 4 months: DTaP, RV, IPV, Hib, PCV
- 6 months: DTaP, IPV (6 to 18 months), PCV, and Hep B (6 to 18 months); RV; Hib
- 6 to 12 months: seasonal influenza vaccination yearly (the trivalent inactivated influenza vaccine is
available as an intramuscular injection)

Nutrition
- Breastfeeding provides a complete diet for infants during the first 6 months
- Solids are introduced around 4-6 month
- Iron-fortified cereal is the first to be introduced
- New foods should be introduced one at a time, over a 5-7 day period to observe for allergy reactions
- Juice and water usually not needed for 1st 4 months; after 6 months 100% fruit juice limited to 4-6 oz/day
- Appropriate finger foods: Ripe bananas, Toast strips, Graham crackers, Cheese cubes, Noodles, Firmly
cooked vegetables, Raw pieces of fruit (except grapes)
Sleep & Rest
- Nocturnal sleep pattern established 3-4 months
- Sleep 14-15 hr./day & 9-11 hr. at night around 4 months
- Sleep through night & take 1-2 naps by 1 yr.
Injury prevention
- Avoid small objects (grapes, coins, and candy)
- Handles of pots and pans should be kept turned to the back of the stove
- Sunscreen should be used when infants are exposed to the sun
- Hot water thermostats set at or below 120F
- Infants and toddlers remain in a rear-facing car seat until age 2
- Crib slats should be no farther than 6 cm apart
- Pillows should be kept out of the crib
- Infants should be placed on their backs for sleep

Chapter 4: Health Promotion of Toddlers (1 to 3 years)

Physical development
Weight: at 30 months 4x birth weight
Height: Toddlers grow 7.5 cm (3 in) per year
Head circumference and chest circumference: Usually equal by 1 - 2 years
Cognitive development
- Piaget: sensorimotor stage transitions to preoperational stage 19 – 24 months
-Object Permanence: fully developed
Language development
-1 year: using one-word sentences
-2 years: 300 words, multiword sentences by combining 2-3 words
-3 years; combining several words to create simple sentences
Psychosocial Development
-Erickson; Autonomy vs. Shame and Doubt
- Independence is paramount for toddlers who are attempting to do everything for themselves
- Use negativism or negative responses to express their independence
- Ritualism, or maintaining routines and reliability, provides a sense of comfort for toddlers as they
begin to explore the environment beyond those most familiar to them
Moral Development
- Egocentric
Age appropriate activities
- Parallel play: Toddlers observe other children and then might engage in activities nearby
- Appropriate activities: Playing with blocks, Push-pull toys, Large-piece puzzles, Thick crayons
- Toilet training can begin when toddlers have the sensation of needing to urinate or defecate
Motor skill development
- 15 Months; Walks without help; Creeps up stairs; Uses cup well; Builds 2 tower blocks
- 18 Months; Runs clumsily; Throws overhand; Jumps in place w/ both feet; Pulls/Pushes toys; Manages spoon
w/o rotation; Turns pages 2-3 pages /time; Builds 3-4 blocks; Uses crayon to scribble spontaneously; Feeds self
- 24 Months (2 years); Walks backwards; Walks up/downstairs w/ 2 feet on each step; Builds 6-7 blocks;
Turns pages 1 @ a time
- 30 Months (2.5 years); Balances on 1 leg; Jumps across floor / off chair w/ both feet; Walks tiptoe; Draws
circles; has good hand-finger coordination
Immunizations
- 12 to 15 months: inactivated poliovirus (third dose between 6 to 18 months); Haemophilus influenzae
type B; pneumococcal conjugate vaccine; measles, mumps, and rubella; and varicella
- 12 to 23 months: hepatitis A (Hep A), given in two doses at least 6 months apart
- 15 to 18 months: diphtheria, tetanus, and acellular pertussis
- 12 to 36 months: yearly seasonal trivalent inactivated influenza vaccine; live, attenuated influenza vaccine
by nasal spray (must be 2 years or older)

Nutrition
- Whole milk at 1 year old; 24- 28 oz/day; Can start drinking low-fat milk after 2 years
- Juice should be limited to 4-6 oz. per day
- Food serving size = 1tbsp per year of age
- Foods that are potential choking hazards: Nuts, Grapes, Hot dogs, Peanut butter,
Raw carrots, Tough meats, Popcorn

Sleep & Rest

- Average 11-12 hrs./day including 1 nap; naps often eliminated in older toddlerhood

Chapter 5: Health Promotion of Preschoolers (3-6 years)

Physical development
Weight: Gain 2-3 kg (4.5-6.5 lb.) per year
Height: Grow 6.9-9 cm (2.4-3.5 in) per year
Fine and gross motor skills
- 3 Years; Toe& heel walks; Rids Tricycle; Jumps off bottom step; Stands on one foot for a few seconds
- 4 Years ; Hops & skips on one foot; Throws ball overhead; Catches ball reliably
- 5 Years; Jumps rope; Walks backward; Throws and catches a ball
Cognitive development
- Piaget: preoperational stage
-Moves from totally egocentric thoughts to social awareness & ability to consider the viewpoint of others
- Magical thinking: Thoughts are all-powerful and can cause events to occur
-Animism: Ascribing life-like qualities to inanimate objects
Psychosocial development
- Erikson: Initiative vs. guilt:
- Become energetic learners, despite not having all the physical abilities needed to be successful at everything
- Guilt can occur when preschoolers believe they have misbehaved or when are unable to accomplish a task
Moral Development
- Kohlberg; Early preschoolers continue in the good-bad orientation of the toddler years, and actions are
taken based on whether or not it will result in a reward or punishment.
- Older preschoolers primarily take actions based on satisfying personal needs yet are beginning to
understand the concepts of justice and fairness.

Age appropriate activities

- Transition to associative play
- Play is not highly organized, but cooperation does exist between children
- Appropriate activities: Playing ball, Putting puzzles together, Riding tricycles, Playing pretend
dress up activities, Role-playing
Immunizations
- 4 TO 6 YEARS: Diphtheria and tetanus toxoids and varicella; and inactivated poliovirus (IPV)
- 3 TO 6 YEARS: Yearly seasonal influenza vaccine; trivalent inactivated influenza vaccine; or live, attenuated
influenza vaccine by nasal spray

Nutrition
- Mildly active req 1200-1440 kcal/day; average 1800 kcal/day
- Need 13-19g protein/day

Sleep and rest

- Need about 12 hours of sleep
- Keep consistent bedtime routine
- Avoid allowing preschoolers to sleep with their parents

Chapter 6: Health Promotion of School-Age Children (6-12 years)

Physical development
Weight: Gain 2-3 kg (4.4-6.6 lb.) per year
Height: Grows 5 cm (2 in.) per year
Cognitive development
- Piaget: Concrete operations
- Able to see the perspective of others
Psychosocial development
- Erikson: Industry vs. Inferiority
- A sense of industry is achieved through development of skills &knowledge that allows child to
provide meaningful contributions to society
- A sense of accomplishment is gained through the ability to cooperate and compete with others
- Peer groups play an important part in social development
Age appropriate activities;
- 6-9; Competitive and cooperative play is predominant; Play simple board and number games;
Play hopscotch; Jump rope; Ride bicycles; Join organized sports (for skill building)
- 9-12; Make crafts, Build models, Collect things/Engage in hobbies, Solve jigsaw puzzles, Play board
& card games, Join organized competitive sports
Immunizations
- If not given between 4 and 5 years of age, children should receive the following vaccines by 6 years of
age: diphtheria and tetanus toxoids and pertussis (DTaP); inactivated poliovirus; measles, mumps, and
rubella (MMR); and varicella
- Yearly seasonal influenza vaccine: inactivated influenza vaccine or live, attenuated influenza vaccine
(LAIV) by nasal spray
- 11 to 12 years: tetanus and diphtheria toxoids and pertussis vaccine (Tdap); human papillomavirus vaccine
HPV vaccine, and meningococcal vaccine

Health Screenings
Scoliosis: School-age children should be screened examining for a lateral curvature of the spine before and
during growth spurts. Can take place at schools or health care facilities.

Sleep and rest: Need 9 hrs. of sleep at age 11

Dental health : First permanent teeth erupt around 6 years of age

 Chapter 7: Health Promotion of Adolescents (12 to 20 years)

Physical development
- Final 20-25% of height is achieved during puberty
- Girls stop growing at about 2-2.5 years after the onset of menarche; grow 2-8 in & gain 15.5-55 lb.
In girls, sexual maturation occurs in the following order:
-Breast development
-Pubic hair growth
-Axillary hair growth
-Menstruation
- Boys stop growing around 18-20; Grow 4-12 in & gain 15.5-66 lb.
In boys, sexual maturation occurs in the following order:
-Testicular enlargement
-Pubic hair growth
-Penile enlargement
-Growth of axillary hair
-Facial hair growth
-Vocal changes
Cognitive development
- Piaget: Formal operations
- Increasingly capable of using formal logic to make decisions
Psychosocial development
- Erikson: Identity vs. role confusion
-Adolescents develop a sense of personal identity and to come to view themselves as unique individuals
Age-appropriate activities; Nonviolent videogames, Nonviolent music, Sports, Caring for pet, Reading

Immunizations
- Yearly seasonal influenza vaccine: Trivalent inactivated influenza vaccine or live, attenuated influenza vaccine
by nasal spray. Recommendation can be season-specific.
- 16 to 18 years: Meningococcal (MCV4) booster recommended if first dose received between
ages 13 and 15 years; booster dose not needed if the first dose is received at age 16 or older.

Health Screenings: Scoliosis screenings should continue during adolescent years

Chapter 8: Safe Medication Administration

Oral
- Preferred route of medication administration for children
- Avoid mixing medication with formula or putting in bottle of formula because infant may not take the entire
feeding, & the medication can alter the taste of the formula
- Use the smallest measuring liquid medication for doses of liquid medication
- Avoid measuring liquid medication in a tsp. or tbsp.
- Administer the medication in the side of the mouth in small amounts
- Stroke the infant under the chin to promote swallowing while holding the cheeks together

Otic
- Children younger than 3 years: Pull the pinna downward and straight back
- Children older than 3 years: Pull the pinna upward and back
Rectal
- Insert beyond both rectal sphincters (small child less than 0.5 inches, older child 1 inch).
- Hold the buttocks gently together for 5 to 10 min.
- If necessary to half the dose, cut the medication lengthwise.

Subcutaneous
- Inject volumes of less than 0.5 mL.
- Use a 1 mL syringe with a 26- to 30-gauge needle.
- Insert at a 90° angle. Use a 45° angle for children who are thin.
Intramuscular
- Use a 22-25 gauge, 1/2-1 inch needle
**Vastus lateralis is recommended site in infants and small children place child supine
- Other sites; ventrogluteal, deltoid; DORSOGLUTEAL is NOT recommended
- Inject up to 0.5ml for infants, up to 2ml for children
Intravenous
- Avoid terminology such as “bee sting” or “stick”
- Use 24-22 g catheter
- Apply EMLA to the site for 60 minutes prior to attempt (helps numb)
- Keep equipment out of site until procedure begins
- Perform procedure in a treatment room (don’t do it in their room)
- Allow parents to stay if they prefer
- Swaddle infants; Offer nutritive sucking to infants before, during, and after the procedure

Chapter 9: Pain management

Atraumatic measures; GOAL Do no harm

- Use play therapy to explain procedures, allowing the child to perform the procedure on a doll or toy
Pharmacological measures
- Give medications routinely, vs. PRN, to manage pain that is expected to last for an extended period of time
- Combine adjuvant medications w/ other analgesics
- IM injections not recommended for pain control in children
- Intranasal medication not recommended for children <18
Pain assessment tool
-FLACC: 2 months- 7 years
-Faces: 3 years and older
-Oucher: 3-13 years
-Numeric scale: 5 years and older

Chapter 10: Hospitalization, Illness, & Play

Impact Based on Development

Infant
- Experiences stranger anxiety between 6-8 months
- Displays physical behaviors as expressions of discomfort due to inability to verbalize

Toddler
- Limited ability to describe illness; Limited ability to follow directions
- Experiences separation anxiety
- Can exhibit an intense reaction to any type of procedure; Behavior can regress
Preschooler
- Fears related to magical thinking
- Can experience separation anxiety
- Might believe illness and hospitalization are a punishment
- Explain procedures using simple, clear language Avoid medical jargon
- Give choices when possible, such as, “Do you want your medicine in a cup or spoon?”

