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PEDIATRIC NURSING. Care of the Child and Family. Developmental Theorists. Maslow’s Hierarchy of Needs (1954) Erik Erikson - Psychosocial Theory Jean Piaget - Cognitive Theory. Maslow’s Hierarchy of Needs. Principles: An individual’s needs are depicted in ascending levels on the

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pediatric nursing


Care of the Child and Family

developmental theorists
Developmental Theorists
  • Maslow’s Hierarchy of Needs (1954)
  • Erik Erikson - Psychosocial Theory
  • Jean Piaget - Cognitive Theory
maslow s hierarchy of needs
Maslow’s Hierarchy of Needs
  • Principles:
  • An individual’s needs are depicted in ascending levels on the


  • Needs at one level must be met before one can focus on a higher
  • level need
  • Levels of Maslow’s Hierarchy of Needs:
  • Physiologic/Survival Needs
  • Safety and Security Needs
  • Affection or Belonging Needs
  • Self-esteem/Respect Needs
  • Self-actualization Needs
trust vs mistrust
  • Birth - 1 year
    • World/Self is good
    • Basic needs met
  • Met = happy baby
  • Unmet = crying, tense, clinging
  • Stranger Anxiety
  • Separation Anxiety

Photo Source: Del Mar Image Library; Used with permission

autonomy vs shame doubt

1 – 3 years

    • Sense of control
    • Exerts self/will
    • Pride in self-accomplishment
  • Negativism
  • Ritualism/Routines
  • Parallel play

Photo Source: Del Mar Image Library; Used with permission

initiative vs guilt

3 – 6 years

  • “Can-do” attitude
  • Behavior is goal-directed and imaginative
  • Play is work
  • Be careful with criticism

Photo Source: Del Mar Image Library; Used with permission

industry vs inferiority

6 – 12 years

  • Mastery of skills
  • Peers in both play and work
  • Rules important
  • Competition
  • Predictability

Photo Source: Del Mar Image Library; Used with permission

identity vs role confusion

12 -18 years

  • Sense of “I”
  • Peers are very important
  • Independence from parents
  • Self-image

Photo Source: Del Mar Image Library; Used with permission

piaget s cognitive theory
Piaget’s Cognitive Theory

Development of Thought Processes:

30 – 2 years: Sensorimotor

32 – 7 years: Preoperational

37 – 11 years: Concrete Operations

311 years + : Formal Operations


Birth - 2 years

  • Reflexive behavior leads to intentional behavior
  • Egocentric view of world
  • Cognitive parallels motor development
  • Object Permanence
preoperational thought

2 - 7 years

  • Egocentric thinking
  • Magical thinking
  • Dominated by self-perception
  • Animism
  • No irreversibility
  • Thoughts cause actions

Photo Source: Del Mar Image Library; Used with permission

concrete operations

7 - 11 years

  • Systematic/logical
  • Fact from fantasy
  • Sense of time
  • Problem solve
  • Reversibility
  • Cause & effect
  • Humor

Photo Source: Del Mar Image Library; Used with permission

formal operations

11 years - Adult

  • Abstract thinking
  • Analyze situations
  • New ideas created
  • Factors altering this:
    • Poor comprehension
    • Lack of education
    • Substance abuse

Photo Source: Del Mar Image Library; Used with permission

infant physical tasks
Infant Physical Tasks
  • Physical Tasks: 0 - 6 months:
  • Fastest growth period
  • Gains 5-7 oz (142-198 g) weekly for 6 months
  • Grows 1 inch (2.5 cm) monthly for 6 months
  • Head circumference is equal to or larger than chest circumference
  • Posterior fontanel closes at 2-3 months*
  • Obligate nose breathers*
  • Vital signs: HR and RR faster and irregular*
  • Motor: behavior is reflex controlled
  • sits with or without support at 6 mo*
  • rolls from abdomen to back
  • Sensory: able to differentiate between light and dark
  • hearing and touch well developed
  • TOYS = Mirror, Music, Mobile
infant physical tasks1
Infant Physical Tasks
  • Physical Tasks 6 - 12 months:
  • Gains 3-5 oz (84-140g) weekly for next 6 months
  • * triples weight by 12 months
  • Gains 1/2 in (1.25 cm) monthly for next 6 months
  • Teeth begin to come in
  • Motor:

Intentional rolling over from back to abdomen*

  • Starts crawling and pulling to a stand*
  • Develops pincer grasp*
  • Sits without support by 9 months*
  • Sensory:

Can fixate on and follow objects

  • Localizes sounds
infant psychosocial tasks
Infant Psychosocial Tasks


  • Distinction in cry at 1 month
  • Coos at 3 months
  • Begins to imitate sound at 6 months – babbles
  • Verbalizes all vowels at 9 months
  • Can say 4–5 words at 12 months


  • Social smile at 2 months
  • Demands attention & social interaction at 4 months
  • Stranger anxiety & comfort habits begin at 6 months*
  • Separation anxiety develops at 9 months*

Photo Source: Del Mar Image Library; Used with permission

infant cognitive tasks
Infant Cognitive Tasks

Neonates Reflexes only

1-4 months Recognizes faces

Smiles and shows pleasure

Discovers own body and surroundings

5-6 months Begins to imitate

7-9 months Searches for dropped objects

*Object Permanence begins

Responds to simple commands

Responds to adult anger

10-12 months Recognizes objects by name

Looks at and follows pictures in books


Physical Tasks:

  • Slow growth period
  • Gains 11 lbs (5 kg)
  • Grows 8 inches (20.3 cm)
  • Anterior fontanel closes at
  • 12 - 18 months*
  • Primary dentition (20 teeth) complete by 2½ years
  • Develops sphincter control – toilet training possible*

Motor Tasks:

  • Walks alone by 12 - 18 months*
  • Climbs and runs fairly well by 2 years
  • Rides tricycle well by 3 years

Photo Source: Del Mar Image Library; Used with permission

toddler cognitive tasks
Toddler Cognitive Tasks
  • Follows simple directions by 2 years
  • Uses short sentences by 18 months
  • *favorite words “no” and “mine” = Autonomy
  • Knows own name by 12 months, refers to self
  • Achieves object permanence
  • Uses “magical” thinking
  • Uses ritualistic behavior
  • Repeats skills to master them and decrease anxiety
  • Egocentric thinking - thoughts cause actions
toddler psychosocial tasks
Toddler Psychosocial Tasks
  • Increases independence
  • Able to help with dressing self
  • Temper tantrums (autonomy)
  • Beginning awareness of ownership (me and mine)
  • Shares possessions by 3 years
  • Vocabulary increases to over 900 words
  • Toilet training
  • Fears: separation anxiety, loss of control

TOYS = Push-pull toys, large blocks


Physical Tasks:

  • Slow growth rate continues
  • Weight increases 4-6 lbs (1.8–2.7 kg) a year
  • Height increases 2½ inches (5-6.25 cm) a year
  • Permanent teeth appear

Motor Tasks:

  • Walks up & down stairs
  • Skips and hops on alternate feet
  • Throws and catches ball, jumps rope
  • Hand dominance appears
  • Ties shoes and handles scissors well
  • Builds tower of blocks

Photo Source: Del Mar Image Library; Used with permission

preschooler cognitive tasks
Preschooler Cognitive Tasks
  • Can only focus on one idea at a time
  • Begins awareness of racial and sexual differences
  • Develops an understanding of time
    • Learns sequence of daily events
    • Able to understand some time-oriented words
  • Begins to understand the concept of causality
  • Has 2,000 word vocabulary
  • Is very inquisitive and curious
preschooler psychosocial tasks
Preschooler Psychosocial Tasks
  • Becomes independent
  • Gender-specific behavior is evident by 5 years
  • Egocentricity changes to awareness of others
  • Understands sharing
  • Aggressiveness and impatience peak at 4 years
  • Eager to please and shows more manners by 5 years
  • Behavior is goal-directed and imaginative
  • Play is work*

TOYS = Dolls, Dress-up, Imagination

preschooler psychosocial tasks1
Preschooler Psychosocial Tasks

Fears: about body integrity (Fear & Injury) are common

Magical and animistic thinking allows illogical fears to develop*

Observing injuries or pain of others can precipitate fear

Able to imagine an event without experiencing it

Guilt and shame are common*

school age

Physical Tasks:

  • Slow growth continues
  • Weight doubles over this period
  • Gains 2 inches (5 cm) per year
  • At age 9, both sexes are the same size
  • At age 12, girls are bigger than boys
  • Very limber but susceptible to bone fractures
  • Develops smoothness & speed in fine motor skills
  • Energetic, developing large muscle coordination, stamina & strength
  • Has all permanent teeth by age 12

Photo Source: Del Mar Image Library; Used with permission

school age cognitive tasks
School-Age Cognitive Tasks
  • Period of Industry:
  • Likes to accomplish or produce
  • Interested in exploration & adventure
  • Develops confidence
  • Rules become important*
  • Concepts of time and space develop:
  • Understands causality, permanence of mass & volume
  • Masters the concepts of conservation, reversibility,
  • arithmetic and reading
  • Develops classification skills
  • Begins to understand cause and effect*
school age psychosocial tasks
School-Age Psychosocial Tasks
  • School occupies half of waking hours; has cognitive and
  • social impact on child
  • Morality develops
  • Peer relationships start to be developed
  • Enjoys family activities
  • Has increased self-direction - tasks are important
  • Has some ability to evaluate own strengths & weaknesses
  • Enjoys organizational activities (sports, scouts, etc.)*
  • Modesty develops as child becomes aware of own body*

TOYS = Board games, computer games, learning activities


Physical tasks:

  • Period of rapid growth
  • Puberty starts
  • Girls: height increases 3 inches/year
  • Boys: growth spurt around 13-yrs-old

height increases 4 inches/year

weight doubles between 12-18 yrs

  • Body shape changes:

Girls have fat deposits in thighs, hips & breast, pelvis broadens

Boys become leaner with a broader chest

Photo Source: Del Mar Image Library; Used with permission


Sexual Development


Breasts develop Facial Hair growth

Menses begins Voice changes

First 1 –2 years infertile Enlargement of testes at 13 yrs

Nocturnal emission during sleep

Reaches reproductive maturity

with viable sperm at 17 yrs

adolescent cognitive tasks
Adolescent Cognitive Tasks
  • Develops abstract thinking abilities
  • Often unrealistic
  • Sense of invincibility = risk taking behavior*
  • Capable of scientific reasoning and formal logic
  • Enjoys intellectual abilities
  • Able to view problems comprehensively

ACTIVITIES = Music, video games, communication with peers

adolescent psychosocial tasks
Adolescent Psychosocial Tasks

Early Adolescent: Prone to mood swings

Needs limits and consistent discipline

Changes in body alter self-concept

Fantasy life, daydreams, crushes are normal

Middle Adolescent: Separate from parents

Identify own values and define self*

Partakes/conforms to peer group/values*

Increased sexual interest

May form a “love” relationship

Formal sex education begins

adolescent psychosocial tasks1
Adolescent Psychosocial Tasks

Late Adolescent: Achieves greater independence*

Chooses a vocation

Finds an identity*

Finds a mate

Develops own morality

Completes physical and emotional maturity

Fears: Threats to body image – acne, obesity


Injury or death, but have sense of “invincibility”

The unknown

let s review

Let’s Review

A 10 month-old baby was admitted to the pediatric unit. Each time the nurse enters the room the baby begins to cry. The most appropriate action by the nurse would be to:

A. Complete all procedures quickly in order to decrease the

amount of time the baby will cry.

B. Ask another nurse to assist you with the baby’s care.

C. Distract the baby.

D. Encourage the parent to stay by the bedside and assist with

the care.

let s review1
Let’s Review

A 6 month-old is admitted to the pediatric unit for a 3 week course of treatment. The infant’s parents cannot visit except on weekends. Which action by the nurse indicates an understanding of the emotional needs of an infant?

A. Telling the parents that frequent visits are unnecessary.

B. Placing the infant in a room away from other children.

C. Assigning the infant to different nurses for varied contacts.

D. Assigning the infant to the same nurse as much as possible.

let s review2
Let’s Review

Which child is most likely to be frightened by hospitalization?

