Peds Notes

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Peds

Notes Luanne Linnard-Palmer, RN, MSN, EdD

Purchase additional copies of this book at your health science bookstore or directly from F.A. Davis by shopping online at www.fadavis.com or by calling 800-323-3555 (US) or 800-665-1148 (CAN) A Davis’s Notes Book

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F. A. Davis Company 1915 Arch Street Philadelphia, PA 19103 www.fadavis.com Copyright © 2010 by F. A. Davis Company All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Printed in China by Imago Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1 Publisher, Nursing: Lisa B. Deitch Senior Developmental Editor: William Welsh Director of Content Development: Darlene D. Pedersen Senior Project Editor: Padraic J. Maroney Cover Design: Carolyn O’ Brien Consultants: Kathleen Barta, EdD, RN; Jacqueline Brandwein, RN, MA, CPNP; Tammy Bryant, RN, BSN; Sandra Brzoza, MSN, RN; Nathania Bush, MSN, APRN, BC; Stephanie C. Butkus, MSN, RN, CPNP; Kathleen M. Cahill, MS, RN; Anne Citarella, RN, MSN; Jennifer J. Coleman, PhD, RN, CNE; Thomas W. Connelly, Jr., Ph.D, RN; JoAnn Crownover, RN, MSN, CNE; Christy Davidson, RNC, MSN; Cynthia A. Dyson, MSN, RN, BC, CNE; Emily Gilmore Fite, RN, MSN, CFNP; Betty Fruend, MSN, RN-BC; Linda Nicholson Grinstead, PhD, RN, CPN, CNE; Laura M.J. Kerr, RN, MSc, CON(C); Leslie Guthrie, RN, MS, BSN, NRP; Michele Hinds, PhD, RN, CNE; Marita B. Hoffart, RN, MS, PhD; Jill Holmstrom, RN, MS; Deborah Kramer, EdD, CPNP, FNP; Sarah Kulinski, MA, MSN; Patti Luttrell, MS, RN; Cherie L. McCann, MSN, RN, BC, CPN; Donna Miles Curry, RN, Ph.D; Carol Murphy Moore, MSN, RN, CRNP; Jean Rodgers, RN, MSN; Bridget Parsh, RN, MSN, CNS; Susan Perkins, MSN, RN; Susan Scholtz, RN, PhD; Laurel R. Talabere, PhD, RN, AE-C; Catherine Webb, RN, MA; Jeannie Weston, MS, BSN, CNS. As new scientific information becomes available through basic and clinical research, recommended treatments and drug therapies undergo changes. The author(s) and publisher have done everything possible to make this book accurate, up to date, and in accord with accepted standards at the time of publication. The author(s), editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of the book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation. The reader is advised always to check product information (package inserts) for changes and new information regarding dose and contraindications before administering any drug. Caution is especially urged when using new or infrequently ordered drugs. Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by F. A. Davis Company for users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, provided that the fee of $.2510 per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy license by CCC, a separate system of payment has been arranged. The fee code for users of the Transactional Reporting Service is: 8036-2178-71169-2/1004 0 + $.2510.

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Place 27⁄8 ⫻ 27⁄8 Sticky Notes here for a convenient and refillable note pad

✓ HIPAA Compliant ✓ OSHA Compliant

BASICS

SAFETY

PLAY

ASSESS

PAIN

NUTRI

CLIN SKILLS

EMERG

PATHO A–G

PATHO H–Q

PATHO R–Z

TOOLS

TRANS

MEDS

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Look for our other Davis’s Notes titles available now!

RNotes®: Nurse’s Clinical Pocket Guide, 2nd edition ISBN-13: 978-0-8036-1335-5

MedSurg Notes: Nurse’s Clinical Pocket Guide, 2nd edition ISBN-13: 978-0-8036-1868-8

LPN Notes: Nurse’s Clinical Pocket Guide, 2nd edition ISBN-13: 978-0-8036-1767-4

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IV Med Notes: IV Administration Pocket Guide ISBN-13: 978-0-8036-1446-8 IV Therapy Notes: Nurse’s Clinical Pocket Guide ISBN-13: 978-0-8036-1288-4 LabNotes: Guide to Lab & Diagnostic Tests, 2nd edition ISBN-13: 978-0-8036-2138-1 MedNotes: Nurse’s Pharmacology Pocket Guide, 3rd Edition ISBN-13: 978-0-8036-1531-1

OB Peds Women’s Health Notes: Nurse’s Clinical Pocket Guide ISBN-13: 978-0-8036-1466-6 PsychNotes: Clinical Pocket Guide, 2nd edition ISBN-13: 978-0-8036-1853-4 Critical Care Notes: Clinical Pocket Guide ISBN-13: 978-0-8036-2084-1 Assess Notes: Assessment and Diagnostic Reasoning ISBN-13: 978-0-8036-1749-0

For a complete list of Davis’s Notes and other titles for health care providers, visit www.fadavis.com.

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Contacts • Phone/E-Mail Name Ph:

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1 Unique Aspects of Pediatric Nursing ■ Number of children in America (2009): 73.7 million ■ Percentage of children without health insurance (2009): 11.2% overall, including 12% to 28% of poor children ■ Percentage of children living at or below poverty level in United States: 13 million, ranging from 7% in New Hampshire to 27% in Mississippi ■ Ethnic breakdown of poverty levels: ■ African American: 35% ■ Native American: 29% ■ Latino: 28% ■ Asian: 11% ■ White: 10% ■ 16% of American children report the experience of food insecurity ■ 26.3% of American children are covered exclusively by Public Health Insurance (32.1% age 0–3 yr old) Source: Centers for Disease Control and Prevention, www.cdc.gov/nchs/fastats/children.htm; Health, United States (2008–2009) at www.cdc.gov/hus.htm

Society of Pediatric Nurses The mission of the Society of Pediatric Nurses is to promote excellence in nursing care of children and families through support of its members via clinical practice, education, research and advocacy. Their Web site, www.spn.org, is a resource for conferences, regional meetings, policy updates, clinical information and guidelines, professional support, and numerous Web links.

Adult Nurses Caring for Children Adult nurses need specific competencies to adequately provide safe care to children whose ages range from neonate to adolescent. Competencies include medication dosage calculations; pediatric-specific skills; neonatal, infant and child resuscitation techniques; play therapy; family-centered care principles; and developmentally appropriate care/ communication.

BASICS

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BASICS Follow institutional policy concerning required competencies and do not perform pediatric patient care duties that you are not competent to perform. Read national documents concerning scope of pediatric nursing practice, standards of care, and required competencies (National Council of State Boards of Nursing). Seek nationally recognized pediatric nursing certification to attain a core body of knowledge and enhance practice. The two national certification boards that offer nationally recognized certification are the Pediatric Nursing Certification Board (PNCB) and the American Nurses Credentialing Center (www.pncb.org or www.nursingworld.org).

Common Acute Care Hospitalization Diagnoses ■ ■ ■ ■ ■ ■

Treatment for infectious diseases Treatment for consequences of injuries/accidents Surgical procedures Treatment for acute exacerbations of chronic childhood conditions Treatment of congenital heart defects Treatment of hematological, and oncological diagnoses

Critical Pediatric Nursing Issues ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Societal violence and unsafe neighborhoods Divorce rate, drug and alcohol abuse Lack of prenatal care, screenings through childhood Numbers of medically uninsured children in nation Violence and bullying in school settings Injury and accident rates across childhood Poor nutrition and increasing obesity rates Exposure to peer pressure with drugs, alcohol, and early sex Rates of STDs Mental health issues and depression Eating disorders Teen pregnancy rates School dropout rates Child abuse and neglect

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3 Roles of the Pediatric Nurse ■ Health promotion through education, screening, and prevention measures ■ Disease prevention through rapid assessments and early interventions ■ Health restoration via acute, critical, and outpatient care ■ Community health nursing focusing on communities and client groups ■ Complex care coordination for children with multiple morbidities or complex chronic diseases requiring a multidisciplinary approach ■ Death and dying care, symptom management at end of life

Education concerning all aspects of children’s health.

Pediatric Care Locations ■ ■ ■ ■ ■ ■ ■ ■ ■

Acute care hospital units Critical care hospital units Specialty clinics for children with special needs Outpatient clinics Public health departments Home care Hospice care Private primary care provider offices Schools

Definition of Family Biological, legal and/or emotional relation between two or more persons. May have a variety of constellations including nuclear, alternative, adoptive, foster, and group. A family is who they say they are.

BASICS

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BASICS

Differences Between Children and Adults Anatomical, Physiological, Metabolic, and Biochemical Differences ■ ■ ■ ■ ■ ■ ■

Medication pharmacodynamics and pharmacokinetics Anatomy and physiology Cognitive, motor, and psychosocial aspects Developmental processes and milestones Immune status Responses to illness Need for health promotion, frequent regularly scheduled screenings

Body System Differences ■ Respiratory ■ Tongue is disproportionally larger ■ Obligate nose breather for first 8–12 weeks ■ Underdeveloped intercostal muscles ■ Airway diameter approximate size of infant’s little finger ■ Less tidal volume ■ With respiratory compromise, rapid development of distress ■ Skin: Proportionally larger body surface area leading to body fluid loss and less temperature regulation ■ Cardiac: Higher heart rates, potential for congenital anomalies, lower blood pressures, higher oxygen demands ■ Fluids: Less ability to regulate body fluids and concentrate urine; higher specific gravity of urine in younger years ■ Electrolytes: Values differ in age groups, narrow fluctuations in values result in display of symptoms ■ Neurological: Primitive reflexes in infancy replaced slowly with gross to fine motor movements ■ Sensory: Born with all sensory organs intact except for vision (approximate visual acuity for a newborn is 20/100 to 20/200) ■ Immune system: Need acquired immunity to build adequate immune response; breast milk provides passive immunity

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5 ■ Hematology: Fetal hemoglobin present at birth; rapid heart rate and higher hematocrit assists with oxygen delivery ■ Musculoskeletal: ■ Sequencing of growth is patterned by “spurts” and “lulls” ■ Mastery of motor skills is influenced by environment and for each child is highly individualized ■ Genital/urinary: ■ Smaller bladder capacity, must learn toileting skills and hygiene to prevent UTI: girls need to learn wiping front to back ■ Urine output at birth is 1–2 cc per hour per kg of body weight; newborn bladder capacity is 15 cc ■ Expectation of newborn and young infant is 6 to 8 wet diapers per day ■ Gastrointestinal: Feces change from newborn meconium to milk stools adjusting thereafter to eating habits, toileting capacities, and diet; first meal of protein beyond breast milk or formula may lead to rash ■ Endocrine: Inability to regulate blood glucose levels for first few years; newborns may demonstrate pseudomenstruation, “witches milk”

Stages of Childhood ■ ■ ■ ■ ■ ■ ■ ■

Premature infant: Born prior to 36 weeks’ gestation Newborn: First 28 to 30 days of life Infant: 30 days to first birthday Toddler: One year old to 3 years old Preschooler: Three years old to fifth birthday Early school age: 6 to 10 years old Late school age: 10 to 12 years old Adolescent: 13 to 18 years old

Family-Centered Care The philosophy of family-centered care recognizes the family as the constant in the child’s life and the need to provide support based on respect, encouragement, enhancement of strengths, and encouragement of competence.

BASICS

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BASICS

Principles ■ Respect that the family is the constant in a child’s life ■ Treat the family as a unit because the entire family is affected by the child’s illness ■ Enforce that service systems and personnel support, respect, encourage, and enhance the family’s competence and strengths ■ Support natural care giving ■ Support decision-making roles within the family ■ Build unique strengths as individuals and families ■ Promote living at home and in the family’s community ■ Consider the needs of all family members and their role in the family structure ■ Include siblings and extended family members in care provision ■ Acknowledge diversity among structures and promote cultural practices ■ Promote normalization and encourage identities beyond the illness state ■ Support family goals, dreams, strategies, and activities ■ Locate support systems, services, education, and information for all members

Overarching Concepts ■ Empowerment: The interaction between the family and health providers is such that a sense of control over their family lives continues while members are supported to foster their own strengths, abilities, and actions through the caregiving/helping role ■ Enabling: Professionals provide opportunities for family members to master child’s care

Implementation ■ ■ ■ ■ ■ ■

Incorporate the philosophy into institutional policy Facilitate collaboration at all levels Exchange complete and unbiased information Incorporate the respect for cultural diversity into all aspects of care Provide opportunities for family-to-family support and networking Ensure that flexible, accessible and comprehensive services, support and care is given in all areas of specialized health ■ Appreciate that families have a wide range of strengths, emotions, concerns, and aspirations beyond their need for pediatric health care

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7 Examples ■ Collaborative care conferences ■ Involvement in child’s care from the beginning of care ■ Teaching various members of the family to provide needed skills and care

Developmental Theorists Defined Erikson’s Developmental Theory Cognitive ■ Infant ■ Trust versus mistrust ■ Consistency of care is essential for an infant to develop trust Attend to expressed needs immediately and consistently ■ Need to learn object permanence (9–10 months) ■ Need to learn they are separate from primary caregiver ■ Toddler ■ Autonomy versus shame and doubt ■ Begin to tolerate some separation from primary caregiver ■ Temper tantrums are normal and negativism is common Egotistical at this time ■ Enjoy rituals, consistency, learning toileting skills and locomotion ■ Preschooler ■ Initiative versus guilt ■ May talk incessantly ■ Evolving from egocentrity to seeing other’s viewpoints ■ May have magical thinking to solve problems and make sense of their environment. Most at risk for effective symptom management as they may deny pain, nausea through their magical thinking ■ May be dependent on security objects and items (handle with care in the hospital and do not lose) ■ School-age ■ Industry versus inferiority ■ Acquisition of skills achieves a sense of competency, failure to do this leads to a sense of inferiority ■ The conscience is forming and peer group interactions are highly influential

BASICS

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BASICS ■ Adolescent ■ Identity versus role confusion ■ Think beyond the present, are logical and use reasoning ■ Group identity is paramount and risk taking is common secondary to peer pressures

Kohlberg Theory of Moral Development ■ Infant: NA ■ Toddler: Preconventional, oriented toward obedience and punishment, discipline patterns affect moral development, praise appropriate behaviors ■ Preschooler: Preconventional, conscience emerges, emphasis on external control, moral standards are those of others ■ School age: Increased desire to please others and be seen as “good” ■ Adolescent: Postconventional, defined set of morals

Piaget ■ Infant: Sensorimotor stage, intellect develops, gains knowledge via environment through senses. Predictable survival reflexes (sucking and grasping), own body is point of central anxiety ■ Toddler: Sensorimotor to preconceptual and preoperational, egocentric, expressive jargon, 300 words ■ Preschooler: Preconceptual phase, intuitive phase, cannot see other’s viewpoints, magical thinkers, average 900 words ■ School age: Concrete operations, inductive reasoning, logical operation ■ Adolescent: Formal operations, abstract reasoning

Freud ■ Infant: Oral stage, sucks for enjoyment, meets the world orally ■ Toddler: Anal stage, experiences frustrations and satisfaction as she/he gains control ■ Preschooler: Phallic stage, masturbation, oedipal conflict where jealousy/rivalry with same sex person, strong bonding with opposite sex ■ School age: Latency period, relative sexual indifferences ■ Adolescent: Genital stage, masturbation, sexual relations, body image concerns

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9 Principles of Growth and Development Infant Physical ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Ht increases 1 in. per month Wt doubles by 5–6 months Wt increases by 1.5 lb/month Teeth: 6–8 first year Head circumference (HC) increases by 0.5 in./month Gross/fine motor Rolls back to side at 3 months Hold head erect at 4 months Voluntary grasp at 5 months Rolls from front to back at 5–6 months Language Coos at 1–2 months Laughs at 2–4 months Makes consonant sounds at 3–4 months Imitative sounds at 6 months

Personal-Social ■ ■ ■ ■

Regards a person’s face at 1 month Displays social smile and follows object 180 degrees at 2 months Recognizes familiar faces at 3 months Stranger anxiety begins at 6 months

Older Infant Physical ■ ■ ■ ■ ■ ■ ■ ■

Ht increases 50% of birth ht by 1 year Wt increases 1 lb/month Triples wt by 1 year HC increases by 33% Posterior fontanel closes by 2–3 months Anterior fontanel closes by 12–18 months Central incisors erupt at 5–7 months Gross/fine motor

BASICS

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BASICS ■ ■ ■ ■ ■ ■

Begins to crawl at 7 months Sits unsupported at 8 months Pulls up to stand at 9 months Drinks from cup at 9 months Builds two-block tower at 12 months Walks alone or holding onto one hand at 12 months

Language ■ ■ ■ ■ ■

Pronounces syllables (dada, mama) at 8 months Says 4–10 words at 12 months Personal–social Marked stranger anxiety at 8 months Emotions such as jealousy at 12 months

Toddler Physical ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Ht increases 3 in. a year Wt increases 5 lb a year Weighs about 4 times birth wt HC equals chest circumference at 1–2 years 10–14 temporary teeth erupt Gross/fine motor Walks without help at 15 months Walks up and down stairs placing both feet on each step at 24 months Scribbles spontaneously at 15 months Builds 3–4 block tower at 18 months Jumps with both feet at 30 months

Language ■ ■ ■ ■ ■ ■ ■ ■ ■

Says 300 words at 2 years old Uses 2- to 3-word phrases and pronouns Understands speech at 2 years old States first and last name at 2.5 years old Personal–social Separation anxiety peaks Ritualism is very important to child Negativism occurs (favorite word is no) Striving for independence but very unsafe and needs supervision at all times

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11 Preschooler Physical ■ ■ ■ ■

Ht increases by 2.5 to 3 in. per year Wt increases by 4–6 lb per year HC increases by 0.5 in. per year Vision is 20/20 with color vision intact at 5–6 years old

Gross/Fine Motor ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Rides tricycle at 3 years old Climbs stairs using alternate feet at 3 years old Stands on one foot at 3 years old Has broad jump at 3 years old Builds 9–10 block tower by 3 years old Skips by 4 years old Catches a ball by 4 years old Laces shoes by 4 years old Ties shoelaces by 5 years old Uses scissors well by 5 years old Prints letters and numbers and name by 5 years old

Language ■ ■ ■ ■ ■ ■ ■

Says 900 words by 3 years old Speaks in 3- to 4-word sentences Says 1500 words by 4 years old Asks “why” questions at 4 years old Says more than 2000 words by 5 years old Knows and names colors by 5 years old Names days of the week by 5 years old

Personal-Social ■ Shares toys with others ■ Imitates caregivers ■ Enjoys domestic role-playing

BASICS

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BASICS

Early School Age Physical ■ ■ ■ ■

Ht increases by 2–3 in. a year Wt increases by 4.5–6.5 lb/year Secondary teeth erupt and deciduous teeth are shed Tanner stage 3 may begin

Gross/Fine Motor ■ Rides bike ■ Roller skates (needs lessons on safety and use of protective equipments ■ Runs, jumps, and swims ■ Cursive writing at 8 years old ■ Computer and craft skills become important

Language ■ Develops ability to read at grade level

Personal-Social ■ School relationships and work important ■ Separating from family ■ Best friends” develop

Later School Age and Adolescent Physical ■ ■ ■ ■

Puberty begins in girls at 8–14 years old Puberty begins with boys at 9–16 years old Ht and Wt increases are highly varied Progressive Tanner stages of development

Gross/Fine Motor ■ Gross motor reaches adult level although takes risks with sense of invincibility ■ Fine motor continues to be refined

Language ■ Develops formal thought including idealism, egocentrism, and ability to consider abstract possibilities

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13 Personal/Social ■ Works through identity issues, status, and relationships

Emotional Factors Associated with Care of Children Separation Anxiety ■ Manifests in toddlerhood ■ Becomes clingy ■ Three phases: ■ Protest: Cries for caregiver ■ Despair: Disinterested in play and environment, show passivity ■ Detachment: Adjustment is superficial, detached but shows shallow interest, occurs after prolonged separation ■ Try short periods of separation in the beginning

Stranger Anxiety ■ ■ ■ ■ ■

Peaks at 9 months of age Unfamiliar situations and people set off child Cuddling can ease fears May need security object from home Try to plan care of child by same providers

■ ■ ■ ■ ■ ■ ■ ■

Peaks at 24 months Common in toddlers and an expected form of behavior in all children Considered normal, healthy way to deal with frustrations Avoid situations that are triggers Do not give in: Remain calm, gentle but firm Offer choices whenever possible Reward desired behavior with attention and praise Do not overcontrol and be flexible when able

Tantrums

BASICS

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BASICS

Communicating with Children Infants ■ ■ ■ ■ ■

Direct eye contact: Get to their level Imitation sounds Emphasizing vowels and consonants Close contact with primary caregiver Promotion of security through contact and immediate needs gratification

Toddlers ■ Playing of age-appropriate games such as large balls, simple games, reading picture books ■ Simple conversations that encourage autonomy ■ Praise for desired behaviors ■ Inclusion in conversations ■ Only make promises you can keep!