School-age child
- Ability to describe pain; Increasing ability to understand cause and effect
- Provide factual information; Encourage contact with peer group

Adolescent
- Increasing ability to understand cause & effect
- Perceptions of illness severity are based on the degree of body images
- Develops body image disturbance
- Experiences feelings of isolation from peers
- Provide factual information
- Encourage contact with peer group

Chapter 11: Death and Dying

Grief and mourning

- Anticipatory grief: When death is expected or a possible outcome
- Complicated grief: Extends for more than 1 year following the loss

Current stages of development

- Infants/toddlers (birth-3 years): Have little to no concept of death; Mirror parental emotions;
Can regress to an earlier stage of behavior
- Preschool (3-6); Magical thinking allows for belief that thoughts can cause an event such as death resulting in
feeling guilt and shame; Interpret separation from parents as punishment for bad behavior; View dying as temporary
- School-age (6-12): Begin to have adult concept of death; Fear often displayed through uncooperative behavior
- Adolescent (12-20): Can have adult-like concept of death; Can have difficulty accepting death; Rely more on
peers than the influence of parents; Can become increasingly stressed by changes in physical appearance

Physical manifestations of death

- Sensation of heat when the body feels cool
- Decreased sensation and movement in lower extremities
- Swallowing difficulties
- Bradycardia/hypotension
- Cheyne-strokes respirations

NURSING: After death

- Allow family to stay with the body as long as they desire
- Allow family to rock the infant/toddler
- Remove tubes and equipment
- Offer to allow family to assist with preparation of the body
 Chapter 12: Acute Neurological Disorders

Meningitis
Viral (aseptic) Meningitis: supportive care for recovery
Bacterial (septic) Meningitis: contagious infection
**Hib and PCV vaccines decrease the incidence
s/s; Photophobia, vomiting, irritability, headache
Newborns: Poor Muscle Tone, Weak Cry, Poor Suck-Refuses Feedings, Vomiting/Diarrhea,
Bulging Fontanels (late sign)
3 Months – 2 Years: Seizures with a High-Pitched Cry, Fever & Irritability, Bulging
Fontanels, Poor Feedings, Vomiting, Possible nuchal rigidity, Brudzinski’s sign and Kernig’s
sign not reliable for diagnosis
2 Years – Adolescence: Seizures (often initial sign), Nuchal rigidity, Fever/chills, Headache/vomiting,
Irritability/restlessness that can progress to drowsiness/stupor, Petechiae or purpuric type rash (with
meningococcal infection), + Brudzinski Sign: flexion of extremities with deliberate flexion of the neck,
+ Kernig’s Sign: resistance to extension of the leg from a flexed position
Labs; Blood Cultures; CBC; CSF Analysis
- Viral CSF; Clear Color, Slightly Elevated WBC & Protein, Normal Glucose, Gram -
- Bacterial CSF; Cloudy Color, Elevated WBC, Elevated Protein, Decreased Glucose, Gram +
DX: Lumbar Puncture (Definitive Diagnostic Test); Empty Bladder, EMLA Cream 45min – 1-hour prior,
Side-lying Position, Head Flexed, Knees Drawn to Chest; Remain in Flat Position to prevent Leakage& Spinal HA
NURSING:: Droplet precautions; Maintain NPO status if decreased LOC;  environmental stimuli -
Medications: IV antibiotics for bacterial infections
Complications: ICP: Newborns and Infants; Bulging or Tense Fontanels, Increased Head Circumference, High-
Pitched Cry, Irritability, Distended Scalp Veins, Bradycardia, Respiratory Changes
Children; Headache, N/V, Diplopia, Seizures, Bradycardia Respiratory Changes
double insion
Reye Syndrome: Primarily affects the liver (liver dysfunction) and brain (cerebral edema)
- Follows viral illness (Influenza, Gastroenteritis, Varicella), Giving Aspirin for fevers
s/s; lethargy, irritability, combativeness, confusion, delirium, profuse vomiting, seizures, LOC
Labs:  ALT and AST,  serum ammonia
Diagnostic procedures: Liver biopsy/CSF analysis
NURSING: Maintain hydration while preventing cerebral edema, Position client (avoid extreme flexion,
extension, or rotation), Monitor coagulation & prevent hemorrhage, Implement seizure precautions
Medications: Osmotic diuretic (Mannitol)
Complications: Neurologic sequalae, Death

Chapter 13: Seizures

Risk factors; Febrile Episode, Cerebral Edema, Intracranial Infection / Hemorrhage, Brain Tumors
/ Cyst, Toxins or Drugs, Lead Poisoning, Hypoglycemia, Electrolyte imbalances

Generalized seizures
Tonic-clonic seizures: AKA Grand mal
- Tonic Phase (10-30 seconds); Loss of Consciousness, Loss of Swallowing Reflex, Apnea leading to
Cyanosis; Tonic Contraction of entire body: arms and legs flexed, head and neck extended
- Clonic Phase (30-50 seconds); Violent jerking movements of the body
- Postictal State (30 minutes); Remains semiconscious but arouses w/ difficulty &confused, No recollection of
the seizure

Absence seizure; AKA petit mal or lapses; Onset between 4– 12 years and ceases by teenage yrs.
- Loss of Consciousness lasting 5 – 10 seconds, Minimal or no change in behavior,
Resembles daydreaming or Inattentiveness, Can drop items being held, but the child seldom falls
- Automatisms; Lip Smacking, Twitching of Eyelids or Face, Slight Hand Movements

Myoclonic seizure: Brief contraction of muscle or groups of muscle; No postictal state ; can involve only face
& trunk or one or more extremities; might not lose consciousness

Atonic or akinetic seizure AKA “drop attacks”; Onset 2-5; Muscle tone is lost for a few seconds often causes fall;
period of confusion follows

DX: -EEG Abstain from caffeine for several hours prior to the procedure; Wash hair (no oils or sprays)
before and after the procedure to remove electrode gel
NURSING: Initiate Seizure Precautions:
- Pad side rails of Bed | Crib | Wheelchair
- Keep bed free of objects that could cause Injury
- Have Suction and Oxygen Equipment available –
- During a Seizure:
- Protect from Injury (move furniture away, hold head in lap)
- Maintain a position to provide a patent airway
- Suction Oral Secretions
- Side-lying Position (decreases risk of aspiration)
- Loosen restrictive clothing
- Do NOT restrain the child
- Do NOT put anything in the child’s mouth
- Do NOT open the jaw or insert an airway during seizure, can damage teeth, lips, or tongue
- Remain with the child
- Note onset, time, and characteristics of seizure
- Allow seizure to end spontaneously
- Post-Seizure:
- Side-lying position to prevent aspiration and facilitate drainage of secretions
- Check for breathing, V/S and position of head
- NPO until swallowing reflex has returned
Medications
- Antiepileptic Drugs (AEDs):
-Diazepam (Valium) | Phenytoin | Carbamazepine | Valproic Acid |
TX:
- Focal Resection: of an area of the brain to remove epileptogenic zone
- Corpus Callosotomy: separation of two hemispheres in the brain
- Vagal Nerve Stimulator

Complications
- Status Epilepticus: Prolonged Seizure Activity that Lasts >30 minutes or Continuous seizure activity in
which the client does not enter a Postictal Phase
NURSING: Maintain Airway, Administer oxygen, IV access
 Chapter 14: Head Injury

Concussion; traumatic injury to brain that alters way brain functions

Contusion; bruising of cerebral tissue
Laceration; tearing of cerebral tissue
Skull fractures; caused by direct trauma to skull; can be
- Linear; most common; involve single factor beginning from point of impact; DO NOT cross suture line
- Depressed; broken bone fragments pushed inward
- Comminuted; made up of more than 1 linear fracture; occur following intense impact or repeated trauma to
head (abuse)
- Basilar; involve those at anterior and posterior base of skull
- Open; break in scalp or mucosa of respiratory tract and can lead to osteomyelitis
- Growing; fracture worsens due to pressure from brain herniation, dilated ventricles, or cyst
s/s:
Minor injury: Possible loss of consciousness, Temporary period of confusion, Vomiting, Pallor,
Irritability, Lethargy/drowsiness
Injury Progression; Marked changes in vital ins, Altered mental status, Focal neurologic deficits,  agitation
Severe injury: Increased ICP
**Measurement of ICP** Expected range 1- 10 mm Hg; > 15 requires further assessment
- Infants: Bulging fontanel, Irritability (usually 1st sign), High-pitched cry, Poor feeding
- Children: Nausea/headache, Forceful vomiting, Blurred vision, Seizures
- Late signs: Alterations in pupillary response, Posturing (flexion and extension),  motor
response,  response to painful stimuli, Cheyne-stokes respirations, Seizures, Flexion: severe
dysfunction of the cerebral cortex, Extension: Severe dysfunction at the level of the midbrain
NURSING; Ensure spine is stabilized until a spinal cord injury is ruled out;
Implement actions to decrease ICP: Keep the head midline with the bed elevated 30 degrees, which will also
promote venous draining, Avoid extreme flexion, extension, or rotation of the head and maintain in midline
neutral position, Keep the client’s body in alignment, avoiding hip flexion/extension, Minimize oral suctioning,
Nasal suctioning is contraindicated, Instruct the client to avoid coughing and blowing the nose; Insert and
maintain indwelling catheter; Administer stool softeners to avoid straining
Medications
- Mannitol: Osmotic diuretic used  intracranial pressure & treat cerebral edema
- Antiepileptic: Used to prevent or treat seizures
- Antibiotic; in case CSF leakage, lacerations, or penetrating injuries
- Analgesics (Acetaminophen); for headache, pain, fever; May give morphine and midazolam
TX: Craniotomy: to help relieve pressure; Transfontanel percutaneous aspiration;
Subdural drain; Burr holes; For Depressed fracture surgery to elevate depression
Complications
- Epidural hematoma: Bleeding between the dura and the skull
- Subdural hemorrhage: Bleeding between the dura and the arachnoid membrane
- Brain herniation: Downward shift of brain tissue
 Chapter 15: Cognitive and Sensory Impairments

- Sensory impairments in children most commonly affect eyes & ears

- Down syndrome affects growth & development & results in cognitive & sensory impairments

Visual impairments
- Myopia: (Nearsightedness); Sees close objects clearly, but not objects in the distance
- Hyperopia: (Farsightedness);Sees distant objects clearly, but not objects that re close
- Strabismus: Esotropia: inward deviation of the eye; Exotropia: outward deviation of the eye
- Occlusion therapy: Patch stronger eye to make weaker eye stronger
- Anisometropia; different refractive strength in each eye; Headache, vertigo, xs eye rubbing
- Amblyopia (lazy eye); reduced visual acuity in one eye

Visual screening
- Snellen letter, tumbling E, or picture chart Place the client 10 feet from the chart with heels
on the 10-foot mark
Partial visual impairment; visual acuity 20/70 to 20/200

Hearing impairment
s/s; INFANTS; lack of startle reflex, failure to respond to noise, absence of vocalization by 7 mo., Fail to
localize sound by 6 mo.
OLDER CHILD: Failure to develop understood speech by 24 mo.; Yelling to express emotions; seeming shy or
withdrawn; speaking in monotone
shake In have (3 5)
.

attach hold
-
(5-10)
exhale Chapter 16: Oxygen and Inhalation Therapy
tilt

Metered-dose Inhaler
- Shake the inhaler 5-6 times, Attach the spacer (Helps facilitate proper inhalation, Take deep breath & exhale,
Tilt the head back slightly, and press the inhaler, While pressing the inhaler, begin a slow, deep breath that lasts
for 3-5 seconds, Hold the breath for 5-10 seconds; for corticosteroids rinse and spit after
Dry powder Inhaler
- DO NOT shake, Inhale medication & hold breath 5-10 seconds
Chest physiotherapy (CPT); set of technique involving manual or mechanical percussion, vibration,
cough, forceful expiration or huffing, & breathing exercises
- gravity & positioning helps loosen respiratory secretions
- Schedule treatments before meals or at least 1 hr. after meals and at bedtime
-Administer bronchodilator medication or nebulizer treatment prior to CPT

NURSING; Promote drainage of specific areas of lungs

Apical section upper lobes; Fowlers
Posterior section upper lobes; Sitting leaning forward curled over pillows
Anterior segments of both upper lobes; Supine & rotated slightly away from side being drained
Superior segments of both lower lobes; Prone w/ hips elevated on pillows

Hypoxemia easyo
Early signs: Tachypnea, Tachycardia, Restlessness, Use of accessory muscles, Pallor, Nasal flaring
Late signs; Confusion, stupor, cyanosis, bradypnea, bradycardia, hypo, or hypertension
 O2 Therapy Delivery Systems
Oxygen Hood; Min flow rate 4-5 L/min
Nasal Canula; Provide humidification on flow rates > 4L/min
Pediatric Face Mask; Used at flow rate 5-10 L/min

Complications: Oxygen toxicity; Can result from high concentrations of oxygen, long duration of oxygen
therapy, and the child’s degree of lung disease
s/s: nonproductive cough, substernal pain, nasal stuffiness, N/V, fatigue, headache, sore throat, hypoventilation