A. 4 month-old admitted with a diagnosis of bronchiolitis.

B. 2 year-old admitted with a diagnosis of cystic fibrosis.

C. 9 year-old admitted with a diagnosis of abdominal pain.

D. 15 year-old admitted with a diagnosis of a fractured femur.

infant nutrition
Infant Nutrition

Birth – 6 months:

  • Breast milk is most complete diet
  • Iron-fortified formulas are acceptable
  • No solid foods before 4 months*

6 - 12 months:

  • Breast milk or formula continues*
  • Diluted juices can be introduced
  • Introduction of solid foods*(4-6 mo): cereal, vegetables, fruits, meats
  • Finger foods at 9-10 months
  • Chopped table foods at 12 months
  • Gradual weaning from bottle/breast
  • No honey (risk for botulism)
toddler nutrition
Toddler Nutrition
  • Able to feed self – autonomy & messy!
  • Appetite decreases- physiologic anorexia
  • Negativism may interfere with eating
  • Needs 16 – 20 oz. milk/day
  • Increased need for calcium, iron, and phosphorus – risk for iron deficiency anemia
  • Caloric requirements is 100 calories/kg/day
  • No peanuts under 3 years of age (allergies)*
  • Do not restrict fats less than 2 years of age*
  • Choking is a hazard (no nuts, hot dogs, popcorn, grapes)*

Photo Source: Del Mar Image Library; Used with permission

preschooler nutrition
Preschooler Nutrition
  • Caloric requirements is 90 calories/kg/day
  • May demonstrate strong taste preferences
    • 4 years old – picky eaters
    • 5 years old – influenced by food habits of others
  • Able to start social side of eating
  • More likely to try new foods if they assist in food preparation
  • Establish good eating habits - obesity
school age nutrition
School-Age Nutrition
  • Caloric needs diminish, only need 85 kcal/kg
  • Foundation laid for increased growth needs
  • Likes and dislikes are well established
  • “Junk” food becomes a problem
  • Busy schedules – breakfast is important
  • Obesity continues to be a risk
  • Nutrition education should be integrated into

the school program

adolescent nutrition
Adolescent Nutrition

Nutritional requirements peak during years of maximum growth:

Age 10 – 12 in girls

Age 14 – 16 in boys

Food intake needs to be balanced with energy expenditures

Increased needs for:

Calcium for skeletal growth

Iron for increased muscle mass and blood cell development

Zinc for development of skeletal, muscle tissue and sexual maturation

Photo Source: Del Mar Image Library; Used with permission

adolescent nutrition continued
Adolescent Nutrition (continued)

Eating and attitudes towards food are primarily family/peer centered

Skipping breakfast, increased junk food, decreased fruits, veggies, milk

Boys eat foods high in calories. Girls under-eat or have inadequate nutrient intake.

let s review3
Let’s Review

The nurse recommends to parents that popcorn and peanuts are not good snacks for toddlers. The nurse’s rationale for this action is:

A. They are low in nutritive value.

B. They cannot be entirely digested.

C. They can be easily aspirated.

D. They are high in sodium.

let s review4
Let’s Review

Nutrition is an important aspect of health promotion for the infant. Priority information to give the parents concerning infant nutrition would include (check all that apply):

A. Restrict the fat intake of the infant to help reduce the

chances of an obese child.

B. Breast or infant formula must be continued for the first


C. Encourage the use of a pacifier for non-nutritive sucking


D. Introduction of solid foods should begin at 4-6 months.

play is the work of children
Play is the work of Children
  • Enhances Motor Skills
  • Enhances Social Skills
  • Enhances Verbal Skills
  • Expresses Creativity
  • Decreases Stress
  • Helps Solve Problems
appropriate play activities
Appropriate Play Activities

Infants - Solitary Play, stimulation of senses (music, mirror)

Toddler - Parallel Play, make believe, locomotion (push-pull toys), gross & fine motor, outlet for aggression & autonomy

Preschooler - Associative Play, Imaginary Playmate, dramatic & imitative, gross & fine motor

School Age - Cooperative Play, rules dominate play, team games/sports, quiet games/activities, joke books

Adolescent - Group activities predominate, activities involving the opposite sex in later years

preparation for procedures
Preparation for Procedures
  • Allow child to play with equipment
  • Demonstrate procedure on doll for young child
  • Use age-appropriate teaching activities
  • Describe expected sensations
  • Use simple explanations
  • Clarify any misconceptions
  • Involve parents in comforting child
  • Praise/reward child when finished

Photo Source: Del Mar Image Library; Used with permission

communicating with children
Communicating with Children
  • Provide a trusting environment
  • Get down to child’s eye level
  • Use words appropriate for age
  • Always explain what you are doing
  • Always be honest
  • Allow choices when possible
  • Allow child to show feelings/talk
let s review5
Let’s Review

The single most important factor for the nurse to recognize when communicating with a child is:

A. The child’s chronological age.

B. Presence or absence of the child’s parents.

C. Developmental level of the child.

D. Nonverbal behaviors of the child.

health promotion
Health Promotion

Childhood Immunizations

Well child check-ups


Screenings throughout childhood

(APGARS, newborn screenings, lead poisoning, vision/hearing, scoliosis)

Health Teaching

  • Primary prevention of many communicable diseases
  • Vaccines safety
    • MMR vaccine and autism (no correlation)
    • Reactions (pre-medicate with Tylenol)
  • Live attenuated vaccines (MMR, Varicella)
    • Weakened form of disease
    • Body produces immune response
    • Contraindicated in immunosupressed individuals
  • Inactivated (killed virus/bacteria or synthetic)
    • 1st dose only “primes” system- immunity develops after 3rd
injury prevention safety issues
Injury Prevention& Safety Issues
  • Accidents are the leading cause of death in infants and toddlers (falls, burns, poisons)
  • Toddlers and Preschoolers – drowning
  • School-age and adolescents – motor vehicle accidents and firearms
  • 90% of all accidents are preventable!
  • Safety education is the answer
injury prevention
Injury Prevention
  • Methods of Injury Prevention
    • Understanding and Applying Growth and
    • Developmental Principles
    • Anticipatory Guidance
    • Childproofing the environment
    • Educating caregivers and children
    • Legislation
  • Precipitating Factors
  • Potential Outcomes
pediatric poisonings
Pediatric Poisonings
  • Highest incidence occurs in children in 2-year-old age group and under 6 years of age
  • Major contributing factor – improper storage, allowing children to play with “bottles” – rattling of pills, “drink” syrups, toxic portion of plants.
    • Teach parents about proper storage
    • Knowledge of plants in household, and keep away from infants and children who might “chew”
  • Emergency treatment depends on agent ingested
    • Teach parents to have poison control number available
    • Refer to appropriate method according to substance ingested

First Intervention is to call POISON CONTROL CENTER

types of poisonings
Types of Poisonings

Lead Poisoning

Salicylate Poisoning

Acetaminophen Ingestion

lead poisoning
Lead Poisoning
  • Major environmental health concern
  • Found in older homes (built before 1978), lead-contaminated soil, water through lead pipes, lead-based paint in ceramics products, Mexican candies made in lead containers
  • Body rapidly absorbs lead – specially in periods of rapid growth – most harmful to children under 6 years
  • Absorbed in GI tract and accumulates in bones, brain, kidneys
  • Low levels in blood can cause behavioral/learning problems, mid-levels anemia-like symptoms and skeletal growth interference, and high levels can be fatal from CNS edema and encephalopathy
  • Diet high in fat, low in iron & calcium can increase lead absorption
  • Intervention=teaching for prevention. If blood level ≥ 45, chelation therapy is needed – monitor kidney function during treatment.
salicylate poisoning
Salicylate Poisoning
  • Can be acute or chronic ingestion
  • S/S = nausea, disorientation, vomiting, dehydration, hyperpyrexia, oliguria, coma, bleeding tendencies, tinnitus, seizures
  • Nursing interventions = activated charcoal, sodium bicarbonate for metabolic acidosis, external cooling measures for hyperpyrexia, anticonvulsant and seizure precautions (think patient safety!), vitamin K for bleeding, possible hemo (NOT peritoneal) dialysis
acetaminophen poisoning
Acetaminophen Poisoning
  • Most common drug poisoning in children
  • Acute ingestion
  • S/S start as nausea, vomiting, pallor, sweating » hepatic involvement (jaundice, confusion, coagulation problems, RUQ pain)
  • Treatment is activated charcoal first, then the antidote N-acetylcysteine (Mucomyst) PO every 4 hours for 17 doses after a loading dose given

Always assess Level of Consciousness (LOC) before administering PO med!

let s review6
Let’s Review

Which would be the best approach for gastric emptying in a lethargic 18-month-old who ingested antihistamine tablets an hour ago?

A. Diluting toxic substance with water or milk

B. Administering naloxone (Narcan)

C. Gastric lavage

D. Administering ipecac syrup

physical assessment of infant
Physical Assessment of Infant
  • Assessment is NOT in the head-to-toe manner
  • When quiet, auscultate heart, lungs, abdomen
  • Assess heart & respiratory rates before temperature
  • Palpate and percuss same areas
  • Perform traumatic procedures last
  • Elicit reflexes as body part examined
  • Elicit Moro reflex last
  • Encourage caretaker to hold infant during exam

Distract with soft voice, offer pacifier, music or toy

physical assessment of toddler
Physical Assessment of Toddler
  • Inspect body areas through play – “count fingers and toes”
  • Allow toddler to handle equipment during assessment and distract with toys and bubbles
  • Use minimal physical contact initially
  • Perform traumatic procedures last
  • Introduce equipment slowly
  • Auscultate, percuss, palpate when quiet
  • Give choices whenever possible

Photo Source: Del Mar Image Library; Used with permission

physical assessment of preschooler
Physical Assessment of Preschooler
  • If cooperative, proceed with head-to-toe
  • If uncooperative, proceed as with toddler
  • Request self undressing and allow to wear underpants
  • Allow child to handle equipment used in assessment
  • Don’t forget “magical thinking”
  • Make up “story” about steps of the procedure
  • Give choices when possible
  • If proceed as game, will gain cooperation

Photo Source: Del Mar Image Library; Used with permission

physical assessment of school age child
Physical Assessment of School-Age Child
  • Proceed in head-to-toe
  • May examine genitalia last in older children
  • Respect need for privacy – remember modesty!
  • Explain purpose of equipment and significance
  • Teach about body function and care of body
physical assessment of the adolescent
Physical Assessment of the Adolescent
  • Ask adolescent if he/she would like parent/caretaker

present during interview/assessment

  • Provide privacy
  • Head-to-toe assessment appropriate
  • Incorporate questions/assessment related to

genitals/sexuality in middle of exam

  • Answer questions in a straightforward, non-

condescending manner

  • Include the adolescent in planning their care
  • Causes – Often unknown, may be due to dehydration, most often viral induced
  • Danger in infants is febrile seizures – most common between 3 months to five years. The seizure is a result of how quickly the temperature rises.
  • Hydration (20mls/kg is formula for bolus)
  • Antipyretics – acetaminophen or ibuprofen
  • Cooling measures – avoid shivering
    • Tepid bath
    • Remove excess clothing and blankets
    • Cooling blankets/mattresses


pediatric differences fluid electrolyte
Pediatric DifferencesFluid & Electrolyte

Percent Body Water compared to Total Body Weight:

  • Premature infants: 90% water
  • Infants: 75 - 80% water
  • Child: 64% water

Higher percentage of water in extracellular fluid in infants

Infants and toddlers more vulnerable to fluid and electrolyte disturbances

Concentrating abilities of kidneys not fully mature until 2 years

Metabolic rate is 2-3 times higher than an adult

Greater body surface area per kg body weight than adults; dehydrates more quickly

  • Types:
    • Isotonic – Most common; salt and water lost. Greatest threat – Hypovolemic Shock
    • Hypotonic – Electrolyte deficit exceeds water deficit- physical signs more severe with smaller fluid losses
    • Hypertonic – Water loss higher than electrolyte

Vomiting leads to metabolic alkalosis

Diarrhea leads to metabolic acidosis

LAB WATCH: monitor sodium, potassium, chloride, carbon dioxide, BUN, and creatinine

assessment of dehydration
Assessment of Dehydration
  • Skin gray, cold, mottled, poor to fair, dry or clammy
  • Delayed capillary refill
  • Mucous membranes/lips dry
  • Eyes and fontanels sunken
  • No tears present when crying
  • Pulse and respirations rapid
  • Irritability to lethargy depending on cause and severity, not responsive to parent and/or environment
dehydration nursing interventions
Dehydration:Nursing Interventions
  • Daily weight, I/O
  • Assess hydration status
  • Assess neurological status
  • Monitor labs (electrolytes)
  • Rehydrate with fluids both PO and IV (20 mls/kg of NS)
  • Diet progression: Pedialyte modified Bread-Rice-Apple Juice-Toast (BRAT)  Diet-for-age (DFA)
  • Skin care for diaper rash
  • Stool output (Amount, Color, Consistency, Texture - ACCT)

Priorities: fluid replacement & assess for S/S of shock

  • Often specific etiology unknown, but rotavirus is most common cause of gastroenteritis in infants and kids
  • Don’t forget contact precautions!!
  • Leading cause of illness in children younger than 5
  • May result in fatality if not treated properly
  • History very important
  • Treatment aimed at correcting fluid imbalance and treating underlying cause
  • Metabolic acidosis = blood pH < 7.35
  • Often result of infections, improper feeding techniques, GI blockage (pyloric stenosis), emotional factors
  • Management directed toward detection, treatment of cause and prevention of complications
  • Metabolic alkalosis = blood pH >7.45
let s review7
Let’s Review

The most appropriate type of IV fluid to infuse in treatment of extra-cellular dehydration in children is:

A. Isotonic solution.

B. Hypotonic solution.

C. Hypertonic solution.

D. Colloid solution.

let s review8
Let’s Review

Which laboratory finding would help to identify that a child experiencing metabolic acidosis?