Preschoolers ■ ■ ■ ■

Imaginative play Introduction to group play and conversations Learning how to take turns in conversation Preschoolers are very aware of surroundings, include child in conversations within earshot

Early School Age ■ Engage about schoolwork and accomplishments ■ Talk during shared crafts and art projects ■ Encourage and praise efforts: “You are doing a great job”

Later School Age ■ Enjoys competitive games, support sports by being actively involved ■ Enjoys mastering technology/computer games, engage child while playing

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15 Adolescent ■ ■ ■ ■ ■ ■ ■

Engage in conversations about teen’s goals and life plans Ask about peer group members Provide time with peers, cell phones, and computer social groups Provide Internet access if appropriate Discuss family structure and home life Provide ample times of privacy Ask family to step out when interviewing

BASICS

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SAFETY

Environmental Safety ■ Never leave a child unattended in a treatment room, on a scale, in a stroller, swing, highchair, bouncy seat, or wagon ■ Double-check that bed side rails or crib rails are up and locked in place ■ Use crib top covers to prevent a child from climbing out ■ Do not use cribs with greater than 35/8-in. gap between bars as child may place head between bars and suffocate ■ Do not allow helium- or air-filled latex or plastic balloons into the hospital or clinic; they pose a risk for aspiration as well as a risk for latex allergy ■ Always use security straps on every product/device according to manufacturer’s recommendation ■ Never leave a child alone during a procedure: Prevent injuries and falls ■ Follow all institutional policies concerning wrist or ankle alarms: Prevent abductions ■ Learn the institution’s infant or child abduction policy and procedure ■ Wash hands before and after all patient contact to prevent infection; wash as well between going from a dirty area to a clean area in the same patient ■ Monitor adolescents for evidence of high-risk behaviors: Educate ■ Prevent hypoglycemia and hypothermia in the newborn: Monitor nutritional intake and check child’s temperature and environmental temperature frequently. Keep infant wrapped and prevent cold stress ■ Place infants on their backs for sleep unless medically contraindicated: Prevent SIDS. Do not allow parents to sleep in the same bed as infant ■ Inspect toys brought from home for buttons, sharp edges, removable pieces, or defective parts ■ Never prop bottles in infant’s mouth: Prevent choking. Do not allow parents or caregivers to do so either as this is an aspiration hazard

Equipment Safety ■ Never leave scissors, hemostats, syringes, gloves, or any other medical equipment within reach of young children ■ Always cover electrical outlets: Prevent electrical injuries

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17 ■ Never place heating pads or water-based warm packs in the microwave because they can cause burns: Use commercially prepared products ■ Do not leave ice packs on a child’s skin for longer than a few minutes ■ Do not microwave formula or baby food as there is uneven heating and can lead to burns; use water baths to heat formula bottles or baby food jars, or frozen/chilled breast milk

Medication Safety ■ Always use two patient identifiers before administering medications ■ Double-check with your institution to see which medications require two nurses for verification ■ Do not administer oral medications to a crying child as this poses a risk for aspiration ■ Include family members in medication administration: Teach and role-model safety ■ Never place medications in an alternative container. Leave in original container with safety caps and administration guidelines

Anticipatory Guidance: Accident and Injury Prevention ■ Teach parents about developmental issues that contribute to childhood injuries: ■ Newborn fall prevention safety practices ■ Choking prevention ■ SIDS prevention: “Back to Sleep” practices only (www.nichd.nih. gov/sids/) ■ Stair safety for toddlers ■ Water burns and kitchen burns prevention ■ Use of safety gates ■ Drowning safety for toddlers: Never leave child alone in or near any size body of water ■ Monitoring of play/interaction with animals, especially dogs ■ Car restraint safety: Appropriate car seat use ■ Use of sports safety devices: Wrist, elbow, knee protectors

SAFETY

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SAFETY ■ ■ ■ ■ ■ ■ ■ ■

Prevention of drowning Hand gun/firearms storage guidelines Fireworks safety and prevention of burn injuries Teach children stranger danger Fire safety in the home ATV safety for school-age children and teens Sun exposure safety including keeping infants out of the direct sun Personal safety at the appropriate developmental level: Internet safety, never give out personal information, say no to drugs and smoking

Teaching Families to Prevent Childhood Injuries: Risk Factors Anticipatory Care Guidelines for All Parents, Caregivers, and Guardians ■ Gender: Behavioral characteristics of males cause them to experience large number of childhood injuries ■ Difficult temperaments lead to increased injuries ■ Stress increases risk of self-destructive behaviors ■ Natural curiosity leads to exploration and potential dangers in the home ■ Parents should see the home environment at the child’s level; crawl around on floor to see what dangers are present at the child’s level of vision and access ■ Developmental ages: ■ Infants explore through their mouths, leading to ingestions • Prevent aspiration and choking by inspecting toys • Keep cribs safe: No soft pillows, prevent suffocation • Car seat safety: Backward facing until 20 lb and 12 months • Prevent falls: Never leave infant alone on high surfaces • Prevent injury: Never leave infant alone with pets or young siblings. Never shake a baby • Check temperatures of warmed formula • Constantly hold on to infant in a bath tub • Use baby gates • Pad coffee tables or furniture with sharp edges • Lock cabinets with breakables and poisons

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19 ■

Toddler’s and preschooler’s magical thinking means they cannot comprehend danger • Think crib safety as toddlers will climb over rails • Car seat safety: Forward-facing when >20 lb and older than 1 year for toddlers and forward-facing, backseat until 4 years old and 40 lb for preschoolers until they use a booster seat • Use safety gates, lock cabinets • Never leave toddler alone in the bathtub • Never keep buckets of standing water • Keep toilet bowl lids closed • Cover electrical outlets • Do not cook around toddler, cook on back stove top burners, prevent toddler from playing with stove controls • Cut foods in very small pieces to prevent choking • Do not allow young siblings to feed infants and toddlers • Keep matches, candles, fireplaces out of reach • Use helmets when riding tricycles, skates, and scooters (or any mobility toy) ■ Young child may not learn from experience and may repeat dangerous behavior ■ School-age children are still learning causal relationships, may attempt dangerous act without realizing consequences • Use helmets at all times • Use booster seats for children between 4 and 8 years of age and up to 80 lb (state laws vary) • Supervise children in pools, while swimming • Teach stranger safety; never approach cars • Keep guns, swords locked (avoid their storage in homes with children) ■ Adolescents may feel invulnerable and invincible • Provide appropriate sex education • Teach about decreasing risk-taking behaviors • Talk about risks of drugs, smoking, joy riding, alcohol

SAFETY

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SAFETY

Use of Restraints A restraint is “any method, physical or mechanical, that restricts a person’s movement, physical activity, or normal access to his or her body” (Joint Commission on Accreditation of Healthcare Organizations, 2001, www.jointcommission.org/).

Restrictions ■ Policy must be clear and consistent ■ Need for restraint must be documented ■ At least one alternative method must be attempted before restraint is applied ■ Least restrictive method must be used ■ Order must be written and evaluated within 1 hour of application ■ Order must include start and stop time, date, reason for use, type, and signature of person ordering restraint

Nursing Tips ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Always obtain an order before using restraints Follow institutional policy carefully Assess child very frequently while using restraints Prevent injury or death from restraint use Document order, method, assessments, interventions, and child’s response frequently Remove restraints as soon as possible Never leave a restrained child alone Involve and educate parents and caregivers on need for restraint Exhaust all other forms of assisting child and situation before restraining child Restraint use is very frightening for the child: Use developmentally appropriate communication to explain indication

Behavioral Restraints ■ Wrist and ankle restraints ■ Jacket restraints tied to bed and sheets/straps tied to wheelchairs

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21 ■ Blanket/sheet restraints used during procedures ■ Mummy wraps or tight swaddles

Guidelines for Using Behavioral Restraints ■ ■ ■ ■ ■ ■

Must use caution to ensure patent airway Needs either continuous supervision or frequent assessment: Follow policy Assess need for physical restraints every 2 hours Ensure correct and current physician’s order Give supervised rest periods from restraints Assess skin color and integrity, pulses below restraint site

Safety Alerts ■ ■ ■ ■ ■

Never tie restraint to side rails, tie only to bed or crib frames Leave one finger width between skin and device Tie knots for quick release Try to place restraint over clothing Use “No-No’s” when possible as a choice above wrist restraints. “No-No’s” are soft cotton wraparound devices with a Velco closure that covers PICC lines or IV devices. They prevent a young child from picking, chewing or otherwise dislodging bandages or devices. When wrapped around a child’s elbow, they prevent bending the extremity and therefore the child cannot reach up and pull out NG tubes or touch their faces after head, neck, or mouth surgery ■ “No-No’s” and other postoperative devices that are worn 100% of the time do not have the same standards: Assess skin frequently for breakdown and discomfort

Chemical Restraints ■ Medications include: ■ Haldol ■ Lorazepam ■ Diazepam

Guidelines for Using Chemical Restraints ■ ■ ■ ■

Use as a last resort Always check institutional policy Secure sitter or support person to monitor child during use Chemical restraints are a pharmacological means of decreasing combative, self-destructive behaviors

SAFETY

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Restraining Methods During Procedures ■ It is sometimes necessary to restrain a child during a medical procedure. The techniques used involve close physical contact ■ Types: ■ Modified side-lying for lumbar puncture

■

Leg restraint for femoral vein puncture

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23 ■

Mummy wraps for nasogastric tube insertion

Utilize child life specialists/therapists when available if restraints are indicated for a child of any age!

SAFETY

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Play Therapy What Is Play? Play is “work of the child.”All children need opportunities to play. It is sometimes a challenge to provide appropriate play to match a child’s interests and skills.

Why Provide Play? ■ ■ ■ ■ ■ ■

Play Play Play Play Play Play

is pleasurable has no extrinsic goal is spontaneous involves active engagement promotes social, emotional, and physical development provides learning

Types of Play ■ Unoccupied behavior: The child does not seem to be playing. Instead, he or she is watching whatever is going on that is most interesting (Parteri 1932) ■ Onlooker play: The child focuses on play activity of others and remains close by but does not participate ■ Solitary independent play: The child plays alone, using different materials from other children in the vicinity. The child makes no effort to interact with others. Considered intellectually advanced type of play across childhood and should be encouraged. ■ Parallel activity: Two children play in same area with others, using like materials, but they play independently. Often the children play back to back and have minimal interaction. Sharing infrequently happens during parallel play ■ Associative play: Children interact and engage in a common activity. Materials are exchanged. The play is not organized, although the children may attempt to control or limit participation. The children do not have a common goal ■ Cooperative or organized supplemental play: Play with a recognized group goal, often directed by 1 or 2 players and characterized by sets of different roles. Members control entry

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25 Distraction Distraction can be used as a form of play for intellectual and motor development, but is also effective when prepping a child for a procedure, or to help relieve pain. Distractions include: ■ ■ ■ ■ ■

Music Videos Puzzles Books or stories read to the child Infant mobiles, mirrors, rattles

Child Life What Are Child Life Interventions? Child life interventions assist with the serious and long-term consequences of a child’s adverse emotional reaction to hospitalization and other medical encounters. Having a child life specialist provide play allows expression, education, and development for the child and siblings through deliberate interventions that minimize stress and anxiety (Thompson & Stanford, 1981).

Indications for Child Life Interventions ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Help the child cope with stress and anxiety Provide materials for play activities Prepare the child for hospitalization, surgery, or medical procedures Lend emotional support to siblings Maintain receptive environment for family members Advocate a child’s point of view to hospital personnel Promote physical, social, intellectual, and emotional development Prevent aggressive and hostile behaviors Provide stimulating environment and prevent solitude and boredom Encourage self-expression (feelings, emotions, vehicle of communication) Prevent regression by advocating for group participation and preventing isolation and independent play

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Types of Play by Developmental Group Premature Infants ■ Allow uninterrupted sleep ■ Give soft touch with warm palms ■ If the infant is demonstrating signs of stress (decreased O2 sat, increased HR and RR) give rest periods

Newborns ■ Promote attachment to parents/caregiver ■ Demonstrate and encourage En Face positions (close eye/face contact) ■ Provide soothing soft music

Young Infants ■ ■ ■ ■

Hang mobiles above infant Infants enjoy contrasting colors such as black and white Toys with mirrors hold infants’ attention Infant may need breaks: Do not overstimulate

Older Infants ■ Encourage activities that promote development of crude pincer grasp at 8–10 months ■ Challenge infant to pick up items to continue development of pincer grasp at 11 months ■ Enjoys banging objects and making sounds ■ Play hide and seek to encourage development of object permanence ■ Play ball by rolling ball back and forth ■ Enjoys nesting cubes, stacking challenges ■ Large toys with music, variations in sound ■ Encourage child to hold toys

Toddlers ■ Dress-up games provide practice in putting clothes on and off ■ Push-pull toys, low slides promote development of motor skills ■ Toddlers enjoy toy phones, picture books, pail and shovel, safe water play, stacking cubes

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27 Preschoolers ■ Play kitchens, tool chest, medical and nursing kits, and work surfaces allow children to pretend-play adult work roles ■ Tricycles, wagons, trucks, car, puzzles, drawing, crafts of all sorts

School-Age Children ■ Team play, making up new games with rules ■ Secret clubs ■ Board games, card games, computer technology/games

Adolescents ■ Activities that represent adult behavior: Studying drivers training manual ■ Access to peer group members; phones, computers, letter writing ■ Journal writing, challenging arts and crafts (jewelry making, clay) ■ Social clubs, dances, movies ■ Activities that discourage tobacco alcohol, drug use, and early sex

Children with Special Needs ■ Work with child life specialists and primary caregivers to determine appropriate activities ■ Always provide a slight challenge with support and encouragement to promote physical, intellectual, emotional, and social development

See Tab 14 for resources for play, play therapy, safe toys, toy safety regulations and suggestions.

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Vital signs Normal Vital Signs, by Age Group VS HR RR SBP DBP Temp (C) O2 sat

Newborn 100–180 35 65 41 36.5° 95%

Infant 80–120 30 65–100 45–65 37.5° 100%

Toddler 80–110 23–25 90–105 55–70 37.2° 100%

School Age 70–110 17–21 100–120 60–75 36.7° 100%

Adolescent 55–90 17–18 110–135 65–85 36.6° 100%

Tips on Assessment of Vital Signs Temperature ■ Temperature-regulating mechanisms are not well developed in infants and young children, so temperature may fluctuate as much as 3°F in 1 day ■ Young infants do not shiver and lack adequate adipose tissue to insulate against heat loss ■ Factors that influence body temperature include exercise, stress, crying, environmental temperature, and diurnal variations (lowest temp occurs between 1 a.m. and 4 a.m., highest between 4 p.m. and 6 p.m.) ■ When recording temperature, always include route (oral, axilla, rectal, tympanic) on documentation form ■ Always use least traumatic site

Temperature Conversion Chart C 36° 36.5° 37° 37.5° 38°

F 96.8° 97.7° 98.6° 99.5° 100.4°

C 38.5° 39° 39.5° 40° 40.5°

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F 101.3° 102.2° 103.1° 104° 104.9°

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29 Respirations ■ Count respirations for one full minute, especially when child has a respiratory illness ■ Assess for irregularities in respiratory patterns ■ Place hand on chest of infant to assess rate accurately

Respiration Patterns Eupnea

Bradypnea

Tachypnea

Apnea Hyperpnea

Kussmaul’s Respirations

Biot’s (Ataxic) Breathing

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Blood Pressure ■ Assess BP on upper arm when child is quiet ■ Select cuff that is correct size (approx. 2/3 of area between shoulder and AC or knee and ankle) ■ Assess BP on thigh as needed ■ For child between 1–5, blood pressure can be determined by: approx. 90 + age in years for systolic over diastolic of 56 ■ For child between 6–18, approx. 83 + (2 X age in years) systolic over diastolic of 52 + age in years

Appropriate Sizing of BP Cuff

Popliteal artery

Brachial artery Radial artery

Dorsalis pedis artery

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Posterior tibial artery

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31 Pulse ■ Pulse is an accessible indicator of cardiovascular status ■ Variations in HR are much more dramatic in children than in adults ■ Factors that influence HR are medications, activity, pain, hemorrhage, hypoxia, fever ■ Measure pulse when child is quiet, document child’s activity level ■ Count for one full minute ■ Apical pulse is recommended for assessment across childhood

O2 Saturation

■ Oxygen saturation drops slightly when child is asleep ■ Cold fingers or toes will lower readings regardless of type of probe ■ Use self-adhering probes for young children: See packaging for placement

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Normal Weight and Growth Rates Approximate Normal Weight per Age Age Newborn 6 months 1 yr 2–3 yr 4–5 yr 6–8 yr 8–10 yr 10–14 yr 14+ yr

Weight (in kg) 5 7 10 12–14 16–18 20–25 26–32 32–50 50+

Source: From Wong, D. (1991). Pediatric quick reference guide. St. Louis: Mosby.

Average Growth Newborn ■ Height (Ht): 50.5 cm average (50 percentile) at birth ■ Weight (Wt): 3.27 kg; expect up to 10% wt loss by third or fourth day due to loss of extracellular fluids and meconium ■ Head circumference: Increases by 0.5 cm per month

Younger Infant ■ Ht: Increases 18–22 cm/year ■ Wt: Almost doubles birth weight within first 6–8 months ■ Head circumference: Increases by 0.5 cm per month

Older Infant ■ Ht: Increases 14–18 cm/year ■ Wt: Triples birth weight within first year

Toddler ■ Ht: Increases 11 cm/year ■ Wt: Increases 1.8–2.6 kg/year

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33 Preschooler ■ Ht: Increases 8 cm/year ■ Wt: Increases 2.3 kg/year

School age ■ Ht: Increases 5–6 cm/year ■ Wt: increases 2–3 kg/year

Adolescents ■ Rapid accelerating growth; reaches 95% of adult ht by age 17

Adolescent Girls ■ Ht: 5–20 cm total growth ■ Wt: Gains 7–25 kg

Adolescent Boys ■ Ht: 10–30 cm total growth ■ Wt: Gains 7–30 kg

Assessment Principles Across Childhood Following are essential components to include in a health assessment ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Sleep patterns Diet Dentition Immunizations Emotional health/family support and involvement Symptom assessment Discomfort/pain Nausea Sleep disorders Emotional distress Fatigue Dyspnea Hygiene Environmental safety: Car seats/restraints (varies by state) ■ Four steps for kids program (www.ca.gov)

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Rear-facing seats • Newborns and infants up to 20–35 lb • Until 1 year AND at least 20 lb • Never forward facing ■ Forward-facing seats • Children older than 1 year and at least 20 lb • After 40 lb, most can be converted to belt positioning booster ■ Booster seats • More than 40 lb • Use with lap and shoulder belts ■ Seat belt • Age 6 or older or over 60 lb • Back seat only • All children 12 and younger should be in back seat ■ Smoking in the home ■ Toxins remain in home for up to 10 days ■ Smoke on clothes or residual in car can influence the development of respiratory distress syndrome ■ Home safety measures for young children: ■ Crib slats spaced <35/8 in. to prevent injury and suffocation ■ Water heater turned down to below 120°F to prevent burns ■ Electrical outlets covered to prevent electrocution ■ Kitchen secured with gates to prevents burns ■ Animals secured to prevent bite injuries ■ Stairs secured to prevent falls ■ Cleaning supplies and chemicals secured to prevent poisoning and skin irritation ■ Medications with safety lids and kept out of reach to prevent poisoning

Assessment Tips for Body Systems Cardiac Normal Anatomical Differences ■ Innocent heart murmurs may be found in up to 50% of children ■ In infants, heart is large in relation to body size

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35 Assessment Components ■ Inspect for cyanosis, mottling, edema, point of maximum impact (PMI) at apex, nail beds, clubbing, lifts or heaves of chest ■ Auscultate heart sounds starting at the aortic and moving to pulmonic, Erb’s point, tricuspid, and mitral areas. Assess quality, rate, intensity, and rhythm ■ Palpate PMI, all central and peripheral pulses, compare femoral to brachial

Assessment Tips ■ ■ ■ ■ ■ ■

Assess when child is quiet or asleep Assess HR for one full minute Include respiratory system in assessment Warm stethoscope Use both bell and diaphragm Listen to all specific areas (aortic, pulmonic, tricuspid, mitral, apex, Erb’s) ■ Document, describe, and report murmurs ■ Inspect body positioning: Squatting or persistent hyperextension of neck may indicate hypoxia or heart disease

Respiratory Normal Anatomical Differences ■ Large head, short neck, small mandible, large tongue ■ Compliant rib cage, intercostal muscles poorly developed with few type-1 fatigue-resistant fibers ■ Increased likelihood of respiratory failure due to fatigue ■ Cartilaginous tracheal rings; cricoid ring is narrowest part of airway as opposed to larynx in adults ■ Young infants are obligate nose breathers and have narrow nasal passages that are easily obstructed by mucus ■ A small amount of resistance to airflow from edema or mucus will cause increased work of breathing (WOB)

Assessment Components ■ Inspect lip color, nail color, pulse oximetry, blood gases, Hgb ■ Inspect for restlessness, anxiousness, lethargy, irritability, decreased LOC

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ASSESS ■ Inspect for retractions, nasal flaring, use of accessory muscles, tachypnea, head bobbing, shoulder rolling ■ Auscultate for inspiratory and expiratory time ■ Auscultate for adventitious breath sounds such as rales, rhonchi, wheezing, and stridor

Assessment Tips ■ Assess anterior, posterior, and lateral breath sounds to compare ■ Assess when child is quiet or asleep ■ Count RR for one full minute

Skin Normal Anatomical Differences ■ Many contagious childhood illnesses have associated rashes ■ Integument status yields much information about overall status ■ In infants, skin pH is high, skin is thin, and secretion of sweat and sebum is minimal, making infants prone to infections

Assessment Components ■ ■ ■ ■

Inspect overall hygiene, note odors Inspect skin moisture and color; inspect nailbeds and fingers for clubbing Inspect for lesions, rashes, birthmarks, and signs of trauma Palpate temperature, texture, turgor, and edema

Assessment Tips ■ Reduce tickling by touching child’s skin with palm before using fingertips ■ Assess child’s entire body ■ Consider child’s hygiene, nutritional status, body size, and overall care

Gastrointestinal Normal Anatomical Differences ■ Muscle tone of lower esophageal sphincter is not mature until 1 month of age; young infants may regurgitate after meals ■ Stomach capacity is 20 cc in infant compared with 1500 cc in adolescent

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37 ■ Stomach acid is not fully present until 6 months ■ Stools of newborns are meconium (green/black), changing to pasty (yellow) within 3 days of birth

Assessment Components ■ ■ ■ ■ ■ ■ ■

Inspect umbilicus of newborn for color, discharge, odor, and herniation Check for patency of anus in newborn Inspect abdomen contour Auscultate bowel sounds for one full minute Percuss all areas for tympany (air), dullness (organs) Palpate superficial to deep for masses, tenderness Assess elimination pattern and fluid volume status

Assessment Tips ■ Reduce tickling by assessing abdomen with palm before using fingertips ■ Assess GI system last: Child may not remain quiet ■ Note types of stools: ■ Red currant jelly may indicate intussusception ■ Ribbon-like may indicate Hirschsprung’s disease ■ Frothy, fatty, and foul may indicate cystic fibrosis ■ Liquid or watery green or black indicates diarrhea ■ Clay or gray may indicate intestinal atresia

Genitourinary Normal Anatomical Differences ■ Young girl’s urethra is short ■ Bladder capacity is 15–20 cc in infant compared with 600–800 cc in adult ■ Kidney size is relatively large compared with adult, kidneys are susceptible to trauma ■ Infants’ kidneys are not fully developed: Urine is not concentrated, nephrons are immature, and filtration and absorption is poor

Assessment Components ■ ■ ■ ■

Inspect genitalia Assess odor, color, volume of urine Palpate kidneys Percuss kidney size

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ASSESS Assessment Tips ■ Provide privacy, respect shyness ■ Presence of STD in children may indicate sexual abuse

Endocrine Normal Anatomical Differences ■ For most body functions, hormonal control is lacking until 12–18 months of age; younger children are at risk for hormone imbalances ■ Maternal sex hormones can cause pseudomenstruation, breast milk production (witch’s milk), and hypertrophy of labia ■ Blood glucose levels are labile until close to age 5 ■ Preadolescent growth spurts may begin by age 8 years in girls and age 12 years in boys

Assessment Components ■ Assess blood glucose level if indicated ■ Inspect overall appearance for normal growth patterns

Assessment Tips ■ Be sensitive to the endocrine-related differences between genders; some children are very shy concerning variability of growth patterns and sexual maturation

Immunity Normal Anatomical Differences ■ Recurrent respiratory infections are common in children ■ Suspect an immune disorder if chronic, or unusual infections are present

Assessment Components ■ Laboratory tests for a child with repeat infections include: ■ CBC with manual diff ■ ESR ■ Immunoglobulin levels ■ Screenings for B-cell, T-cell, and phagocyte defects ■ Screenings for complement deficiency

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39 Assessment Tips ■ If HIV/AIDS is suspected, follow strict HIPAA guidelines; respect the child’s privacy ■ Follow institutional policy concerning labeling specimens

Sexuality Normal Anatomical Differences ■ Infant male’s foreskin is normally tight (do not retract newborn’s foreskin) ■ Infant male’s testicles may be retracted or in the canals (undescended) ■ Hypertrophied hymen, pseudomenstruation, and prominent labia minora are normal in infant girls due to maternal hormones

Assessment Components ■ Infants and young children: Inspect external genitalia for normalcy; descended testes ■ Preteens and teens: Tanner stages of sexual development ■ Teens: Sexual activity, STD testing, Pap smears, examine testicles or breasts

Assessment Tips ■ ■ ■ ■

Show respect and maintain privacy Uncover and inspect only needed site To visualize young children’s genitals, use a flashlight Do not use a speculum for internal vaginal examinations on young girls unless warranted

Members of some cultural groups will request a health-care provider of the same gender as the child: To provide family-centered care, this request must be respected if at all possible

Cognitive Components of assessment include: ■ Pediatric mental status examination ■ Assessment of short- and long-term memory ■ Assessment of recall

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Emotional Developmental Differences ■ Young children are prone to emotional distress ■ Depression can be diagnosed in children as young as 3 years old

Assessment Components ■ ■ ■ ■ ■ ■

Emotional distress Situational stress Depression Attention-deficit disorder Attention-deficit hyperactivity disorder Eating disorders: ■ Bulimia ■ Anorexia

Assessment Tips ■ Include family in assessments of young children ■ Assess and interview teens alone to allow for disclosure that may not take place in the presence of parents, siblings, or friends

Musculoskeletal Anatomical Differences ■ Purposeful movement replaces primitive reflexes seen in infants ■ Average age for walking ranges from 9 to 16 months

Children with delayed developmental milestones will show lags in musculoskeletal performance.