Chapter 17: Acute and Infectious Respiratory Illnesses

Tonsillitis
s/s: Report of sore throat with difficulty swallowing, Mouth odor/mouth breathing, Fever,
Snoring, Difficulty swallowing/eating, Tonsil inflammation with redness and edema
Labs: Throat culture: (For GABHS )
Medications:
- Antipyretics/analgesics: acetaminophen, hydrocodone is indicted for difficulty drinking fluids
- Antibiotics: for Tx of GABHS
TX: Tonsillectomy: for recurring tonsillitis
aspiration POSTOP; Side-lying position after then elevate HOB when child is awake ; Assess for evidence
& of bleeding: Frequent swallowing/clearing the throat, Avoid red-colored liquids, citrus juice, and milk-
based foods, Discourage coughing, throat clearing, and nose blowing to protect surgical site, Avoid
straws: can damage surgical site, Alert parents that there can be clots or blood-tinged mucus in vomit,
Limit activity to decrease the potential for bleeding, Fully recovery usually occurs in 14 days

Bronchitis (tracheobronchitis); ass. w/ upper resp tract infection & inflammation of large airways;
Self limiting
s/s; persistent dry hacking cough from inflammation (resolves 5-10 days)
TX; antipyretics, cough suppressant, increased humidity (cool mist vaporizers)

Bronchiolitis; most often caused by RSV; primarily affects bronchi & bronchioles; occurs at
bronchiolar level
s/s: INITIAL: Rhinorrhea, intermittent fever, pharyngitis, coughing, sneezing, wheezing, possible ear or
eye infection; WITH ILLNESS PROGRESSION: Increased coughing and sneezing, fever, tachypnea and
retractions, refusal to nurse or bottle feed, copious secretions ; SEVERE ILLNESS: Tachypnea (greater than
70/min), listlessness, apneic spells, poor air exchange, poor breath sounds, cyanosis
TX; O2, fluids, Maintain airway, CPT & bronchodilators NOT recommended

Bacterial Pneumonia
s/s: High fever; Cough may be unproductive or productive of white sputum, Tachypnea, Retractions
and nasal flaring, Chest pain, Dullness with percussion, Adventitious breath sounds (rhonchi, fine
crackles), Pale color that progresses to cyanosis, Irritability, restless, lethargic, Abdominal pain,
diarrhea, lack of appetite, and vomiting
TX: VIRAL; O2 w/ cool mist, antipyretics, I &O, CPT & postural drainage
BACTERIAL; rest, ABX, increased oral intake, antipyretics, CPT & postural drainage, IV fluids, O2
Complications; Pneumothorax, Pleural effusion
1) dysphagia
dyspnea
2)

3) dysphonia
43 distress

by His
Croup syndromes can be prevented
vaccine

Bacterial Epiglottis (Acute Supraglottic): MEDICAL EMERGENCY

s/s: Tripod positioning, Drooling, Dysphonia: thick, muffled voice and froglike croaking sound, Dysphagia,
High fever, inspiratory stridor
NURSING: Avoid throat culture/putting tongue blade in the mouth, Prepare for intubation, Administer ABX
therapy starting with IV, then transition to oral to complete a 10-day course, Droplet isolation precautions for
first 24 hr. after IV ABX initiated

Acute Laryngotracheobronchitis (LTB); caused by

Night
RSV, Influenza A & B, Mycoplasma pneumonia Acute Spasmodic Laryngitis (Midnight Croup)
s/s: Low-grade fever, restlessness, hoarseness, s/s: Croupy barky cough, restlessness, difficulty
barky cough, dyspnea, inspiratory stridor, and breathing, hoarseness, and nighttime episodes of
retractions; INFANTS AND TODDLERS: nasal laryngeal obstruction
flaring, intercostal retractions, tachypnea, and
continuous stridor

NURSING: humidity w/ cool mist, O2 as needed, nebulized racemic epinephrine as prescribed; Administer
corticosteroids: oral or IM (dexamethasone), or nebulized (budesonide).

Influenza A and B
s/s: Sudden onset of chills and fever, Body aches, dry throat & nasal mucosa, dry cough, photophobia, flushed
face, myalgia
Antivirals must be given within 48 hrs. of onset Amantadine, Zanamivir, Oseltamivir

Chapter 18: Asthma

Triggers; Allergens, Smoke, Exercise, Cold air or changes in the weather or temperature, colds
s/s: Dyspnea, Cough, Audible wheezing, Use of accessory muscles, mucous, restlessness, anxiety, tripod
position
DX:
- Pulmonary function test (PFT); most accurate
- Peak Expiratory Flow Rates (PEFR); uses flow meter to measure amount of air that can be forcefully
exhaled in 1 second
- Bronchoprovocation Testing; exposure to methacholine, cold air or histamine
Medications
- Bronchodilators; (Sort acting beta 2): albuterol, levalbuterol, terbutaline; (Long acting) Salmeterol;
SE: tremors/tachycardia
- Anticholinergics: atropine/ipratropium; relief of acute bronchospasms; Dries you up
- Anti-inflammatory; (Corticosteroids) prednisone; Rinse mouth afterwards; Leukotriene modifiers; Mast cell
stabilizers (cromolyn); Monoclonal antibodies (omalizumab); Theophylline; Magnesium sulfate
NURSING: How to use a peak flow meter; Ensure the marker is zeroed, Close lips tightly around the
mouthpiece, Blow out as hard and as quickly as possible, Repeat 3 more times, Record highest number
Complications
- Status asthmaticus: Airway obstruction that is often unresponsive to treatment; Prepare for emergency
intubation
-Respiratory failure
 Chapter 19: Cystic Fibrosis

Cystic fibrosis; Both biological parents carry the recessive trait for CF
- Characterized by mucus glands that secrete an increase in the quantity of thick, tenacious mucus, which
leads to mechanical obstruction of organs muchmus
too

s/s: EARLY; Wheezing, rhonchi, Dry, nonproductive cough; Increased involvement: Dyspnea,
Paroxysmal cough, Obstructive emphysema, and atelectasis on chest x-ray; ADVANCED: Cyanosis,
Barrel-shaped chest, Clubbing of fingers and toes
GI : Large, frothy, bulky, foul-smelling stools (steatorrhea), Failure to gain weight or weight loss, Delayed
growth patterns, Distended abdomen, Thin arms and legs, Deficiency of fat-soluble vitamins (Vitamin A,D,E,K)
SKIN; Sweat, tears, and saliva having high content of sodium and chloride
DX: Sweat chloride test (most definitive) Chloride > 40for infants < 3 mo & > 60 for all others; Sodium > 90
NURSING ; CPT, High protein/calorie, Give pancreatic enzymes within 30 min of eating a
meal or snack, Multivitamin A,D,E,and K
Medications
- Bronchodilators: albuterol
- Anticholinergics: ipratropium bromide
- Fluticasone propionate/ salmeterol
- Dornase alfa (pulmozyme): decreases viscosity of mucus and improves lung function
- ABX; tobramycin, ticaricillin,gnetamicin
- Pancreatic enzymes
- Vitamins A, E, D, K

Chapter 20: Cardiovascular Disorders

blood to the longs
too much

Defects that INCREASE Pulmonary Blood Flow; (left-to-right shunt)

- Ventricular septal defect (VSD): Loud, harsh murmur at the left sternal border
- Atrial septal defect (ASD): Loud, harsh murmur with a fixed split second heart sound
- Patent ductus arteriosus (PDA): Connection between pulmonary artery and aorta stays open after birth
polmonic vages
causing mixing of blood; Murmur (machine hum), Bounding pulses Pulmonarystenosis narrowing
: of
muscre development
: too much
hypertrophy
blood longs ight ventricular
not enough to the
Bending aorta overuse

septe wall
Defects that DECREASE Pulmonary Blood Flow USD : hole between centricle
- Hypercyanotic (Tet) spell manifest as acute cyanosis and hypernea
- Tricuspid atresia: complete closure of the tricuspid valve that results in mixed blood flow; Infants:
Cyanosis, dyspnea, tachycardia; Older children: Hypoxemia, clubbing of fingers
- Tetralogy of Fallot: Pulmonary stenosis, right ventricular hypertrophy, overriding aorta, &
ventricular septal defect (PROV); Cyanosis at birth: progressive cyanosis over the first year of life;
Systolic murmur; Episodes of acute cyanosis and hypoxia (blue or “Tet” spells)

Obstructive Defects not enough blood flow

·

- Pulmonary stenosis: narrowing of the pulmonary valve or pulmonary artery that results in
obstruction of blood flow from the ventricles; Systolic ejection murmur
- Aortic stenosis: narrowing of the aortic valve; INFANTS: Faint pulses, hypotension, tachycardia, poor
feeding tolerance; CHILDREN: Intolerance to exercise, dizziness, chest pain, possible ejection murmur
- Coarctation of the aorta: narrowing of the lumen of the aorta; hardens
-

Elevated blood pressure in the arms, Bounding pulses in the upper extremities, Decreased blood pressure in the
lower extremities, Cool skin of lower extremities, Weak or absent femoral pulses
 oxygenated
- - beoxygenated
Mixed defects blood mix

- Transportation of the great arteries; aorta connected to the right ventricle instead of left & pulmonary
artery is connected to the left ventricle instead of right; Severe to less cyanosis depending on the size
of the associated defect
- Truncus arteriosus: Failure of septum formation, resulting in a single vessel that comes off of the
I does not form

ventricles; Murmur, variable cyanosis, Lethargy, Fatigue, Poor feeding

- Hypoplastic left heart syndrome: Left side of the heart is underdeveloped; Lethargy/cyanosis, cold hands & feet

Pulmonary Artery HTN (PAH); high BP in arteries of the lungs; progressive & fatal; no cure
s/s: Dyspnea w/ exercise; Chest pain; Syncope

Infective (Bacterial) Endocarditis; Infection of inner lining of heart & valves, can enter bloodstream;
caused by Streptococcus viridians, Candida albicans, Staphylococcus aureus
s/s: Fever, malaise, new murmur, myalgia, arthralgias, diaphoresis, weight loss, splinter hemorrhages
under fingernails; NEONATES: feeding problems, respiratory distress, tachycardia, septicemia
NURSING: Counsel the family of high-risk children about the need for prophylactic antibiotics prior to
dental and surgical procedures
TX: ABX parenterally for extended period of time (2-8 wks.)
increased HR
↑ d contractility
=

Cardiomyopathy; abnormities of myocardium that interfere w/ ability to contract effectively;

can lead to HF
Classifications
- Dilated (DCM); most common; Hypertrophic (HCM); autosomal genetic increase in heart muscle
mass lead t abnormal diastolic function; Restrictive; rare, prevents filling of ventricle & causes decrease
in diastolic volume
s/s: tachycardia, dysrhythmias, dyspnea, hepatosplenomegaly, fatigue & poor growth

Shock
Cardiogenic shock; results from impaired cardiac function that leads to decrease in CO
Anaphylactic Shock allergic reaction
s/s: Dyspnea, Breath sounds with crackles, Grunting, Hypotension, Tachycardia, Weak peripheral pulses
**MANIFESTATIONS OF HEART FAILURE
Impaired myocardial function: Sweating, tachycardia, fatigue, pallor, cool extremities with weak pulses,
hypotension, gallop rhythm, cardiomegaly
Pulmonary congestion: Tachypnea, dyspnea, retractions, nasal flaring, grunting, wheezing, cyanosis, cough,
orthopnea, exercise intolerance
Systemic venous congestion: Hepatomegaly, peripheral edema, ascites, neck vein distention, periorbital
edema, weight gain

DX: Cardiac catherization

NURSING: Check for allergies to iodine or shellfish, Provide for NPO status 4-6 hr. prior, Locate, and mark
the Dorsalis pedis and posterior tibial pulses on both extremities, Prevent bleeding by maintaining the affected
extremity in a straight position for 4-8 hr. ; Limit activity for 24 hrs.