A. Serum potassium of 3.8

B. Arterial pH of 7.32

C. Serum carbon dioxide of 24

D. Serum sodium of 136

pain assessment infants
Pain Assessment: Infants

Assessment of pain includes the use of pain scales that usually evaluate indicators of pain such as cry, breathing patterns, facial expressions, position of extremities, and state of alertness

Examples: FLACC scale,

NIPS scale

pain assessment toddlers
Pain Assessment: Toddlers

Toddlers may have a word that is used for pain (“owie,” “boo-boo,” “ouch” or “no”); be sure to use term that toddler is familiar with when assessing.

Can also use FLACC scale, or Oucher scale (for older toddlers)

pain assessment preschoolers
Pain Assessment:Preschoolers

Think pain will magically go away

May deny pain to avoid medicine/injections

Able to describe location and intensity of pain

FACES scale, poker chips and Oucher scale may be used

Photo Source: Del Mar Image Library; Used with permission

pain assessment older children
Pain Assessment:Older Children

Older children can describe pain with location and intensity

Nonverbal cues important, may become quiet or withdrawn

Can use scales like Wong’s FACES scale, poker chips, visual analog scales, and numeric rating scales

let s review9
Let’s Review

The nurse begins a full assessment on a 10 year-old patient. To ensure full cooperation from this patient it is most important for the nurse to:

A. Approach the assessment as a game to play.

B. Provide privacy for the patient.

C. Encourage the friend visiting to stay at the

bedside to observe.

D. Instruct the child to assist the nurse in the


let s review10
Let’s Review

During a routine health care visit a parent asks the nurse why her 10 month-old infant is not walking as her older child did at the same age. Which response by the nurse best demonstrates an understanding of child development?

A. “Babies progress at different rates. Your infant’s

development is within normal limits.”

B. “If she is pulling up, you can help her by holding her


C. “She’s a little behind in her physical milestones.”

D. “You can strengthen her leg muscles with special

exercises to make her stronger.”

let s review11
Let’s Review

When assessing a toddler identify the order in which you would complete the assessment:

  • Ear exam with otoscope
  • Vital signs
  • Lung assessment
  • Abdominal assessment
let s review12
Let’s Review

When assessing pain in an infant it would be inappropriate to assess for:

  • Facial expressions
  • Localization of pain
  • Crying
  • Extremity movement
genetic disorders
Genetic Disorders

7Principles of Inheritance

g Autosomal Dominant

g Autosomal Recessive

g Sex-linked (X-linked) Inheritance

g Chromosome Alterations

7Down’s Syndrome

7Tay-Sachs Disease

Nursing intervention is supporting parents and resources

down s syndrome
Down’s Syndrome
  • Most common cause of cognitive impairment (moderate to severe)
  • 1 in 600 live births
  • Risk factor- pregnancy in women over 35 yrs old
  • Cause - extra chromosome 21 (faulty cell division)
  • Causes change in normal embryogenesis process resulting in:
    • Cardiac defects, GI conditions, Endocrine disorders, Hematologic
    • abnormalities, Dermatologic changes
  • Physical features: small head, flat facial profile, broad flat nose, small
  • mouth, protruding tongue, low set ears, transverse palmar creases,
  • hypotonia
  • * Feeding is often a problem in infancy *
tay sachs disease
Tay-Sachs Disease
  • Occurs predominately in children of Eastern European Jewish ancestry
  • Fatal Disease - death usually occurs before age 4
  • Autosomal recessive inheritance
  • Degenerative brain disease
  • Caused by absence of hexosainidase A from body tissue
  • Symptoms: progressive lethargy in previously healthy 2-6 months old

infants, loss of milestones, visual acuity, seizures, hyper-reflexia, posturing, malnutrition, dysphagia

  • Diagnosis: Classic cherry red spot on macula, enzyme measurement in

serum, amniotic fluid, white cells

let s review13
Let’s Review

The infant with Down’s Syndrome is closely monitored during the first year of life for which condition?

A. Thyroid complications

B. Orthopedic malformations

C. Cardiac abnormalities

D. Dental malformations

pediatric differences neurosensory system
Pediatric DifferencesNeurosensory System

Size and Structure:

Rapid head growth in early childhood

Bones are not fused until 18-24 months


Autonomic Nervous System is intact - neurons are completely myelinized by 1 year

Infants behavior initially reflexive, but are replaced with purposeful movement by 1 year

Infants demonstrate a dominance of flexor muscles

Motor development occurs constantly in head to toe progression

pediatric differences neurosensory system1
Pediatric DifferencesNeurosensory System

Eye and Vision:

Changes in development of eye and eye muscles

*strabismus normal until 6 months

Vision function becomes more organized

Papilledema rarely occurs in infants due to expansion of fontanels with increased ICP

Ear and Hearing:

Hearing fully developed at birth

Abnormal physical structures may indicate genetic problems

the neurosensory system
The Neurosensory System

Disorders of the Nervous System

3 Hydrocephalus

3 Spina Bifida

3 Reyes Syndrome

3 Seizures

3 Cerebral Palsy (CP)

3 Meningitis

  • Develops as a result of an imbalance of production and absorption of CSF
  • The increase of CSF causes increased ventricular pressure, leading to dilation of the ventricles, pressing on skull
  • Signs/Symptoms of Increased ICP:
    • Poor feeding and vomiting
    • Bulging fontanel, head enlargement, separation of sutures
    • Lethargy, irritability, restlessness, not responsive to parents
    • CHILD - Headache, vomiting, diplopia, ataxia, papilledema
    • Seizures

A child’s head with an open fontanel (under 2 years old) has the ability to expand and better compensate for the increased intracranial pressure.

ventriculoperitoneal vp shunts
Ventriculoperitoneal(VP) Shunts
  • Relief of hydrocephalus
  • Prevention/treatment of complications
  • Management of problems related to psychomotor development
  • Surgical intervention: ventriculoperitoneal (VP) shunt
    • One-way pressure valve releasing CSF into peritoneal cavity where it is reabsorbed

Photo Source: Del Mar Image Library; Used with permission

general nursing interventions
Monitor Neuro Status

Determine baseline

Assess LOC

Assess motosensory

Pupil checks

Vital signs, Head circ

Provide Patient Safety

Seizure precautions

Fall precautions

Possible restraints

Determine LOC ac

Decrease ICP

Cluster care/  stress

Quiet environment

 HOB 30-45 degrees

Appropriate position (head midline, no hip flexion, no prone)

Medications(pain meds,corticosteroids, diuretics, stool softeners, anti-infectives, anticonvulsants)

General Nursing Interventions
general nursing interventions1
Maintain Adequate Cerebral Perfusion

Maintain airway

Monitor oxygenation and apply O2 PRN

Monitor temperature and administer antipyretics PRN

Maintain normovolemia

Monitor I/O

Assess perfusion

Maintain Nutritional & Fluid Needs

Determine swallow ability prior to PO’s

NGT feedings may be necessary

Dietary consult PRN

Daily weight

Monitor lab results

Psychosocial Support

Child Life consult


General Nursing Interventions
spina bifida o cculta and cystica meningocele and myelomeningocele
Spina Bifida:Occulta and Cystica (meningocele and myelomeningocele)
  • Etilogy is unknown, but genetic & environmental factors considered.
    • Maternal intake of folic acid
    • Exposure of fetus to teratogenic drugs
  • The severity of clinical manifestations depend on the location of the lesion.
    • T12 - flaccid lower extremities,  sensation, lack of bowel control and dribbling urine
    • S 3 and lower - no motor impairment
  • Other complications may occur.
    • Hydrocephalus (80-90%)
    • Orthopedic issues such as scoliosis, kyphosis, club foot
    • Urinary retention
    • Skin breakdown/Trauma

Photo Source: Del Mar Image Library; Used with permission

spina bifida
Spina Bifida

Nursing Interventions

  • Sterile dressing pre/post-op
  • Monitor VS, S/S infection
  • Use latex free items
  • Avoid stress on sac - prone position only, especially pre-op; no supine until incision healed
  • Monitor for S/S  intracranial pressure (ICP)
  • Interventions to  ICP
  • Encourage touch & talk
  • Social service consult
reye s syndrome
Reye’s Syndrome
  • A true pediatric emergency - cerebral complications may reach
  • an irreversible state. Vomiting & change in LOC to coma
  • Acute encephalopathy with fatty degeneration of the liver
  • causing fluid & electrolyte imbalances, metabolic acidosis,
  • hypoglycemia, dehydration, and coagulopathies.
  • Most frequently seen in children recovering from a
  • viral illness during which salicylates were given.
  • Therapeutic management is intensive nursing care and
  • maintaining adequate cerebral perfusion, &↓ICP.
    • Increased ICP secondary to cerebral edema is major contributing factor to morbidity and mortality.
  • Febrile seizures are the most common in children, caused by by a RAPID elevation in temperature, usually above 102°.
  • Most children do not have a second febrile seizure episode and only about 3% develop epilepsy.
  • Focus of care is on patient safety, cause of fever and education of parents for home care.
  • Remember basic CPR during seizures – airway before oxygen
  • Seizure precautions: Suction, oxygen, padded rails
  • Infants often have subtle seizures with only occular movements or some extremity movements.
cerebral palsy cp
Cerebral Palsy (CP)
  • 1.5 - 5 in 1,000 live births
  • Neuromuscular disorder resulting from damage or
  • altered structure of part of the brain
  • Caused by a variety of factors:
    • Prenatally - genetic, trauma, anoxia
    • Perinatally - fetal distress, drugs at delivery, precepitate
    • or breech delivery with delay
    • Postnatally - kernicterus or head trauma
cerebral palsy continued
Cerebral Palsy (continued)

Spasticity - exaggerated hyperactive reflexes

Athetosis - constant involuntary, purposeless, slow writhing motions

Ataxia - disturbances in equilibrium

Tremor - repetitive rhythmic involuntary contractions of flexor and extensor muscles

Rigidity - resistance to flexion and extension

Associated Problems: Mental retardation, hearing loss, speech defect, dental & orthopedic anomalies, GI problems and visual changes

cerebral palsy nursing interventions
Cerebral Palsy: Nursing Interventions
  • Safety

Feed in upright position

Seizure precautions

Ambulate with assistance if able

Medication administration

  • Special Needs

Nutritional needs include increased calories, assist with feeds, possible GT feeds.

Speech, Occupational and Physical therapies

bacterial meningitis
Bacterial Meningitis
  • Infectious process of CNS causing inflammation of meninges and spinal cord.
  • Signs and symptoms include those of increased ICP plus photophobia, nuchal rigidity, joint pain, malaise, purpura rash, Kernig’s and Brudinski’s signs
  • Can occur at any age, but often between 1 month-5 years
  • Most common sequele: hearing and/or visual impairments, seizures, cognitive changes
  • Diagnostic confirmation is done by lumbar puncture and CSF is cloudy with increased WBCs, increased protein, and low glucose
  • Nursing Interventions include: appropriate IV antibiotics and meds for increased ICP as well as interventions to decrease ICP
causes of blindness
Causes of Blindness

Genetic Disorders:

Tay-Sach’s disease

Inborn errors of metabolism

Perinatal: prematurity, retrolental fibroplasia

Postnatal: trauma, childhood infections,

Juvenile Arthritis

causes of deafness
Causes of Deafness


Interference in transmission from outer ear to middle ear from chronic OM


Dysfunction of the inner ear

Damage to cranial nerve VIII from rubella, meningitis or drugs

let s review14
Let’s Review

Which test would confirm a diagnosis of meningitis in children?

A. Complete blood count

B. Bone marrow biopsy

C. Lumbar puncture

D. Computerized Tomography (CT) scan

let s review15
Let’s Review

In performing a neurological assessment on a patient which data would be most important to obtain?