Assessment Components ■ ■ ■ ■ ■ ■ ■

Watch child walk, sit up, carry objects, and play Assess for stiffness, swelling, pain, limping Assess spine for lateral curvatures (scoliosis), kyphosis, or lordosis Assess upper and lower extremity strength Palpate extremities Assess for genu varum (bow-leg) or genu valgum (knock-knee) Assess for meningeal irritation by flexing child’s hips, then straightening each knee (Kerning’s sign)

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41 Assessment Tips ■ Use developmental milestone guidelines to predict lags/delays ■ Screen for congenital disorders such as clubfoot, congenital hip dislocation (Galeazzi’s sign, Ortolani’s sign, Barlow’s test) ■ Removing clothing assists with inspection

Neurological Anatomical Differences ■ Infants have poorly myelinated nerves ■ Assessment of 12 cranial nerves varies with child’s development stage and age as well as ability to understand and cooperate ■ Primitive infant reflexes disappear as child develops

Assessment Components ■ ■ ■ ■ ■ ■ ■ ■

Level of consciousness (LOC) Pupil reaction (PERRLA) Vital signs (trauma: decreased HR and RR, increased BP) Motor activity Posturing Response to painful stimuli Fluid status Infant primitive reflexes: ■ Sucking ■ Startle ■ Tonic neck/fencing ■ Blinking ■ Palmar grasp ■ Babinski’s sign ■ Rooting ■ Crawling ■ Moro ■ Dance/step ■ Deep tendon reflexes

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Pediatric Modification of the Glasgow Coma Scale Eye Opening 1 year 4 Spontaneously 3 To verbal command 2 To pain 1 No response

0–1 year 4 Spontaneously 3 To Shout 2 To pain 1 No response

Best Motor Response >1 year 6 Obeys 5 Localizes pain 4 Flexion withdrawal 3 Flexion abnormal (decorticate) 2 Extension (decerebrate) 1 No response

0–1 year 6 Normal spontaneous movements 5 Localizes pain 4 Flexion withdrawal 3 Flexion abnormal (decorticate) 2 Extension (decerebrate) 1 No response

Best Verbal Behavior 0–2 years 2–5 years 5 years 5 Coos, babbles 5 Appropriate words 5 Oriented, converses 4 Irritable 4 Inappropriate words 4 Disoriented 3 Cries to pain 3 Cries/screams 3 Inappropriate words 2 Moans to pain 2 Nonspecific sounds 2 Incomprehensible sounds 1 None 1 None 1 No response Scoring: • 13-15: mild head injury • 9-12: moderate head injury • <8: severe head injury; intubation may be required Modified from Jennet, B. & Teasdale, G. (1977). Aspects of coma after severe head injury. Lancet. 1: 878; James, H. E. (1986). Neurologic evaluation and support in the child with an acute brain insult. Pediatric Ann. 15:16; Siberry, G., & Iannone, R. (2000). The Harriet Lane handbook (15th ed.).St. Louis, Moseby, p. 14); and Andreoni, C. Klinkhammer, B. (2000). Quick reference guide for pediatric emergency nursing. Saunders, Philadelphia).

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43 Assessment Tips ■ ■ ■ ■

Assess for trauma, infections, cerebral edema, and ICP Include VS, fontanelles, pupil size and reactivity Assess for developmental delays Assess child’s speech articulation (at age 3, child should be easily understood)

Sensory (Infant Development and Assessment) Sight ■ Visual acuity ■ Infant: 20/300 to 20/50 ■ 2 yr: 20/70 ■ 4 yr: 20/40 ■ 5 yr: 20/30–20/20 ■ Strabismus common until 6 months old ■ Four-month old should fix on colored objects ■ Older children, use Snellen’s visual acuity test

Hearing ■ Hearing intact at birth ■ Audiometry is needed for newborn screening

(Some states mandate screening prior to discharge, document carefully)

Touch, Smell, and Taste ■ Intact at birth

Dehydration Dehydration is an imbalance caused by loss of a significant amount of body fluid. It is associated with vomiting, diarrhea, GI suction, fevers, diabetes insipidus, overuse of diuretics, tube feeding without free water, excessive sweating, and decreased fluid intake.

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Types of Dehydration Isonatremic Dehydration ■ Na: 130–150 mEq/L ■ Cause: Equal loss of sodium and body water

Hyponatremic Dehydration ■ Na: <130 mEq/L ■ Cause: Loss of sodium in excess of water

Hypertonic Dehydration ■ Na: >150 mEq/L ■ Cause: Loss of water in excess of sodium

Assessment Assessment includes all of the following: ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Mucous membranes Skin turgor Percent weight loss Urine output (UOP) Pulses Blood pressure Jugular vein distention (JVD) Weight hemodynamics Laboratory values Neurological status Thirst

Levels of Dehydration ■ Mild: Less than 5% total body weight loss (less than 50 cc/kg loss) ■ Moderate: 10% total body weight loss (100 cc/kg loss) ■ Severe: 10%–15% total body weight loss (100–150 cc/kg loss)

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45 Obesity Obesity is excessive accumulation of adipose tissue relative to lean body mass. It is evaluated by plotting body mass index (BMI) percentile on growth chart. ■ BMI = wt (in kg) divided by ht (in meters), squared ■ 85% percentile: At risk for overweight ■ 90% percentile: Overweight ■ 95% and above: Obesity

Incidence United States ■ Ranges from 17% to 32% of population, depending on geographic location ■ Affects approximately 13% of all 6- to 12-year-olds nationwide

International ■ Rising in areas of economic development

Assessment To asses for obesity, refer to growth charts from the National Institute of Health or the National Center for Health Statistics, found at www.cdc.gov/ growthcharts. ■ ■ ■ ■

Assess child’s height, weight, and BMI Assess child’s BP: Obesity is related to childhood hypertension Plot the child’s values on the growth chart associated with his or her age Use the 5th and 95th percentiles as parameters in assessing normal ranges

Genetic Influences ■ High association between pediatric and parental adiposity: ■ 80% incidence in children of obese parents ■ 14% incidence in children of normal-weight parents

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ASSESS Racial and Ethnic Influences ■ Groups at greatest risk for obesity are African Americans, Latinos, and Native Americans

Cultural Influences ■ ■ ■ ■ ■

Inactivity Valuing larger size child: May be seen as sign of health or status Cultural eating patterns promoted and encouraged Lower economic groups at greatest risk Overeating in response to: ■ Boredom ■ Loneliness ■ Sadness ■ Tiredness ■ Stress

Complications ■ ■ ■ ■ ■ ■ ■

Heart disease Hypertension Respiratory disorders Increased blood cholesterol levels Associated with some adult cancers Endocrine diseases such as diabetes mellitus Poor wound healing and longer postoperative recovery periods

Interventions ■ Do not discuss “dieting” with child; instead, emphasize healthy eating and activity lifestyle ■ Intervene via counseling for child and family ■ Make early referrals to clinics with nutritional specialists ■ Increase daily activity ■ Slow, steady weight loss is best achieved through diet modification but requires support and encouragement from family members and change in food at home

Best Prognosis for Weight Loss It is very difficult for a child to lose weight. The most important factor is for the child to change his or her self-image and accept his or her body

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47 while embarking on a new healthy lifestyle. Other factors that contribute to success are: ■ Lean parents ■ Good academic performance ■ Absence of affective or emotional disorders

Ideal Outcomes ■ ■ ■ ■ ■

Absence of emotional reactions No metabolic or endocrine complications Growth needs met No development of eating disorders Slow and steady wt loss while child grows into the new body size (ht and wt)

Arterial Blood Gas and pH Interpretation Tips ■ Look at pH first: ■ If <7.35 consider acidosis ■ If >7.45 consider alkalosis ■ Look at PaCO2 next: ■ If >45 consider respiratory acidosis ■ If <35 consider respiratory alkalosis ■ Look at O2 (Values in mean [mm Hg]): ■ 60 for newborn ■ 90 for infant ■ 96 for child ■ Look at HCO3 ■ If <22 consider metabolic acidosis ■ If >26 consider metabolic alkalosis

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Quick Reference: Metabolic and Respiratory Acidosis and Alkalosis Disorder Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

pH Low High Low High

Abnormality Increased PCO2 level Decreased PCO2 level Decreased HCO3 level Increased HCO3 level

Compensation Increased HCO3 level Decreased HCO3 level Decreased Pco2 level Increased Pco2 level

Example Airway obstruction Hyperventilation Diabetic ketoacidosis Pyloric Stenosis

Laboratory Values Hematology Laboratory Test Hemoglobin

Hematocrit

Platelets White blood cells

Age Newborn 2–8 weeks 3–5 months 1–2 years 5 years 10 years 15 years Newborn 3 months 3 years 10 years Newborn Child Newborn 3 months 3 years 10 years 15 years

Normal Range 15.5–24.5 g/dL 10.7–17.3 g/dL 9.9–15.5 g/dL 9.0–14.6 g/dL 9.4–15.5 g/dL 10.7–15.5 g/dL 13.4 g/dL 42%–68% 29%–54% 31%–44% 34%–45% 84,000–478,000 150,000–450,000 9000–30,000 5700–18,000 6000–17,500 4500–13,500 4500–11,000 Continued

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49 Hematology—cont’d Laboratory Test Glucose

Age Newborn <24 hours Newborn >24 hours 1 year 5 years 10 years 15 years

Normal Range 40–60 mg/dL 50–80 mg/dL 60–100 mg/dL 60–100 mg/dL 60–100 mg/dL 70–105 mg/dL

Liver Panels Laboratory Test Albumin Direct bilirubin Total bilirubin

Cholesterol

Ammonia

Age

Newborn 2 days 5 days 1 month 1–4 years 5–14 years 15–20 years Newborn Child

Metabolic Panels Electrolytes Potassium: 3.5–5 mEq/L Sodium: 135–145 mEq/L Calcium: 8.5–10.5 mg/dL Bicarbonate: 24–28 mEq/L Phosphorus: 2.8–4.5 mg/dL Chloride: 98–108 mEq/L Magnesium: 1.5–2.5 mEq/L

ASSESS

Normal Range 3.8–5.5 g/dL 0.1–0.4 mg/dL 2–6 mg/dL 6–7 mg/dL 4–12 mg/dL 0.3–1.2 mg/dL 210 mg/dL or less 220 mg/dL or less 235 mg/dL or less 64–107 mg/dL 29–70 mg/dL

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Laboratory Values: Serum Levels of Pharmaceuticals Following are serum levels at which effectiveness is attained:

Aminoglycosides ■ ■ ■ ■ ■ ■ ■ ■

Gentamycin peak: 6–10 mcg/cc Gentamycin trough: <2 mcg/cc Vancomycin peak: 30–40 mcg/cc Vancomycin trough: <7.5 mcg/cc Tobramycin peak: 8–10 mcg/cc Tobramycin trough: <2 mcg/cc Amikacin peak: 20–30 mcg/cc Amikacin trough: <10 mcg/cc

Electrolytes ■ Calcium, ionized: 1.18–1.32 mmol/L

Cardiac Meds ■ Digoxin: 0.8–2.0 ng/cc ■ Lidocaine: 2–6 mcg/cc

Immunosuppressant ■ Cyclosporine trough: 250–800 ng/cc

Antiseizure Meds ■ ■ ■ ■ ■

Phenytoin, total: 10–20 mcg/cc Phenobarbital: 10–20 mcg/cc Valproic acid: 50–150 mcg/cc Clonazepam: 15–20 mcg/cc Carbamazepine: 4–12 mg/L

Antibronchospasm Meds ■ Theophylline: 7–15 mcg/cc

Chemotherapeutics ■ Methotrexate 48–72 hours after chemo, level should return below 10 to the negative 7th, or 10 to the negative 8th (follow chemotherapy protocols carefully)

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51 Blood Thinners ■ Warfarin: Monitor INR at 2–3.5 depending on indication for use

Laboratory values vary across medical/health-care institutions; therefore, always check with a pharmacist and laboratory specialist for specific serum therapeutic drug levels for your institution!!

Specimen Collection Blood ■ Use microcontainers for infants and young children to prevent significant blood loss with repeated specimens ■ Use heel sticks for infants; use commercially made heel warmers to induce vasodilatation

Urine ■ Place cotton balls in diaper to collect specimen for urinalysis or use commercially prepared uro-bags that adhere to perineum for urine collection (trim to make appropriate size for infant boy’s testicles) ■ Use sterile technique with straight catheters for urine cultures ■ Assist young child with clean catch

Sputum ■ ■ ■ ■

Use clean suction with trap for infant Place specimen in sterile container for laboratory May require deep sterile suction with trap School age children and adolescents can follow instructions for expectoration of sputum

Feces ■ Use diaper specimen or new hat in toilet to obtain specimen ■ Try to separate urine from feces specimen

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Nasal Secretions: ■ Use olive tip at low suction to remove secretions ■ Perform 2–3 second sterile NS nasal wash for RSV specimen

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53 Myths About Pain in Infants and Children Beware the following false statements concerning pain in infants and children: ■ Infants do not feel pain: FALSE! Infants have a definitive presentation of pain symptoms just like older children and adults. ■ Young children cannot describe their pain: FALSE! Children with language skills can tell about their pain. ■ Young children cannot localize their pain: FALSE! Children can accurately place their hand over the place where it hurts. ■ Infants and children do not need pain medication: FALSE! Children need pain medications just like adults. ■ Children become easily addicted to pain medication: FALSE! Children who take narcotics when in pain do not become addicted. ■ Assessment of a child’s pain is difficult: FALSE! Use age-appropriate objective and subjective pain tools to accurately measure pain—see “Assessment.” ■ Children always tell the truth about their pain: FALSE! Children may lie about their level of pain to avoid injections or oral medication. ■ Children’s vital signs do not demonstrate pain: FALSE! Pulse rate, respiratory rate, and blood pressure may increase, and oxygen saturation may decrease. ■ Children should never be given narcotics: FALSE! Narcotics such as morphine are important treatments for severe pain during childhood. ■ Newborns do not experience pain: FALSE! Even fetuses in the womb react to painful stimuli. ■ Children experience more severe side effects of narcotics than adults: FALSE! Children experience side effects similar to those of adults. ■ If a child is playing, he or she is not in pain: FALSE! Children play even when in severe pain.

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PAIN

Consequences of Untreated Pain in Infants Immediate Responses ■ ■ ■ ■ ■ ■ ■

Decreased oxygen saturations Increased HR Increased BP HR variability Decreases in peripheral skin blood flow Increased caloric consumption: Prolonged hyperglycemia to hypoglycemia Mistrust in environment

Long-Term Consequences ■ Poor motor performance ■ Poor adaptive behavior, learning disorders, cognitive defects ■ Temperament changes and psychosocial problems

Pain Control Tips Plan ahead and intervene before pain starts: ■ Offer sucrose-dipped nipple to infants before procedures ■ Use nonpharmacological pain management techniques as well as pharmacological pain control measures ■ Distraction ■ Relaxation ■ Deep breathing ■ Guided imagery ■ Heat or cold to site ■ Positions of comfort ■ Most favorite blanket, stuffed animal, toy, or personal possession (ask child and parent for ideas) ■ Warm blankets wrapped around child ■ Being held or rocked in a rocking chair ■ Lowered noise environment ■ Reduced lighting ■ Use topical cream anesthetics such as EMLA before starting IVs or giving injections (not on young infants)

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55 ■ Believe children about their pain: It is a symptom that occurs whenever a child says it does. Take all reports of pain seriously and intervene appropriately ■ Pain thresholds vary; expect variations in children of similar ages, developmental stages, diagnoses, and surgical procedures ■ Inquire about previous pain experiences and ways of coping that were successful ■ Involve parents and caregivers in pain assessment and interventions ■ Fatigue can increase a child’s sensitivity to pain, as well as anxiety and fear ■ Use a variety of words to describe pain; take into account the child’s developmental level (ouch, ouchie, booboo, owie, hurtie) and the words the family uses. Ask the parents what words they use; write the words on a card and keep at the bedside; document for interdisciplinary team ■ Use a team approach for pain control: Involve child life specialists ■ Assess effectiveness of pain interventions within 1 hr; document findings ■ Pain is reported by parents as being the most feared experience for their child ■ Provide ongoing education and support for parents or guardians ■ Explain to parents that addiction is a rare phenomenon ■ Understand the side effects of narcotic administration including GI distress, constipation, and sedation. Education parents on what to expect

Principles ■ Children continue to be undermedicated for pain ■ Pain should be assessed on a frequent basis ■ Culture has an influence on the pain experience: Culture may effect a child’s expression of pain, verbalization of the experience and/or the meaning given to the pain experience ■ Children have painful experiences in the hospital on a regular basis ■ Child life departments and play therapist should be involved with all painful procedures ■ An accurate weight is the key to safety in calculating pain medication doses ■ Always medicate a child for pain before the pain experience becomes intense

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Pain Management: Key Points ■ ■ ■ ■

Evaluate pain and discomfort regularly and frequently Try to prevent pain, not treat it after it occurs Believe the child’s reports of pain Use pain scales that are developmentally appropriate; use behavioral indexes ■ Use the QUESTT protocol (Baker & Wong, 1987): ■ Question the child about his/her pain ■ Use appropriate pain tools ■ Evaluate the pain experience: Identify physiological and behavioral changes ■ Secure the parents’ or caregivers’ involvement ■ Take all influencing factors into account ■ Take action, report, reevaluate Pain is not the only symptom of concern for children of all ages. Consistently perform a complete symptom assessment, including the management and evaluation of interventions for all symptoms experienced in childhood. Use creative measures to assess, intervene, and document all of the following symptom experiences associated with illness, hospitalization, and chronic disease.. Differentiate between clinical signs (vomiting, retching, increased RR) and symptoms. Symptoms may be unique for each child as each child is unique in his or her symptoms experience. All of the following symptoms should be assessed:

Universal Human Symptom Experiences ■ ■ ■ ■ ■ ■

Discomfort Nausea Fatigue Emotional distress Sleep deprivation Dyspnea

Assessment Neonates ■ Rigidity, thrashing, generalized body response ■ Use CRIES assessment tool

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57 Infants ■ Local reflex withdrawal, high-pitched loud crying with eyes closed, pushes stimulus away after it is applied, localized body response ■ Use CRIES or FLACC assessment tools

Toddlers ■ Loud crying, screaming, verbal expressions of one word, uncooperative, pushes stimulus away before applied, thrashing ■ Use CRIES or FLACC assessment tools

Preschoolers ■ Loud crying, screaming, may put hand on site or misrepresent actual location of pain, may describe pain but not intensity ■ Use CRIES, FLACC or Wong-Baker Faces scale

School Age ■ Often see stalling behaviors, clenches teeth, body stiffens, closed eyes ■ Use FLACC or Wong-Baker Faces scale for younger school age child ■ Use Wong-Baker Faces Scale or numerical scale for older school age

Adolescents ■ May talk about pain openly, less protesting, uses expressive words to describe pain experience ■ Use numerical scale, Wong/Baker Faces, or adolescent-specific tools

Pharmaceutical Interventions for Pain General Procedures ■ Consult current drug guide for correct doses; follow institutional policy ■ Follow safety procedures for narcotics ■ Double-check infant doses with second RN

Doses of Specific Drugs ■ Acetaminophen: 10–20 mg/kg PO, every 4–6 hr (do not exceed five doses in 24 hr) ■ Ibuprofen: 5–10 mg/kg, every 4–6 hr

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PAIN ■ ■ ■ ■ ■ ■ ■

Morphine: 0.1–0.2 mg/kg IV every 2–4 hr Codeine: 0.5–1 mg/kg PO, every 4–6 hr Oxycodone: 20–30 mg PO, every 3–4 hr Hydrocodone: 30 mg PO, every 3–4 hr Tylenol with codeine: follow institutional policy Meperidine: 1–2 mg/kg IM every 4–6 hr Methadone: 0.1–0.2 mg/kg PO as ordered

Topical Local Anesthetics ■ Should be used during invasive procedures such as IM injections and IV starts. EMLA and NUMBY STUFF are two examples ■ Do not use on young infants ■ Secure a physician’s order ■ Apply creams according to manufacturer’s directions and allow ample time to work ■ Cover cream with a clear dressing

Evaluation: Pain Assessment Tools Wong-Baker Faces Scale ■ Used for children as young as 3 years old ■ Six cartoon faces ranging from smiling (0) to tearful face (5) ■ Tell child the faces represent a person with no pain to a person with the worst pain they can imagine. Ask child to select the face that represents their own pain. Point to each face and describe the words with each face ■ This scale provides three scales: Expressions, words and numerical values ■ 0 to 10 numbers can replace the 0–5 numbers if desired

Use this script for the child after you point to each face using the words to describe the pain intensity. Ask the child to choose the face that best describes his or her own pain and record the appropriate number. Each face is for a person who feels happy because he has no pain or hurt or sad because he has some or a lot of pain. Face 0 is very happy because he does not hurt at all. Face 1 hurts just a little bit. Face 2 hurts a little more. Face 3 hurts even more. Face 4 hurts a whole lot. Face 5 hurts as much as you can imagine, although you don’t have to be crying

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59 to feel this bad. Ask the child which face best describes how he or she is feeling.