Medications
- Digoxin: Improves myocardial contractility;
- Infant: hold if pulse<90; Children: hold if pulse <70
 - Monitor for toxicity: Bradycardia, Dysrhythmias, N/V, Anorexia
- Ace inhibitors: captopril; Monitor BP & potassium levels
- Beta-blockers: metoprolol; Monitor BP, Bulse, & for adverse effects (dizziness, hypotension, headache)
- Potassium-wasting diuretics: furosemide; Watch for hypokalemia (nausea/vomiting/dizziness),
Give Foods high in potassium: (Bran cereal, potatoes, tomatoes, dark green leafy veggies, bananas,
orange juice, oranges, and melons )
of another physiologic problem
Grant
Rheumatic fever ; inflammatory disease; Usually occurs within 2-6 weeks following an untreated or
partially treated upper respiratory infection (strep throat) with GABHS – joins
s/s: Fever, tachycardia, cardiomegaly, new or changed heart murmur, muffled heart sounds, pericardial
friction rub, nontender subcutaneous nodules over bony prominence, polyarthritis, pink, nonpruritic
macular rash, CNS involvement (chorea), irritability, poor concentration, behavioral problems
Laboratory tests: Throat culture for GABHS, Blood antistreptolysin-O titer Elevated or rising titer, most
reliable diagnostic test); CRP & ESR ( in response to inflammation)

·
Jones Criteria: Diagnosis of rheumatic fever is made on the basis of modified jones
criteria; child should demonstrate the presence of 2 major criteria or the presence of 1 major
and 2 minor criterion following an acute infection with GABHS infection
- Major criteria: Carditis, Subcutaneous nodules, Polyarthritis, Rash (erythema marginatum),
Chorea: involuntary muscle movements
- Minor criteria: Fever, Arthralgia
TX: ABX prophylaxis (Two daily oral doses of penicillin V OR Monthly IM injection of
penicillin G OR Daily oral dose of sulfadiazine
Remember
Blood inflammation RED
venel

Kawasaki disease; Acute systemic vasculitis (inflammation of the blood vessels in the body) lumph nodes
I

s/s: ACUTE PHASE; Fever greater than 102 F lasting 5 days to 2 weeks and unresponsive to antipyretics,
Irritability, Red eyes without drainage , Bright red, chapped lips, Strawberry tongue with white coating or
red bumps on the posterior aspect, Red oral mucous membranes with inflammation including the
pharynx, Swelling of hand and feet with red palms and soles; SUBACUTE PHASE; Peeling skin around the
nails, on the palms/soles
Medication: Gamma globulin: IVGG, Aspirin
Client education: Avoid live immunizations for 11 months
Complications; Coronary artery dilation aneurysm

Chapter 21: Hematologic Disorders

mode
ore
Epistaxis; Have the child sit up with the head tilted slightly forward to prevent aspiration of blood; Apply
pressure to the lower nose with the thumb and forefinger for at least 10 min; If needed, pack cotton or tissue into
the side of the nose that is bleeding; Apply ice across the bridge of the nose if bleeding continues

Iron deficiency anemia; Adolescents at risk due to poor diet, rapid growth, menses, strenuous activities, &obesity
Risk factors: Excessive intake of cow’s milk in toddlers, Milk is not a good source of iron, Milk takes the place
of iron-rich solid foods
NURSING: Modify infants diet to include high iron& vitamin C; Provide iron supplements for preterm and
low-birth-weight infants by age 2 months; Provide iron supplements to full term infants by age 4 to 6 months.
Iron supplements (Give 1 hr. before or 2 hr. after milk or antacid to prevent decreased absorption, Give with
vitamin c to increase absorption, Use a straw to prevent staining of the teeth); Use a z-track method for
Dairy can decrease
iron
absorption of
 injection, Do not massage the injection site; Tarry green stools are expected Instruct the child to brush teeth after
oral dose to minimize or prevent staining
Dietary sources of iron:
- Infants: Iron-fortified cereals and formula
- Older children: Dried beans, lentils, peanut butter, green leafy veggies, iron fortified breads & flour, red meat

Sickle cell anemia; autosomal recessive genetic disorder; Primarily affects African Americans; Causes cell
lacofO2 to be sickle shape causing increased blood viscosity, obstruction of blood flow, and tissue hypoxia
s/s: Reports of pain: due to tissue ischemia, Shortness of breath/fatigue, Pallor, Jaundice
- Vaso-occlusive crisis (painful episode):ACUTE r/t dehydration &  O2; severe pain, usually in bones, joints,
and abdomen, swollen joints, hands, and feet, Abdominal pain, Hematuria, Obstructive jaundice, Visual
disturbances; CHRONIC; Increased risk of respiratory infections and osteomyelitis, Retinal detachment and
blindness, Systolic murmur, Renal failure and enuresis, Liver cirrhosis; hepatomegaly, Seizures, Skeletal
deformities; shoulder or hip avascular necrosis
- Sequestration; Excessive pooling of blood primarily in the spleen (splenomegaly), and sometimes in the liver
(hepatomegaly); Reduced circulating blood volume results in hypovolemia and can progress to shock
- Aplastic Crisis; Extreme anemia as a result of a temporary decreased RBC production, Typically triggered by
an infection with a virus
- Hyperhemolytic crisis; Increased rate of RBC destruction leading to anemia, jaundice, and/or reticulocytosis
Medication; Opioids, Antineoplastics
NURSING: Keep patient hydrated, Schedule administration of analgesics to prevent pain
Complications: Stroke, acute chest syndrome, Infections, Kidney Scarring,  Visual Acuity, Priapism (males)
A: 8 ,B: 9 , von willebrands
Hemophilia; Bleeding disorders characterized by difficulty controlling bleeding; deficiencies in clotting factors
Hemophilia A (Classic): deficient of factor VIII
Hemophilia B (Christmas Disease): deficient of factor IX
s/s; Excessive bleeding, Reports of joint pain and stiffness, Easy bruising, Activity intolerance
Labs: Prolonged aPTT; PLT and PT within expected ranges
NURSING: Avoid unnecessary skin punctures; Elevate and apply ice to the affected joints; Set activity
restrictions to avoid injury; Low-contact sports: bowling, fishing, swimming, and golf; Use soft-bristled
toothbrushes; Control bleeding episodes using RICE (rest, ice, compress, and elevate)
Complications: Uncontrolled bleeding, Joint deformity

Chapter 22: Acute Infectious GI Disorders

Marsha
Rotavirus; Viral; Most common cause of diarrhea in children younger than 5 years; Fecal-Oral Transmission;
Incubation 48 hrs.
s/s: Onset of watery stools, Fever, Diarrhea for 5-7 days, Vomiting for 2 days

Enterobius vermicularis (pinworm); Fecal-Oral Transmission;

s/s: Perineal itching, enuresis, sleeplessness, restlessness
NURSING; Perform a tape test over anus at night 3; Diarrhea Avoid: Fruit juices, carbonated sodas, and
gelatin, Caffeine, Chicken or beef broth, BRAT diet, Cleanse toys and childcare areas thoroughly to prevent
further spread or reinfestation (eggs can survive 2-3 wks. on surfaces); Avoid undercooked or under-
refrigerated food; Do not share dishes and utensils
Types of Dehydration
- Isotonic; Water and sodium are lost in nearly equal amounts.; Major loss of fluid from extracellular fluid
leads to a reduced volume of circulating fluid; Hypovolemic shock can result; Blood sodium is within
normal limits (130 to 150 mEq/L).
- Hypotonic; Electrolyte loss is greater than water loss; Water changes from extracellular fluid to
intracellular fluid; Physical manifestations more severe with smaller fluid loss; Shock is likely; Blood
sodium is less than 130 mEq/L.
- Hypertonic; Water loss is greater than electrolyte loss; Fluid shifts from intracellular to extracellular;
Shock is less likely; Neurologic changes (change in level of consciousness, irritability, hyperreflexia) can
occur; Blood sodium concentration is greater than 150 mEq/L.

Levels of Dehydration
- Mild; Capillary refill greater than 2 seconds; Possible slight thirst
Nursing; 50mL/kg rehydration fluid within 4 hrs.
- Moderate: Capillary refill between 2-4 seconds; Possible thirst and irritability
Nursing; 100mL/kg rehydration fluid within 4 hrs.
- Severe: Capillary refill >4; Tachycardia; Extreme thirst; Very dry mucous membranes and
tented skin; No tearing with sunken eyeballs; Sunken anterior fontanel; Oliguria and anuria
Nursing; Replacement of diarrhea loses with 10 mL/kg each stool

Chapter 23: Gastrointestinal Structural & Inflammatory Disorders

spoon
Cleft Lip & Cleft Palate use
Cleft Lip: Results from incomplete fusion of the oral cavity during intrauterine life
- Repair usually done withing 2-3 months of age ; POST OP place upright and on back or on side, apply
elbow restraints, use water, or dilute hydrogen peroxide to clean site
Cleft Palate: Results from the incomplete fusion of the palates during intrauterine life
- Repair usually done between 6-12 months of age; POST OP; Place upright; Change position frequently to
facilitate breathing and drainage; NPO for 1st 4 hrs., then liquids for 3-4 days
For isolated cleft lip: Use a wide-based nipple for bottle-feeding
For CP or CL and CP: Use a specialized bottle with a one-way valve and a specially cut
nipple; Avoid having the infant suck on a nipple or pacifier
Complications: Ear infections and hearing loss, Speech and language impairment, Dental
problems of speech problems
doned 6 mos .
to decrease rick
GERD : S/S w/ tissue damage
GERD; GER: S/S wo tissue damage ,

Gastroesophageal reflux (GER) occurs when gastric contents reflux back up into the esophagus, making
esophageal mucosa vulnerable to injury from gastric acid; self-limiting and usually resolves by 1 year of age.
Gastroesophageal reflux disease (GERD) is tissue damage from GER; GER is
s/s: INFANTS; Sitting up or forceful vomiting, Irritability, Arching of back ; CHILDREN; Difficulty
swallowing; Chronic cough; Non-cardiac chest pain
NURSING: GER; Small, Frequent Meals, Thicken infant’s formula with 1 tsp. to 1 tbsp. rice cereal per 1oz
formula, Avoid: Caffeine | Citrus | Peppermint | Spicy or Fried Foods, Assist with weight control, HOB elevated
during and after meals (at least 30 degrees); GERD; Initiate interventions for GER, plus administering a proton
pump inhibitor (omeprazole, esomeprazole, pantoprazole and rabeprazole), or an H2-receptor antagonist
(cimetidine or famotidine).
pepcid
TX: Nissen fundoplication: for severe cases of GERD; Laposcopic procedure wraps the fundus of the stomach
around the distal esophagus to decrease reflux pyloric sphincter
thickens
↑
Hypertrophic pyloric stenosis; Thickening of the pyloric sphincter, which creates an obstruction –
s/s: vomiting after feeding & becomes projectile as obstruction worsen; Constant hunger/dehydration; Olive-
shaped mass in the right upper quadrant of the abdomen
TX: Pylorotomy

Hirschsprung’s disease; Lack of ganglionic cells in segments of the colon resulting in decreased motility and
unable digest/process e adequate rate
to an
mechanical obstruction
s/s: NEWBORN; Failure to pass meconium within 24-48 after birth; Episodes of vomiting bile; Refusal to eat;
Abdominal distention; INFANT: failure to thrive, constipation, vomiting; CHILD; undernourished anemic
appearance, abdominal distention, visible peristalsis, palpable fecal mass, constipation, Foul-smelling, ribbon-
like stool
NURSING: High-protein/calorie and low-fiber diet
TX: Surgical removal of the aganglionic section of the bowel; may require temporary colostomy
Complications; Enterocolitis (inflammation of bowel); Anal stricture & incontinence
boweltelescopes
Twists

Intussusception; Proximal segment of the bowel telescopes into a more distal segment; common 3 months- 6 years
s/s: sudden episodic abdominal pain, screaming w/ drawing knees to chest during pain, vomiting, fever,
tender/distended abdomen, Abdominal mass (sausage-shaped), Stools mixed with blood and mucus that
resembles the consistency of red currant jelly
TX: Air enema w/ or w/o contrast
canforceintoMol
a
Appendicitis; Inflammation of the vermiform appendix; Average age is 10
s/s: Abdominal pain in the right lower quadrant, Decrease or absent bowel sounds, rigid abdomen, diarrhea
or constipation, lethargy, tachycardia, rapid, shallow breathing, anorexia, Fever
Labs: CBC
DX: CT scans
NURSING: Avoid applying heat to the abdomen, avoid enemas or laxatives; Watch for
pain: if patient no longer feels pain, appendix ruptured can cause sepsis
-

TX: Removal of nonruptured appendix:

- Pre-op: Give IV fluid replacement/IV antibiotic
- Post-op: Place NG tube for decompression, assess for bowel sounds
think "gim"

Meckel’s Diverticulum; complication from failure of omphalomesenteric duct to fuse during embryonic
development
s/s: Rectal bleeding (painless); abdominal pain; bloody, mucus stools
DX: Meckel’s scan
TX: Surgical removal of diverticulum
in intestines present at birth
-
small pouch

Chapter 24: Enuresis and Urinary Tract Infections

T bedwetting
Enuresis; uncontrolled or unintentional urination after age bladder control is achieved
- Must be at least 5 years of age before there’s consideration about diagnosing enuresis; at least 2x/wk.
for at least 3 months
Primary enuresis: A child has never been free of bed-wetting for any extended periods of time
Secondary enuresis: A child who started bed-wetting after development of urinary control
startedafter
none
TX: Conditioning therapy ( placing alarm or sensor that rings when child voids to awaken child to
use bathroom); Kegel/pelvic exercises; Retention Control Measured
Medications; ADH (Desmopressin acetate reduces volume of urine), TCAs (Imipramine
hydrochloride inhibits urination), Anticholinergics (Oxybutynin chloride reduces bladder
contractions

C
NURSING: Have the child empty bladder before bedtime; Encourage fluids during the day and
restrict fluids in the evening; Avoid fruit and fruit drink, caffeinated or carbonated drinks after 1600;
Use positive reinforcement; Avoid punishing, scolding, or teaching the child following an incident