A. Vital signs.

B. Head circumference.

C. Neurologic “soft signs”.

D. Level of consciousness (LOC).

let s review16
Let’s Review

A neonate born with myelomeningocele should be maintained in which position pre-operatively?

A. Prone.

B. Supine.

C. Trendelenberg.

D. Semi-Fowler.

let s review17
Let’s Review

The nurse witnesses a pediatric patient experiencing a seizure. The primary nursing intervention would be:

A. Careful observation and documentation of the

seizure activity.

B. Maintain patient safety.

C. Minimize the patient’s anxiety.

D. Avoid over stimulation and promote rest.

let s review18
Let’s Review

Which assessment finding in an infant first day post-op placement of a ventriculoperitoneal (VP) shunt is indicative of surgical complications?

A. Hypoactive bowel sounds.

B. Congestion in upper airways.

C. Increasing lethargy.

D. Incisional pain.

cardiovascular system pediatric variances
Cardiovascular System:Pediatric Variances
  • Cardiac arrest is related to prolonged hypoxemia
  • Heart Rate (HR) higher
  • Cardiac Output depends on HR until heart muscle is fully

developed (around 5 years of age)

  • Innocuous (benign) murmurs
  • Sinus arrhythmias normal in infants
  • Congenital defects present at birth – the greater the defect,

the more severe the clinical manifestations (S/S)

fetal circulation

Photo Source: Del Mar Image Library; Used with permission

cardiovascular system changes from fetal circulation
Cardiovascular System:Changes from Fetal Circulation

Fetal Circulation - Pattern of Altered Blood Flow

Normal Circulatory Changes at Birth:

Oxygenation takes place in Lungs

Structural changes occur:

* Ductus venosus constricts by 3-7 days

becomes ligamentum venosum

* Foramen ovale closes within first weeks

* Ductus arteriosus functional closure at

24 hours, anatomic closure 1-3 weeks

cardiovascular system changes from fetal circulation1
Cardiovascular System:Changes from Fetal Circulation
  • Abnormal Circulatory Patterns After Birth
  • Abnormal openings between the pulmonary
  • and systemic circulations can disrupt blood flow.
  • Blood will follow the path of least resistance
  • -Left side of heart has greater pressure, so . . .
  • Blood normally shunted from left to right
  • Obstructions to pulmonary blood flow may cause right

to left shunting of blood

normal heart anatomy blood flow

Photo Source: Del Mar Image Library; Used with permission

the cardiovascular system
The Cardiovascular System

Y Care of the Child with Congestive Heart Failure

Y Congenital Heart Defects

Increased Pulmonary Blood Flow

Decreased Pulmonary Blood Flow

Obstruction to Systemic Blood Flow

Y Acquired Heart Disease

goals of nursing care with congenital heart disease
Goals of Nursing Care with Congenital Heart Disease

Y Reduce workload-Improve cardiac function

Y Improve respiratory function

Y Maintain nutrition to meet metabolic demands

and promote growth

Y Prevent infection and support/instruct parents

congestive heart failure review
Congestive Heart Failure Review
    • Tachycardia, especially at rest
    • Diaphoresis
    • Fatigue
    • Poor Feeding
    • Failure to Thrive (FTT)
    • Exercise Intolerance
    • Decreased Peripheral Perfusion
    • Pallor and/or Cyanosis
    • Cardiomegaly
clinical manifestations chf




Crackles Retractions

Nasal Flaring



Edema (facial)

Sudden weight gain

Decreased Urine Output



Jugular Vein Distention (JVD, children)


chf focused review nursing interventions
CHF: Focused Review Nursing Interventions

Therapeutic Management

  • Improve cardiac function – Digitalization; Infant dose calculated 1000micrograms=1mg, ACE inhibitors
  • Diuretics, fluid restrictions, daily weights, I/O
  • Decrease tissue demands – Promote rest, minimize stress
  • Increase tissue oxygenation – Oxygen
  • Nutrition – Nipple feeds vs. gavage or GT, higher-calorie feeds
general nursing interventions2
Improve Cardiac Function


Cardiac glycosides (Digoxin)

Promote Fluid Loss





Fluid Restriction

Daily Weight

Monitor I/O

Decrease Cardiac Demands

Promote rest

Minimize Stress

Monitor VS (temp)

Reduce Respiratory Distress

HOB elevated

Possible supplemental oxygen

Maintain Nutrition

Nipple vs. Gavage/GTT

Higher-calorie feeds (more than 20 cals/oz)

increased pulmonary blood flow acyanotic
Increased Pulmonary Blood Flow (Acyanotic)
  • Atrial Septal Defect (ASD)
  • Ventricular Septal Defect (VSD)
  • Patent Ductus Arteriosus (PDA)
  • CHF
  • Feeding intolerance
  • Activity intolerance
  • Poor growth, failure to thrive
  • Frequent Pulmonary Infections due to “boggy
  • lungs”
decreased pulmonary blood flow cyanotic
Decreased Pulmonary Blood Flow (Cyanotic)
  • Pulmonary Stenosis
  • Tetralogy of Fallot
  • Transposition of the Great Vessels

Assessment findings/Compensatory mechanisms

    • Oxygen desaturation
    • Varying degrees of cyanosis
    • Polycythemia
decreased pulmonary blood flow cyanotic1
Decreased Pulmonary Blood Flow (Cyanotic)

Photo Source: Del Mar Image Library; Used with permission

obstruction to systemic blood flow
Obstruction to Systemic Blood flow
  • Aortic Stenosis
  • Coarctation of the Aorta
  • Think perfusion issues
  • -Diminished or unequal pulses
  • -Poor color
  • -Delayed capillary refill time
  • -Exercise intolerance
obstruction to systemic blood flow1
Obstruction to Systemic Blood flow

Photo Source: Del Mar Image Library; Used with permission

rheumatic fever
Rheumatic Fever

Acquired Heart Disease

Inflammatory disorder involving heart, joints, connective tissue, and the CNS

Peaks in school-age children

Linked to environmental factors and family history

Thought to be an autoimmune disorder:

Commonly preceded by a Strep Throat

Prognosis depends upon the degree of heart damage

Rest important in recovery – priority intervention in acute stage

Strep prophylaxis for 5 years or throughout adolescence

hematologic system pediatric variances
Hematologic System:Pediatric Variances

All bone marrow in a young child is involved in the

formation of blood cells.

By puberty, only the sternum, ribs, pelvis, vertebrae,

skill, and proximal epiphyses of femur and

humerus are involved in blood cell formation.

During the first 6 months of life, fetal hemoglobin is

gradually replaced by adult hemoglobin.

the hematologic system
The Hematologic System
  • Disorders of Red Blood Cells
    • Iron Deficiency Anemia
    • Sickle Cell Anemia
  • Disorders of Platelets/Clotting Factors
    • Idiopathic Thrombocytopenia Purpura (ITP)
    • Hemophilia
iron deficiency anemia
  • Most common nutritional anemia in childhood
  • Severe depletion of iron stores resulting in a low HGB level
  • Decreased O2 to tissues = fatigue, headache, pallor, increased heart rate
  • Occurs after depletion of iron stores in body

(6-9 mo of age)

  • Most likely to occur during rapid physical growth and low iron intake
iron deficiency anemia1
  • Often occurs as a result of increased milk intake
  • Lab results show low HGB, HCT, MCV, MCH, MCHC, iron, ferritin
  • Teach parents proper nutrition
    • Meat, spinach, legumes, sweet potatoes, egg yolks, seafood
    • Calcium inhibits iron, Vitamin C enhances iron absorption
sickle cell disease
Sickle Cell Disease

Photo Source: Del Mar Image Library; Used with permission


  • Normal RBC has a flexible, round shape
  • RBC w/HbS has a normal shape until it’s O2 delivered to tissue, then sickle shape occurs
    • Stiff, non-pliable – can’t flow freely
    • Trapped in small vessels = causes vaso-occlusions, tissue ischemia and infarctions – painful episodes, most common area is joints
    • Hemolysis of RBC- lifespan down to 20 days
    • Compensatory mechanism is increased reticulocytes
sickle cell disease1

High mortality rate

<5 years old

Splenic dysfunction begins at 6 mo old

Prophylactic PCN

BID at 2-3 mo old

Monitor for Infection

Temp > 101.5

Respiratory S/S


Highly vascular

Susceptible to injury/infarction

Occurs 6 mo-3yrs

Pallor, fatigue, abd pain, splenomegaly, CV compromise

Treatment: IV fluids, PRBC’s

Sickle Cell Disease
sickle cell disease nursing interventions

Hydration is Priority!

Fluid Bolus & maintenance + 1/2

Oxygen - to decrease sickling of of cells

Pain Management

Assess frequently/appropriately

IV Morphine q3-4 hr, PCA

Non-pharmacological methods


Pain Control



Early Identification of infection


Avoid dehydration

Sickle Cell Disease:Nursing Interventions
idiopathic thrombocytopenic purpura itp
Idiopathic Thrombocytopenic Purpura (ITP)
  • Acquired hemorrhagic disorder characterized by thrombocytopenia and purpura
  • Cause is unknown, but is to believed to be an auto-immune response to disease-related antigens
  • Usually follows an URI, measles, rubella, mumps, chickenpox
  • Greatest frequency is between 2-8 years of age
  • Platelet count is below 20,000
  • Therapeutic management is supportive with safety concerns. Activity is usually restricted.
  • Acute presentation therapy can include prednisone, IV immunoglobulin, or Anti-D antibody (causes a hemolytic anemia to rid the body of the antibody-coated RBC’s)
  • Chronic ITP will involve a splenectomy.
  • Group of genetic bleeding disorders of which there is a deficiency of a clotting factor
  • Most common are Factor VIII (A) & Factor IX (B)
  • Bleed LONGER not faster
  • Clinical manifestations: prolonged bleeding, bruising, spontaneous hematuria
  • Management: replacement of missing clotting factor (recombinant factor VIII concentrate), cryoprecipitate, DDAVP
  • NSAIDS (aspirin, Indocin) are contraindicated, they inhibit platelet function
  • Regular non-contact exercise/physical therapy is encouraged


  • Bleeding into muscle tissue
  • Hemarthrosis can cause joint pain & destruction
    • Acute Treatment is rest, ice, elevation, ROM

Photo Source: Del Mar Image Library; Used with permission

let s review19
Let’s Review

When assessing a child for any possible cardiac anomalies, the nurse takes the right arm blood pressure (BP) and the BP in one of the legs. She finds that the right arm BP is much greater than that found in the child’s leg. The nurse reacts to these findings in which way?

A. Charts the findings and realizes they are normal.

  • Suspects the child may have coarctation of the aorta.

C. Suspects the child may have Tetralogy of Fallot.

D. Notifies the physician and alerts the surgery team.

let s review20
Let’s Review

A 1-month-old infant is being admitted for complications related to a diagnosed ventricular septal defect (VSD). Which physician’s order should be questioned by the nurse?

A. Blood pressure every 4 hours.

B. Serum digoxin level.

C. Diet: Enfamil 20, nipple 6 oz q2H.

D. Supplemental oxygen via nasal cannula prn maintain

SaO2 >92%.

let s review21
Let’s Review

A nursing intervention most pertinent for the child with hemophilia is:

A. Sedentary activities to prevent bleeding episodes.

B. Meticulous oral care with dental floss to prevent


C. Warm compresses to bleeding areas to increase


D. Active range of motion exercises for joint mobility.

let s review22
Let’s Review

Which is the most appropriate information to teach a parent of a 14 month-old child with iron deficiency anemia?

A. Increase the child’s daily milk intake to a minimum of

24 ounces.

B. Administer oral iron supplement for the child to drink

in a small cup.

C. Increase the amount of dark green, leafy vegetables

and eggs in the child’s diet.

D. Encourage the parents to let the child choose foods he


let s review23
Let’s Review

Which strategy is appropriate when feeding the infant in congestive heart failure?