Source: From Hockenberry MJ, Wilson D, and Winkelstein ML: Wong’s essentials of pediatric nursing, ed. 7. St. Louis: Mosby, 2005, p. 1259. Used with permission. Copyright, Mosby.

Cries ■ ■ ■ ■

Best used with infants who are 32 to 60 weeks gestational age Used for infants who are preverbal Used for neonatal postoperative pain Assess crying, requirement of oxygen, increased HR and BP, facial expressions, and sleepless state ■ A score of 4 or higher indicates need for pain management ■ 0 = no pain, 10 = worst pain ■ Based on assessment of five presentations with a scoring of 0 to 2: ■ Crying ■ Requiring oxygenation ■ Increased VS such as HR, BP ■ Expressions of grimacing and grunting ■ Sleeplessness: Waking at frequent intervals or constantly awake Source: Krechel, S. W., & Bildner, J. (1995). CRIES: a new neonatal postoperative pain measurement score: initial testing of validity and reliability, Pediatric Anaesthia, 5, 53-61.

FLACC ■ Can be used on ages between 2 months and 7 years old ■ Based on the assessment of on child’s: ■ Facial expressions such as grimacing, frowning ■ Legs: Relaxed to tense, restless, or kicking ■ Activity: Quiet to arched, rigid, or jerking ■ Cry: None to crying steadily, sobbing ■ Consolability: Content to difficult to console

Scale is scored between 0 and 2 in each of the five categories for a total score between 0 and 10. Source: Merkel, S., Voepel-Lewis, T., Shayevitz, J., & Malviya, S. (1997).The FLACC: A behavioral scale for scoring postoperative pain in young children. Pediatric Nurse 23(3), 293-297. Available at www.childcancerpain.org/content.cfm?content=assess08

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PAIN Numerical Scale (0–5) or (1–10): ■ Use only when child is old enough and developmentally ready enough to conceptualize numerical values and distance between digits. Children as young as 5 years maybe able to conceptualize these numbers and their values ■ Explain to child and family that one side of the scale (0) represents the absence of pain and the other side of the scale (10) represents the child’s perception of the worst pain he or she could imagine No pain

0

Mild pain

1

2

Moderate pain

3

4

5

Severe pain

6

7

8

Worst pain

9

10

Oucher Tool ■ Series of photographs used to evaluate pain, scored on 0–10 scale ■ Can be used for children as young as 3 years old ■ Pictures include Caucasian, African American, Hispanic, and Asian children

Photographed children’s faces delineate no pain at all (smiles) to worst pain experience (sobbing)

Visual Analog Scale A straight line or a numbered line used to describe no pain to the worst pain the child can imagine. The child draws a perpendicular line across a line exactly 100 mm in length with the left side representing zero and the right side of the line representing 100, or worst pain child can imagine.

Adolescent Pediatric Pain Tools Tools are available online to download for use with adolescents that cover numerical values and a variety of categories of descriptive words and temporal measurements. Teens also have options to use color markers to describe their pain or shades of pencil markings to denote severity of their pain experience. (See Tab 14: Resources for Web sites.)

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61 Approximate Normal Weight per Age Always have an accurate weight upon admission for each hospitalization or clinic visit. Estimated body weight in a child aged 1 to 10 years: Weight (kg) = (Age in years +4) times 2. Age Newborn 6 months 1 year 2–3 years 4–5 years 6–8 years 8–10 years 10–14 years 14+ years

Weight (in kg) 5 7 10 12–14 16–18 20–25 26–32 32–50 50

Assessment of Nutritional Status ■ Conduct oral intake history over 3–5 days using food diary ■ Have registered dietitian assess diary ■ Observe child for gross changes in body composition including edema, inadequate or excess adipose tissue, dehydration, increased or decreased muscle mass ■ Assess height, weight, and body mass index ■ Assess midarm circumference (head circumference if child is less than 2 yr old) ■ Assess laboratory results as indicated, including albumin ■ Plot all data on NIH growth charts (www.cdc.gov/growthcharts)

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Body System Assessment General Growth ■ Plot height, weight, head circumference (under 5th or over 95th percentile?) ■ Sexual development appropriate for age

Deviations from normal: Consider protein and vitamin deficiencies

Skin ■ ■ ■ ■ ■ ■

Dryness Elasticity Rashes Hyperpigmentation Edema Poor turgor

Deviations from normal: Consider deficiencies of essential and unsaturated fatty acids, vitamin B12, folic acid, niacin, water and sodium, iron

Hair ■ Shiny, firm ■ Presence or absence

Deviations from normal: If hair is brittle, thin, scarce, dull, or dry, consider protein and calorie deficiency

Eyes ■ Clear, shiny, bright, without infection, weeping, or redness

Deviations from normal: Biot’s spots (gray spots on cornea), dull, symptoms of infection, vitamin A deficiency

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63 Teeth and Gums ■ Firm gums, teeth healthy, white, smooth

Deviations from normal: Poor and defective enamel, brown spots on teeth, bleeding gums

Musculoskeletal ■ Muscles firm, well developed, pain free, flexible joints, symmetrical

Deviations from normal: Muscular atrophy, dependent edema, pain, fatigued, bowleg, knock-knee, vitamin D or C deficiency, protein and calorie deficiencies

Neurological ■ Alert, neurologically intact, expected development and coordination for age

Deviations from normal: Listless, tetany, diminished reflexes, irritable, lethargy; and thiamine, niacin, iron, protein, and calorie deficiencies

Cardiovascular ■ HR, pulses, BP all within normal limits

Deviations from normal: Palpitations, arrhythmias, rapid HR

Average Daily Calorie Requirement Across Childhood ■ ■ ■ ■

0–30 days: 100–110 kcal/kg/day 1–4 months: 90–100 kcal/kg/day 5 months–5 years: 70–90 kcal/kg/day >5 years: 1500 kcal for first 20 kg + 25 kcal for each additional kg/day

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Number and Volume of Infant Feeds ■ Breast Feeding: 8–12 feedings/24 hours during first 6 months ■ Formula Feeding ■ 6–8 feedings of 3–4 oz each/24 hours of commercially prepared iron-fortified formula during first 6 months (unless otherwise indicated) ■ 5 feedings/24 hours after solid food is introduced at 6 months ■ Weaning ■ Should be gradual, based on infant’s desire ■ Usually occurs 8–12 months of age ■ Highly individualized for each family and influenced by cultural practices and norms ■ World Heath Organiztion (WHO) encourages breastfeeding longer than 1 year

Laboratory Studies Associated with Poor Nutritional Status ■ ■ ■ ■ ■ ■

Low albumin status Calcium deficiencies Electrolyte imbalances Acid-base status complexities Iron and ferritin abnormalities Hemoglobin and hematocrit abnormalities

Breastfeeding ■ The American Academy of Pediatrics (AAP) recommends breastfeeding (BF) for all infants ■ Many mothers need instruction and support: Provide lactation education regardless of previous births ■ WHO recommends human milk as exclusive food for full-term infants until 6 months

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65 ■ ■ ■ ■

Short hospitalization may have negative influence on BF In 2001, 69.5% of all mothers initiated BF; 32.5% continued to 6 months Healthy People 2010 goal is 75% initiation of BF rate BF should last for at least 12 months and should continue as long as mutually desired

Benefits For infants: ■ Faster gastric emptying ■ Provides host defense immunity factors IgA, growth factors, cytokines, lactoferrin, lysozymes, and nucleotides ■ Reduces incidence of otitis media, GI diseases, respiratory diseases, atopic conditions ■ Protects preterm infants from from necrotizing enterocolitis ■ Improves long-term cognitive and motor abilities

For mothers: ■ Allows more rapid postpartum weight loss and uterine involution. ■ Provides contraceptive effects that contribute to child-spacing (Unreliable) ■ Provides economic advantages and cost savings in comparison to formula

General Recommendations ■ Provide 8 to 12 feedings/day in first few weeks ■ Prevent maternal fatigue and anxiety, which may affect milk production ■ Count number of wet diapers and stools; assess color of stools to determine if BF is adequate ■ No supplemental water, glucose water, or formula should be given unless medically indicated ■ Administer vitamin K supplement at birth to prevent rickets ■ Breast milk storage: ■ In the refrigerator for up to 48 hr ■ In the freezer for 3–6 months ■ Call for consultation by lactation educator or consultant prn

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Breastfeeding Positions

Developmental Eating Habits and Practices Infants ■ ■ ■ ■

Breastfeeding or formula for at least 6 months Solids introduced after 6 months Introduction of solids culturally influenced Start with vegetables, then fruits, then meats ■ Deviations: Introducing new foods can lead to colic, allergies, rashes, milk anemia

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67 Toddlers ■ Erratic appetite, smaller appetite than infant ■ May have definite dislikes ■ May experience “food jags”: Eating just one food for several days ■ Deviations: Too many snacks and foods on the go; mealtimes may become a battle, parent may express concerns over diminished appetite ■ Family Education Tips: Toddlers and preschoolers often pose extra challenges to parents about eating: • Allow choices if possible • Set limits but do not use mealtime for a punishment • Do not allow toddler to eat and run/walk • Avoid hot dogs, hard foods like carrots or sugar candies

School Age ■ Plain foods preferred ■ Advertisements and peers influence food selections and desires ■ Enjoy learning about food labels, vitamins, minerals, proteins and calories/fat in foods ■ Include children in food selections and let them make their own nutritious lunch ■ Deviations: Obesity risk, eating in front of TV, eating alone, consumption of empty calories, sports and afterschool programs compete with proper mealtimes

Adolescents ■ ■ ■ ■

Calorie consciousness, leading to skipping meals and dieting Fast-food cravings Need to understand limiting high-sugar, fructose beverages Should be discouraged from consuming coffee or caffeinated drinks ■ Deviations: Development of eating disorders, obsessions, alcohol consumption

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Eating Disorders Anorexia Definition: Restriction of food or caloric intake ■ May include the denial of existence of hunger ■ Considered to be a self-inflicted condition resulting from severe distorted body image ■ May be a relentless pursuit of thinness ■ Child may demonstrate marked preoccupation with food ■ Associated with child abuse, traumatic emotional events, teasing, dysfunctional family dynamics ■ Parents may be controlling, rigid, lacking in problem-solving skills ■ Leads to emaciation ■ Mean age of onset: 13 years ■ Less than 10% of patients are males ■ Predominately affects white females in upper-class families ■ May be associated with depression, introversion, and addiction in families ■ Female patients are often high achievers and model students

Clinical Manifestations ■ ■ ■ ■

Skeletal-like appearance secondary to severe weight loss Bradycardia, decreased BP and temperature Brittle hair, dry skin, hair loss Amenorrhea

Treatment ■ Reversal of severe malnutrition ■ Individual and family counseling ■ May require hospitalizations

Prognosis ■ Less than 25% achieve full recovery ■ 50% will demonstrate improvement

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69 Bulimia Definition: The experience of repeated binge eating followed by purging ■ Use of vomiting, laxatives, diuretics, fasting, or high levels of exercise to eliminate food or water weight ■ Secretive behaviors: High caloric intake followed by weight loss measures ■ Patient acknowledges that behavior is self-destructive and abnormal ■ Associated depression may be present ■ Usually associated with older teen and young female adults ■ Crosses all socioeconomic levels, uncommon in males ■ Destructive cycle of behavior increases with time and may develop into obsessive-compulsive behavior ■ Patient may consume enormous amounts of high-calorie foods

Clinical Manifestations ■ Loss of impulse control ■ Lack of satiety regulation with increased insulin production during episodes of binge eating and vomiting leads to further hunger sensations

Treatment ■ May require hospitalization to intervene with cycles ■ Integration of counseling, family therapy ■ Antidepressants have been shown to reduce obsessive-compulsive behaviors

Fluids Fluid Maintenance Calculation Fluid calculation based on weight of child in kilograms: ■ 0-10 kg: 100 cc/kg/24 hours ■ 11-20 kg: 1000 cc plus 50 cc/kg/24 hours for each kg between 11–20 ■ 21-70 kg: 1500 cc plus 20 cc/kg/24 hours for each kg between 21–70

Example: A 15-month-old child weighing 32 pounds (14.6 kg) needs 1000 cc plus (50 cc × 4.6 = 230 cc) or 1230 cc per 24 hours. At an hourly rate, this is 51.25 cc per hour.

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Dehydration Definition: Body fluid imbalance, loss of significant amount of body fluid

Pathophysiology ■ Associated with vomiting, diarrhea, GI suction, fevers, diabetes insipidus (DI), overuse of diuretics, tube feeding without free water, excessive sweating, and decreased intake

Types of Dehydration ■ Isonatremic dehydration ■ Na = 130–150 mEq/L ■ Cause: Equal loss of sodium and body water ■ Hyponatremic dehydration ■ Na <130 mEq/L ■ Cause: Loss of sodium in excess of water ■ Hypertonic dehydration ■ Na >150 mEq/L ■ Cause: Loss of water in excess of sodium

Assessment Assess all of the following: ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Mucous membranes Skin turgor % weight loss Urinary output (UOP) Pulses Blood pressure Jugular vein distention (JVD) Weight Hemodynamics Laboratory values Neurological status Thirst

Degrees of Dehydration ■ Mild: Less than 5% total body weight loss (equals 50 cc/kg loss) ■ Moderate: 10% total body weight loss (equals 100 cc/kg loss) ■ Severe: 10%–15% total body weight loss (equals 150 cc/kg loss)

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71 Fluid Resuscitation ■ If child was previously healthy, give 20 cc/kg boluses of isotonic crystalloid solution (NS or LR). Administer rapidly ■ Assess UOP, VS, LOC, and peripheral perfusion ■ Repeat bolus as needed ■ With septic shock, inotropic support may be necessary if more than 60 mL/kg is needed

Oral Rehydration Therapy (ORT) ■ 1–2 ounces of electrolyte solution every 1 hour ■ Do not use juices or soda

Fluid Resuscitation for Burn Patients ■ Start IV for burns greater than 10% ■ Begin with 20 cc/kg of normal saline (NS) or lactated Ringer’s (LR) over 20–30 minutes

Subsequent Fluids Parkland Formula 1st 24 hours post burn 4 cc/kg/% burn crystalloid No colloid No dextrose in water 2nd 24 hours post burn 50%–75% of 1st day requirement of fluids Maintain albumin >2g/dL

Brooke Formula 1st 24 hours post burn 1.5 cc/kg/% burn crystalloid 0.5 cc/kg/% burn colloid 2000 cc dextrose in water 2nd 24 hours post burn 0.75–1.125 cc/kg/% burn crystalloid 0.25–0.375 cc/kg/% burn colloid 2000 cc dextrose and water

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NUTRI ■ First half of fluids are administered within first 8 hours, the second half over next 16 hours ■ Maintain urine output > 1 cc/kg throughout the post burn treatment period

IV Solutions and Indications Isotonic Isotonic fluids have no effect on cells as they expand intravascular compartment only. ■ Normal saline: Increases plasma volume ■ Lactated Ringer’s: Neutralizes metabolic acidosis and replaces body fluid ■ Ringer’s: Increases plasma volume but can cause fluid retention and fluid overload due to Na content

Hypotonic Hypotonic fluids increase cell size, decrease extracellular fluid (ECF) volume, and hydrate intracellular space. ■ ■ ■ ■

⁄2 NS: Raises total body fluid volume ⁄4 NS: Dilutes ECF 2.5% dextrose D5W 1 1

Hypertonic Hypertonic fluids increase extracellular fluid volume, decrease cell size, and dehydrate intracellular and interstitial compartments. ■ 1⁄2 NS ■ D5NS ■ D5LR

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73 Major Electrolytes Electrolyte Sodium

Normal Values 135–145 mEq/L

Potassium

3.5–5 mEq/L

Calcium

8.5–10.5 mg/dL

Bicarbonate Magnesium

24–28 mEq/L 1.5–2.5 mEq/L

Phosphorus

2.8–4.5 mg/dL

Chloride

98–108 mEq/L

Functions • Maintains active transport mechanism with potassium • Controls body fluids via retention or movement of water • Helps to create energy by aiding enzymatic activities • Promotes nerve transmission • Activates enzymatic reactions • Regulates acid-base balance • Supports cardiac conduction • Maintains intracellular osmolality • Supports cardiac contraction and conduction • Maintains cellular permeability • Necessary for bone health • Buffers acidity • Facilitates transmission of neuromuscular activity • Maintains cellular active transport systems • Maintains acid-base balance • Promotes health of red blood cells • Required for bone and teeth health; deposited with calcium • Maintains acid-base balance • Required for acidity levels of gastric fluids

Total Parenteral Nutrition (TPN) ■ TPN: Intravenous nutritional support for children who cannot consume nutrition orally or enterally ■ Peripheral TPN: • Solutions with osmolarity of <900 mOsm/L

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NUTRI • Should be limited to time period of infusion of less than 14 days to prevent venous damage, irritation • Used more for nutritional supplement rather than nutritional alternative ■ Central TPN: • High concentration of dextrose (15%–20%) • Used with central line • Use of tunneled central catheter may allow for indefinite duration ■ Lipids: Source of essential fat/lipids

Indications ■ ■ ■ ■ ■ ■ ■ ■

Malnourishment Inability to absorb nutrients Long periods of NPO status Inflammatory bowel diseases Severe catabolic state Acute pancreatitis Bowel rest after major surgeries Nutritional support for AIDS, cancer, and other chronic disease

Potential Complications ■ ■ ■ ■

Sepsis Instability of blood glucose levels: Hyper- and hypoglycemia Electrolyte imbalances Hypertriglyceridedemia, trace element deficiency

Nursing Administration Tips ■ TPN: ■ Never leave bottle hanging longer than 24 hours; change tubing q 24 hours ■ Do not use line to draw blood unless essential. If the line is needed to draw lab specimens flush well with sterile normal saline, follow protocol. Failure to flush well may cause false readings of electrolyte levels ■ Observe patient for signs of hyperglycemia; if TPN line is disrupted, hang D10 to avoid fluctuations in blood glucose levels

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75 ■

Follow institutional protocols and orders for blood glucose finger stick assessments; report blood glucose levels >200 ■ Weigh patient daily, using same scale ■ Check vital signs, monitor for signs of sepsis ■ Double-check content of each new bag against order with second RN ■ Always double-check medication compatibility before administration; flush well with 20 cc NS (or follow institutional policy based on child’s wt and age) before and after administering medication. When in doubt, call the pharmacy ■ Always use aseptic technique when handling bag, tubing, and central line ■ Check for precipitates: Call pharmacy and return bag if precipitates are present ■ Lipids: ■ Do not hang above TPN filter ■ Monitor patient for nausea ■ Assess solution for discolorations or impurities ■ Handle solution carefully (dispensed in glass bottles) ■ Open air vent on bottle to allow solution to flow through IV tubing

Assessments Associated with TPN ■ Blood glucose checks per institutional policy ■ Assess for hyperglycemia: ■ Thirst ■ Flushed appearance ■ Nausea ■ Check VS at specific time periods to assess for infection ■ Measure weight daily, using same scale ■ Assess for fluid overload: ■ Adventitious lung sounds ■ Edemas and Specialty Diets

NUTRI

Formula Similac Special Care

24

20

Kilocalories per Ounce

Low birth wt

Indication Low birth wt

Special Considerations E: PUFA ratio Concentrated Calcium and phosphate Hypercaloric E: PUFA ratio Concentrated Calcium and phosphate Promotes growth in height and weight DHA, ARA, Iron Whey protein, iron MCT, nutrient rich Iron, 100% veg oil Whey protein, iron Casein/whey ratio is 60:40, minerals Nonmilk based Soy protein isolate 100% free amino acid Lactose-free 100% L-amino acids

Infant Formulas and Specialty Diets

Similac Special Care

Low birth wt

Full term Full term Hypocalcemic

24

20/24 20 20

Protein allergy

Sim Human Milk Fortifier

Enfamil with Iron Similac Advance Similac PM 60/40

20

Hypoallergenic

Prematurity Prematurity

Isomil Advance

30

Malabsorption

22 22

Neocate One Plus

24

NeoSure Advance Enfacare

Vivonex Pedi

Continued

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Alimentum

Neocate

20 20 30

20

20

30

Food allergies Malabsorption Fat malabsorption

Food allergies

Hypoallergenic

Indication Hypoallergenic

Kilocalories per Ounce

Nutramigen Pregestimil Portagen

30 30 2 Kcal/cc

Formula

PediaSure with fiber PediaSure without fiber Polycose liquid

3.8 Kcal/g

Elecare

Polycose powder

7.7 Kcal/cc 28 Kcal/scoop

Nutrient dense Nutrient dense Carbohydrate supplement Carbohydrate supplement Extra fat needs Protein supplement

MCT oil ProMod

Special Considerations 100% free amino acid Iron 100% free amino acid Iron Lactose-free, iron Protein hydrolysate No considerations No considerations Iron, Lactose-free 87% Met oil 0.5 g/dL soy fiber Complete balanced Carbohydrate balanced

Carbohydrate balanced

Fat supplement, MCT Protein rich

NUTRI

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TRANS

Blood Products ■ Packed RBCs: (approx. 225–350 cc with Hct of 55%–65%, must be ABO and Rh[D] compatible). Transfused to increase circulation of RBCs after blood loss, severe anemia, or hemoglobinopathies ■ Whole blood: Used primarily during emergencies. High risk of transfusion reactions ■ Platelets: Transfused for severe microvascular bleeding, DIC, severe depletion, or massive dilutional loss from massive transfusion of blood. Also transfused for conditions of severe platelet destruction such as ITP, lupus, drug reactions, or viral infections ■ Granulocytes: Used for last efforts in severely immunocompromised patients with antibiotic-resistant infections. Associated with severe reactions and clinical complications ■ Plasma (FFP): Used to prolong clotting times and in patients with abnormal coagulation or microvascular bleeding ■ Immunoglobulins: Transfused for children experiencing postviral syndromes such as ITP ■ Cryoprecipitate: Used to increase fibrinogen levels: Rich in factor VIII, von Willebrand’s factor, and fibrinogen