UTI
Bacteriuria: bacteria in the urine; Asymptomatic bacteriuria: bacteriuria with no s/s of UTI;
Symptomatic bacteriuria: bacteriuria with manifestations of UTI
Recurrent UTI: multiple occurrences of asymptomatic or symptomatic bacteriuria
Persistent UTI: bacteriuria that does not resolve with antibiotic therapy
Febrile UTI: symptomatic bacteriuria with fever; Urosepsis: febrile UTI with systemic manifestations.
Cystitis: inflammation of the bladder febrile : Sever
Urethritis: inflammation of the urethra
Pyelonephritis: inflammation of the upper urinary tract and the kidneys
s/s: INFANTS; Poor feeding, vomiting, or failure to gain weight, Increase in thirst, Frequent urination, Foul-
smelling urine, Fever, Seizure, Pallor
CHILDREN: abdominal or back pain, pain w/ urination, poor appetite, vomit, slow growth, increased thirst,
enuresis, dysuria, swelling of face, pallor, fatigue, blood in urine, HTN, tetany
Labs: Urinalysis and urine culture and sensitivity (Nitrates & leukocytes will be , acidic pH,
+ for protein, glucose, ketones, RBC))
Education: Teach females to wipe the perineal area from front to back, Use of cotton underwear, Instruct
avoidance of bubble baths, Encourage frequent voiding, Empty complete bladder

Chapter 25: Structural Disorders of the Genitourinary Tract and Reproductive System

Defects of the genitourinary tract

Obstructive Uropathy; structural or functional obstruction of urinary system
s/s: hydronephrosis, UTI, oligohydramnios
TX: Surgical procedure that divert flow of urine to bypass obstruction (ureteral stent, pyelostomy tube,
cutaneous ureterostomy tube

Chordee; ventral curvature of penis

TX: surgical release of fibrous band
bladder sticks out
Bladder Exstrophy: Eversion of posterior bladder through anterior bladder wall &lower abdominal wall
TX: Cover the exposed bladder with sterile, nonadherent dressing; Prepare the child for immediate surgery

Hypospadias: Urethral opening located just below the glans penis, behind the glans penis, or on the ventral
surface of the penile shaft; Meatus opening below the glans penis; possible chordee present
,
brethral openening doesn't wate y perils opening abnormalopening below retre
Epispadias: abnormal opening aboverta
MALE: widened pubic symphysis; Urethra opened on dorsal surface of the penis; possible exstrophy of bladder
FEMALE: Wide urethra; Bifid clitoris; possible exstrophy of bladder
TX: Surgery 1st year of life
Phimosis:
do
Inability to retract foreskin of penis; normal finding in infants & young boys, usually disappears with age
it
not
force
-

Cryptorchidism; undescended testes

TX: surgery performed at 6 & 24 months

Hydrocele; Fluid in scrotum, enlarged scrotal sac; can resolve spontaneously

Varicocele; elongation, dilation & tortuosity of the veins of the spermatic cord superior to the testicle; may
experience discomfort w/ sexual stimulation

Testicular torsion: Testes hang free from vascular structures; pain is acute or insidious in onset & radiates to groin
area; Immediate surgery required
Chapter 26: Renal Disorders

Acute glomerulonephritis; benign inflammation of glomeruli that causes intravascular coagulation

that lasts 1-2 wks.; associated with GABHS
s/s: : oliguria, edema, HTN, circulatory congestion, hematuria, proteinuria; Cloudy, tea-colored urine,
Decreased urine output, Periorbital edema, Facial edema that is worse in the morning but spreads to extremities
&abdomen with progression of the day
Labs: Urinalysis: Proteinuria, smoke or tea-colored urine, hematuria,  specific gravity; Renal function:  BUN
& creatinine; Antistreptolysin O (ASO) titer; Positive indicator for the presence of streptococcal antibodies
strepscreening
NURSING: Possible restriction of sodium and fluid; Monitor for skin break down (at risk due to edema);
Encourage frequent turning and repositioning
Medications: Diuretics and antihypertensives; ABX; Phosphate binders; Sodium polystyrene sulfonate

Nephrotic syndrome; Alterations in the glomerular membrane allow proteins (especially albumin) to pass into
the urine, resulting in decreased serum osmotic pressure leading to proteinuria, hyperlipidemia, & edema
s/s; weight gain over period of days or weeks, Facial and periorbital edema: decreased throughout the day,
ascites, edema in lower extremities & genitals, Muehrcke lines on fingernails ( white lines parallel to lunula),
pallor, lethargy, dyspnea, Decreased frothy urine, BP within expected range or slightly below
Labs: Urinalysis/24-hour urine: Proteinuria: up to 15 g
Hypoalbuminemia: reduced serum protein and albumin, Hyperlipidemia: elevated serum lipid levels
Hemoconcentration: elevated Hgb, Hct, and platelets, Total Ca: decreased, ESR; increased
NURSING: Monitor daily weights, Monitor edema, and measure abdominal girth daily, Salt
can be restricted during the edematous phase, Assess skin for breakdown
Medications: Corticosteroids: prednisone; Diuretic: furosemide; 25% albumin: increases volume and
decrease edema; Immunosuppressant: cyclophosphamide

Hemolytic Uremic Syndrome (HUS); acute renal disease characterized by acute renal failure, hemolytic
anemia, & thrombocytopenia; peak incidence 6 mo- 4 yrs.
s/s: after prodromal period of V/D, occasionally occurs after varicella, measles, or UTI, loss of appetite,
irritability, lethargy, stupor, hallucinations, edema, pallor, bruising, purpura, or rectal bleeding, anuric or
HTN in severe form, urinary output may be  or 
Labs;  Reticulocyte, BUN, Creatine;  Hgb & Hct; UA + for blood, protein & casts
NURSING; I&Os, daily weights, fluid replacements, treat HTN, correct acidosis & electrolyte
imbalances, Seizure precautions; Enternal nutrition once V/D resolve
Acute Renal Failure; inability of the kidneys to excrete waste material, concentrate urine, and conserve
electrolyte
s/s: Oliguria: in reversible ARF there is a period of severe low urinary output, Abrupt diuresis: with return to
normal urine volumes, Edema, Drowsiness, Circulatory collapse, Cardiac arrhythmia: from hyperkalemia
(irregular, weak pulse, abdominal cramps, weakness, Seizures: from hyponatremia or hypocalcemia (tetany),
Tachypnea: from metabolic acidosis, CNS manifestations: from continued oliguria
Labs;  K+, Phosphorus, Creat, BUN;  Na+, Ca; Metabolic acidosis, anemia, azotemia,
NURSING; Treat underlying cause; Monitor strict I&Os; assess fluid & electrolyte balance; Limit fluid intake,
Daily weights, Maintain neutral temp, Maintain urinary cath, limit activity, assess for infection, seizure
precautions
Medications; Mannitol & furosemide; provoke flow of urine w/ oliguria & no lower obstruction. Calcium
Gluconate; 0.5 mL/kg IV Q2-4 min to  K. Sodium Bicarb; 2-3 mEq/kg IV Q30-60min,  blood pH &
causes transient fluid shift to  K levels. Glucose & Insulin IV; glucose & K move into cells. Sodium
polystyrene sulfonate;1 g/kg orally/rectally to bind& excrete K; Labetalol or sodium nitroprusside IV; (with
close monitoring) hypertension if encephalopathy threat present. Hydralazine, clonidine, or verapamil IV for
less urgent HTN. Captopril, hydralazine, minoxidil, propranolol, nifedipine, or furosemide oral for HTN

Chronic Renal Failure; diseased kidneys can no longer maintain the normal chemical structure of body fluids
under normal conditions, and there is extensive irreversible damage to the [Link] to slow imminent progression
s/s: loss of energy, increase fatigue on exertion, pallor, delayed growth, anorexia, N/V, uremic breath odor,
headache, muscle cramps, weight loss, puffy face, malaise, bone/joint pain, itchy, bruised skin, Amenorrhea in
adolescent girls; Circulatory overload manifested by hypertension, congestive heart failure and pulmonary
edema; Neurologic involvement (tremors, muscle twitching, confusion, seizures, coma).

Chapter 27: Fractures

Types of Fractures
- Plastic deformation (bend): The bone is bent no more than 45° without breakage.
- Buckle (torus): Compression of the bone resulting in a bulge or raised area at the fracture site
- Greenstick: Incomplete fracture of the bone.
- Transverse: Break is straight across the bone.
- Oblique: Break is diagonal across the bone.
- Spiral: Break spirals around the bone. suspect for
-

abuse
- Physeal (growth plate): Injury to the end of the long bone on the growth plate.
- Stress: Small fractures/cracks in the bone due to repeated muscle contractions
- Complete: Bone fragments are separated.
- Incomplete: Bone fragments are still attached.
- Closed or simple: The fracture occurs without a break in the skin.
- Open or compound: The fracture occurs with an open wound and bone protruding.
- Complicated fracture: The fracture results in injury to other organs and tissues.
- Comminuted: The fracture includes small fragments of bone that lie in surrounding tissue
NURSING; Maintain ABC’s; Stabilize the injured area, avoiding unnecessary movement; Elevate the affected
limb and apply ice packs (not to exceed 20 min); Neurovascular assessment: Sensation: Assess for numbness or
tingling sensation of the extremity, Skin Temperature: Assess the extremity for temperature. Skin Color: Assess
the color of the affected extremity-Check distal to the injury and look for changes of pigmentation; Capillary
Refill: Press the nail beds of the affected extremity-Blood return should be within 3 seconds; Pulses: Should be
palpable and strong; Movement: The client should be able to move the joints distal to the injury
TX: Casting-Elevate the cast above the level of the heart during the first 24, Apply ice for the first 24 hours to
prevent swelling, Turn and position every 2 hours (cast dries faster | prevents cast from changing shape), Assess
for increased warmth or hot spots on the cast surface (infection): Plaster Casts: Use Palms of Hands to avoid
Denting, Expose the Cast to Air, Instruct the client not to place any foreign objects inside the cast to avoid trauma
Traction care Maintain body alignment, Interventions for Pain and Muscle Spasms,
Assess, and monitor neurovascular status, Assess pin sites for pain, redness,
swelling, drainage, or odor, Weights should hang freely
- Skin traction uses pulling force that is applied by weights. Using tape and straps applied to the skin along
with boots and/or cuffs, weights are attached by a rope to the extremity (Buck, Russell, Bryant traction).
- Skeletal traction uses a continuous pulling force that is applied directly to the skeletal structure and/or
specific bone. It is used when more pulling force is needed than skin traction can withstand. A pin or rod is
inserted through or into the bone. Force is applied through the use of weights attached by rope. The weights
are never to be removed by the nurse.
- Halo traction (cervical traction) uses a halo-type bar that encircles the head. Screws are inserted into the
outer skull. The halo is attached to either bed traction or rods that are secured to a vest worn by the client.
Complications; Compartment syndrome (compression of nerves, blood vessels, and muscle inside a
confined place, resulting in neuromuscular ischemia) Renal Calculi; Embolism (Findings: 5 P’s: 1. Pain:
unrelieved with elevation or analgesics, increases with passive movement. 2. Paresthesia: numbness (early
finding). 3. Pulselessness: distal to fracture. 4 Paralysis: inability to move digits (nerve damage). [Link]:
cold skin and cyanosis to nail beds )

Osteomyelitis: infection w/in bone secondary to bacterial infection from an outside source;
Endogenous w/ open fractur & Hematogenous from bloodborne bacterial source
s/s: fever, irritability, Tachycardia, Edema, Pain is constant but increases with movement
NURSING; Administer IV and oral ABX therapy; Monitor hepatic, hematologic, & renal function; Monitor
for super infection; Pain meds as prescribed

Chapter 28: Musculoskeletal Congenital Disorders

Clubfoot; complex deformity of the foot and ankle; can affect 1 or both feet, occur as isolated defect or
w/ other disorders
- Categorized as positional clubfoot (occurs from intrauterine crowding), syndromic (occurs in
association with other syndromes), and congenital (idiopathic)
s/s: Talipes varus: inversion (foot bending inward); Talipes valgus: eversion (foot bending outward); Talipes
calcaneus: dorsiflexion (toes are higher than the heels); Talipes equinus (“horse foot”): plantar flexion (toes are
lower than the heels); Talipes equinovarus: toes are facing inward and lower than the heel
TX: Series of castings start shortly after birth & continue until max correction

Legg-calve-Perthes disease; Aseptic necrosis of the femoral head can be unilateral or bilateral; Stages-
synovitis, necrotic, fragmentation, reconstruction; affects 2-12 yrs. but 4-8 most common
s/s: Intermittent painless limp, Hip stiffness, Limited ROM, Shortening of affected leg, Hip/thigh/knee pain
TX: Maintain rest and limited weight bearing: Abduction brace, Casts, Physical therapy, Traction
Surgical intervention: Osteotomy of the hip or femur
becomeflat
cassing it collaps
ball of femur lose blood supply to