A. Continue the feeding until a sufficient amount of

formula is taken

B. Bottle feed no longer than 30 minutes

C. Feed the infant every 2 hours

D. Rock and comfort the infant during feedings

respiratory system pediatric variances
Respiratory SystemPediatric Variances
  • The airway is smaller and more flexible.
  • The larynx is more flexible and more susceptible to spasm.
  • The lower airways are smaller with underdeveloped


  • The tongue is large.
  • Infants < 6 months old are obligate nose breathers.
  • Chest muscles are not well developed
  • The diaphragm is the neonate’s major respiratory muscle.
  • Irregular breathing pattern and brief periods of apnea (10 -

15 secs) are common

  • Abdominal muscles are used for inhalation until age 5-6 yrs.
  • Respiratory rate is higher
  • Increased BMR raises oxygen needs
the respiratory system
The Respiratory System

Upper Airway Disorders




Foreign Body Aspiration

Lower Airway Disorders



Cystic Fibrosis

Photo Source: Del Mar Image Library; Used with permission


Sore throat

Mouth breathing

Sleep Apnea

Difficulty swallowing


Throat C&S/Rapid Strep


Ease Respiratory Efforts

Provide Comfort

Warm saline gargles

Pain Medication

Throat lozenges

Reduce Fever

Promote Hydration

Administer Antibiotics

Provide Rest

Patient Teaching

Tonsillectomy may be necessary


Pre-operative Nursing Care

Monitor Labs (CBC, PT, PTT)

Age-appropriate Preparation/Teaching

Surgical Consent

Post-operative Nursing Care

Frequent site assessment - visualize!

Monitor for S/S of Complications

Pain Management

Diet (push fluids-no citrus juices or red, advance diet)

Patient Teaching

croup epiglottitis
  • Infection and swelling of larynx, trachea, epiglottis, bronchi
  • Often preceded by URI traveling downward
  • Causative agent: Viral
  • Characterized by hoarseness, barky cough, inspiratory stridor, and respiratory distress
  • Most common ages 6 mo-3 yrs
  • LTB form most common

Photo Source: Del Mar Image Library; Used with permission

acute epiglottitis
Acute Epiglottitis
  • Bacterial form of croup affecting epiglottis
  • Wellness to complete obstruction in 2-6 hours
  • Most common in ages 2-5 years
  • Do not examine throat!
  • Have functional emergency equipment at bedside - Priority!
  • Often the child is intubated
  • 4 D’s - Drooling, Dysphagia, Dysphonia, Distressed Inspiratory Effort
  • Lateral Neck X-ray shows “thumb sign”
  • HIB vaccine has reduced the cases dramatically
croup epiglottitis1
Nursing Interventions

Maintain Patent Airway

Assess and Monitor

Ease Respiratory Efforts

Promote Hydration

Reduce Fever

Calm Environment

Promote Rest

Nursing Interventions

Administer Meds


(HHN) Nebulizer treatment of Racemic Epinephrine PRN stridor

Antibiotic for epiglottitis

foreign body aspiration
Foreign Body Aspiration
  • Occurs most often in small children
  • Choking, coughing, wheezing, respiratory difficulty
  • Often it is round food, such as hot dogs, grapes, nuts, popcorn
  • Bronchoscopy often needed for removal
  • Age-appropriate preparation needed for procedure
  • Prevention and parent education is very important
bronchiolitis rsv
  • Acute viral infection of the bronchioles causing an inflammatory/obstructive process to occur
  • Increased amount of mucus and exudates preventing expiration of air and overinflation of lungs
  • Causative agent in 85% of cases is Respiratory Syncytial Virus (RSV). It is highly contagious - contact isolation must be enforced.
  • Nasal swab or nasal washing obtained for viral panel, including RSV
  • CXR shows hyperinflation and consolidation if atelectasis present
  • Primarily seen in children under 2 years of age
  • Most common in winter and early spring
  • Palivizumab (Synagis)
bronchiolitis rsv1

Nasal Congestion


Rhonchi, Crackles, Wheezes

Increased RR & SOB

Respiratory Distress


Poor Feeding


Suction – priority

Bronchodilator via HHN


Promote fluids

Monitor VS , SaO2, lung

sounds & respiratory effort

Supplemental oxygen

Reduce fever

Promote rest




SaO2 below 95% on RA

Wheezes, crackles

Retractions, nasal flaring

Non-productive cough

Silent chest

Restlessness, fatigue


Abdominal pain

CXR = hyperinflation


Monitor VS (HR, RR)

Monitor SaO2

Auscultate lung sounds

Monitor respiratory effort

Humified oxygen

Calm environment

Ease respiratory efforts

Promote hydration

Promote rest

Monitor labs/x-rays

Patient teaching


Administer Medications

  • Bronchodilator via HHN or MDI with spacer (Albuterol) -Peak flows should always be done before and after Tx
  • Mast cell inhibitor via HHN or MDI (Cromolyn Sodium - Intal)
  • Corticosteroid IV or PO (Solu-medrol or Decadron)
  • Antibiotic if precipitated from a respiratory infection

Home Medication Management

  • Bronchodilator via HHN or MDI with spacer (Albuterol -Proventil, Levalbuterol - Xopenex)
  • Inhaled steroids (Beclamethasone - Vanceril)
  • Mast cell inhibitor via HHN or MDI (Cromolyn Sodium - Intal)
  • Leukotriene modifiers PO for long-term control - Singular
cystic fibrosis
Cystic Fibrosis

1 in 1,500-2,000 live births

Dysfunction of the exocrine gland (mucus producing)

Multi-system disorder

Secretions are thick and cause obstruction and fibrosis of tissue.

The clinical manifestations are the result of the obstructive process.

Sweat has a characteristic high sodium- Sweat Chloride Test

Pancreatic involvement in 85% of CF patients

Disease is ultimately fatal. Average age at death: 32 years

cystic fibrosis1



Dry, non-productive cough

Eventual & Progressive

Repeated lung infections

Wet & paroxysmal cough



- Clubbing

- Cyanosis


Large, loose, frothy and foul-smelling stools

Increased appetite (early)

Loss of appetite (later)

Weight loss


Distended abdomen

Thin extremities

Deficiency of A,D, E, K


Cystic Fibrosis
cystic fibrosis2
Cystic Fibrosis


  • Airway Clearance - Chest physiotherapy (CPT) Priority
  • Drug Therapy
    • Bronchodilators - via HHN
    • Mucolytic Agent (Dnase-Pulmozyme) - via HHN
    • Antibiotics - via HHN, IV, or PO
    • Digestive enzymes
  • Nutrition - needs are at 150%
    • Increased calories and protein - TPN or GT feedings at night
    • Additional fat soluble vitamins
    • Additional salt with vigorous exercise and hot weather
  • Exercise
  • Patient Teaching
otitis media
Otitis Media
  • Most common childhood illness
  • Inflammation of middle ear
  • Impaired eustachian tube causes

decreased ventilation and drainage

  • Acute otitis media (AOM)
    • Infectious process by pathogen
    • Infection can spread leading to meningitis
    • S/S: pain, pulling on ears, fever, irritability, vomiting, diarrhea, ear drainage, full/bulging tympanic membrane
  • Otitis media with effusion (OME)
    • Inflammation of middle ear with fluid behind tympanic membrane-no infection
    • Peaks spring and fall (allergies)
  • Chronic otitis media
    • Inflammation of middle ear > 3 mo
    • Can lead to hearing loss/delayed speech

Photo Source: Del Mar Image Library; Used with permission

otitis media1
Otitis Media


  • Secondary smoke
  • Formula feeding (positioning)
  • Day care
  • Pacifier > 6 mo old


  • Antibiotics (for AOM)
  • Myringotomy with Pressure Equalizing (PE) tubes


  • Teaching
    • No bottle propping
    • Feeding techniques
    • Medication regimen


    • Fever management
    • Surgery prep if needed

Photo Source: Del Mar Image Library; Used with permission

let s review24
Let’s Review

The nurse’s first action in responding to a child with tachypnea, grunting, and retractions is to:

A. Place the child in an upright, semi-fowler’s position.

B. Apply a pulse oximeter to determine oxygen


C. Assess for further symptoms.

D. Call for a stat respiratory nebulizer treatment (HHN).

let s review25
Let’s Review

A 3-year-old child is brought to the emergency room with a sore throat, anxiety, and drooling. The priority nursing action is to:

A. Inspect the child’s throat for infection.

B. Prepare intubation equipment and call the physician.

  • Obtain a throat culture for respiratory syncytial virus


  • Obtain vital signs and auscultate lung sounds.
let s review26
Let’s Review

An assessment finding in a child with asthma requiring immediate action by the nurse is:

A. Diminished breath sounds.

B. Wheezing in bronchi.

C. Crackles in lungs.

D. Refusal to take PO fluids.

let s review27
Let’s Review

Which sign is indicative of air hunger in an infant?

A. Nasal flaring.

B. Periods of apnea lasting 15 seconds.

C. Irregular respiratory pattern.

D. Abdominal breathing.

let s review28
Let’s Review

The priority nursing intervention in caring for the infant with Respiratory Syncytial Virus (RSV) induced bronchiolitis is:

A. Nasopharyngeal suctioning.

B. Coughing and deep breathing exercises.

C. Administration of intravenous antibiotic.

D. Administration of antipyretics for fever.

gastrointestinal system
Gastrointestinal System
  • Many GI issues require surgical intervention
  • Nursing interventions will often include general pre and post-op care
  • Bilious vomiting is a sign of GI obstruction and requires immediate intervention
  • Assess stools!
  • Assess hydration status

Photo Source: Del Mar Image Library; Used with permission

gastrointestinal system pediatric variances
Gastrointestinal System Pediatric Variances
  • Mechanical functions of digestion are immature at birth
  • Liver functions are immature throughout infancy
  • Production of mucosal-lining antibodies is decreased
  • Infants have decreased saliva
  • Infant’s stomach lies transversely
  • Peristalsis is faster in infants
  • Digestive processes are mature as a toddler
  • The child’s liver and spleen are large and vascular
  • Infants and children who vomit bile-colored emesis
  • require immediate attention
  • Gastric acidity is low at birth
the gastrointestinal system
The Gastrointestinal System

8 Altered Connections

3 Esophageal Atresia/Tracheoesophageal Fistula

3 Cleft Lip and Palate

8 Gastrointestinal Disorders

3Gastroesophageal Reflux3 Pyloric Stenosis

3 Hirschsprung’s Disease3 Imperforate Anus


8Acquired Gastrointestinal Disorders

3Celiac Disease


3 Parasitic Worms

esophageal atresia tracheoesophageal fistula
  • Congenital defects of esophagus
  • EA is an incomplete formation of esophagus
  • TEF is a fistula between the trachea and esophagus
  • Classic 3 “C’s” - coughing,choking,cyanosis

Photo Source: Del Mar Image Library; Used with permission

esophageal atresia tracheoesophageal fistula1

Copious, frothy oral secretions

Abdominal distension from air in stomach

Look for 3 C’s

Confirmed with radiographic studies


Surgery: either a one- or two-stage repair

Pre-op care focuses on preventing aspiration and hydration

Post-op care focus is a patent airway, prevent incisional trauma

cleft lip palate
Cleft Lip/Palate
  • May present as single defect or combined
  • Non-union of tissue and bone of upper lip and hard/soft palate during fetal development
  • CL-failure of nasal & maxillary processes to fuse

at 5-8 weeks gestation

  • CP-failure of palatine planes to fuse 7-12 weeks gestation
  • Cleft interferes with normal anatomic structure of lips, nose, palate, muscles – depending on severity and placement
  • Open communication between mouth and nose with cleft palate
cleft lip palate1
Cleft Lip/Palate
  • Multidisciplinary care throughout childhood and early adulthood
  • Nutrition is a challenge in infancy
    • ESSR method (enlarge, stimulate, swallow, rest)
    • Risk for aspiration
    • Respiratory distress
  • Altered bonding is a possibility

Photo Source: Del Mar Image Library; Used with permission

cleft lip cleft palate operative care
  • Cleft lip surgery by 4 weeks & again at 4-5 yrs
  • Cleft palate surgery at 6-24 months of age, usually done by 1 year so speech will not be affected
  • Protect suture lines- priority
  • Monitor for infection
    • Clean Cleft Lip incision
  • Pain Management
  • Cleft Palate starts feedings 48-hour post-op:
    • Clear and advance to soft diet
    • No straws, pacifiers, spouted cups
    • Rinse mouth after feeding
gastroesophageal reflux
  • Regurgitation of gastric contents back into esophagus - 50% healthy term babies affected
  • Related to inappropriate relaxation of Lower Esophageal Sphincter (LES) making the LES pressure less than the intra abdominal pressure
  • GER may predispose patient to aspiration and pneumonia
  • Apnea has been associated with GER
  •  chance of GER after 12-18 mo old related to growth due to elongation of esophagus and the LES drops below the diaphragm

Photo Source: Del Mar Image Library; Used with permission

gastroesophageal reflux1

Vomiting/spitting up

Gagging during feedings



Frequent URI’s/OM


Bloody stools


History of feedings/PE

Upper GI/Barium swallow to eliminate anatomical problems

Upper GI endoscopy to visualize esophageal mucosa

pH probe study

gastroesophageal reflux therapeutic management

Prone HOB  30°

Right side

Dietary modifications

Small, frequent feedings, burp often

Possibly thicken formula

Avoid fatty, spicy foods caffeine, & citrus



Prokinetic agents:  LES pressure & gastric motility

Histamine H-2 antagonists are added if esophagitis :  acid

Proton Pump Inhibitors if H-2 ineffective:acid

Mucosal Protectants

Surgery: fundoplication

hirshsprung s
  • Aganglionic megacolon

No ganglion cells at affected area usually at rectum/proximal portion of lower intestine

Absence of peristalsis leads to intestinal distension, ischemia & maybe enterocolitis

  • Treatment

Mild-mod: stool softeners & rectal irrigations

Mod-severe: single or 2-step surgery

Colostomy with later pull-through

Photo Source: Del Mar Image Library; Used with permission

hirshsprung s1


Unable to pass meconium stool within 24 hours of life

Abdominal distention

Bilious vomiting

Refusal to feed

Failure to thrive


Chronic constipation

Pellet or ribbon-like stools (foul-smelling)



Surgery prep: bowel cleansing, antibiotics, NPO, IVF’s, therapeutic play for surgery preparation

Infection & Skin Integrity: monitor ostomy/anus

Nutrition & Hydration: NGT, NPO then advance to Diet as tolerated, assess bowel function and abdominal status

  • Prolapse or “telescoping” of one portion of the intestine into another
  • Abrupt onset
  • Usually occurs in 3-24 months of age
  • Sudden abdominal pain
  • Vomiting
  • Red, current jelly stool
  • Abd distention/tender
  • Lethargy
  • Can lead to septic shock

Photo Source: Del Mar Image Library; Used with permission


Barium or air enema

Abdominal ultrasound


Hydrostatic reduction: force exerted using water-soluble contrast and air to push the affected intestine apart

Surgical reduction if hydrostatic reduction is unsuccessful



Monitor for infection, shock, pain

Maintain hydration - assess status!