Normal Blood Volume, by Age Group ■ Premies: 100 cc/kg ■ Infants: 80 cc/kg ■ Children: 70 cc/kg

Calculations to Determine Amount of Blood for Transfusion 10–15 cc per kg OR (Weight in kg x 3) X desired rise in Hb level in g/dL

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79 Transfusion Compatibility ■ All blood must be crossmatched before transfusion ■ Only during emergencies can this step be eliminated and Type O Rh-negative blood be used Blood Type O A B AB

■ ■ ■ ■ ■

Whole O A or O B or O Any

Platelets O A or O B or O Any

FFP Any A or AB B or AB AB

Albumin Any Any Any Any

Cryo O A A A

Whole blood: Required Platelets: Not required unless patient is Rh neg FFP: Preferred, especially with Rh neg patients Human albumin: Not applicable Cryoprecipitate: Preferred, especially with Rh neg patients

Nursing Responsibilities During Transfusions ■ ■ ■ ■

Assess baseline vital signs and report clinically significant findings Assess if child has received previous transfusion therapy Verify order and presence of blood transfusion consent Administer premedications if ordered: ■ Antipyretics ■ Antihistamines ■ Corticosteroids ■ Double-check order for special need: ■ Phenotypically matched ■ Leukocyte depleted ■ Washed ■ CMV negative ■ Irradiated ■ Set up administration set using only blood tubing and Y-ed with normal saline

TRANS

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TRANS ■ Start administering the blood product within 30 minutes of its arrival from blood bank. If administration is delayed (due to infiltration or inadequate IV site), deliver the product back to blood bank for storage ■ Do not place any blood product in any type of refrigerator on nursing unit! ■ Administer blood product over specific time as ordered ■ Start transfusion slowly (no more than 50 cc over first 15 minutes) and stay with child to assess for transfusion reactions ■ Monitor vital signs at regular intervals per institutional policy. Minimum standards are: ■ Immediately before transfusion (identify a new fever or change in VS) ■ 15 minutes after initiation ■ At completion of administration ■ Ensure that the product is administered within expected time frame: ■ PRBCs: Do not leave hanging at the bedside for more than 4 hours, and administration time should not be more than 4 hours: Institutions may vary on this so check policy or call your blood bank directly ■ Platelets: As ordered, over 1 hour, at 10 cc/kg/hr IV push, or as fast as tolerated ■ Check post-transfusion Hgb 2–4 hours after completion

Documentation of Transfusion Therapy Documentation should include: ■ Signatures of two nurses who checked the blood against the patient’s name, medical record number, and date of birth at the bedside ■ Pretransfusion laboratory specimens, including cross matching ■ Pretransfusion premedications: ■ Drug ■ Dose ■ Time ■ Route ■ Pretransfusion clinical status: ■ Lung sounds ■ Vital signs ■ Symptoms ■ General status

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81 ■ Type of product and product number ■ Use of filters, blood warmer, or any other supplies or pumps ■ Time blood was hung, time transfusion was started, and length of transfusion ■ Any change in VS (follow institutional policy on frequency of VS) ■ Fluid status changes ■ Report any change of clinical status to primary caregiver/physician

Medications Used for Transfusion Reactions ■ ■ ■ ■ ■ ■

Acetaminophen: To reverse temperatures Diphenhydramine: To treat rash and pruritus Steroids: To treat fever, shaking, chills, pallor, diaphoresis Narcotics: To treat rigors Fluid: Boluses of 20 cc/kg for hypotension, repeat as needed/indicated Epinephrine: To treat shock, bronchospasm, hypotension

Use of Filters ■ ■ ■ ■ ■ ■ ■ ■

Whole blood: Microaggregate filter via an infusion pump Packed red blood cells: Microaggregate filter via infusion pump Platelets: 170-mm microaggregate filter FFP: Microaggregate filter Albumin: None needed Cryoprecipitate: None needed Immunoglobulins: None needed Granulocytes: Use 170-mm microaggregate filter

Use of Blood Warmers ■ Blood warmers may be used if cold blood needs to be administered quickly ■ Never use any other means to warm blood other than an officially approved and standardized blood-warming device

Never warm blood in hot- or warm-water baths. Never microwave blood or blood products.

TRANS

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Half-Life of Blood and Blood Products ■ ■ ■ ■

FFP: 4 days in circulation Platelets: 5 days in circulation Albumin: 19 days (estimated) Whole blood, packed red blood cells: Variable. RBCs live 120 days when produced in body, transfused cells have variable life depending on recipient’s response to transfusion and age of cells. Blood product bag dispensed from the blood bank will state on the label the exact shelf life of the product

Risks of Transfusions Transmission of Infectious Diseases ■ ■ ■ ■ ■ ■ ■

HIV Hepatitis B and C CMV Blood-borne bacterial infections Malaria Syphilis Other viruses

Transfusion Errors ■ Clerical errors, misidentification, and subsequent transfusion administration can cause errors ■ All laboratory specimens must be meticulously labeled and patient identification double-checked ■ Two licensed nurses must double-check blood according to institutional policy prior to administration, including order check and blood type verification

Transfusion Reactions ■ Allergic reactions manifested by urticaria, wheezing, and edema ■ Febrile reactions manifested by chills, diaphoresis, and fever

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83 ■ Acute hemolytic reactions caused by immunological destruction of transfused cells ■ Delayed reactions may occur 2 to 14 days after transfusion ■ Hemolytic reactions from incompatible blood infused ■ Circulatory overload from too rapid infusion or excess quantity ■ Air emboli ■ Hypothermia from rapid infusion of cold blood ■ Electrolyte disturbances (hyperkalemia) ■ Alloimmunization (formation of antibodies against transfused product) ■ Delayed hemolytic reaction ■ Symptoms to monitor: ■ Fever ■ Flushing ■ Urticaria ■ Itching ■ Vomiting ■ Diarrhea ■ Flank pain or severe backache ■ Headache ■ Rigor ■ Circulatory failure ■ Discomfort or pain at infusion site

Prevention of Reactions ■ ■ ■ ■

Use of specific product filters Irradiation of blood products Providing CMV-negative blood Use of single-donor platelet infusions versus pooled product from several donors ■ Use of leukocyte-depleted products to remove reaction causing WBCs (can remove up to 99.9%) ■ Use of washed products to remove WBCs

Steps to Take If Transfusion Reaction Suspected ■ Stop infusion ■ Have child stay in bed

TRANS

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TRANS ■ ■ ■ ■ ■ ■ ■ ■ ■

Take vital signs Inform medical team Do not leave child Start normal saline infusion as close to the port as possible Save all tubing, filters, and remaining blood products to send to the laboratory Anticipate laboratory draw for Coombs’, H&H, and other analyses May require emergency drug administration: Have support and emergency equipment readily available Document entire episode: Frequent VS record, all interventions, laboratory tests drawn, and medications administered Severe reaction may require transfer to intensive care

Renal Failure Associated with Transfusion Therapy If renal failure occurs and acute kidney shutdown ensues from antigenantibody complexes causing renal vasoconstriction, anticipate: ■ Diuresis with IV diuretics ■ Alkalinizing body fluids ■ Rapid IV fluids

Alloimmunization Alloimmunization results from subsequent exposure to antigens in further transfusions. It leads to accelerated removal of transfusion product. Always ask family/caregiver if child has had blood or blood product transfusions in the past. If the answer is yes: ■ Inquire about the need for premedications or special filter systems ■ Anticipate the possibility of transfusion reaction in all children who have had blood transfusions in the past

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85 Safety in Medication Administration ■ Assume a young child will be uncooperative and secure assistance for positioning or use of gentle, appropriate restraining holds ■ Always use needle safety devices to prevent inadvertent needle sticks ■ Never leave medications at bedside or in unlocked drawers in patient rooms; never leave medications on food trays ■ Do not leave small plastic sterile caps from syringes at bedside: They are aspiration risks ■ Always label syringes with medication, dose, route, and time of administration ■ To prevent aspiration or choking, do not give medication to a crying infant or child ■ Always leave multidose bottles in child-proof containers ■ Always double-check safe dose range for child’s weight or body surface area ■ Have two licensed nurses double-check all high-risk medications. ■ High-risk medications include: ■ Controlled substances ■ Procedural sedation meds ■ Digoxin ■ Albumin ■ Heparin ■ IV push medications ■ Chemotherapy ■ Alteplase (tPA) ■ Immunoglobulins ■ RhoGAM ■ Insulins ■ Electrolytes

Check institutional policy for a more extensive list. Post list in medication preparation room for rapid reference.

MEDS

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MEDS

Anaphylactic Reactions ■ If child exhibits an immediate allergic reaction to an administered medication, regardless of route, assess for severe bronchospasm, cardiovascular collapse, and acute respiratory distress ■ Treat anaphylactic reactions with bronchodilators, antihistamines, and epinephrine

Report all suspected allergic reactions (rashes, itching, hives).

Seven Patient Rights of Medication Administration ■ Right drug ■ Right dose ■ Right patient ■ Always use two patient identifiers such as birthday, name, or medical record and confirm correct child/infant with parent ■ Right time of administration ■ Right route ■ Right to refuse ■ Check institutional policy and report refusals of medications or treatments to primary care provider immediately. Typically, minors do not have the right to refuse medications and young children may need to be gently restrained in order to administer. School age children and adolescents should be taught the indication of medications ordered and be encouraged to adhere to the treatment plan ■ Right documentation ■ Determine if patient or family have cultural, ethnic, or religious objections to certain medications ■ Report promptly any delays in treatment, refusals of treatment, or nonadherence to treatment plans

If there is ever a question about adhering to these patient rights, consult with a physician, primary care giver, hospital administrator, or pharmacist.

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87 Medication Administration Tips ■ Never call medicine candy to any age child ■ Compliment the child for cooperating and give positive reinforcement. Avoid giving rewards for compliance, and never threaten the child ■ Only allow choices when they really exist ■ Use distraction, visual imaging, music, or play therapy. Request a play therapist to work with a resistant or refusing child ■ Involve parents or guardians in medication administration from the start. Assess their learning needs and reinforce safety principles with them ■ Mix medications with the smallest amount of additive (flavored syrup) or solution. Do not mix liquid medication in juice ■ Allow young children to self-administer medication if appropriate. Allow older children and teens to choose the time and means of administration whenever possible ■ Discourage stalling. Be kind but firm ■ Try different types of administration devices or means as needed. For example: ■ Medication pacifier ■ Small oral syringes ■ Mixing in small amount of thickened formula ■ Mixing in small about of flavored syrup such as cherry; this is provided by the pharmacy ■ Dividing the dose into smaller increments and administering with a few minutes apart from each dose ■ For school age children and teens, explain what the medication is for and when it should be taken. Involvement and understanding will increase the likelihood that they will adhere to the protocol

Physiological Considerations The following physiological considerations affect absorption, clearance, and effectiveness of medication in children: ■ Blood-brain barrier is immature in young infants. Medications readily pass to brain tissue ■ Young children have a fast metabolic rate, so medications have a rapid onset

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MEDS ■ Medication clearance may be delayed by slow liver processing and slow renal clearance ■ Children produce less gastric acid than adults and have slower gastric emptying times ■ Children absorb transdermal and topical medications quickly due to large body surface area and thin skin layers ■ Children have low blood pressure and, therefore, receive greater blood flow to the brain ■ Children have high total body water content, which dilutes water-soluble medications rapidly

Pharmacological Principles ■ Pharmacokinetics (movement of medicine molecules in the body) ■ Absorption: rate, amount, route ■ Distribution (transport of medicines to site of action by body fluids): circulation, barriers, plasma protein binding (medications compete for protein binding sites as one medication displaces another) ■ Metabolism (mainly in the liver)

Factors Influencing Metabolic Rate in Children ■ Nutritional status ■ Age: Infants have limited ability to metabolize medication ■ Excretory status: Kidney dysfunction may increase concentration of the blood in circulation and prolong action of medications

Therapeutic Index The therapeutic index is the ratio of the amount of a medication that causes the therapeutic effect to the amount that causes toxic effects ■ Low therapeutic index means the medication has a narrow safety margin, and serum medication level monitoring is indicated ■ High therapeutic index means the medication has a wide safety margin, and serum medication level monitoring is not indicated

Peaks and Troughs Draw serum to determine peak and trough levels of medication in blood ■ Peak: Highest amount of medication circulating in blood; draw within 30 minutes of administering IV medication ■ Trough: Lowest amount of medication circulating in blood; draw immediately before next dose is due (regardless of route of administration)

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89 ■ Medications that may require peak and trough levels: ■ Aminoglycoside antibiotics ■ Anticonvulsants ■ Specific cardiac medications ■ Specific anticoagulants ■ Always follow institutional policy on timing of serum laboratory draws of peaks and troughs as these do vary: Call pharmacy and/or laboratory for clarification

Preassessment for New Medication Therapy Before beginning new medication therapy, assess the following: ■ ■ ■ ■ ■

Child’s age and developmental level Current health problem and reason for seeking care Know allergies to foods and medications; reactions Current symptoms Use of alternative, complementary, or herbal treatments

Administering Medication Routes Oral ■ Mix with the smallest amount of juice, flavored syrup, or liquid as possible ■ Do not administer to a crying child as this is a choking hazard

Sublingual (under tongue) ■ Child should hold medication in place while it melts/dissolves

Parenteral ■ ■ ■ ■

Follow institutional policy for all IV medications Follow pharmacy instructions carefully concerning rate of delivery Flush IV sites well Do not allow movement of child to dislodge IV catheter before, during, or after administration

MEDS

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MEDS ■ Monitor carefully for infiltration. Stop infusion immediately if infiltration is suspected ■ Infuse all antibiotics into a central line using a 10-cc syringe as opposed to a 3-cc syringe. Remember to irrigate line with normal saline before and after the administration of an antibiotic when there are no continuous fluids infusing

Subcutaneous (SQ) ■ ■ ■ ■

Check for depth of adipose tissue and angle needle accordingly Rotate sites and document site used Use a 25-gauge needle for administration Do not rub site after administration

Intramuscular (IM) ■ Use developmentally appropriate techniques but do not allow child to stall ■ Obtain help in restraining child as needed ■ Use sheets, blankets, or devices for restraining limbs as needed ■ Use topical anesthetics if warranted

Topical ■ Do not use topical medications on very young infant unless required. Thin skin of young infant readily absorbs medications to systemic circulation ■ Do not allow young children to bite or suck on site of administration

Nasal ■ Check patency of nares prior to administration ■ Obtain help in restraining child as needed

Respiratory ■ Asthma medications frequently given by this route ■ Make sure med is completely administered before removing aerosol mouthpiece ■ Use developmentally appropriate equipment, such as devices with facial masks for very young children ■ To prevent others from breathing medication during administration, use masks if indicated ■ Confer with respiratory therapist of your institution to determine whose role it is to perform administration of the various respiratory medications, as some institutions will only allow a respiratory therapist to

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91 administer racemic epinephrine whereas nursing staff is responsible for albuterol nebulizers. Policies vary, so check with administration, pharmacy, or within the policy and procedure manual ■ Assess for response; document response ■ When administering dry powders or inhaled medications, child should exhale first, then inhale medication deeply through mouth, then hold breath for several seconds ■ Implement good oral hygiene following administration of an inhaler to prevent the development of thrush (corticosteroids pose greatest risk)

Transdermal ■ ■ ■ ■ ■ ■ ■ ■ ■

Not given to young children Make sure previous patch is removed to prevent overmedicating Cleanse and dry skin prior to application Date and time patch with felt-tip pen Assess adherence after diaphoretic period Do not move existing patch to a new skin location Cover patch carefully and secure well before child bathes or showers Double-check patch after bathing Check site frequently; document administration

Rectal ■ Always lubricate suppository ■ Insert gently beyond internal sphincter ■ Suppositories may need to be refrigerated before use: Check packet insert ■ Cut suppository in half lengthways if indicated for smaller doses ordered ■ Insert slowly, allowing gloved finger to be inserted deep enough to ensure complete placement ■ Do not administer rectal medications if child is thrombocytopenic

Gastrostomy or Nasogastric ■ Always check tube placement before administering each dose ■ Allow medication to flow into child via gravity or gently push on medication syringe ■ Flush tube well between medications and at the end of administration to clear tubing

MEDS

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MEDS

Dosage Calculations Standard Conversion Factors 1 mg = 1,000 mcg 1 g = 1,000 mg 1 kg = 1,000 g 1 oz = 30 cc 1 L = 1,000 cc 1 Tbs = 15 cc 1 Tbs = 3 tsp 1 tsp = 5 cc 1 kg = 2.2 lb 1 gr = 60 mg Note: cc = mL

Calculation of Dosage Based on Weight Medications are calculated in pediatrics based on milligrams per child’s kilogram measurement of weight. You must double-check the safe dose range for all medications administered to ensure the dose is safe for a particular child. For instance: If the order reads for the child to receive 4 mg of an antiemetic, the only way you know that the dose is appropriate for the child’s age and body size is to check in a medication text (or institution’s formulary) that the dose is within the safe dose range for a child’s particular weight. The resource will typically give a safe dose range, such as 50–100 mg per kg per dose, and you will then calculate the dose range and double-check that your child’s dose falls within the safe range, is accurate and safe for administration.

Calculation of Body Surface Area (BSA) Calculating body surface area (BSA) is done frequently when double checking chemotherapy doses in pediatrics. Calculate BSA by multiplying the child’s height in cm by child’s weight in kg then divide by 3600, and square-root the final answer. When a child has lost weight or has lost a limb (such as amputation with a bone cancer), the BSA must be recalculated. Use the most recent weight for BSA (daily or upon admission).

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93 Injection Sites Intramuscular (IM) Vastus Lateralis Greater trochanter

Femoral nerve, artery,vein

Tensor fascia latae

Sartorius Vastus lateralis Rectus femorus

Deltoid

Clavicle Acromion process Deltoid

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MEDS Ventral Gluteal Site of injection (Gluteus medius) Anterior superior iliac spine

Posterior iliac crest

Tensor fascia latae Palm over greater trochanter

Gluteus maximus

Dorsogluteal Site of injection (Gluteus medius) Anterior superior iliac spine

Posterior iliac crest

Tensor fascia latae

Gluteus maximus

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95 Tips for Reducing Pain During IM Injections ■ Change the needle after puncturing a rubber stopper to aspirate medications ■ Use topical anesthetics if ordered ■ If administering more than 1 cc of medication, consider using two sites ■ Some medications can be mixed with a compatible anesthetic such as lidocaine. Secure order and check with pharmacist for policy and compatibility ■ If child’s condition requires repeated IM injections, consider a temporary PICC line or central line. Discuss with health-care team

Subcutaneous (SQ) Subcutaneous injections can be given anywhere on the child’s body where there is adequate subcutaneous tissue.

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MEDS ■ Angle the needle at 90 degrees, or 45 degrees for a child with minimal adipose layer ■ Some institutional policies will direct the nurse to aspirate just prior to administration to check for an unwanted blood return into the needle. This practice is not universal ■ Rotate sites so no one part of the child’s body becomes sensitive ■ For repetitive SQ injections, include the child in the selection of the site

Intradermal (ID) Intradermal sites are used to administer very small amounts of medications or TB tests. A small bleb is created just under the skin.

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97 Antimicrobial Medications ■ Always collect specimens for culture and sensitivity prior to administration of antibiotic medications (blood or urine) ■ Educate family about the importance of finishing entire medication dose or course of treatment to prevent the development of resistant strains ■ Monitor for use of contraceptives in adolescents, as many anti-infective medications decrease the effectiveness of oral contraceptives. Check with pharmacy for guidance

Penicillins ■ Always check for a history of allergic reactions to penicillins. ■ First choice for gram-positive cocci such as Strep ■ First choice for meningitis caused by gram-negative cocci such as

Neisseria meningitides ■ May be prescribed prophylactically against the development of bacterial endocarditis or infections related to sickle cell disease ■ High doses may cause hyperkalemia ■ Penicillins inactivate aminoglycosides when mixed in the same IV solution

Cephalosporins ■ Considered broad-spectrum, beta-lactam antibiotics ■ Effective against gram-negative and anaerobic bacteria

Tetracyclines ■ Considered broad-spectrum ■ First-line drug for gastroenteritis caused by Helicobacter pylori and periodontal diseases ■ Tetracyclines decrease the effectiveness of oral contraceptives ■ Should not be taken with milk products, iron supplements, or antacids ■ May cause teeth discoloration, so have child brush teeth after taking oral suspensions ■ May cause photosensitivity

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Aminoglycosides ■ Medication of choice for aerobic gram-negative bacilli such as

Escherichia coli ■ May cause ototoxicity: Report symptoms immediately ■ Infants may require baseline audiometry ■ Penicillins will inactivate aminoglycosides when mixed in same IV solution ■ Serum peaks and troughs should be determined after third dose and after dose adjustments (follow institutional policies)

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99 IV Therapy Pumps To prevent too-rapid infusions, incorrect infusion rates and volumes, and fluid overload, IV therapy must be delivered to pediatric patients through reliable electronic IV infusion pumps. The only exceptions to this rule should be situations of extreme emergency when the supervision of expert nurses is available.