Developmental dysplasia of the hip (DDH); variety of disorders resulting in abnormal development of hip
structures that can affect infants or children
- Acetabular dysplasia: delay in acetabular development (acetabular roof is shallow and oblique
- Subluxation: incomplete dislocation of the hp
- Dislocation: femoral head does not have contact with the acetabulum
-
look for uneven glotedfolds
 s/s: INFANT; Asymmetry & unequal number of skin folds on posterior thigh, Limited hip abduction,
Widened perineum, shortening of femur, Positive Ortolani test- Hip is reduced by abduction, Positive
Barlow Test- Hip is dislocated by adduction; CHILD: One leg shorter than the other, walk w/ lip, walking
on tow on 1 foot
TX: Pavlik harness: For newborn to 6 months; Maintain harness placement for up to 12 weeks, Check
straps every 1 to 2 weeks for adjustment, Perform neurovascular and skin integrity checks (2-3 times/day),
Teach the family not to adjust the straps, Teach the family skin care (Use an undershirt, Wear knee socks,
Gently massage skin under straps, Avoid lotions/powders, Place diaper under the straps)
When adduction contracture present
Bryant traction: skin traction, hips flexed at 90* angle w/ butt raised off bed
Hip spica cast (maintains external rotation of hip); needs to be changed to accommodate growth
Surgical closed reduction w/ placement of hip spica cast (6 months- 2yrs)

Osteogenesis imperfecta “Brittle bone disease”; inherited condition that results in bone fractures and
deformity along with restricted growth
s/s: Multiple bone fractures, Blue sclera, Early hearing loss, Small, discolored teeth
Medications: Pamidronate: Increase bone density; SE: decreases electrolytes
NURSING: treatment is supportive; Teach the family and client low-impact exercises; caution w/ live
vaccines

Scoliosis; Characterized by a lateral curvature of the spine and spinal rotation that causes rib asymmetry
Screening; Have the child bend over at the waist with arms hanging down and observe for asymmetry of
ribs and flank
TX: Bracing: Customized braces slow the progression of the curve.
Surgical; Spinal fusion with rod placement-Used for curvatures > 45 degrees

Chapter 29: Chronic Neuromusculoskeletal Disorders

Cerebral Palsy (CP); non-progressive impairment of motor function, especially that of muscle control,
coordination, and posture; can cause abnormal perception and sensation; visual, hearing, and speech
impairment; seizures; and cognitive disability
Risk factors: Exact cause is unknown; Prenatal, perinatal, and postnatal risk factors
movements
s/s: mussies + jerky
Stiff ,right
- Spastic CP (pyramidal): Hypertonicity, increased deep tendon reflex; clonus; and poor control of motion,
balance and posture; impairment of gross & fine motor skills
florms- Dyskinetic CP (nonspastic, extrapyramidal): Athetoid; Involuntary jerking movements that appear slow,
writhing, and wormlike involve extremities, trunk, neck, face, & tongue; Dystonic; slow twisting movements of
trunk or extremities w/ abnormal posturing from muscle contractions, drooling & speech impairment
- Ataxic CP (nonspastic, extrapyramidal): Poor ability to do repetitive movements, Lack of coordination
with purposeful movements (ex: reaching for an object)
Medications: Baclofen, Diazepam, Botulinum toxin A, Antiepileptics, Dopaminergic
Complications: Aspiration, Injury
cannot do things
-( partpeace
o

Spina Bifida; neural tube defect present at birth; failure of the osseous spine to close

Spina bifida occulta; not visible externally

s/s: dimpling in lumbosacral area, port wine angioma, dark hair tufts, subcutaneous lipoma
Spina bifida cystica; visible externally
s/s: flaccid muscles, lack of bowel control, rectum prolapse, spinal curvature abnormalities
- Meningocele: The sac contains spinal fluid and meninges
- Myelomeningocele: *most common; The sac contains spinal fluid, meninges, and nerves
Risk factors: Medications/substances taken during pregnancy, Insufficient folic acid intake during pregnancy
TX: Closure of myelomeningocele sac as soon as possible to prevent complications of injury and
infection; Apply a sterile, moist, nonadherent dressing with 0.9% sodium chloride on sac, changing Q2 hr.;
Place in the infant in prone position with hips flexed, legs abducted
Complications: Skin ulceration, Latex allergy (Also bananas, avocados, kiwi, chestnuts) -
Increased intracranial pressure, Bladder issues, Orthopedic issues

Juvenile idiopathic arthritis; Chronic autoimmune inflammatory disease affecting joints and other tissues -
s/s: Joint swelling/stiffness/redness/warmth that tends to be worse in the morning or after inactivity, fever,
rash, delayed growth, limp in AM
NURSING; Apply heat or warm moist packs to affected joints prior to exercise, Encourage warm baths
Medications: NSAIDs (Ibuprofen, naproxen, diclofenac, indomethacin, tolmetin): control pain & inflammation
Methotrexate; DMARD: slows joint degeneration &progression of RA when NSAIDs don’t work alone
Corticosteroid: Prednisone; relief of pain & inflammation reserved for life threatening complication, severe
arthritis, pericarditis & uveitis
Etanercept; DMARD when methotrexate not effective

Muscular Dystrophy (MD); group of inherited disorders with progressive degeneration of symmetric
skeletal muscle groups causing progressive muscle weakness and wasting
- Duchenne (psuedohypertrophic) muscular dystrophy (DMD): most common form of MD; Onset
between 3 and 5 years; lifespan of early adulthood passed from parent
one

- Facioscapulohumeral muscular dystrophy autosomal dominant inherited; age of onset early

adolescence; Progression is slow with normal life span; characterized by facial weakness & inversion of
shoulders.
- Limb-girdle muscular dystrophy autosomal dominant and recessive, heterogeneous disorder. appears
later in childhood with a slow progression.
s/s: Muscle weakness beginning in the lower extremities, Unsteady gait, with a waddle, Lordosis, Delayed
motor skill development, Frequent falling, Learning difficulties, Progressive muscle atrophy, Respiratory
and cardiac difficulties as the disease progresses
Medications: Corticosteroids: Prednisone (increases muscle strength)
Complications: Respiratory compromise
 Chapter 30: Skin Infections and Infestations

Bacterial skin infections;

Impetigo contagiosa: spreads peripherally & via direct contact
s/s: Reddish macule becomes vesicular Erupts easily leaving moist erosion on the skin, secretions dry forming
crusts, Pruritus common
TX: Topical bactericidal or triple antibiotic ointment
Cellulitis:
s/s: Firm, swollen, red area of the skin and subcutaneous tissue; possible systemic effects (Fever/malaise)
TX: Oral or parenteral ABX, Warm/moist compress

Fungal skin infections

Tinea capitis (ringworm of the scalp):
TX: Use selenium sulfide shampoos, Treat infected pets
Tinea corporis (Ringworm of the body):
TX: topical antifungal (tolnaftate, Clotrimazole)
Tinea pedis (athletes foot): Between toes or on the plantar surface of the feet
TX: ciclopirox or clotrimazole

Skin infestations
Scabies mite (Sarcoptes scabiei):
s/s: Itchy, especially at night; Rash, especially between the fingers; Thin, pencil-like marks on the skin
INFANTS; widespread on body, Pimples on the trunk, Blisters on the palms of the hands and soles of the feet
TX: Scabicide such as 5% permethrin all over body; Treat entire family and persons that have been in contact
w/ infected person during and 60 days after infection; Wash underwear, towels, clothing, sleepwear in hot water
Pediculosis capitis (Head lice):
s/s: Intense itching, Nits (white specs) on the hair shaft
TX: 1% permethrin shampoo; Remove nits w/ a nit comb; repeat in 7 days after shampoo TX; Wash clothing,
bedding in hot water w/ detergent; bag items that can’t be washed into tightly sealed bag for 14 days; boil
combs, brushes, and hair accessories for 10 min or soak in lice-killing products for 1 hr; Discourage sharing of
personal items

Chapter 31: Dermatitis and Acne

Dermatitis
- Diaper dermatitis
TX: Clean urine in the perineal area with a nonirritating cleanser; Expose the affected area to air; Use
superabsorbent disposable diapers to reduce skin exposure (no cloth); Apply a skin barrier (zinc oxide)
- Seborrheic dermatitis: (thick flakes on scalp i.e., cradle cap)
TX: gently scrub scalp to remove scales and crusted areas; Petrolatum, vegetable oil, or
mineral oil can be helpful; Use a fine-tooth comb to remove the loosened crusts from the hair;
Shampoo daily with antiseborrheic shampoo
- Poisonous plant exposure:
TX: Cleanse exposed area as soon as possible with cold running water, then soap and water shower; Apply
calamine lotion; burrow solution compresses, or natural colloidal oatmeal baths; Use topical corticosteroid gel
Atopic dermatitis (AD); type of eczema; cannot be cured but well controlled
- INFANTS: onset 2- 6 mo; Generalized distribution of lesions on cheeks, scalp, trunk, hands/feet, extensor
surfaces of extremities ; Lesions- Erythema, Vesicles, papule, Weeping, oozing, crusting, scaling
- CHILD: onset 2-3, can follow infantile eczema; Lesions in the flexural areas (antecubital and popliteal
fossae, neck), wrists, ankles, and feet with symmetric involvement – clusters, erythematous or flesh colored
papules, dry, lichenification, keratosis pilaris
- ADOLESCENT: onset 12; similar distribution & lesions as children; lesions dry, thick, confluent papules
TX: Dress in Cotton Clothing (avoid wool and synthetic fabrics), Avoid excessive heat and perspiration
(increase itching), Avoid irritants (Bubble Baths | Soaps | Perfumes | Fabric Softeners), Place gloves or cotton
socks over hands for sleeping, apply emollient within 3 min of bathing, after pat dry
Medications: Antihistamines, topical corticosteroids, topical immunomodulators

Acne
NURSING: Teach child to gently wash face & other affected areas, avoiding scrubbing and abrasive cleaners
Medications: Tretinoin:(Avoid Sun Exposure | Use Sunscreen Daily (SPF 15 or greater)
Benzoyl peroxide: Can bleach clothing but not skin
Isotretinoin: SE:  cholesterol/triglycerides, Depression/suicidal ideation/violent behaviors, Contraindicated in
women who are not taking oral contraceptives

Chapter 32: Burns

NURSING; Check immunization status, and determine the need for immunization (Administer tetanus vaccine
if it has been more than 5 years )Educate the family to avoid using greasy lotions or butter on burns; Maintain
airway and ventilation; Initiate IV access with large-bore catheter (Multiple access points may be necessary); Fluid
replacement is important during the first 24 hours (Isotonic crystalloid solutions, such as 0.9% sodium chloride or
lactated ringers are used during the early stage of burn recovery); Maintain urine output of 0.5 to 1 ml/kg/hr is <30
kg; Maintain urine output of 30 ml/hr for >30 kg; Manage pain - Use IV opioid; Provide nutritional support:
Increase caloric intake/protein, Vitamin A, C, and zinc for wound healing; Maintain active and passive ROM
Medications Topical agents: Silver sulfadiazine/ Mafenide acetate; Use with 2nd and 3rd degree burns; Apply to
cleansed, debrided area; Wear sterile gloves for applications
Bacitracin: Use for prevention of secondary infection 4. Skin coverings

Biologic skin coverings: may be used to promote healing of large burns; req repeated surgical application
- Allograft (homograft): Skin from human cadavers used for partial and full thickness burn wounds
- Xenograft: Obtained from animals: pigs for partial thickness burns
- Synthetic skin coverings; used for partial thickness burns
- Artificial skin; allows dermis to regenerate, used for partial & full thickness burns (healing is faster)
Permanent skin coverings: may be treatment of choice for burns covering large areas
- Autografts: Client’s skin
- Sheet graft; sheet of skin used to cover wound
- Mesh graft; sheet of skin placed in mesher, so skin graft has small slits in it; allows larger areas of burn cover
- Cultured epithelium; epithelial cells cultured for use when grafting sites limited

Chapter 33: Diabetes Mellitus

Risk factors; Genetics; Toxins/viruses: can destroy the beta cells causing type 1; Obesity/physical
inactivity/HTN causes type 2 DM
s/s: Hypoglycemia: blood glucose <60, Hunger, lightheadedness, and shakiness, Pale, cool
skin/diaphoresis, Decreasing LOC, Slurred speech, headache and blurred vision, Seizures leading to coma
Hyperglycemia: blood glucose >250, Thirst, Polyuria (early sign)/oliguria (late sign), Nausea, vomiting, and
abdominal pain, Skin that is warm, dry, and flushed with poor turgor, Dry mucous membranes, Confusion,
Weakness, Lethargy, Weak pulse, Diminished reflexes, Rapid, deep respirations with acetone/fruit odor due
to ketones (Kussmaul respirations)
DX: 8-hr fasting blood glucose level of 126 or more; Random blood glucose of 200 or more
with classic sign of diabetes; An oral glucose tolerance test of 200 or more in the 2 hr sample
- Glycosylated hemoglobin (HbA1c):Expected reference range is 4%-5.9%; Acceptable target
for children <6 7.5%-8%, 6-12 <8%, 12 + < 7.5%; If >7%: not regulating sugar well
NURSING; Trimming toenails straight across with clippers and filing edges with a nail file; Caution
against wearing sandals, walking barefoot, or wearing shoes without socks; Dry feet completely; Can use
mild foot powder: cornstarch; Never use commercial remedies for removing callus/corn; Sock: cotton or
wool; No heating pads for feet
Education; Teach the child illness management: Monitor blood glucose and urinary ketone
levels every 3 hr , Continue to take insulin or oral Antidiabetic agents, Encourage sugar-free,
noncaffeinated liquids to prevent dehydration
Call the provider for: Blood glucose >240, Fever 102F, Positive ketones in the urine, Disorientation or
confusion occurs, Rapid breathing, vomiting more than once, liquids not tolerated
Treat Hypoglycemia with 10-15 g simple carbohydrates (1tbsp sugar) (Ex: 4 OZ orange juice/8OZ milk)
- If unconscious or unable to swallow: Administer glucagon SC or IM; Administer simple carbohydrates when
tolerated
Medications