Prepare child/parent for hydrostatic reduction - teach, consent, NPO, NGT

Monitor stools pre & post procedure

If surgery: general pre & post-op care

pyloric stenosis
  • Hypertrophy of pyloric sphincter, causing a narrowing/ obstruction (bands pylorus)
  • Usually occurs between 2-8 weeks of age
  • Infant presents with non-bilious projectile vomiting, and is “always hungry”
  • Can lead to dehydration and hypochloremic metabolic alkalosis
  • Weight loss

Photo Source: Del Mar Image Library; Used with permission

pyloric stenosis1

History/PE: “olive” palpated in epigastrum

Upper GI (string sign)

Abdominal Ultrasound


Surgical Intervention: Pyloromyotomy


Pre-op: NPO, NGT to LIS, hydration, I/O, monitor electrolytes

Post-op: Start feedings in 4-6 hrs. Progressive feeding schedule begin w/5cc GW half strength formula  Full strength formula

imperferate anus
  • Anorectal malformations
  • No obvious anal opening
  • Fistula may be present from distal rectum to perineum or GU system
  • Diagnostic Eval: patency of anus in newborn, passage of meconium; ultrasound is suspected
  • Therapeutic Management: manual dilatation for anal stenosis, surgical treatment for malformations
  • Nursing Implementations: pre and post-op care – IV fluids, consent, assessing surgical site for infection and monitoring for complications, possible NGT, diet progression, possible colostomy and teaching; preferred post-op condition is side-lying.
celiac disease
Celiac Disease
  • Malabsorption syndrome characterized by intolerance of gluten (rye, oats, wheat and barley)
  • Familial disease - more common in Caucasians
  • Thought to be an inborn error of metabolism or an immunological disorder
  • Reduced absorptive surfaces in small intestine which causes marked malabsorption of fats (frothy, foul-smelling stools)
  • Child has diarrhea, abdominal distention, failure to thrive
  • Treatment is lifelong low-gluten diet; corn and rice are substituted grain foods
Inflammation and infection of vermiform appendix, usually related to an obstruction

Cause may be bacteria, virus, trauma

Ischemia can result from the obstruction, leading to necrosis causing perforation

S/S: periumbilical painRLQ pain (McBurney’s point), fever, vomiting, diarrhea, lethargy, irritability,  WBC’s

Surgery is necessary

If ruptured, often child will receive IV antibiotics for 24 hrs prior to OR

Pre-op Care: NPO, pain management, hydration, prep & teaching, consent

Post-op Care: routine post-op care, IVF/antibiotics, NPODAT, ambulation, positioning, pain management, wound care, possible drains.

pinworm enterobiasis
PINWORM (enterobiasis)
  • Transmission: oral-fecal
  • Persist in indoors for up to 3 weeks contaminating anything they contact (toilets, bed linens)
  • S/S: intense perianal itch, sleeplessness, abd pain, vomiting
  • Scotch tape test – collects eggs laid by female outside of anus. Must be obtained in am prior to bath or BM.
  • Treatment:

*mebendazole (Vermox) for over 2 years of age. Under 2 years of age treatment may be pyrvinium pamoate

(Povan) which stains stool and emesis red

*All family members must be treated.

let s review29
Let’s Review

Which intervention would have the highest priority for the nurse assisting in the feeding of a child post cleft palate repair?

A. Permiting the child to choose the liquids desired.

B. Providing diversional activities during feeding.

C. Applying wrist restraints.

D. Cleansing the mouth with water after each feeding.

let s review30
Let’s Review

Which food choice by a parent of a child with celiac disease indicates a need for further teaching?

  • Oatmeal
  • Rice
  • Cornbread
  • Beef
let s review31
Let’s Review

Which assessment finding would the nurse find in a child with Hirschsprung’s Disease?

  • Current jelly stool
  • Diarrhea
  • Constipation
  • Foul-smelling, fatty stool
let s review32
Let’s Review

Children with gastroenteritis often receive intravenous fluids to correct dehydration. How would you explain the need for IV fluids to a 3 year-old child?

A. “The doctor wants you to get more water, and this is the

best way to get it.”

B. “Your stomach is sick and won’t let you drink anything.

The water going through the tube will help you feel


C. “See how much better your roommate is feeling with his

IV! You will get better, too.”

D. “The water in the IV goes into your veins and replaces

the water you have lost from vomiting and diarrhea.”

let s review33
Let’s Review

The nurse caring for a child with suspected appendicitis would question which physician order?

  • NPO status
  • Start IV fluids of D5 ½ NS at 50 mls/hour
  • Complete Blood Count (CBC)
  • Apply heating pad to abdomen for comfort
genitourinary system anatomy physiology review
Genitourinary SystemAnatomy & Physiology Review
  • The GU system maintains homeostasis of the body (water & electrolytes)
  • Responsible for the excretion of waste products
  • Nephron is the workhorse of the kidney (filter blood at the rate of 125mL/minute)-GFR
  • Renin helps maintain Na & water balance (and B/P)
  • Kidneys produce erythropoeitin which stimulates RBC production in marrow

Photo Source: Del Mar Image Library; Used with permission

pediatric variances genitourinary system
Pediatric VariancesGenitourinary System
  • Infants & young children excrete urine at a higher rate related to the increased BMR producing more waste
  • Infant kidneys have  function if under stress
  • Infant can’t concentrate urine well until 3-6 mo
  • In infants, kidney & bladder are abdominal organs
  • Infant kidneys are less protected because of unossified ribs, less fat padding & large size
  • Young children have shorter urethras
  • Nephrons continue to develop after birth
the genitourinary system
The Genitourinary System

Minimum urine outputs by age groups:

    • 2-3 ml/kg/hr
    • 1-2 ml/kg/hr
    • 0.5-1 ml/kg/hr
  • TIP: Bladder capacity in ounces: AGE in years + 2

Example: a 2-year-old’s bladder can hold up to 4 ounces or 120 mls

the genitourinary system1
The Genitourinary System

dDisorders of the Genitourinary System

F Enuresis

FNephrotic Syndrome

FAcute Glomerulonephritis

F Hemolytic Uremic Syndrome (HUS)

  • Group of kidney disorders that show main focus of injury is the glomerulus
  • It is characterized by inflammation of the glomerular capillaries
  • Acute disorders occur suddenly and resolve completely
  • Acute poststreptococcal glomerulonephritis (APSGN) is the most common type
  • History, presenting symptoms, and lab results establishes the diagnosis of APSGN

Photo Source: Teresa Simbro, RN, Santa Ana College, Used with permission.




Edema: periorbital, ankles

 Urine Output



Possible fever

Abdominal discomfort

Labs: +ASO,  Bicarb,K BUN, Creat,  H & H


Monitor Urine (Dipstick)

Monitor fluid overload

Assess lung sounds/Resp effort

Possible fluid & salt restriction

Monitor I/O, Daily Weights

Monitor VS

Antibiotic, diuretic & antihypertensive medications

Promote & provide rest

Provide comfort measures

Monitor labs

nephrotic syndrome
Nephrotic Syndrome
  • Kidney disorder characterized by proteinuria, hypoalbuminemia, and edema.
  • There is primary (involving kidney only) and secondary (caused by systemic disease or heavy metal poisoning) NS. Primary is the most common (MCNS).
  • Cause not fully understood-may have an immunologic component.
  • Primary age affected is 2-6 years (boys 2:1)
  • There is no occlusion of glomerular vessels.
  • Loss of immunoglobulins also occur (IgG)
  • Hypovolemia and the severe proteinuria put the child in a hypercoagulable state
  • Treatment is prednisone (2mg/kg/day) for about 4-6 weeks. Remission is obtained when the urine protein is 0-tr for 5-7 days
  • Albumin followed by furosemide may be given for the edema
nephrotic syndrome1
Nephrotic Syndrome

Photo Source: Teresa Simbro, RN, Santa Ana College, Used with permission.

nephrotic syndrome2

Proteinuria (3-4+), frothy urine

Edema (pitting):periorbital, genitals, lower extremities, abdominal

 Urine Output (Hypovolemia)

Normotensive or hypotensive


Recent URI, Pneumonia

Abdominal Pain/Anorexia



 Platelets

H & H

 Cholesterol

 Triglycerides


Monitor Urine (Dipstick)

Monitor edema/dehydration

Assess skin integrity/turn often

Possible fluid & salt restriction

Monitor I/O, Daily Weights

Monitor VS & S/S of infection

Administer medications

Promote & provide rest

Monitor labs

HANDWASHING/monitor visitors

Nephrotic Syndrome
hemolytic uremic syndrome hus
Hemolytic Uremic Syndrome (HUS)
  • It is the most common cause of acute renal failure (ARF) in children.
  • HUS is characterized by the triad of anemia, thrombocytopenia, and ARF.
  • Most children have associated GI symptoms- almost all are caused by e. coli 0157.
  • Treatment is supportive and based on symptoms.
  • No antibiotics are given; more damage can be caused.
  • Serum electrolytes may be outside of normal limits.
  • Blood transfusions and/or dialysis may be necessary.
  • More than 90% of the children recover with good renal function.
hemolytic uremic syndrome hus1
Hemolytic Uremic Syndrome (HUS)

Photo Source: Teresa Simbro, RN, Santa Ana College, Used with permission.

hemolytic uremic syndrome hus2

History: emesis, bloody diarrhea, abd pain,  Urine

Petechiae, bruises, purpura

Edema (possible CHF)


Altered LOC, seizure



Abdominal discomfort

Labs: Lytes may be abnormal


 Creatinine

 H & H

 Platelets


Monitor I/O, Daily Weights

Evaluate for signs of bleeding

Monitor fluid overload/edema

Assess for dehydration

Monitor VS with neuro checks

Seizure Precautions, HOB 

Diuretic & antihypertensive medications

Provide rest/calm environment

Provide comfort measures

Monitor labs closely

Hemolytic Uremic Syndrome (HUS)
  • Involuntary passage of urine in children whose chronological or developmental age is at least 5 years of age
  • Voiding occurs at least twice a week for minimum 3 months
  • More common in boys
  • Alteration in neuromuscular bladder function
  • Often benign and self-limiting
  • Organic factor could be the cause
  • Familial tendency
  • Emotional factor could be considered
  • Therapeutic techniques include: bladder training, night fluid restriction, drugs (imipramine, oxybutynin, DDAVP)
let s review34
Let’s Review

A clinical finding that warrants further intervention for a child with acute post-streptococcal glomerulonephritis is:

A. Weight loss to 1 pound of pre-illness weight.

B. Urine output of 1 ml/kg per hour.

C. A normal blood pressure.

D. Inspiratory crackles.

let s review35
Let’s Review

A 3 year-old is scheduled for surgery to remove a Wilms tumor from one kidney. The parents ask the nurse what treatments, if any, will be necessary after recovery from surgery. The nurse’s explanation is based on knowledge that:

A. No additional treatments are necessary.

B. Chemotherapy may be necessary.

C. Chemotherapy is indicated.

D. Kidney transplant is indicated.

let s review36
Let’s Review

Fluid balance in the child who has acute glomerulonephritis is best estimated by assessing:

A. Intake and output

B. Abdominal circumference

C. Daily weights

D. Degree of edema

let s review37
Let’s Review

In evaluating the effectiveness of nursing actions when caring for a child with nephrotic syndrome, the nurse expects to find:

A. A recurrence of pneumonia.

B. Weight gain.

C. Increased edema.

D. Decreased edema.

pediatric variances musculoskeletal system
Pediatric VariancesMusculoskeletal System

Bone Growth:

Linear growth results from skeletal development

Bone circumference growth occurs as new bone tissue is formed beneath the periosteum

Skeletal maturity is reached by age 17 in boys and 2 years after menarche in girls (14 yrs)

Bone growth affected by Wolff’s Law - bone grows in the direction in which stress is placed on it

Certain characteristics of bone affect injury and healing

Children’s bones are softer and are easily fractured

pediatric variances musculoskeletal system1
Pediatric VariancesMusculoskeletal System

Muscle Growth:

Responsible for a large part of increased body weight

The number of muscle fibers is constant throughout life

Results from increase in size of fibers and increased number of nuclei per fiber

Most apparent in adolescent period

the musculoskeletal system
The Musculoskeletal System
  • QDisorders of the Musculoskeletal System
    • m Developmental Dysplasia of the Hip
    • m Talipes (Clubfoot)
    • m Osteogenesis Imperfecta
    • m Scoliosis
    • m Muscular Dystrophy
    • m Juvenile Rheumatoid Arthritis
developmental dysplasia of the hip ddh
Developmental Dysplasia of the Hip (DDH)
  • Variety of hip abnormalities – shallow acetabulum, subluxation or dislocation
  • Often made in newborn period – often appears as hip joint laxity rather than dislocation
  • Ortolani click if < 4 weeks old, older ultrasound needed to diagnose
  • Treatment is Pavlik Harness (abducted position) for newborn to 6 months old – monitor for Avascular Necrosis
  • 6-18 months – traction followed by spica cast
  • Older children – operative reduction
  • Priority nursing interventions are skin care and facilitating normal growth and development
talipes clubfoot
Talipes (Clubfoot)
  • Most common type is when foot is pointed downward and inward
  • Often associated with other disorders
  • May be due to decreased movement in utero
  • Treatment requires surgical intervention
  • Serial casting is begun shortly after birth and usually lasts for 8-12 weeks
  • Priority nursing interventions are skin care and facilitating normal growth and development
osteogenesis imperfecta oi
Osteogenesis Imperfecta (OI)
  • Inherited disorder of connective tissue and excessive fragility of bones
  • Pathologic fractures occur easily
  • Incidence of fractures decrease at puberty related to increased hormones making bones stronger
  • Treatment is supportive: careful handling of extremities, braces, physical therapy, weight control diet, stress on home safety
  • Surgical techniques for correcting deformities and for intermedullary rodding
  • Abnormal curvature of the spine (lateral)
  • Congenital or develops later, most common during the growth spurt of early adolescence (idiopathic)
  • Diagnosis is made by physical exam and x-rays
  • Treatment for curvatures < 40 degrees is bracing
  • Surgical intervention is for severe curvatures – internal fixation and instrumentation (Harrington)
  • Postoperative care includes logrolling, neurologic assessments, pain management, skin care, assessing for paralytic ileus and possible mesenteric artery syndrome
  • Don’t forget the developmental needs of the adolescent
muscular dystrophy
Muscular Dystrophy
  • Duchenne’s Muscular Dystrophy most common
  • Gradual degeneration of muscle fibers
  • S/S begin to show about 3 years of age – difficulties in running and climbing stairs
  • Changes to having difficulty moving from a sitting/supine position
  • Profound muscular atrophy continues, wheelchair by 12 yrs
  • Respiratory and cardiac muscles affected and death is usually respiratory or cardiac in nature
  • Diagnosis made with physical exam, muscle biopsy, EMG, serum studies: AST (SGOT), aldolase, creatine phosphokinase high first 2 years of life
  • Nursing care is to maintain optimal level of functioning and to help the child and family cope with the progression and limitations of the disease
juvenile rheumatoid arthritis
Juvenile (Rheumatoid) Arthritis
  • Inflammatory disease with an unknown cause
  • Occurs in children < 16 years; lasts > 6 weeks
  • Clinical manifestations: stiffness, swelling, and loss of motion in affected joints, tender to touch
  • Therapeutic management includes drug therapy (NSAID’s, SAARD’s, cytoxic drugs, corticosterioids), physical and occupational therapy, exercise (swimming), moist heat for pain and stiffness, general comfort measures
general nursing interventions for children with musculoskeletal dysfunctions immobility
General Nursing Interventions for Children with Musculoskeletal Dysfunctions (immobility)
  • Maintain optimal level of functioning
  • Promote general good health
  • Facilitate compliance
  • Facilitate optimal growth and development
  • Maintain skin integrity
  • Safety considerations at home
  • Pain management
  • Support child and family
let s review38
Let’s Review

An infant is being treated non-surgically for clubfoot. Which describes a major goal of care for this patient? Prevention of:

A. Skin breakdown

B. Calf atrophy

C. Structural ankle deformities

D. Thigh atrophy

let s review39
Let’s Review

The nurse is helping parents create a plan of care for their child with osteogenesis imperfecta. A realistic outcome is for this child to:

A. Have a decreased number of fractures

B. Demonstrate normal growth patterns

C. Participate in contact sports

D. Have no fractures after infancy

let s review40
Let’s Review

During acute, painful episodes of juvenile arthritis, a priority intervention is initiating:

A. A weight-control diet to decrease stress on the


B. Proper positioning of the affected joints to

prevent musculo-skeletal complications.

C. Complete bedrest to decrease stress to the joints.

D. High-resistance exercises to maintain muscular

tone in the affected joints.

pediatric variances endocrine system
Pediatric VariancesEndocrine System
  • Growth Hormone:
    • Does not effect prenatal growth
    • Main effect on linear growth
    • Maintains rate of body protein synthesis
  • Thyroid-stimulating hormone (TSH):
    • Important for growth of bones, teeth, brain
    • Secretion decreases throughout childhood and
    • increases at puberty
  • Adrenocorticotrophic Hormone (ACTH):
    • Activated in adolescent
    • Stimulates adrenals to secrete sex hormones
    • Influences production of gonadotropic hormone
the endocrine system
The Endocrine System

Disorders of the Endocrine System

8 Type 1 Diabetes Mellitus

8Congenital Hypothyroidism

8 Growth Hormone Deficiency

8 Precocious Puberty

type 1 diabetes mellitus pediatric considerations
Type 1 Diabetes MellitusPediatric Considerations


  • Most children are well-controlled with BID dosing of fast acting (Lispro) short acting (regular) and intermediate acting (NPH, Lente) insulin. There is also Lantis, an insulin that acts a “basal.”
  • U-20 insulin is also available for infants
  • Insulin pump, pen
  • “Honeymoon” phase
  • Stress, infection, illness and growth at puberty can increase insulin needs
type 1 diabetes mellitus pediatric considerations1
Type 1 Diabetes MellitusPediatric Considerations
    • In small children it is more difficult to determine and may just be a behavior change.
    • Treatment is the same – simple sugar – assess LOC first!
    • Carb counting – most children’s calories should not be restricted; meal plan might change as child grows.
    • Some sweets may be incorporated into the diet and may help with compliance.
    • 3meals with 3 snacks per day
type 1 diabetes mellitus pediatric considerations2
Type 1 Diabetes MellitusPediatric Considerations


  • Important for normal growth and development
  • Assists with daily utilization of dietary intake
  • Enhances insulin absorption, so may decrease amount needed
  • Add 15-30 grams of carbs for each 45-60 minutes of exercise
  • Watch for hypoglycemia with strenuous exercise
type 1 diabetes mellitus pediatric considerations3
Type 1 Diabetes MellitusPediatric Considerations


  • Infant/Toddler
    • Autonomy & choices, rituals, hypoglycemia identification difficult
  • Preschooler
    • Magical thinking-let them know they did not cause it
    • Use dolls for teaching
    • Urine testing may be done
    • Can choose finger to use for testing
  • School-age
    • Very busy with school and activities
    • Likes tasks and explanations
    • Can do self blood testing; injections at age 8-10 years
  • Adolescents
    • Peers and body image preoccupation
    • High risk for non-compliance
    • Collaborative health care with parent involvement very important
congenital hypothyroidism
Congenital Hypothyroidism
  • Thyroid is not producing enough thyroid hormone to meet needs of the body (resulting in↓oxygen consumption, BMR and protein synthesis)
  • Clinical manifestations: cool, mottled skin, bradycardia, large tongue, large fontanel, hypothermic, hypotonia, lethargy, feeding problems - THINK SLOW!
  • Labs: High TSH, low T4
  • Decreased brain development will result with cognitive impairments
  • Part of newborn screening
  • Therapeutic management is life-long thyroid hormone replacement (levothyroxine)
growth hormone gh deficiency
Growth Hormone (GH) Deficiency
  • Deficient secretion of growth hormone
  • Definitive diagnosis is made with GH levels (using stimulation testing) under 10mg/ml and x-rays of hand and wrist for ossification levels
  • Treatment is replacement of GH (subcutaneous daily injections) until goals met
  • Nursing care is directed at child and family support
  • Remember to interact and speak to the child at her appropriate developmental level!
precocious puberty
Precocious Puberty
  • Manifestations of sexual development in boys younger than 9 years and girls younger that 8 yrs
  • Causes also an early acceleration of growth with closure of growth plates
  • Therapeutic management is directed toward the specific cause, if known
  • The early secretion of sex hormones will be treated with monthly subcutaneous injections of leuteinizing hormone-releasing hormone (LHRH)
  • Priority interventions are directed at psychological support of child and family – encourage play with same age peers
let s review41
Let’s Review

A child weighing 25 kilograms is being treated with synthetic growth hormone. The recommended dosage range is 0.3 – 0.7 mg/kg/week. The mother informs the nurse that her child receives 1.25 mg subcutaneously at bedtime 6 times per week. The proper response from the nurse would be:

  • “That dose is too high, the doctor needs to be notified.”
  • “You are doing a great job, that is the correct dose for your child.”
  • “The injection should be given intramuscular, not subcutaneous.”
  • “That dose is too low based on your child’s new weight.”
let s review42
Let’s Review

The nurse should include which information in teaching the parents of a recently diagnosed toddler with Type 1 diabetes mellitus?

A. Allow the toddler to choose which finger to use for

blood glucose monitoring

B. Allow the toddler to assist with the daily insulin


C. Test the toddler’s blood glucose every time she

goes out to play

D. Let the toddler determine meal times

let s review43
Let’s Review

Which is the most appropriate teaching intervention for a nurse to give parents of a 6-year-old with precocious puberty?

A. Advise the parents to consider birth control for their


B. Inform the parents there is no treatment currently


C. Explain the importance for the child to foster

relationships with peers

D. Assure the parents there is no increased risk for

sexual abuse.

let s review44
Let’s Review

Number in order of priority the following interventions needed while caring for a patient in diabetic ketoacidosis.