Safety ■ Young children should not have physical access to their IV therapy pumps if at all possible ■ Keep pumps out of sight and as far away from the young child as possible ■ If the IV pump has a safety device that allows the keyboard to be locked, this should be used ■ Teens should be instructed not to touch their pumps ■ Answer pump alarms immediately and problem-solve reason for alarm ■ Instruct parents not to silence alarms but to call for assistance ■ Two RNs should check IV pump setups and changes in rate to ensure accuracy and avoid medication errors. Follow institutional policies

Principles ■ Infusion pumps use computer programming to set the following: ■ Rate of infusion ■ Length of time of infusions ■ Pressure settings ■ Primary (main bag) and secondary (IV piggyback) infusions

Tips ■ Check pressure level to ensure lowest functioning level. Higher levels may cause IV site trauma and lead to loss of function ■ Double-check child’s IV site (peripheral or central) for patency before initiating an IV pump infusion

CLIN SKILLS

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CLIN SKILLS ■ Make sure size of IV catheter is appropriate for ordered infusion rates. Small-gauge IV catheters may not be suitable for fast IV therapy rates ■ In infants and young children, do not attempt high-pressure flushes to open a suspected clotted IV catheter. If IV access is interrupted and a clot is suspected, attach syringe and aspirate before attempting to flush ■ If there are any identifiable problems with a pump, remove pump from service, label pump with date/time and problem, and contact the department of biomedicine or engineering ■ To keep IV tubing out of sight, use paper tape on child’s skin, wrap tubing over the child’s shoulder, and place T-shirt or gown over tubing ■ If child becomes fussy or inconsolable, suspect IV fluid infiltration and/or dislodged IV catheter. Check site frequently and document

Syringe Pumps ■ Used with infants and young children who require small volumes of IV therapy medications, blood products, or fluids ■ The use of syringe pumps minimizes the possibility of fluid overload in young infants ■ Syringes of various sizes and from various manufacturers can be used

Syringe pump

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101 Safety ■ Do not leave syringe pumps in a crib or isolette lying next to a small infant or young child ■ Syringe pumps should be secured to IV poles or placed safely on a table

Principles ■ Infusion pumps use computer programming to set the following: ■ Rate of infusion ■ Length of time of infusions ■ Pressure settings

Tips ■ Double check the setup of a syringe pump with another RN to ensure accuracy ■ Make sure the syringe is placed correctly according to the pump manufacturer’s instructions. A syringe that is slightly tipped or placed incorrectly will not infuse and may set off an alarm

Starting Peripheral IVs ■ Venipuncture can be very challenging in young children. Use a gentle restraining method such as a blanket wrap, and obtain assistance. ■ Gather all equipment before starting ■ Select cannula size appropriate to child’s vein size ■ Secure all sites well with IV “house” protector devices or soft gauze wraps. Use arm boards when indicated ■ Check the child’s IV site frequently. Check under protector devices and gauze wraps frequently for evidence of infiltration, bleeding, moisture buildup, or dislodgement ■ Always document date, time, number of insertion attempts, catheter size, location of site, presence of blood return, and use of protector devices

CLIN SKILLS

Median antebrachial v. Median basilic v.

5th interdigital v.

Umbilical v. Basilic v. (newborn only)

Pediatric I.V. Sites

Great saphenous v.

Dorsal venous arch Median marginal v.

Supraorbital v.

Frontal v.

Superior temporal v. Posterior auricular v. Jugular v.

Cephalic v.

Basilic v.

Cephalic v.

Median cephalic v.

Dorsal arch

Preferred sites for venous access for infants

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103 Use of PCA Pumps ■ Patient-controlled analgesia (PCA) pumps are used regardless of the child’s age, developmental level, or ability to use the self-administration control device ■ The PCA patient button may be removed to ensure safety, and a basal rate of medication can be administered

Principles The PCA order for pain control measures should include: ■ ■ ■ ■ ■ ■

Date, time, and indication for use Medication (such as morphine, Dilaudid, or, more rarely, meperidine) PCA dose of specific medication (in mg or by volume) Frequency of allowable dose (e.g., every 10, 15, 30 minutes) Basal or hourly dose: Medication is infused regardless of PCA dose Primary caregiver’s signature or order

Safety ■ Oversedation is rare but may be avoided by having only the nurse or the child administer a PCA dose. Parents require education on administration policies ■ Keyboards should be locked to prevent the child from pushing buttons or changing settings ■ Narcotic syringes used in the PCA pump should be double-checked by two RNs before administration ■ Pump settings should be double-checked by two RNs at the following times: ■ During initiation of the PCA ■ With every setting change ■ With every syringe change ■ At the end of the each shift ■ Document initiation, checks, and all nursing actions carefully

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Tips ■ If child is not experiencing pain relief with the use of the PCA pump delivery system, assess the child’s pain level and take VS. Report lack of pain control and discuss medication order. Basal rate, frequency of PCA dose, or amount of medication per dose may need adjustment ■ Assess child’s readiness to learn to use the PCA; teach child how to use self-administration button ■ Involve parents or caregivers in instruction but warn them not to administer a dose for the child as this can lead to excessive dosing. Ask parents to call the nurse for assistance if they have questions or feel their child’s pain is not adequately controlled ■ Keep PCA button close to child. Secure to pillow for easy access.

6

PCA machine

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105 Chest Tube Drainage Systems Overview ■ Chest tube (CT) drainage systems are used to: ■ Remove air (pneumothorax), fluid, blood (hemothorax), or pus from the lungs ■ Allow reexpansion ■ Restore the normal negative pressure in the pleural space. ■ May be required after open-heart surgery, chest trauma, tamponade, or atelectasis ■ A stab wound is made through which the chest tube is inserted ■ Although two chest tubes can be Y-connected together, it is better practice to have two separate chest tube systems and to closely monitor drainage from each ■ Basic operating systems include: ■ Water seal chamber ■ Fluid collection chamber ■ Suction control device

Care Tips ■ Medicate for pain prior to insertion and after at regular intervals. Insertion of a chest tube is a very painful experience and is frightening for a child and family ■ Secure tube well to prevent dislodgement ■ Do not allow air to enter the pleural space through the incision ■ Secure unit to the floor to prevent tipping over; tape well ■ Follow institutional policy for stripping tubing or removing clots ■ Use sterile procedures to obtain fluid samples from CT ports ■ Assessment: ■ Frequent, accurate assessment of the respiratory system is imperative ■ Assessing for reexpansion is essential ■ Take frequent vital signs and report concerns ■ Premedicate patient for pain before removal of chest tube

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CLIN SKILLS ■ After removal: ■ Assess VS ■ Assess for subcutaneous emphysema or returning pneumothorax ■ Ensure the site is sutured closed and a petroleum dressing is applied under an occlusive dressing to create an airtight seal

Suction chamber

Water seal chamber

Drainage collection chamber

Chest tube drainage system

Urinary Catheterization and Specimen Collection Skills Purposes ■ To closely monitor an acutely or critically ill child’s output ■ To monitor fluid retention or diuresis ■ To relieve urinary retention

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107 Urinary (Foley) Catheter Sizes Age Group Preterm Newborn Infant Toddler Preschooler School age Adolescent

Catheter Size 5 5–8 5–8 8 8 10–12 >12

Tips for Urine Specimen Collection ■ Infant: Place collection bag by cleaning area and making skin sticky with Benzoin. ■ Use cotton balls to collect urine for SG or simple UA in diaper ■ Straight-catheterize infant for sterile specimen for urine culture ■ Young child: use bedside commode and assist child with clean catch urine specimen ■ Older child: provide verbal instructions to collect clean mid-stream specimen

Minimum urine output in children: 0.5 to 2 cc/kg/hour minimum depending on illness and situation.

Use a pedi uro bag (urinary collection device) for specimen collection.

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Use of Oxygen Delivery Devices Oxygen Delivery Systems Nasal Cannula (prongs) ■ Provides low-to-moderate oxygen concentrations (22%–40%) at flow rates of 0.25–4 liters per minute ■ Higher flows can cause drying of mucous membranes and headaches ■ Difficult to maintain on small children, needs tape/transparent dressing to secure ■ Requires humidification for flow rates above 4 L/min; at higher flow rates, assess nares for irritation ■ Tubing extensions can be added to allow child to move around ■ Attach to portable oxygen tank to ambulate child. Assess tank O2 levels to ensure continuous flow while child is ambulating or being transported

Simple Face Mask ■ Provides FIO2 of 35%–55% with rates of 6–10 L/min ■ Requires snug fit; therefore, difficult to maintain on young children ■ Assess for potential pressure ulcers at least every 2 hours

Partial Rebreathing Mask ■ Provides FIO2 of 60%–95% ■ Contains a reservoir bag but no valve system to prevent expired air from entering bag

Nonrebreathing Mask ■ Provides FIO2 of close to 100% ■ Requires tight seal on child’s face ■ Contains a reservoir bag and valve system to prevent expired air from entering bag

Venturi Mask ■ Provides specifically ordered oxygen concentrations based on a jet that mixes with specified amounts of room air ■ Used for children with chronic lung disease who require precise, predictable oxygen concentrations

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109 Blow-By ■ Provides low levels of oxygen mixed with room air ■ Placed near child’s face but does not touch child ■ Used for children with acute respiratory illnesses who need small amounts of oxygen ■ May be created by wrapping cloth around large tubes from nebulizers ■ Some consider controversial; check with institution’s Respiratory Therapy Department

Positive End-Expiratory Pressure (PEEP) ■ Provides positive end-expiratory pressure via device that resembles cannula

Resuscitative Mask/Bag (Ambu bag) ■ Allows for rapid oxygen administration during emergencies ■ Make sure the correct size mask is at each child’s bed for unexpected emergencies ■ Two types are available: Anesthesia bag and traditional mask/bag ■ Anesthesia bags require source of oxygen to inflate bag

Tracheostomy Mask ■ Provides a relatively controlled source of oxygen for a child with a tracheostomy ■ Attaches directly over tracheostomy site

Oxygen Hood ■ ■ ■ ■

Provides high O2 concentrations for infants (up to 100%) Monitor for CO2 accumulation Must be removed for feedings and care Make sure hood does not rub child’s skin on head or shoulders

Oxygen Tent ■ Provides up to 50% FIO2 ■ Leaks are problematic with active child or frequent accessing

Intubation/Ventilator ■ Provides mechanical ventilation for critically ill child ■ Parameters include: ■ Inspiratory time or length of inspiratory phase ■ Inspired oxygen concentration ■ Respiratory rate: Intermittent mandatory ventilations ■ Peak inspiratory pressure

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Positive end-expiratory pressure Tidal volume ■ Mean airway pressure ■ Power: amplitude of pressure waveform ■

Adapted from Siberry, G., & Iannone, R. (2000) The Harriet Lane handbook (15th ed.). St. Louis: Mosby.

Oxygen Delivery Tips ■ All oxygen requires medical order ■ In emergencies, institutional policy may allow for rapid placement by the RN without immediate order ■ Oxygen is combustible; child must be in a safe environment ■ Some equipment and devices cause feelings of claustrophobia: Enlist parents’ involvement to reassure child

Nasal cannula

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Simple oxygen mask

Oxygen hood

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Crib tent

Universal Precautions ■ Isolation precautions are used to reduce risk of transmission of pathogens ■ Four major routes of transmission: ■ Contact ■ Airborne ■ Droplet ■ Vector ■ Standard precautions can include use of: ■ Gloves ■ Mask ■ Gown ■ Goggles

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113 Levels of Precaution Universal ■ Considered gold standard ■ Use mask, goggles, gloves, gown, shoe covers and hair/head covers as deemed appropriate for the situation ■ Use soap and water hand washing or alcohol-based gels before and after patient contact ■ Never recap needles ■ Dispose of sharps carefully and minimize exposure to body fluids, secretions, and blood

Contact Precautions ■ Used to reduce the risk of transmission of pathogens by direct or indirect contact ■ Used for respiratory, GI, wound, and skin infections ■ Use gloves and gown, wash hands before and after patient contact

Droplet Precautions ■ Used to reduce the risk of transmission of Haemophilus influenzae, Mycoplasma pneumoniae, rubella, and pertussis ■ Use gown, gloves, mask, wash hands before and after contact

Airborne Precautions ■ Used for known or suspected infections whose microbes are very small in size such as varicella, TB, and measles ■ Wear gown, gloves, mask (type of mask should be per institutional policy)

Enteric Precautions ■ Use gown and gloves, wash hands before and after contact

Specific Disease Guidelines Tuberculosis (TB) ■ Airborne ■ Patient in single room with negative-pressure ventilation ■ Health-care professionals should wear HEPA respirator or particulate respirator mask when entering child’s room

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CLIN SKILLS Varicella ■ Airborne ■ Use mask ■ Patient in single room with negative pressure ventilation

Methicillin-resistant Staphylococcus Aureus (MRSA) ■ Highly communicable ■ Use universal precautions carefully

Neutropenia ■ Protect child from infection ■ Use HEPA filters ■ Patient in single room, preferably with positive-pressure ventilation system

Respiratory Syncytial Virus (RSV) ■ Droplet and contact precautions needed ■ Highly contagious; wash hands before and after all contact with patient or patient’s equipment/room, especially faucets, doorknobs, IV poles, VS equipment ■ Group infected children together if needed; follow institutional policy

Tips ■ Isolation cart should be kept directly outside patient’s room ■ Trash can should be next to cart to dispose of gloves and gowns ■ Depending on infection, patients may need their own VS equipment including thermometer and BP cuff ■ Reduce transmission by not sharing toys or equipment ■ Wipe down all medical equipment and toys with commercial-grade cleaner before using again for other patients ■ Wash hands after removing gloves and gowns

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115 Infectious Disease Prevention Guidelines Disease RSV TB Lyme disease Lice Pertussis Rotavirus Cat scratch fever Impetigo Rabies Ear infections Fifth disease West Nile virus Giardia Varicella Conjunctivitis Rotaviral enteritis Influenza Scabies Swine flu

Incubation Period/Transmission 24–48 hours, droplet and contact transmission 4–12 weeks, airborne droplets from sputum 3–32 days after tick bite Eggs hatch in 7 days, infestation of hair, direct transmission 7–10 days, direct contact 48 hours, direct contact 3–14 days after cat scratch Bacterial infection by Strep or Staph 2–8 weeks from contact with virus-laden saliva of rabid animal Varies, may be bacterial or viral 6–14 days 3–14 days, vector bite (mosquito) 5–25 days 14–21 days, contagious from 1 day before eruptions 24–72 hours, transmitted by contact with eye discharge 48 hours, fecal-oral transmission 24–72 hours, direct or droplet transmission 2–8 weeks, direct skin contact transmits mite 1–7 days, airborne, contact

Immunization Requirements ■ Immunizations are given to infants to produce antibodies (active immunity) against various diseases that can be acquired in the community ■ Immunizations may take weeks to months for a full effect but offer lasting protection against infectious diseases

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CLIN SKILLS ■ The use of immunizations has eradicated previously devastating diseases such as smallpox and polio ■ Immunizations prevent complications from infectious diseases, some with quite profound consequences ■ Recommendations are made by the Centers for Disease Control and Prevention (CDC) for all infants ■ Schedules are published for health-care providers and educational materials are published for parents and caregivers. Immunization schedules are updated annually: Check www.cdc.gov ■ Check the January issue of Pediatrics and Morbidity and Mortality Weekly Report for updates and guidelines ■ As of January 2009, immunizations rates for the nation are at 90%, demonstrating the need for further education and promotion (www.cdc.gov/vaccines/stats) ■ Call 1-800-232-SHOT for consultation and printed material on vaccines ■ Immunizations are administered at set intervals for healthy infants ■ Schedules may vary due to office visit timing, wellness state of infant, missed doses, and limited vaccine supply ■ Some parents/caregivers refuse immunizations. Reasons for refusal include: ■ Belief that the immunization is more dangerous than the disease ■ Belief that some vaccines cause autism ■ Belief that scientists have gotten “rid of” the diseases ■ Belief that infants have sufficient natural immunity via breast milk ■ See www.cdc.gov for further discussion on reasons for refusal or delayed immunizations ■ Give families written information about each disease and immunization, possible side effects, and schedules. Document discussion of concerns, questions, and refusal. Informed consent must be secured ■ Needle sizes: ■ SC injections: 25-gauge needle 7/8 inch length ■ IM injections: 22- to 23-gauge needle 7/8 inch length ■ If giving simultaneous injections, choose sites at least 2 inches apart ■ When infant is preterm, vaccines may be given according to chronological age ■ Four types of immunizations: ■ Live attenuated such as MMR, OPV ■ Inactivated virus such as HiB and HB

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117 ■

Inactivated toxoid such as tetanus and diphtheria ■ Immunoglobulins (IVIG) such as RSV immune globulin ■ Some preexisting conditions may require that immunizations be delayed. These include cancer, pregnancy, congenital immunodeficiency, prior history of anaphylactic reactions, febrile illness, history of thrombocytopenia or thrombocytopenia purpura, or children taking immunosuppressive medications ■ Always request medical history and report findings to primary care provider

Safety ■ Assess prior allergies or sensitivities to the following and report: ■ Hypersensitivity to egg proteins ■ Allergies to baker’s yeast ■ History of allergies to neomycin ■ History of allergies to gelatin ■ Always use safety syringes to prevent needle sticks ■ Have parent/caregiver assist by holding infant during injections ■ Inform parents not to administer aspirin to their infants as this is associated with the risk of developing Reye’s syndrome. Ibuprofen or acetaminophen may be used

Tips ■ Some immunizations can be combined in syringes to reduce number of injections. See published guidelines at www.cdc.gov ■ Some products are supplied as combined immunizations, such as tetanus, diphtheria and pertussis (DPT) ■ Remind parents/caregivers to maintain their child’s immunization records as they will be required for entrance to public school and will be requested at each subsequent office visit or hospitalization

Recommended Immunization Schedule ■ Hepatitis B: Birth, 1–2 months, 6–18 months ■ Diphtheria/tetanus/pertussis: 2, 4, 6, 15–18 months, and 4–6 years ■ Haemophilus influenzae type B (HiB): 2, 4, 6, and 12–15 months

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CLIN SKILLS ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Measles: 12–15 months and 4–5 years Mumps: 12–15 months and 4–5 years Rubella: 12–15 months and 4–5 years Varicella: Single dose at 12–18 months or 2 doses 4 weeks apart after age 13 Pneumococcal conjugate (PCV): 2, 4, 6, and 12–15 months Hepatitis A: 2 doses 5 months apart after age 12 years Influenza: Annually for all infants older than 6 months, children, and teens. Check www.cdc.gov for annual guidelines Meningococcal meningitis (MCV4): One dose at 11–13 years old Rotavirus: Check www.cdc.gov for guidelines Human papilloma virus (HPV): Check www.cdc.gov for guidelines

Possible Side Effects of Immunizations ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Local reactions such as rash, swollen glands with pain under jaw Anorexia Fatigue Fever Inconsolable crying Seizures (rare) Anaphylaxis (rare) Encephalopathy (rare) Guillain-Barré syndrome (rare) Vaccine-associated paralytic poliomyelitis with IVP (rare)

Tips on Documentation ■ Note time, date, injection location, and route on child’s immunization record ■ Follow storage and reconstitution directions and document ■ Use the vastus lateralis muscle for young infants and young children and the deltoid for older children ■ Sign and date the immunization record and clearly and accurately document the immunization given

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119 Pediatric Apnea Monitoring Devices ■ Apnea monitors are used in acute care environments to warn health providers that a child is experiencing bradycardia with prolonged cessation of breathing (also called A and Bs for apnea and bradycardia) ■ Apnea monitors typically have two leads under a soft stretch band that encircles the child’s chest ■ The device provides a high shrill alarm ■ High-risk infants maybe prescribed an apnea monitor for home use

Electrode Placement for Standard Chest Electrographic Monitoring

Electrodes with attached wires are often color coded: White for right Green (or red) for ground Black for left Apnea (if indicated)

Apnea monitor

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Standard Chest Electrocardiography Monitoring Electrode Placement ■ Three leads: ■ White for right side of chest ■ Black for left side of chest ■ Red or green for ground

Think “white on right, smoke (black) above fire (red).”

Infant’s chest, showing placement of leads.

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121 Assessing Temperature Temperature is assessed frequently in children with suspected or diagnosed infectious diseases.

Routes ■ Oral: Do not use if child has just eaten or has been vomiting ■ Axillary: Least traumatic site. Reading may be slightly low ■ Rectal: May be traumatic. Not used with young infants or with children with diarrhea ■ Temporal: Rapid assessment ■ Tympanic: Follow manufacturer’s instructions carefully. Aim probe posterior to ensure reading of tympanic membrane

Safety Concern ■ Do not use glass mercury thermometers in pediatrics due to risk of breakage and contamination ■ Young children may bite glass thermometers, causing injury and exposure

Tips ■ Provide chart of temperature conversions for families ■ Calculate conversions as needed: ■ Celsius to Fahrenheit: (9/5 × Temp) + 32 ■ Fahrenheit to Celsius: (Temp – 32) × 5/9

Pediatric Devices Available ■ ■ ■ ■ ■

Oral and rectal electronic devices (red markings for rectal) Electronic temporal devices Electronic tympanic devices Skin probes and devices taped to skin for continuous assessment Digital devices

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Pediatric Suctioning Indications: To remove secretions from mouth or nose during illness that increases mucus production (RSV, colds, allergies) or to clear the airway in children with conditions or procedures that increase saliva production.