Complications;
- DKA: >330 mg/dL, Ketone levels in the blood and urine, Fruity scent to the breath, Mental
confusion, Dyspnea, Nausea and vomiting, Electrolyte imbalances: Metabolic acidosis/hyperkalemia
NURSING; Monitor serum potassium levels; Administer sodium bicarbonate by slow IV infusion
for severe acidosis (pH <7); Have a cardiac monitor
Long term complications; Kidney disease, Eye disease, Neurologic complications

Chapter 34: Growth Hormone Deficiency

- Human growth hormone (GH), somatotropin, is a naturally occurring substance secreted by pituitary gland.
GH is important for normal growth, development, and cellular metabolism. A deficiency in GH prevents
somatic growth throughout the body.
Hypopituitarism is the diminished or deficient secretion of pituitary hormones (primarily GH). Consequences
of the condition depend on the degree of the deficiency.
s/s: Short stature but proportional height and weight, Delayed epiphyseal closure, Delayed sexual development,
Underdeveloped jaw, Delayed dentition,  insulin sensitivity
Medications -Somatropin: Given SC until epiphyseal plate closes

Chapter 35: Immunizations

Contraindications
- The common cold and other minor illnesses are not contraindications to immunizations
- Severe febrile illness is a contraindication to all immunizations
- Do not administer live virus vaccines, such as varicella or MMR, if severely Immunocompromised

- DTaP: Occurrence of encephalopathy within 7 days following prior doses of the vaccine
- IPV: Anaphylactic reaction to neomycin, streptomycin, polymyxin B -MMR, eggs, gelatin,
and neomycin
- Influenza vaccine: Hypersensitivity to eggs
-Varicella: If taking corticosteroids

NURSING; Give IM immunizations in the Vastus lateralis or ventrogluteal

muscle in infants and young children; Give IM immunization in the deltoid muscle
for older children/adolescents; Give infants a concentrated oral sucrose solution 2
min prior to, during, and 3 min after immunization administration
Document date, route, site of immunization, lot number, manufacturer, and exp. Date

Chapter 36: Communicable Diseases

Conjunctivitis; Spread via direct contact (viral/bacterial)

s/s: Pink or red color in the sclera of the eyes, Crusting of the eyelids in the morning

Epstein-Barr virus (EBV)/mononucleosis; Spread via saliva

s/s: Fever, Swollen lymph glands, Splenomegaly, Hepatic involvement
Complications: ruptured spleen (no contact sports)

Erythema infectiosum (fifth disease)/parvovirus B19; Spread via droplet/blood

s/s: before rash ( fever, runny nose, headache); Rash (7 days to several weeks), Red rash on face (slapped
cheek) appears from day 1 to 4
Complications; self-limiting arthritis & arthralgia (more common in women)

Mumps/paramyxovirus; Spread via droplet & direct contact

s/s: Painful, swollen parotid glands
Pertussis (whooping cough)/Bordetella pertussis; Spread via direct contact/droplet/indirect contact
s/s: Common cold manifestations (Runny nose/congestion, sneezing, mild fever, mild cough)
Severe coughing starts 1-2 weeks (Coughing fits, Violent& rapid coughing, Loud “whooping” sound on inspiration)

Rubella (German measles)/rubella virus; Spread via droplet

s/s: low grade fever & sore throat, headache, malaise, cough lymphadenopathy; Red rash that starts on the face and
spreads to the rest of the body, lasting 2-3 days
Complications: Birth defects (deafness; heart defects; mental, liver, and spleen damage) in fetus of
women infected during pregnancy

Rubeola (measles)/rubeola virus: Spread via droplet

s/s: conjunctivitis, Cough, runny nose, red eyes, sore throat; Rash: Kolpik spots (tiny white spots) in mouth 2 days
before rash, red or reddish brown rash begins on face & spreads down, spike in fever w/ rash
Complications: ear infections, pneumonia, encephalitis, death, laryngitis

Varicella (chicken pox)/varicella-zoster virus; Spread via droplet (airborne), direct & indirect contact
s/s: Manifestations 1-2 days prior to rash: Fever/fatigue, headache, loss of appetite; Rash: Macules start in
center of trunk, spreading to the face and proximal extremities, Progresses from macules, to papules, to vesicles,

we
and crust formations follow
Complications; pneumonia, bleeding problems, bacterial skin infection, encephalitis
Aspirin
exept
NURSING; Admin antipyretic for fever-do not administer aspirin, due to the risk of Reye Syndrome,
Provide calamine lotion for topical relief, Keep the child’s fingernails clean and short, keep out of sun,
Isolation Precautions;
- Airborne/Contact: Varicella
- Airborne: Measles
- Droplet: Fifth disease, Mumps, Pertussis, Rubella
- Standard: Conjunctivitis, Mononucleosis

Medications: Antihistamine; ABX or Antiviral therapy: Acyclovir for high-risk

clients who have varicella , ABX for pertussis, ABX eye drops for conjunctivitis

Chapter 37: Otitis Media

Risk factors: Most common in the first 24 months of life and again when children
enter school ages (5-6)
s/s: AOM; Rubbing or pulling on ear, Crying, Lethargy, Bulging yellow or red tympanic membrane, Purulent
material in middle ear or drainage from external canal, Decreased or no tympanic movement with pneumatic
otoscopy, Lymphadenopathy of the neck and head, Temperature: can be as high as 40° C (104° F), Hearing
difficulties and speech delays if otitis media becomes a chronic condition
OME; Feeling of fullness in the ear; Orange discoloration of the tympanic membrane wit decreased movement;
Vague findings including rhinitis, cough, and diarrhea ; Transient hearing loss and balance disturbances
Medications: Acetaminophen/ibuprofen ( analgesia & fever); ABX (PO 10-14 days
or IM once- Ceftriaxone)
TX: Myringotomy and placement of tympanoplasty tubes for multiple episodes; small incision is made in
the tympanic membrane; The tubes come out spontaneously (usually in 8-18 months); Instruct parents to
notify the provider when tubes come out
 Chapter 38: HIV/AIDS

HIV/AIDS; HIV infection is a viral infection in which the virus primarily infects a specific subset of T-
lymphocytes, the CD4 T cell causing immune dysfunction; 44This leads to organ dysfunction and a variety of
opportunistic illnesses in a weakened host

s/s: CATEGORY N: NONE

CATEGORY A MILD; 2 or more; Lymphadenopathy, Hepatomegaly, Splenomegaly, Parotitis, Recurrent URI,
sinusitis or OM, Oral Candidiasis
CATEGORY B MODERATE: Anemia, Bacterial meningitis, pneumonia, or sepsis (single episode),
Oropharyngeal candidiasis, CMV, Cardiomyopathy, Herpes zoster, Herpes simplex virus (HSV), bronchitis,
pneumonitis, or esophagitis, Hepatitis, Lymphoid interstitial pneumonia (LIP) or pulmonary lymphoid
hyperplasia complex, Leiomyosarcoma, Toxoplasmosis
CATEGORY C SEVERE: Multiple serious bacterial infections, Kaposi’s sarcoma: skin infection , Pneumocystis
carinii pneumonia, Wasting syndrome, TB, Lymphoma, Encephalopathy w/ developmental delays
NURSING; Diet high in calories and protein, Provide good oral care, Prevent infection using standard
precautions-Does not need special precautions, Teach to avoid individuals who have colds/infections/viruses,
Encourage immunizations: Pneumococcal vaccine and yearly influenza vaccine
Medications
- Antiretroviral: Nucleoside reverse transcriptase inhibitors: Zidovudine, didanosine, stavudine, lamivudine, and
abacavir suppress the synthesis of viral DNA: Non-nucleoside reverse transcriptase inhibitors: Delavirdine,
efavirenz, and nevirapine bind to the viral DNA, causing direct inhibition. Protease inhibitors: Indinavir, ritonavir,
nelfinavir, amprenavir, saquinavir, and lopinavir inhibit an enzyme needed for the virus to replicate.
- Antibiotics: Trimethoprim-sulfamethoxazole
- IV gamma globulin; prevent recurrent or serious bacterial infection
Complications; Failure to thrive, Pneumocystis carinii pneumonia

Chapter 39: Organ Neoplasms

common
Wilms’ tumor (Nephroblastoma);malignancy that occurs in the kidneys or abdomen; Tumor is usually
unilateral; Most cases diagnosed between 2-3 years of age; Metastasis is rare
s/s: Painless, firm, nontender abdominal swelling or mass, Fatigue, malaise, and weight loss, Fever,
Hematuria, HTN; Manifestations of metastasis include dyspnea, cough, shortness of breath, and chest pain
DX: Abdominal ultrasonography, Abdominal and chest CT scan, Bone marrow aspiration (rule out metastasis)
TX: Surgical removal of tumor & kidney, chemo, radiation
NURSING: IF WILM’S TUMOR SUSPECTED DO NOT PALPATE THE ABDOMEN (can cause spread)

Neuroblastoma; malignancy that occurs in the adrenal gland; Usually manifested during toddler years;
Half of all cases have metastasized before diagnosis
s/s: Half of children who have a Neuroblastoma have few findings
Manifestations of metastasis: Ill appearance, Periorbital ecchymosis, Bone pain Irritability
DX: Skeletal survey, Skull, neck, chest, abdominal and bone CT scans, Bone marrow aspiration (rule out metastasis)
TX: surgical removal of tumor, chemo, radiation
 looku
Chemotherapy; Provide antiemetic prior to administration, Observe mouth for mucosal ulcerations
Educate about the SE of chemotherapy: Mouth sores, Loss of appetite, Nausea/vomiting, Hair loss,
Diarrhea/constipation, Increased risk of infection, Easy bruising or bleeding, Fatigue

Radiation: Nurse: wear lead aprons; Instruct the child and family not to wash off marks on the skin that outline
the targeted areas; Avoid use of soaps, creams, lotions, and powders unless prescribed; Keep the areas protected
from the sun by wearing a hat and long-sleeved shirts

NURSING: Encourage the child to avoid crowds while undergoing chemotherapy; Avoid fresh fruits and
vegetables; Avoid invasive procedures; Administer SC daily filgrastim (a granulocyte colony-stimulating
factor that stimulates WBC production); Administer epoetin alfa give SC 2-3 times per week( Stimulate RBC
production); Administer Oprelvekin SC daily (For PLT formation); Encourage the use of soft toothbrush;
Mucositis and dry mouth: Lubricate the child’s lips; avoid hydrogen peroxide and lemon glycerin swabs

Chapter 40: Blood Neoplasms

Leukemia; group of malignancies that affect the bone marrow and lymphatic system; peak onset 2-5 ; causes
increase in the production of immature WBCs (leukoblasts) with neoplastic characteristics, which leads to
infiltration of organs and tissues
s/s: EARLY; Low-grade fever, Pallor, Increased bruising and petechiae, Listlessness, Enlarged liver, lymph
nodes, and joints, Abdominal, leg, and joint pain, Constipation, Headache, Vomiting and anorexia, Unsteady
gait; LATE; Pain, Hematuria, Ulcerations in the mouth, Enlarged kidneys and testicles, Manifestations of
increased intracranial pressure
Labs: CBC Anemia (low blood count); Thrombocytopenia (low platelets); Neutropenia (low
neutrophils);Leukemic blasts (immature WBCs); Blood smear (immature WBC)
DX: Bone marrow aspiration or biopsy analysis: Topical anesthetic such as EMLA cream 45 min-1 hr prior
CSF analysis: Have the child empty their bladder, EMLA cream 45 min-1 hr prior, Side-lying position with the
head flexed and knees drawn up toward the chest, and assist in maintaining the position (during procedure),
Remain in bed 4-8 hr in a flat position to prevent leakage and a resulting spinal headache (after)

Medications; Chemo admin at different phases

- Induction/remission therapy: To achieve complete remission or < than 5% of leukemic cells in bone marrow
- Intensification therapy (consolidation): To destroy any remaining leukemic cells followed by a delayed
intensification to prevent any resistant leukemic cells from emerging
- Maintenance therapy: To sustain the remission phase. Also requires frequent monitoring of CBC
TX: Hematopoietic stem cell transplant (HCST)
Allogeneic transplant; blood forming stem cells donated by another person
NURSING; administer donor stem cells via IV infusion
- Implement protective isolation; Private, positive-pressure room, At least 12 air exchanges/hr, HEPA
filtration for incoming air, Respirator mask, gloves, gowns, No dried or fresh flowers, and no potted plants
 Chapter 42: Bone & Soft Tissue Cancers