_____ Hydration

_____ Electrolyte replacement

_____ Dietary intake

_____ IV Insulin

_____ Subcutaneous insulin

pediatric variances integumentary system
Pediatric VariancesIntegumentary System

Evaporative water loss is greater in infants/small children

Skin more susceptible to bacterial infections

More prone to toxic erythema

More susceptible to sweat retention and maceration

the integumentary system
The Integumentary System
  • Disorders of the Integumentary System
    • Impetigo
    • Roseola
    • Diaper Rash
  • Superficial bacterial skin infection, often secondary from insect bite
  • Highly contagious
  • Late summer outbreak
  • Toddlers & preschoolers
  • Rash is bullous or honey-colored crusted lesions
  • Treatment: topical & systemic antibiotics, comfort measures, teaching, preventing comps

Photo Source: Del Mar Image Library; Used with permission

  • Transmission: contact with secretions (saliva)
  • Virus
  • 6 - 18 months
  • Fever »flu symptoms » rose-pink macular rash
  • Fades with pressure
  • Treatment is supportive

Photo Source: Del Mar Image Library; Used with permission

diaper rash
Diaper Rash
  • Cause could be fungal in nature; assess mucous membranes for thrush
  • Cause could be due to infrequent diaper changes, an allergic reaction to the diaper product or diarrhea
  • Skin care includes appropriate skin barrier cream/ointment, keeping area dry
  • Teach parents appropriate skin care
medication administration
Medication Administration
  • Oral Medication
    • Hold infant with head elevated to prevent
    • aspiration
    • Slowly instill liquid meds by dropper along side of the tongue
    • Crush pills and mix with sweet-tasting liquid if permitted, but don’t add too much liquid!
    • Allow choices for the child such as which
    • med to take first
    • Flush following gastrostomy or NG tube
factors to consider when selecting im sites
Factors to consider when selecting IM sites
  • Age
  • Weight
  • Muscle development
  • Amount of subcutaneous fat
  • Type of drug
  • Drug’s absorption rate
im and sq meds
IM and SQ Meds
  • Select needle length according to muscle size for IM
    • Infant - should use 1 inch needle
    • Preemies can use 5/8 inch needle
    • Use Z-track for iron and tissue-toxic meds
    • Apply EMLA or other topical anesthetic 45-60
    • minutes prior to injection
    • May mix medication with lidocaine
    • Some medications may be need to be separated
    • into 2 injections depending on amount
peds im injection sites
Peds IM Injection Sites
  • Vastus lateralis for infants
  • Ventrogluteal and dorsogluteal

Don’t inject into dorsogluteal until age 3 years - muscle not well developed until child walks and sciatic occupies a larger portion of the area.

  • Deltoid after 3 years
iv meds
IV Meds
  • Site may be peripheral or central
  • Administer IV fluids cautiously
  • Always use infusion pumps with infants and small


  • Inspect sites frequently (q 1-2 hours) for signs of


  • Cool blanched skin, puffiness( infiltration)
  • Warm and reddened skin (inflammation)
nose drops
Nose Drops
  • Instill in one nare at a time in infants because they are

obligate nose breathers.

  • Suction nare with bulb syringe prior to administration

if nasal congestion present

ear meds
Ear Meds
  • Pull the ear down and back to instill eardrops
  • in infants/toddler (↓3 years pull ↓)
  • Pull the ear up and out to instill in older
  • children (↑ 3 years pull ↑)
  • Have medication at room temperature
rectal medication
Rectal Medication
  • Insert the suppository past the anal sphincter
  • Hold buttocks together for a few seconds after insertion to prevent expulsion of medication

It is a very stressful route for children, and the school-age and adolescent have issues with modesty.

inhalers and spacers
Inhalers and Spacers
  • Shake the inhaler for 2-5 seconds.
  • Position inhaler into spacer (with mask or mouthpiece).
  • After normal exhale, place mask on face or mouthpiece in mouth – both with a good seal.
  • Have child inhale slowly after canister is pressed down .
  • Have child take a few breaths with a spacer and without a spacer have them hold breath for few seconds after medication released.
  • Inhalers without spacers aren’t placed in the mouth because spacers require a seal around mouthpiece; masks with spacers can be used for infants.
mdi with spacer mdi with spacer and mask
MDI with Spacer MDI with Spacer and Mask

Photo Source: Del Mar Image Library; Used with permission

let s review45
Let’s Review

The nurse would prepare which site for an intramuscular injection to a 11 month-old?

  • Dorsogluteal
  • Deltoid
  • Vastus lateralis
  • Ventrogluteal
pediatric oncology
Pediatric Oncology

Cancer is the leading cause of death from disease in children from 1 - 14 years.

Incidence: 6,000 children develop cancer per year

2,500 children die from cancer annually

Boys are affected more frequently

Etiologic factors: environmental agents, viruses, host

factors, familial/genetic factors

Leukemia is the most frequent type of childhood cancer followed by tumors of the CNS system.

oncology stressful events
Oncology Stressful Events

“Treatment is worse than the disease.”

1. Diagnosis

2. Treatment - multimodal

3. Remission

4. Recurrence

5. Death

oncology interventions
Oncology Interventions


8 Radiation Therapy

8 Chemotherapy

8 Bone Marrow Transplant

stages of cancer treatment
Stages of Cancer Treatment
  • 1. Induction
  • 2. Consolidation
  • 3. Maintenance
  • 4. Observation
  • 5. Late Effects of Treatment
        • Impaired growth & development
        • CNS damage
        • Psychological problems
pediatric oncology1
Pediatric Oncology
  • Types of Childhood Cancers
      • D Leukemia
      • D Brain Tumors
      • D Wilm’s Tumor
      • D Neuroblastoma
      • D Osteogenic Sarcoma
      • D Ewing’s Sarcoma
  • Most common form of childhood cancer
  • Peak incidence is 3 to 5 years of age
  • Proliferation of immature WBCs (blasts)
  • May spread to other sites (CNS, testes)
  • Types of Leukemia:
    • Acute lymphocytic leukemia (ALL)
      • 80-85% of childhood leukemia
      • 95% chance of remission
    • Acute nonlymphocytic Leukemia (ANLL)
      • 60-80 % chance of remission
  • Treatment is chemotherapy: prednisone, allupurinol, selected chemotherapeutic agents

Purpura, Bruising


Fever Unknown Origin

Fatigue, Malaise

Weight loss

Bone pain





↑ WBC’s (50-100) or

Very low WBC’s

↓Hgb, Hct, Platelets

Blast cells in differential



BONE SCAN possible

brain tumors
Brain Tumors

Second most prevalent type of cancer in children

Males affected more often

Peak age 3 - 7 years

Types: Medulloblastoma


Brain Stem glioma

Look for S/S of increased ICP and area of brain affected

wilm s tumor
Wilm’s Tumor
  • Also known as Nephroblastoma
  • Large, encapsulated tumor that develops in the renal parenchyma (do not palpate abdomen!)
  • Peak age of occurrence: 1 - 3 years
  • Prognosis is good if no metastases- lungs first
  • Treatment is surgery, chemotherapy and sometimes radiation

Highly malignant tumor – extracranial

Often develop in adrenal gland, also found in head, neck, chest, pelvis

Incidence: One in 10,000

Males slightly more affected

From infancy to age 4

Often diagnosed after metastasis occurs

Treatment includes surgery, chemotherapy and radiation

bone tumors
Bone Tumors
  • Osteogenic Sarcoma:
    • Occurs most often in boys between 10-20 yrs
    • 10-20% 5 year survival rate
    • Primary bone tumor of mesenchymal cell
    • Treatment:surgery (amputation or salvage) and chemo
  • Ewing’s Sarcoma:
    • Occurs in boys between 5 - 15 years
    • Primary tumor arising from cells in bone marrow
    • Treatment is radiation and chemotherapy
pediatric oncology nursing interventions

Leukopenia (Nadir)









Monitor visitors

Monitor for infection

Meticulous oral care

Antiemetics ATC

Monitor Labs


Pediatric Oncology:Nursing Interventions
pediatric oncology nursing interventions1
Pediatric Oncology:Nursing Interventions
  • Supportive care for radiation treatment, focusing on skin care
  • Surgical interventions are based on location and type of surgery
    • Basic pre and postoperative care
  • Psychosocial care for patient and family – utilize Child Life and Social Services
pediatric oncology2
Pediatric Oncology
  • Teach, teach, teach!
  • Support the child and family
  • Provide resources
  • Be honest
  • Include the child in the care planning

Photo Source: Del Mar Image Library; Used with permission

let s review46
Let’s Review

In caring for the child with osteosarcoma, it is important for the nurse to inform the child and family of the treatment plan. Which would be appropriate?

A. The affected extremity will have to be amputated.

B. The child will only need chemotherapy.

  • Both surgery and chemotherapy are indicated.
  • Only palliative measures are taken.
let s review47
Let’s Review

The nurse assessing a child who is undergoing chemotherapy finds the child to be suffering from mucositis. Which intervention would be the highest priority?

A. Meticulous oral care.

B. Obtain dietician consult.

C. Place the child on a full liquid diet only.

D. Medicate for pain around the clock.

let s review48
Let’s Review

The priority nursing intervention in caring for a child with acute lymphocytic leukemia (ALL) during the child’s nadir period is:

A. Handwashing.

B. Monitoring lab results.

C. Administering antiemetics.

D. Monitoring visitors.

death dying
Death & Dying
  • Child’s Response to Death:
  • Infants & Toddlers:
    • Do not understand
    • Viewed as a form of separation
    • Can sense sadness in others
  • Preschooler:
    • Death is temporary
    • Viewed as sleep or separation
    • Feel guilty and blames self
    • Dying children may regress in behavior
death dying1
Death & Dying
  • School-Age:
    • Have concept of irreversibility of death
    • Fear, pain, mutilation and abandonment
    • Ask many questions
    • Feel death is a punishment
    • May personify death (bogeyman)
    • Will ask directly if they are dying
    • Interested in the death ceremony
    • Comforted by having parents and loved ones with them
death dying2
Death & Dying
  • Adolescent:
    • Have an accurate understanding of death
    • Death as inevitable and irreversible
    • May express anger at impending death
    • May find it difficult to talk about death
    • May wish to leave something behind to remember them by
    • May wish to plan own funeral
death dying3
Death & Dying
  • Parental responses to death:
    • Major life stress
    • Experience grief at potential loss of child
    • Related to circumstances regarding child’s death (denial, shock, disbelief, guilt)
    • Confronted with major decisions regarding care
    • May have long term disruptive effects on family
    • Bereaved parents experience intense grief of long duration
communicating with the dying child and family
Communicating with the Dying Child and Family
  • Use child’s own language
  • Don’t use euphemisms
  • Don’t expect an immediate response
  • Communicate through touch
  • Encourage questions and expressions of feelings
  • Strengthen positive memories
  • Listen, touch, cry
impending death care guidelines
Impending Death Care Guidelines

Do not leave child alone

Do not whisper in the room

Touching the child is very important

Let the child and family talk and cry

Let parents participate in care as much as they are emotionally capable of doing

Continue to read favorite stories or play the child’s favorite music

Be aware of the needs of the siblings

let s review49
Let’s Review

Which intervention would be most helpful in supporting a dying child’s family as they cope with the various decision-making periods of a lengthy terminal illness?

A. Encouraging the parents to take their child home to die.

B. Encouraging the parents to go through all of the Kubler-

Ross stages of dying as quickly as possible.

C. Referring the child’s family to the hospital clergy service

as soon as possible.

D. Using active listening to identify specific fears and

concerns of the child’s family members.

types of child abuse
Types of Child Abuse


Intentional or unintentional omission of basic needs and support

MPhysical Abuse:

Is non-accidental injury to a child by an adult

MSexual Abuse:

Forced involvement of children in sexual activities by an adult

MEmotional Abuse:

Withholding of affection, use of cruel and degrading language towards a child by an adult

child abuse
Child Abuse

MReports of violence against children has almost

tripled since 1976.

MMany of the abused children are infants.

“Red Flags”

Fractures in infants

Spiral fractures

Injuries do not match story told


child abuse1
Child Abuse


  • Physical or emotional maltreatment
  • Failure to thrive
  • Contributing factors may be ignorance or lack of resources

Physical Abuse

  • Minor or major physical injury (bruising, burns, fractures)
  • May cause death
  • Munchausen by Proxy (MSP)
  • Shaken baby syndrome (SBS)


  • Incest, molestation, child porn, child prostitution


  • May be suspected, but difficult to substantiate
  • Impairs child’s self-esteem and competence
child abuse2
Child Abuse

Warning Signs

  • Incompatibility between history of event and injuries
  • Conflicting stories from various people involved
  • History inconsistent with developmental level of child
  • Repeated visits to emergency rooms
  • Inappropriate response from child and/or caregiver

Nursing Interventions

  • Assess: Physical assessment and history of event, observe and listen to caregiver’s and child’s verbal and non-verbal communication
  • Documentation: Complete CAR form and contact Child Protective Services, hospital documentation
  • Support family and child: Social services, resources, teaching



let s review50
Let’s Review

In caring for a 4 year-old with a diagnosis of suspected child abuse, the most appropriate intervention for the nurse is:

  • Avoid touching the child.
  • Provide the child with play situations that allow for

disclosure of event.

  • Discourage the child from speaking about the event.
  • Give the child realistic choices to feel in control.
let s review51
Let’s Review

Which pediatric patient would most necessitate further investigation by the community-based nurse?

A. An adolescent who prefers to spend time with

friends rather than family.

B. A toddler with dark bruises located on both legs.

C. An infant with numerous insect bite marks and

diaper rash.

D. A preschooler with dirty knees and torn pants.


Photo Acknowledgement:All unmarked photos and clip art contained in this module were obtained from the 2003 Microsoft Office Clip Art Gallery.