Devices ■ Suction bulb (deflate before placing in nares, wash after each use) ■ Olive tip (glass or plastic, place on suction tubing, keep at low continuous suction, cleanse by suctioning water between use to clear tubing) ■ Sterile suctioning device (for deep sterile suctioning of large bronchus) ■ Sterile closed system suctioning device (for use with tracheostomy)

Olive tip

Bulb syringe

Suctioning bulb

Olive tip

Deep sterile suctioning device

Sterile suction device

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123 Suction Catheter Sizes Age Group Preterm Newborn Infant Toddler School age Adolescent

Catheter Size 5 Fr 6 Fr 8 Fr 8 Fr 10 Fr 10 Fr

Tracheostomy Care ■ Tracheostomies are surgical incisions into the cricoid cartilage to establish an airway ■ Trach tubes are placed and kept patent with suctioning. Clean dressings are placed between the trach flange and child’s skin to prevent irritation and breakdown ■ Trachs can be temporary or lifelong ■ Tracheostomy care and dressing changes should be done at least once per 8-hour shift ■ Change dressings after soiling or moisture buildup to prevent skin breakdown

Safety ■ Keep correct size tracheostomy tubes (in box) at the child’s beside at all times for emergency replacement when dislodged ■ For a new tracheostomy, keep same size tubes and tubes one size smaller on hand ■ Secure second RN to assist with suction and trach care if child is at risk for dislodgement

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Routine Trach Care ■ ■ ■ ■ ■

■ ■ ■ ■

■

■

Wash hands Educate family on procedure Conduct baseline respiratory assessment Use appropriate droplet precautions (mask, goggles, gloves) Open equipment: Dressing, pipe cleaners, measured and precut twill tape, sterile container, normal saline or sterile water, small hemostat, 1⁄ 2 strength hydrogen peroxide (H O ) 2 2 Position child without hyperextending neck Assess need for preoxygenation with bag/mask Remove inner cannula and clean with H2O2 Cleanse stoma site with cotton-tipped applicator, moving outward from trach stoma. Do not allow solutions to drip into stoma. Dry area with clean gauze Place new twill tape under flange before removing old tape. Tie only tight enough to hold flange securely to prevent dislodgement (one finger width loose to prevent skin breakdown and discomfort) Reassess airway, breathing, overall respiratory status, O2 saturation Outer tube with cuff and inflating tube Obturator Tracheostomy tube Cuff

Cannula

Outer tube Inner with flange cannula

Obturator

Tracheostomy equipment

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Fenestration

Inner cannula

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125 Pediatric Central Lines Overview of Pediatric Venous Access Devices Peripheral IV (PIV or Angiocath) ■ ■ ■ ■

Duration: 3 days to 1 week (follow institutional policy) Tip Location: Peripheral vein Insertion site: Scalp, AC, numerous sites on limbs Flushing: Continuous infusion means no flush; NS or heparin per protocol ■ Dressing: prn if soiled, wet, loose, or bloody ■ Specifics: ■ Numerous products available ■ Some hand sites are painful ■ Use EMLA to numb site ■ Assess site for infiltration ■ Wrap IV site so it is out of sight of with young teething patients

Radial branch of cephalic vein

Inside of arm

Peripheral IV

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CLIN SKILLS Implanted Port (Port-a-Cath) ■ ■ ■ ■

Duration: Indefinite Tip Location: SVC, IVC, right atrium Insertion site: AC, subclavian Flushing: ■ Intermittent infusions require 10 cc NS then 3 cc heparin 10 units/cc per protocol ■ If Huber needle is deaccessed, flushing requires 10 cc NS then 5 cc heparin 100 units/cc ■ Dressing changes: ■ Gauze or new: Daily ■ Tegaderm: 72 hours ■ Biopatch: Weekly with needle change ■ Specifics: ■ Document child’s needle gauge and length for future access times ■ Secure needle well ■ Numb site with sterile technique before accessing

Tip (Groshong valve) Catheter: thin blue flexible tube lies under the skin Entrance to vein Line secured to skin Bung

Port line

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127 Tunneled Catheters (Broviac/Hickman) ■ ■ ■ ■

Duration: Indefinite Tip location: SVC, IVC Insertion site: Subclavian, internal jugular, femoral Flushing: Intermittent infusions require 5 cc NS then 3 cc heparin, 10 units/cc ■ Dressing changes: ■ Gauze: Daily ■ Tegaderm: 72 hours or longer ■ Biopatch: Weekly ■ Specifics: ■ Monitor site for migration ■ Tape to shoulder and down back if child is active or teething ■ Do not allow child to play with scissors

Vein Entrance site Tunnel Cuff Exit site Catheter

Tunneled catheter

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CLIN SKILLS Nontunneled (Short-term) ■ ■ ■ ■ ■ ■

Duration: Days to weeks Tip location: SVC, IVC if femoral Insertion site: Subclavian, internal jugular, femoral Flushing: Intermittent infusions require 5 cc NS then 3 cc heparin Dressing: Gauze q 24 hours; Tegaderm q 72 hours; with Biopatch q week Specifics: Assess sutures frequently for infection and inflammation

Peripherally Inserted Central Venous Catheter (PICC) Lines ■ ■ ■ ■ ■

Duration: Several weeks to months Tip Location: SVC, IVC, innominate subclavian Insertion site: Median cubital, cephalic, basilic Flushing: Intermittent infusions require 5 cc NS then 3 cc heparin Dressing changes: ■ Gauze: 48 hours ■ Tegaderm: 72 hours ■ Biopatch: weekly ■ Specifics: ■ Peripheral location requires frequent assessment and extra securing for children who are young, active, or teething children

Jugular line

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129 Tips ■ ■ ■ ■ ■

Do not flush Groshongs with heparin; use sterile NS only Double-check institution’s flushing policy as these vary greatly Flush well before and after each blood draw Do not infuse incompatible solutions as precipitate may form Check CDC guidelines for prevention of catheter-related infections

Assessment for Central Lines Developmental Issues ■ ■ ■ ■

Assess for “twiddlers syndrome” where children play with catheter Assess for sensitivity of Tegaderm dressing or adhesive allergy Use DuoDerm ring for hypersensitive weeping skin around site Frequency: Assess PIV and central line sites hourly on young children and frequently on older children. Sweat, robust play, paint, and drool may cause need for frequent dressing changes

Care ■ Secure sites so young children do not cause dislodgement or harm to tubing ■ Use distraction during dressing changes, flushes and blood draws ■ Tape removal: ■ Remove adhesive dressings slowly ■ Count down with child ■ Pull toward insertion site ■ Give rest breaks ■ Allow child to remove dressing if appropriate ■ Place young child in parent’s lap for dressing removal

Troubleshooting ■ If needle access on implanted ports is difficult, try various positions for child: ■ Arms up ■ Side-lying ■ Coughing ■ HOB up ■ Neck raised

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CLIN SKILLS ■ Insertion of implanted needles: ■ Have child cough, change positions, and raise arms if needle access is difficult ■ Document implanted needle gauge and length on medical record for ease of reaccessing

Turn, Cough, and Deep Breathe ■ Have child blow bubbles, push cotton ball across table into cup with breath, “blow out the light” of a penlight, or pretend she/he is blowing out birthday candles ■ Have postoperative patients hold a pillow over the abdomen to provide the feeling of support

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131 Overall Response to a Critically Ill Child ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Ensure ABCs Call for backup help immediately: Do not have a wait-and-see attitude!! Do not leave the child alone or unsupervised under any circumstances Bring crash cart to child, open cart, and be prepared for immediate response Monitor pulse oximetry continuously Provide supplemental oxygen therapy Position child for maximal air exchange such as “sniffing” position Monitor BP Apply cardiopulmonary monitor Establish IV access Draw pertinent laboratory tests (chemistry, hemogram, arterial blood gases [ABGs], etc.) Communicate child’s history/present clinical status/medical diagnosis to responding interdisciplinaryresponse team Provide support to parents/family Call nursing supervisor for assistance with coordinating care and support

Signs of Inadequate Ventilation and Respiratory Distress Early Signs ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Nasal flaring Head bobbing Anxiety Lethargy Decreased rate of responsiveness Retractions (subcostal, intercostals, suprasternal and sternum) Wheezing and stridor Use of accessory muscles to breathe Increased energy and effort needed to breathe Feeding problems and refusal (fatigue and decreased ability to suck/swallow) ■ Tachypnea and/or hyperpnea ■ Hypoxia and hypercarbia

EMERG

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EMERG Late Signs ■ ■ ■ ■ ■

Poor perfusion Bradycardia Decreased air movement and diminished breath sounds Expiratory grunting Apnea (cessation in spontaneous breathing for >20 seconds)

Common Causes of Respiratory Distress Lower Airway RSV bronchiolitis Asthma Pneumonia Foreign body in airway Bronchospasm Copious mucus

Upper Airway Tracheal stenosis Foreign body in airway Croup Epiglottitis Tongue swelling (allergic responses)

Cardiopulmonary Resuscitation ■ The majority of pediatric cardiopulmonary arrests are respiratory in origin and follow a significant respiratory event ■ Because an infant and a young child’s airway is much smaller anatomically than an adult’s, a small amount of edema, mucus, or obstruction will significantly increase the airway’s resistance to airflow, and the young child will demonstrate respiratory distress rapidly

ABCs of Pediatric CPR Airway ■ ■ ■ ■ ■

Check responsiveness Assess for obstruction of airway Remove secretions/vomitus Open airway with head tilt/chin lift (or secure C-spine) In the event of an actual or suspected cervical injury, use jaw thrust

Breathing ■ Look, listen, and feel for breath ■ Determine breathlessness

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133 ■ ■ ■ ■

Use bag-valve-mask device Give two slow breaths If rescue breaths are unsuccessful, reposition airway, reattempt If unsuccessful, give 5 abdominal thrusts (>1 yr old) or 5 back blows if (<1 yr old) and 5 chest thrusts ■ Finger sweep (if >8 yr old); if <8 yr old only if foreign object is visible ■ Consider laryngeal mask airway (LMA) or intubation To determine endotracheal tube size for rapid intubation calculate: Age in years ⫼ 4 + 4

Circulation ■ Palpate pulse for 5–10 seconds ■ If <1 yr old, palpate brachial pulse ■ If >1 yr old, palpate carotid pulse ■ If pulse is absent, initiate chest compressions; 80–100/min, 5:1 ratio ■ Infant: Compress chest 1⁄2 inch ■ Child: Compress chest 1 inch ■ Consider 20 cc/kg isotonic fluid boluses ■ Consider inotropic support

Follow American Heart Association guidelines for health-care professionals. Maintain competency: Current CPR certification with pediatric component. CHECK CRASH CART FOR PEDIATRIC LIFE SUPPORT ALGORITHMS. ■ ■ ■ ■ ■

Place child on monitor If >1 yr old, use automated defibrillator device Consider child’s blood glucose level Draw ABGs Do not leave child unattended

Choking/Obstruction by Foreign Object ■ Aspiration and obstruction of airway by foreign object is the numberone cause of death in children <1 yr old ■ The respiratory tract of a young child has a narrow lumen until age 5, which makes the child prone to airway obstruction and respiratory distress from inflammation

EMERG

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EMERG ■ Never let an older sibling feed a younger child without constant direct supervision ■ Maintain a safe environment for young children free of inappropriate toys with small removable parts

Newborn ■ Do not perform blind finger sweep: Remove foreign object via finger sweep only if visible ■ Perform five back blows followed by five chest thrusts ■ Monitor respiratory status continuously after removal of object ■ Provide low-dose oxygen as required after event ■ Position newborn for maximal ventilation

Child ■ Do not perform blind finger sweep: Remove foreign object via finger sweep only if visible ■ If >1 yr old, perform Heimlich maneuver (abdominal thrusts) ■ Continue until successful or child loses consciousness; then begin cardiopulmonary resuscitation (CPR) ■ Monitor respiratory status continuously after removal of object ■ Position child for adequate ventilation ■ Provide low-dose oxygen as required after event ■ Call for medical personnel to assess child after episode

Adolescent ■ Do not perform blind finger sweep: remove foreign object via finger sweep only if visible ■ Perform Heimlich maneuver (abdominal thrusts) ■ Continue until successful or patient loses consciousness, then begin CPR ■ Monitor respiratory status continuously after removal of object ■ Position child for adequate ventilation ■ Provide low-dose oxygen as required after event ■ Call for medical personnel to assess adolescent after episode

Expect continued airway symptoms after removal of obstruction due to residual edema, inflammation, and irritation.

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135 Shock Shock is a state of inadequate delivery of oxygenated blood flow and metabolic chemicals to meet the demands of the child’s tissues.

Clinical Signs ■ Low cardiac output ■ Decreased BP ■ Poor perfusion

Types of Shock ■ Hypovolemic: Severe blood or body fluid loss ■ Septic: Overwhelming bloodstream bacterial infection ■ Neurogenic: Sudden loss of autonomic nervous system signals to smooth muscle in vessel walls and sudden decrease in peripheral vascular resistance. Associated with severe brain and spinal cord damage ■ Cardiogenic: Primary failure of the heart’s ventricles to function effectively leading to inadequate circulation of the blood ■ Anaphylactic: Systemic response to an allergy exposure leading to laryngospasm, hypotension, bronchoconstriction

Shock may be compensated or uncompensated.

Presentation Compensated Shock ■ Normal BP ■ Tachycardia ■ Poor perfusion

Uncompensated Shock ■ ■ ■ ■ ■ ■

Low BP Weak or absent central pulses Increasing metabolic acidosis Increased CRT Decreased UOP Altered level of consciousness (LOC)

Begin cardiopulmonary resuscitation with uncompensated shock.

EMERG

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EMERG

Interventions ■ GET INTERDISCIPLINARY HELP IMMEDIATELY! ■ Provide IV fluid resuscitation with isotonic boluses (20 cc/kg repeated as needed) ■ Draw ABGs and laboratory test ■ Provide oxygenation at 100% ■ Provide inotropic support, including epi ■ Reverse metabolic acidosis with sodium bicarbonate ■ Monitor patient closely ■ Make sure a crash cart with appropriate airway equipment for rapid intubation is available

Intraosseous Needle An intraosseous needle is used if traditional peripheral or central IV access is not possible or unsuccessful during the care of a critically ill child. ■ Place an intraosseous needle directly into the marrow of child’s long bones ■ Vascular network of long bones is sufficient to administer meds, fluids, and blood ■ This site has been found to be as effective as IV injections for medication distribution

Guidelines for Insertion of Intraosseous Needle ■ Clean site with appropriate antiseptic solution, use sterile technique ■ If able, use local anesthetic ■ Ensure proper landmarks on child’s anatomy: 1–2 cm distal of tibial tuberosity and insert perpendicular to the bone at an angle away from the foot ■ Successful placement will feel like a “pop” with sudden absence of resistance ■ Secure needle at site immediately even though needle will stand unsupported

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137 ■ Remove inner stylet ■ Flush well after each med, transfusion

Intraosseous needle

Infant

Intraosseous needle inserted in bone

Neonatal Resuscitation ■ Always remember ABCs: Airway, breathing, and circulation ■ Conduct an APGAR score at 1 and 5 minutes after birth (1–2 score on HR, respiratory effort, muscle tone, reflex irritability and color) ■ If APGAR score is less than 7, intervene with ABCs and continue to assess every 5 min: ■ Stimulate ■ Dry ■ Warm ■ Suction ■ Position

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EMERG ■

Administer oxygen Ventilate carefully with correct size (newborn) bag-valve/mask ■ Intubate ■ Resuscitate (ventilate 40–60/min and chest compressions 120/min with ratio of 1 ventilation to 5 compressions) ■

Newborn Normal Vital Signs ■ Heart rate: 100–180 ■ Respiratory rate: 30–60 ■ Systolic blood pressure: 50–70

■ Diastolic blood pressure: 25–45 ■ O2 sat: 95% ■ Blood glucose: 35–40 mg/dL

Miscellaneous Emergency Skills Quick Mental Status Examination A quick mental status examination gives a rapid determination of neurological status. Serves as a quick communication for pediatric brain traumas (Davies & Hassell, 2001). ■ ■ ■ ■

A: Awake V: Voice P: Pain U: Unresponsive

For Pediatric Glasgow Coma Scale see Tab 4 under assessments.

Increased Intracranial Pressure Increased intracranial pressure (ICP) is a sudden or gradual increase in pressure within the bony cranium. Causes include brain injury, hemorrhage, contusions, edema, tumors, foreign bodies such as bullet, or intracranial hypertension.

Clinical Signs ■ ■ ■ ■

Headaches Vomiting Seizures Irritability, agitation

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139 ■ Loss of consciousness ■ Dilation of one pupil

Severe ICP may lead to decreased cerebral perfusion, irreversible brain dysfunction, herniation, and death.

Treatment ■ Stabilize ABCs ■ Maintain patent airway ■ Monitor Pediatric Glasgow Coma Scores (less than 8 indicates severe brain injuries) ■ Elevate head of bed (HOB) (>30 degree angle) ■ Provide oxygen and suction ■ Treat seizures ■ Provide low-stimulation environment ■ Transfer to a pediatric critical care unit as required ■ Prepare for rapid diagnostics such as CT and MRI

Hypoglycemia Neonate ■ Blood glucose levels naturally drop in first 1–3 hours of life, and then spontaneously increase in healthy newborns ■ Expected values not less than: ■ Birth to 3 hours of life: 35 mg/dL ■ 3–24 hours of life: 40 mg/dL ■ >24 hours of life: 45 mg/dL ■ Treatment: 2 cc/kg of D10 water IV followed by continuous infusion of 6–8 mg/kg/min IV infusion, adjusting rates based on response (Behrman, Kleigman, & Jenson, 2001)

Any newborn with blood glucose levels lower than 40 after 3 hours should be treated and closely monitored. ■ High-risk neonate groups: ■ Very immature neonates ■ Severely ill neonates ■ Infants born to mothers with diabetes or gestational diabetes

EMERG

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EMERG ■ ■

Infants with intrauterine growth retardation Newborns with intrauterine malnutrition and subsequent reduced hepatic glycogen stores

Children ■ Blood glucose levels should always be >40 ■ Normal range: 70–120 mg/dL ■ High-risk groups include children with: ■ Diabetes ■ Sepsis ■ Reye’s syndrome ■ Hepatoma ■ Malabsorption/malnutrition ■ Diarrhea ■ Shock ■ Burns

Hyperglycemia: Diabetic Ketoacidosis (DKA) Diabetic ketoacidosis is a consequence of highly elevated blood glucose levels.

Early Clinical Signs ■ ■ ■ ■ ■ ■

Polyuria, polydipsia and polyphagia Fatigue Headaches Fruity breath odor Dehydration (usually 10% loss of total body fluid) Change in LOC

Late Clinical Signs ■ ■ ■ ■ ■

Kussmaul respirations Metabolic acidosis Ketonuria Ketonemia Possible death

Treatment ■ Immediate expansion of intravascular fluid space with administration of isotonic saline (0.9%) ■ Continuous infusion of IV insulin therapy of 0.1 U/kg/hr

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141 ■ Correction of electrolyte and acid/base imbalances ■ For children, after IV therapy is completed, SQ injections of fast-acting insulin

Near Drowning Near drowning refers to survival (even if temporary) beyond 24 hours after a submersion episode; it is considered the single leading cause of injury death in children <5 years old.

Clinical Signs Clinical signs depend on length of time child was submerged and how rapidly rescue attempts are made ■ ■ ■ ■ ■

Ineffective respirations or apnea Bradycardia or asystole Altered mental status or comatose Severe hypothermia Shock

Treatment ■ ■ ■ ■ ■

Rapid resuscitation, ABCs, advanced life support interventions Ventilatory support Administration of IV fluid administration May require rapid defibrillation and cardioversion Rewarming measures: Remove clothing, dry skin, wrap in warm blankets, provide warm environment, and warmed IV solutions

Best outcomes achieved with rapid restoration of oxygen.

Shaken Baby Syndrome Shaken baby syndrome (SBS) is a form of child abuse in which an infant or young child is aggressively shaken, producing a brain injury from acceleration-deceleration, coup-contrecoup movements leading to shearing that causes trauma to blood vessels. SBS can lead to cerebral edema and subdural hemorrhage. Child may not show any external injury.

EMERG

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EMERG Clinical Signs ■ ■ ■ ■ ■ ■ ■

Irritability Inconsolable crying Lethargy or decreased LOC Increased ICP Retinal bleeds, decreased visual acuity Seizures Coma

Treatments ■ ■ ■ ■ ■

Ensure ABCs Administer supplemental oxygen Monitor pulse oximetry Maintain IV access Prepare for ICP monitoring and diagnostic CT/MRI

Prognosis ■ Depends on severity of cerebral injury/bleed ■ May have lifelong disabilities ■ May cause death

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143 Anemia Pathology Anemia is an overall reduction in the number of red blood cells (RBCs) or of the hemoglobin that RBCs carry. Iron deficiency anemia is the most common childhood form. Anemia is not typically classified as a disease process, but a manifestation of an underlying condition. When circulating hemoglobin is significantly reduced, clinical symptoms present because of hypoxia. Risk factors include: ■ ■ ■ ■

Poor nutritional intake of iron (overconsumption of milk) Bleeding or increased iron requirements Abnormal synthesis of iron Impaired absorption of iron in the digestive tract

Chronic diseases that can lead to anemia include: ■ ■ ■ ■ ■ ■ ■ ■ ■

Thalassemia major Sickle cell disease Cancer Folate deficiency Inflammatory bowel disease Infection Chronic renal disease Aplastic anemia Liver disease

Children at Risk ■ Premature infants already at risk ■ Young children whose daily diets include >24–32 ounces of milk ■ Adolescents with poor nutrition and dietary habits

Assessment ■ ■ ■ ■ ■

Tachycardia and tachypnea Pale skin and pallid mucous membranes Poor appetite and anorexia Poor muscle tone Exercise intolerance

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PATHO A–G ■ Cardiomegaly ■ Splenomegaly ■ Diagnostics

Diagnostic Testing All children should be screened for anemia during infancy. The American Academy of Pediatrics suggests three assessments: During infancy, during early childhood between 1 and 5 years old, and during adolescence between 14 and 20 years old. ■ Health history and physical examination ■ Complete blood count (CBC) with reticulocyte count (indicates body’s response to the increased demand of low circulating RBCs)

Treatment The most effective treatment is early recognition and change in diet to include iron-rich foods. Oral supplementation of iron may be necessary and in severe cases, intramuscular (IM) injections of iron may be required. Last resort treatment of anemia is the administration of blood products Treat early and consistently, and ensure adherence to oral treatments to prevent long-term complications, such as poor growth, developmental delays, and learning difficulties.