Bone Tumors; Osteosarcoma usually occurs in metaphysis of long bones, most often in the femur
Risk Factors; Osteoscoma peaks at age 15 during growth spurts; more common in boys; Ewing’s sarcoma
occurs prior to 30 & more common in Caucasians
s/s: Nonspecific bone pain that is often mistaken for an injury or growing pains, Temporary relief of pain when
extremity is flexed, Weakness, swelling, decreased movement, or limping ● Palpable lymph nodes near the
tumor, Anemia, generalized infection, or unexplained weight loss, Inability to hold a heavy object
Medications; Chemo; Osteosarcoma; used in combo or alone before & or after surgery; High-dose
methotrexate with citrovorum factor rescue, doxorubicin, cisplatin, ifosfamide, and etoposide; Ewing’s
sarcoma; Vincristine, doxorubicin, and cyclophosphamide alternating with ifosfamide and etoposide
Amitriptyline
TX: Localized radiation therapy, Surgical Biopsy
Limb salvage procedure for bone cancers: Includes a course of chemotherapy to shrink the tumor and then
total bone and joint replacement after the tumor and affected bone are removed.
Limb amputation for bone cancer; The child can receive chemotherapy both preoperatively & postoperatively
Complications; Skin desquamation; Myelosuppression
muscle
↑ Smoote
Rhabdomyosarcoma; most common soft tissue malignancy in children; most common in child < 5
s/s: Can cause pain in local areas r/t compression by tumor (sore throat can occur with tumor of nasopharynx);
Possible absence of pain in some parts of body (in the retroperitoneal area) until tumor begins to obstruct organs
BASED ON AFFECTED AREA
CNS: headaches, diplopia, vomiting
Orbit: unilateral proptosis, ecchymosis of conjunctiva, strabismus
Nasopharynx: stuffy nose, pain, nasal obstruction, epistaxis, palpable neck nodes, visible mass (late)
Paranasal sinuses: nasal obstruction, pain, discharge, sinusitis, swelling
Middle ear: chronic otitis media, pain, sanguine purulent discharge, facial paralysis
Retroperitoneal area: usually no findings, abdominal mass, pain, intestinal or genitourinary obstruction
Perineum: visible superficial mass, bowel, or bladder obstruction
Extremity: pain, palpable fixed mass, lymph node enlargement
DX: CT, MRI, Tumor biopsy
Medications: Chemo; Vincristine, actinomycin D, cyclophosphamide, ifosfamide, topotecan, irinotecan, and doxorubicin for about 1 yea
TX: Localized radiation therapy, Surgical Biopsy
Complications; Skin desquamation; Myelosuppression

Chapter 42; Complications of Infants

PKU; inherited metabolic disorder in which the newborn lacks the enzyme phenylalanine hydroxylase. This
enzyme converts phenylalanine, an essential amino acid, into tyrosine. The lack of this enzyme leads to the
accumulation of phenylalanine in the newborn’s bloodstream and tissues, which causes cognitive impairment.
s/s: Growth failure, Frequent vomiting, Irritability, Musty odor to urine, Microcephaly, Heart defects, Blue
eyes, very fair skin, light blonde hair
Labs: Newborn metabolic screen ( w/in 2 days of birth); Guthrie test (confirms +blood spot)
NURSING: Initiate dietary restrictions as soon as PKU is diagnosed, or within 7 to 10 days of birth. Place
newborn on a formula low in phenylalanine ( Intake should be 20 to 30 mg phenylalanine per kilogram of body
weight per day, Monitor phenylalanine level, Goal is a phenylalanine level between 2 and 8 mg/dL)
Complications; Cognitive impairment (can be severe), Hyperactivity with erratic behavior, Bizarre behavior
(fright reactions), Head banging, Arm biting, Disorientation, Spasticity or catatonic-like positions, Seizures
Necrotizing Enterocolitis; inflammatory disease of the gastrointestinal mucosa caused by ischemia or hypoxia.
s/s: Abdominal distention, Gastric residuals, Bloody stool, Periods of apnea begin or worsen, Hypotension,
Lethargy, Poor feeding, Decreased urinary output
NUSING: Treatment begins with prevention. Withhold feedings for 24 to 48 hr from newborns who suffered
birth asphyxia. Discontinue all feedings at first manifestation of NEC. Administer IV or TPN to rest the GI
tract. Insert an NG tube for abdominal decompression.

Plagiocephaly; acquired condition that occurs from cranial molding in infancy. The infant’s head becomes
asymmetric or oblique in shape due to flattening of the occiput. Plagiocephaly is attributed to the supine sleep
position
TX: Physical therapy for neck exercises; Proper use of skull-molding helmet

Chromosomal Abnormalities
Trisomy 21 (Down syndrome; Most frequently occurring chromosomal disorder
- Broad, flat nose, Epicanthal fold, Protruding tongue, short neck with extra pad of fat, Hypotonicity, Low
set ears, Fifth finger curved inward, Single palmar crease, Mild to moderate cognitive deficits, Cardiac
anomalies common, Altered immune system
Trisomy 18 (Edwards syndrome); Most die in infancy
- Severe cognitive deficits, SGA, Low-set ears, small jaw, Misshapen fingers and toes, Rocker-bottom feet
Trisomy 13 (Patau syndrome)
- Severe cognitive deficits, Midline body disorders: cleft lip/palate, cardiac defects, abnormal genitalia,
Microcephaly, Eyes small or missing
Klinefelter syndrome: male who has an extra X chromosome; Characteristics not noticeable until puberty
- Testes remain small leading to sterility, Gynecomastia, Elongated lower limbs
Turner syndrome: Female who has only one functional X chromosome
- Short stature, Small, nonfunctioning ovaries leading to sterility, No secondary sex characteristics develop
at puberty except pubic hair , Neck webbed and short, Mild learning disabilities to severe cognitive
deficits

Chapter 43: Pediatric Emergencies

Respiratory Emergencies
Respiratory insufficiency: Increased work of breathing with mostly adequate gas exchange or hypoxia w/ acidosis
Respiratory failure: Inability to maintain adequate oxygenation of the blood
Apnea: Cessation of respirations for more than 20 seconds; Can be associated with hypoxemia or bradycardia:
Can be central or obstructive
Respiratory arrest: Complete cessation of respirations
Airway obstruction: Can be due to aspiration of a foreign body

s/s: EARLY Resp Distress; restlessness, tachypnea, tachycardia, diaphoresis, nasal faring, retractions, grunting,
wheezing, dyspnea
ADVANCED HYPOXIA; bradypnea, bradycardia, peripheral or central cyanosis, stupor, coma
CHOKING; universal choking sign (clutch neck w/ hands), unable to speak, weak ineffective cough, high
pitched or no sounds, dyspnea, cyanosis

NURSING: Obstructed Airway; CHILDREN/ADOLESCENTS: Use abdominal thrusts

INFANTS; Combination of back blows and chest thrusts
Remove any visual obstruction or large debris from the mouth, but do not perform a blind finger sweep
Drowning
- Submersion injury (near-drowning) incidents: which children have survived for 24 hr. after being
submerged in fluid.
Education; Encourage parents of toddlers to lock toilet seats when their child is at home; Instruct parents to not
leave the child unattended in the bathtub; Inform parents not to leave the child unattended in a swimming pool,
even if the child can swim; Encourage parents to provide life jackets when boating

SIDS
Risk factors: Maternal smoking during pregnancy, Co-sleeping with parent or adult, Prone or side-lying
sleeping, Low birth weight
Education: Place the infant on the back for sleep; Avoid exposure to tobacco smoke; Prevent overheating;
Use a firm, tight-fitting mattress in the infant’s crib; Remove pillows, quilts, and stuffed animals from the
crib during sleep; Offer pacifier at naps and night; Encourage breastfeeding; Avoid co-sleeping

Poisoning
- 1st thing to do is assess child’s breathing
- -2nd thing to do is empty the child’s mouth of remaining pills and residue
- -3rd thing to do is identify medication and strength dosage
- -4th thing to do is call poison control

Acetaminophen
- 2 to 4 hr. after ingestion: Nausea, vomiting, sweating, and pallor
- 24 to 36 hr. after ingestion: Improvement in condition
- 36 hr. to 7 days or longer (hepatic stage): Pain in upper right quadrant, confusion, stupor, jaundice, and
coagulation disturbances
- Final stage: Death or gradual recovery
TX: N-acetylcysteine given orally

Acetylsalicylic acid (aspirin)

- Acute poisoning: Nausea, vomiting, disorientation, diaphoresis, tachypnea, tinnitus, oliguria,
lightheadedness, and seizures
- Chronic poisoning: Subtle version of acute manifestations, bleeding tendencies, dehydration, and seizures
more severe than acute poisoning
TX: Activated charcoal, Gastric lavage, Sodium bicarbonate, Oxygen and ventilation, Vitamin K,
Hemodialysis for severe cases

Supplemental iron
- Initial period (30 min to 6 hr. after ingestion): Vomiting, hematemesis, diarrhea, gastric pain, and
bloody stools
- Latency period (2 to 12 hr. after ingestion): Improvement of condition
- Systemic toxicity period (4 to 24 hr. after ingestion): metabolic acidosis, hyperglycemia, bleeding,
fever, shock, and possible death
- Hepatic injury period (48 to 96 hr. after ingestion): seizures or coma
TX: Emesis or lavage; Chelation therapy using deferoxamine mesylate

Hydrocarbons: Gasoline, kerosene, lighter fluid, paint thinner, turpentine; Gagging, choking, coughing,
nausea, and vomiting Lethargy, weakness, tachypnea, cyanosis, grunting, and retractions
TX: Do not induce vomiting; Intubation with cuffed endotracheal tube prior to any gastric decontamination;
Treatment of chemical pneumonia
Corrosives: Household cleaners, batteries, denture cleaners, bleach
- Pain and burning in mouth, throat, and stomach; Edematous lips, tongue, and pharynx with white mucous
membranes; Violent vomiting with hemoptysis; Drooling; Anxiety; Shock
TX: Airway maintenance; NPO; No attempt to neutralize acid (corrosive); Do not induce vomiting;
Analgesics for pain

Lead
- Low-dose exposure: Distractibility, impulsiveness, hyperactivity, hearing impairment, and mild
intellectual difficulty
- High-dose exposure: Cognitive delays varying in severity, blindness, paralysis, coma, seizures, and death
- Other manifestations: Kidney impairment, impaired calcium function, and anemia
TX: Chelation therapy using calcium EDTA (calcium disodium versenate)

Chapter 44: Psychosocial Issues of Infants, Children and Adolescents

Depression; Findings must be present for 1 year to diagnosis major depressive orders in children & adolescents
Mediations; TCAs or SSRIs

PTSD
s/s; INITIAL; Lasts a few minutes to 2 hr.; Increased stress hormones (fight or flight); Psychosis; SECOND
PHASE; Lasts approximately 2 weeks; Period of calm (feeling of numbness, denial); Defense mechanisms
decrease; THIRD PHASE (COPING); Extends 2 to 3 month; Client gets worse instead of better; Depression,
phobias, anxiety, conversion reactions, repetitive movements, flashbacks, or obsessions
TX: SSRIs

ADHD; Inattentiveness, hyperactivity, and impulsiveness usually revealed prior to age 7; Common in childhood
and can persist into adulthood
- A child must meet diagnostic criteria for diagnosis of attention-deficit hyperactivity disorder (ADHD)
Manifestations are present between the ages of 4 and 18 years.
Manifestations are present in more than one setting.
Evidence of social or academic impairment.
Six or more findings from a category are present (inattention or hyperactivity-impulsivity).
s/s: INATTENTION: Difficulty in sustaining attention, Easily distracted, Forgetfulness; HYPERACTIVITY:
fidgeting, failing to stay in seat, inappropriate running, seeming busy all the time, talking excessively;
IMPULSIVITY: blurting out responses’ for questions asked, trouble waiting turn, striking out, biting, shouting
Medications: Methylphenidate, Dextroamphetamine: Increases dopamine and norepinephrine
levels, Give 30 min before meals, Give last dose of the day prior to 1800 to prevent insomnia
Atomoxetine; SNRI

Autism Spectrum Disorder; complex neurodevelopmental disorders w/ spectrum of behaviors affecting an

individual’s ability to communicate & interact with others in social setting
s/s: Delays in at least one of the following; Social interaction, Social communication, or imaginative play
prior to age 3 years; Distress when routines are changed; Unusual attachment to objects; Delayed or absent
language development; Withdrawn, labile mood; Avoiding eye contact
NURSING: Decrease environmental stimulation, Introduce the child to new situations slowly, Encourage
support groups for parents