Nursing Care and Concerns ■ Teach family members exact dosing of oral iron supplements, as overdosing will cause complications ■ Give child straw to drink oral iron solutions to minimize discoloration of teeth by medication ■ Give oral preparation on an empty stomach or with orange juice as an acidic environment increases absorption of iron solution ■ Warn family that child’s stool may appear dark in color and tarry ■ Support the use of iron-rich formulas for infants who are not breastfed ■ Teach all family members examples of iron-rich foods, such as muscle meats, wheat, green and green-leafy vegetables, eggs, iron-rich cereals and breads

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145 Evidence-Based Practice Tips ■ Children with anemia may develop pagophagia (pica), the desireto ingest noningestible substances such as twigs, dirt, houseplants, or carpet. Teach families to observe for this behavior and discourage it ■ Since concomitant plumbism (lead poisoning) can occur, blood levels of lead should be monitored along with hemoglobin levels ■ The three effective forms of orally administered iron solutions are ferrous sulfate, ferrous fumarate, and ferrous gluconate ■ The incidence and prevalence of iron deficiency anemia are not declining. The incidence rate among adolescent girls is between 11% and 17%. Girls must be encouraged to eat a well-balanced, ironrich diet when menstruation begins ■ The loss of as little as 7 cc of blood a day may lead to iron deficiency anemia. This occurs mostly in the GI tract and may be unnoticed for a long period of time

Anxiety ■ Normal child development includes feelings of fear, mild anxiety, and worry ■ Stranger anxiety and separation anxiety are normal and expected during infancy and young childhood ■ When the anxiety is unattached to an event or becomes disabling, interventions are warranted ■ Anxiety may be manifested as an unexpected panic attack or as a phobia ■ A mental health professional should differentiate between true anxiety and post-traumatic stress disorders in childhood ■ Panic attacks may include any of the following symptoms: ■ Dizziness ■ Faintness ■ Palpitations ■ Tachycardia ■ Nausea, GI distress ■ Flushing ■ Chest pain ■ Fear of losing control or fear of dying

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Treatment ■ Evaluation by a mental health professional ■ If obsessive-compulsive disorder (OCD) accompanies the anxiety disorder, specific behavior therapy is indicated

Nursing Care and Concerns ■ ■ ■ ■ ■

Do not leave a child alone during a panic attack Provide support and comfort Involve parents and family members Try to identify the trigger of the feelings of anxiety or panic attack Assess for a previous pattern of anxiety, phobias, OCD, or panic attacks

Asthma Pathology Asthma is a chronic inflammatory lung disease of the large and small airways associated with exacerbations. It is the most common cause of acute and chronic illness in children. First episodes may be called reactive airway disease. Many children demonstrate an allergic component to their asthma. Immunological factors include an immediate hypersensitivity in the bronchial mucosa from IgE attachment to mast cells and basophils. As the IgE responds to the presence of an allergen, chemical mediators are released that cause significant clinical symptoms. The inflammation has three main consequences: 1. Bronchial constriction of the smooth muscle fibers surrounding the airways 2. Edema of the inner lumen, leading to thickening of the tracheobronchial mucosa 3. Copious mucus production that can lead to plugging

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147 The resulting clinical picture includes: ■ Airway obstruction ■ Airway inflammation ■ Airway hyperresponsiveness

Bronchospasm may develop; complete airway obstruction by mucus plugging may lead to insufficient oxygenation and ventilation caused by air trapping and lung hyperinflation, resulting in acute respiratory distress. During periods of acute exacerbation of asthma, the child may demonstrate anxious behavior and signs of air hunger. The edema, bronchospasms, and mucus production are a result of a complex interaction of chemical mediators (acetylcholine, leukotrienes, prostaglandins, and histamine) and inflammatory cells (mast cells, T lymphocytes, and eosinophils). Autonomic neural regulation of airway is disrupted and clinical symptoms occur. Status asthmaticus is a complication, whereas in an acute, unresolving asthma attack, symptoms continue despite treatment. Aggressive emergency medical attention must be sought to prevent death. Atelectasis and pneumothorax should be considered in acute presentations. Triggers are often identified to help the family prevent exposure leading to acute exacerbation of asthma symptoms. Common triggers include: ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Mold Animal dander Cold Airway irritants Pollen Cold air and wind Exercise Stress Respiratory infection Emotional distress GI reflux Allergens Aerosols Fragrances Tobacco smoke Fumes

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PATHO A–G ■ ■ ■ ■

Strong odors Inhaled illegal drugs Fireplace or wood stove smoke Cockroach remains

Phases of an Asthma Attack Early asthma reactions (EAR) occur within minutes of exposure to allergen or trigger. Mast cells degranulate; histamine, leukotrienes, and prostaglandins are released; and edema, bronchoconstriction, and mucus production leads to wheezing and symptoms. EARs should respond to rapid-acting bronchodilators. Late asthma reactions (LAR) are the result of continued release of inflammatory chemicals leading to hyperresponsive airway and further edema. This phase may cause desquamation of the airway epithelium. Generally LAR responds to steroid anti-inflammatory drugs.

Incidence ■ 5%–10% of the population has asthma and is growing ■ 50% of new cases are diagnosed in the first year of life, 80% by the fifth year of life ■ The majority of children diagnosed with asthma have recurrent mild symptoms with the minority of children experiencing severe and/or intractable asthma ■ Prevalence and mortality associated with asthma have increased dramatically in the past three decades ■ 25% of school absences in childhood can be attributed to asthma ■ Mortality rates for asthma are increasing by 6% per year

Assessment In general, the younger the child, the more severe the symptoms. Assess for gradual or sudden onset of the following: ■ ■ ■ ■ ■

Cough; hacking, productive or nonproductive Use of accessory muscles for breathing Retraction Nasal flaring Dyspnea with prolonged expiration

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149 ■ Expiratory wheezing progressing to inspiratory wheezing as well ■ Anxious and/or anxiety behaviors and the inability to speak from shortness of breath ■ Exercise intolerance

Severe Symptoms ■ Cyanosis ■ Decreased level of consciousness (LOC)

Death occurs due to complete respiratory obstruction.

Diagnostic Testing ■ Continuous or intermittent oxygen saturation levels to determine O2 needs ■ Chest x-ray ■ White blood cell (WBC) count ■ Peak flow meter monitoring ■ Arterial blood gases (ABGs) for severe exacerbation of symptoms; increased PaCO2 ■ Pulmonary function tests ■ Ruling out respiratory infections

Treatment Basic Principles ■ Identify and avoid allergens by modifying child’s environment and exposure ■ Daily management is essential ■ Have children use Aerochamber or other devices, with or without masks, to maximize amount of inhaled medication that reaches the upper and lower airways ■ Treatments prevent both acute asthma attacks as well as the development of the long-term consequence of chronic emphysema ■ Treat exercise-induced asthma by premedicating child prophylactically with short-acting bronchodilator

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PATHO A–G Medications ■ Short-acting rescue meds: ■ Inhaled beta-2 agonists for rapid bronchodilation (e.g., albuterol) ■ Inhaled anticholinergics for reduction of smooth muscle construction ■ IV corticosteroids for rapid reduction of inflammation, such as beclomethasone, prednisone, and methylprednisolone ■ Long-acting prevention meds: ■ Corticosteroids ■ Cromolyn sodium and nedocromil ■ Long-acting beta-2 agonists ■ Methylxanthine ■ Leukotriene modifiers ■ Emergency meds for severe attacks: ■ Epinephrine ■ Antibiotics, if infection is present

Nursing Care and Concerns ■ Raise head of bed, stay with child and provide a quiet environment ■ Monitor closely for sudden change in clinical status: Get help, do not leave child alone. Secure help rapidly if child’s condition worsens. Prevent a transfer to intensive care and avoid need for ventilation if possible ■ Never administer sedatives to a child experiencing respiratory distress ■ Encourage adherence to preventive medication regimen; include family members in teaching ■ Young children with shortness of breath and sensations of air hunger often become dehydrated; provide favorite liquids and encourage child to take frequent small sips ■ May require IV therapy for dehydration. Assess UOP, mucous membranes ■ Teaching for the entire family should include: ■ Pathology ■ Clinical symptoms ■ Short-acting rescue meds ■ Long-acting prevention meds ■ Need for daily monitoring of peak-flow level measurements ■ Exercise and rest balancing ■ Follow-up care with pediatric health-care team

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151 ■ Encourage pulmonary toileting of secretions and respiratory expansion via creative activities such as bubble-blowing, blowing a cotton ball across a table, blowing out a penlight ■ Provide family teaching: ■ Keep medications readily available ■ Ensure that medications are not expired ■ Teach breathing exercises to improve lung function ■ Teach side effects of rapid-acting bronchodilators, including increased HR, tremors, nervousness, and possible headache ■ Prevent status asthmaticus by aggressive management ■ Carefully document teaching. Use asthma action plans that cover prevention, symptoms, treatments, and when to call for help

Evidence-Based Practice Tips ■ If developmentally appropriate, child should perform daily peak flow measurements and document them in a place where all family members can see them, such as on the refrigerator door. This allows the family to determine if a child is experiencing the beginning of an asthma attack and to provide rapid-acting bronchodilators as needed ■ Teach child and family about the green, yellow, and red zones. The child’s baseline peak flow values are used to determine these values: ■ Green zone (above 80% of normal peak flow values) means no interventions other than prescribed daily preventive meds are needed ■ Yellow zone (between 50% and 80% of normal peak flow values) means use extra precautions that day, including rapid-acting bronchodilators and whatever else is prescribed. Rest and fluids ■ Red zone (at or below 50% of normal peak flow values) means the child needs immediate medical care and should be transported to medical center for further diagnostics and emergency interventions ■ Aggressive daily prevention activities and early interventions can prevent complications such as respiratory failure, respiratory arrest, and cardiopulmonary diseases, such as chronic bronchitis, emphysema, pneumonia, and cor pulmonale. Aggressive treatments may prevent death ■ Heliox (helium and oxygen mixed) has shown to be effective in oxygenating children in moderate asthma attacks with airway obstruction during status asthmaticus

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Attention-Deficit Hyperactivity Disorder ■ Most children exhibit both inattention and hyperactive-impulsive behaviors with a poor ability to attend to a task ■ Children typically are diagnosed during the early school-age period ■ Adolescents with untreated attention-deficit hyperactivity disorder (ADHD) typically demonstrate great difficulty complying with academic, social, and work expectations ■ Six times as many males as females are affected ■ Oppositional and aggressive behaviors may coexist with the symptoms of ADHD ■ The cause of ADHD is unknown, but some experts agree that there may be a neurological etiology, because so many children with the disorder respond to central nervous system stimulants ■ Estimates of prevalence ranged from 1% to 20% of children. Different behavioral expectations in various cultural groups may play a large role in the range of estimates

Assessment ■ ■ ■ ■ ■ ■ ■

Inattention to rules, poor listener Inability to sustain attention to tasks, games, or play activities Inability to complete tasks Distractibility Fidgety on-the-go, busy, difficulty with quiet time or leisure activities Excessive talking Impulsivity demonstrated by blurting out answers, inability to take turns, and frequent interruptions of others

Diagnostic criteria for ADHD can be found in the American Psychiatric Association’s Diagnostic and Statistical Manual for Mental Disorders (DSM-V)

Treatment ■ Administration of stimulants (before 4 pm to avoid interrupting the sleep cycle) ■ Tricyclic antidepressants

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153 ■ ■ ■ ■

Biofeedback Parenting support Highly structured environment Collaboration with teachers

Psychological interventions with pharmacology have been deemed the most efficacious. Family counseling assists with the efforts to improve home social interactional problems.

Nursing Care and Concerns ■ Provide support for child and family during the stressful period of diagnosis ■ Assist with screening and testing ■ Educate parents and caregivers on administration times of stimulants and need to keep medications in safe place

Evidence-Based Practice Tips ■ Teach parents that some of the ADHD medications such as pemoline (Cylert) may require up to 3 weeks to demonstrate the desired effect. Other medications may be started at a low dose and then increased slowly until the desired effect takes place ■ Most of the central nervous system medications given to children with ADHD cause anorexia. Small and frequent nutritious meals may help prevent weight loss ■ Tricyclic antidepressants are known to increase incidence of dental caries. Teach parents to reinforce meticulous dental care

Autism Autism generally presents before the child reaches 36 months of age. It can be severely disabling. The key indicators are impaired nonverbal and verbal communication and reciprocal social interactions. Parents report considerable delays in communication patterns and social play compared with other children of the same age and development. The child may display stereotypical body movements and preoccupation with body parts. Autistic children often fall into the functionally retarded range of the intelligence scale. Autism is more common in males than in females and may be associated with other neurological disorders. The cause is unknown at this time.

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Assessment ■ ■ ■ ■

Impaired social interactions Impaired communication Repetitive patterns of behavior Lack of interests and activities expected at the child’s age and level of development ■ Abnormal EEGs and seizures may be found

Treatment Younger Children ■ Treatment focuses on speech and language ■ The child may require special education

Older Children and Adolescents ■ Treatment focuses on their poor social skills and associated psychiatric symptoms, such as depression, anxiety, and obsessive compulsive behaviors

Nursing Care and Concerns ■ Assess and provide support for families. Refer families to support groups for caregivers of autistic children ■ Physical contact should be minimized or avoided whenever possible during nursing care, as it may cause anxiety and distress for the autistic child

Evidence-Based Practice Tips ■ Researchers have demonstrated no connection between autism and childhood immunizations

Child Abuse Child abuse, also called child maltreatment, is a nonaccidental injury or trauma that leads to sexual violation, emotional trauma, physical harm, or death. Child abuse is considered an intentional act of abuse or neglect.

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155 Infants, toddlers, and preschoolers are the most common victims of physical abuse, whereas school-age children and adolescents encounter emotional abuse and sexual abuse more often.

Categories of Child Abuse ■ ■ ■ ■ ■ ■

Physical abuse Physical neglect Emotional abuse Emotional neglect Verbal abuse Sexual abuse

Contributing Factors Child Factors ■ ■ ■ ■ ■ ■ ■

Special needs Difficult or demanding personality Learning disabilities Chronic disease Prematurity Congenital anomaly Frequent illnesses

Parental/Abuser Factors ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Substance abuse or addiction Unemployment Social isolation Adolescent parent age Frequent family moves History of use of violence Multiple stressors Poor impulse control Lack of parenting skills Anger control issues and low tolerance for frustration Experiences of abuse in their own life Low self-esteem, low confidence

Environmental Factors ■ Unsafe neighborhoods ■ Low economic status

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PATHO A–G ■ Low employment rates ■ Crowded living conditions ■ Lack of education of adults present

The highest risk group includes parents who are low-income adolescents with a high-stress environment. Emotional abuse almost always occurs in the presence of physical or sexual abuse.

Prevention Strategies ■ Parenting classes and parenting support via mentoring and rolemodeling from other family members ■ Encouraging respite care for stressed parents/caregivers ■ Education to prevent shaken baby syndrome ■ Support groups for parents who are socially isolated ■ Comprehensive media coverage of prevention strategies ■ Education about mandatory reporting of child abuse

Diagnostic Testing ■ Radiography for presence of fractures ■ Professional collection of secretions to rule out the presence of semen and blood ■ Computed tomography (CT) scan or magnetic resonance imaging (MRI) to rule out neurological consequences of shaken baby syndrome ■ Assessment of retina for detachment and evidence of bleeding from head trauma, blunt force trauma, or shaken baby syndrome ■ Sexually transmitted disease (STD) screening, pregnancy tests

Assessment ■ Incompatibility between injury and history given by parent/ guardian/caregiver, or inconsistent account of how and when the injury occurred ■ Nonaccidental trauma and suspicious injuries

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157 ■ Unusual bruises with definitive shapes, bruises in various stages of healing (various colors such as red, purple, yellow), or bilateral black eyes without trauma, fracture, or bruising of the nose ■ Behavioral signs such as fear, irritability, aggression, withdrawal, apathy, or “radar gaze” (child is constantly surveying the environment) ■ Infected wounds or infections/injuries/disease processes where there was a delay in seeking treatment or no treatment sought ■ Facial fractures, multiple rib fractures, and spinal fractures ■ Unusual burns: Glove or sock burns that are well demarcated, symmetrical, or circumferential; cigarette burns; burns with distinct shapes, such as iron, doughnut, knife ■ Unexplained, traumatic hair loss (presence of bleeding from broken blood vessels under hair loss area is indicative of abuse) ■ Neglect in any area of child’s life (food, fluids, medications, seasonappropriate clothing, supervision, school attendance, or protection from dangerous/inappropriate situations) ■ Failure to thrive (FTT) syndrome ■ STDs, genital irritation and/or trauma, difficulty walking, or underwear stained with blood or feces ■ Age-specific abuse/neglect signs, such as severe diaper rash with ammonia burns, slap marks on young children, blunt force trauma in adolescents

Follow state and institutional policies carefully concerning the assessment of an abused child. Some institutions will not want you to initially assess the child alone. You do not want to be implicated as the one who caused the abuse. Some institutions require photographs of injuries.

Nursing Care and Concerns ■ Provide immediate ABCs in the presence of trauma ■ Provide safe environment for the child: Security/police holds/presence of other staff members ■ Document exactly what the parent/caregiver said about the history of injury and the time the injury took place ■ Understand that child abuse can consist of acts of commission or acts of omission; assess for both

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PATHO A–G ■ Call child protection agency personnel or hospital social services for a social worker to assist in the situation per institutional policy ■ Do not leave child alone with parent/caregiver ■ Do not give opportunity for parent/caregiver to take child away from the health-care setting against medical advice (AMA) ■ Provide play, comfort, soothing support for child to establish a rapport and a sense of calmness and safety

Evidence-Based Practice Tips ■ Witnessing violence is highly detrimental for children of all ages; professionals now realize the need to intervene rapidly ■ Media violence can desensitize children to the meaning of violence and the effect of violent behavior ■ Children who experience or witness violence in their homes tend to be aggressive to their peers ■ Critical facts to consider when evaluating possible abuse: ■ More than 2 million reports are filed each year ■ Approximately 35% are substantiated ■ Approximately 90% of parents suspected of abusing their child have neither criminal records nor a psychotic personality/psychological disturbance ■ Unrealistic expectations of a child from lack of education and understanding of normal growth and development can lead to a level of frustration that influences abuse

Unusual Cases Munchausen Syndrome by Proxy A form of child abuse where a proxy (usually the biological mother) causes, simulates, or fabricates an illness that is often not compatible with the recognized disease or clinical presentation of the child. The proxy may cause the symptoms or actual disease by altering laboratory specimens, exposing child to a toxin or infectious agent, suffocating a child, or administering a medication that makes the child acutely ill. The child is either too young to report the offender, unwilling to expose the proxy, or unable based on the proxy’s protective behaviors. The clinical presentation of a seizure disorder or apnea is common with Munchausen syndrome by proxy. High levels of suspicion should provoke

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159 an attempt to diagnose. When suspicion exists, rapid diagnosis should occur in order to avoid unnecessary diagnostics, laboratory specimen collection, and unpleasant, or painful procedures performed on the child. When the suspicion is confirmed, the parent should be confronted and child protective services contacted. The child’s safety should be the highest priority.

Cleft Lip Pathology Cleft lip is a congenital anomaly caused by a malformation that occurs during fetal development. The cleft may extend from the child’s lip up to or through the nasal anatomy and may be either unilateral or bilateral.

Assessment ■ Cleft lip can be identified in utero via ultrasound ■ Considered a congenital anomaly ranging in severity: May extend from child’s lip up to or through the nasal anatomy and can be either a small anomaly or a large fissure ■ Assessment should include the effectiveness of the child’s sucking ability and need for support devices

Treatment ■ Early surgical intervention to repair a cleft lip is usually performed between 1 and 3 months of age ■ Immediate postoperative care should include the protection of the suture line: Limbs should be restrained with “No-No’s,” and every effort should be taken to reduce crying ■ Postoperative care should include placing the child in a car seat to keep the head elevated ■ Apply antibacterial ointment to minimize scaring and prevent infection ■ Manage pain

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Nursing Care ■ Young child will need to use special nipples/feeding devices that provide a seal to increase sucking adequacy ■ Family will need role modeling and encouragement to accept the child with the anomaly and bond effectively with the child

Cleft Palate Pathology Cleft palate is a congenital anomaly that affects the soft palate or the soft and hard palate, resulting in an abnormal opening between the mouth structures and the nasal cavity. Condition is associated with dental malformations, otitis media, and delayed speech development. Exposure to drugs, environment factors, and genetic disorders may all be associated with the development of cleft palate. Malocclusion of dentition, dental decay, speech difficulties, hearing impairments and altered self-esteem may occur if surgical treatment is delayed during childhood.

Assessment ■ ■ ■ ■

Assess roof of mouth to determine severity of condition Assess for choking and coughing during feedings Assess for family’s adjustment to condition Assess for frequent otitis media and need for frequent hearing assessments

Treatment Surgical repair is usually performed after the infant is 6 months old. More than one surgical intervention may be required to complete the fusion of the open palate.

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161 Nursing Care and Concerns Preoperative Care Until surgical repair, the primary goal is to prevent aspiration during feedings: ■ Hold infant upright ■ Provide special feeding devices and nipples that promote adequate sucking ■ Burp infant frequently, and assess for feeding distress

Postoperative Care ■ Make sure child does not gain access to the suture line; place elbow restraints (No-No’s) on older infants and young children ■ Assess for bleeding and rupture of suture line ■ Do not allow young infants and children to have access to toys with pointed edges or shapes that could cause damage to the suture line while healing ■ Provide pain control ■ Every attempt should be made to reduce crying

Evidence-Based Practice Tips ■ After cleft palate repair, the surgical site will be without sensation until the nerves regenerate. Make sure the child’s lack of sensation does not lead to injury or burns ■ Child with repaired cleft palate may need to be referred to long-term hearing and speech follow-up care

Congenital Heart Disease Pathology Childhood congenital heart disease (CHD) can be divided into two main categories: those that produce cyanosis and those that do not (acyanotic). Acyanotic CHD is further subdivided into conditions that produce a volume load and those that produce a pressure load.

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PATHO A–G Cardinal Signs of Childhood CHD ■ Congestive heart failure ■ Hypoxia ■ Decreased cardiac output

Acyanotic CHD ■ Results in left to right shunting of blood

Lesions That Cause Increased Volume Load These lesions cause oxygenated blood to shunt back to the lungs.

VSD

Ventricular septal defect: Opening between ventricles

ASD

Atrial septal defect: Opening between atriums

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AVC

Atrioventricular septal defect (atrioventricular canal): Low ASD continuous with high VSD and cleft of mitral and tricuspid valves

PDA

Patent ductus arteriosus: Fetal ductus does not close at birth

Lesions That Cause Increased Pressure Load These lesions obstruct blood flow.

AS

Aortic valve stenosis: Narrowing or stricture of the aortic valve

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PATHO A–G CoA

Coarctation of the aorta: Narrowing of aorta at the insertion of the ductus arteriosus

PVS

Pulmonic valve stenosis: Narrowing of the entrance of the pulmonary artery

Right atrium

Left atrium

Tricuspid valve

Left ventricle

Right ventricle

Tricuspid stenosis: Failure of the tricuspid valve to develop

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165

Mitral valve

Mitral stenosis: Failure of the mitral valve to develop

Cyanotic CHD Results in right to left shunting of blood.

Lesions That Cause Decreased Pulmonary Blood Flow Degree of cyanosis depends on the degree of obstruction to the pulmonary blood flow.

ToF

Tetralogy of Fallot: Includes VSD, PS, overriding aorta, and right ventricular hypertrophy

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PA

Pulmonary atresia

TA

Tricuspid atresia

Lesions That Cause Increased Pulmonary Blood Flow Degree of cyanosis depends on degree of mixing of oxygenated (pulmonary venous) with deoxygenated (systemic) blood or on the degree of the ventriculoarterial connections. Transposition of the great vessels (TGV): The aorta arises from the right ventricle, and the pulmonary artery arises from the left ventricle. As a result, there is no communication between pulmonary and systemic circulation. Associated mixed defects include patent ductus arteriosus, ventricular septal defect and atrial septal defect.

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167

TGV

AO

AO PA

PA LA

LA

RA

RA

RV

LV

Normal

Single ventricle

Aorticpulmonic trunk

Truncus arteriosus

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SV

Single ventricle

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Assessment ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Degree of cyanosis Tachycardia Tachypnea Murmurs Palpable thrills Decreased peripheral perfusion (delayed CRT, weak pulses, decreased temps) Polycythemia Poor feeding behaviors Diaphoresis Desaturations Weight loss Sweating on brow Decreased exercise tolerance Frequent respiratory infections Headache, fatigue, and dyspnea in patients with cyanotic heart disease may indicate a state of increasing hypoxemia Acidosis Kidney failure Cardiac dysrhythmias Heart failure

Report Immediately ■ ■ ■ ■

Weight gain RR over 60 Decreased perfusion Nonadherence to medication regimen

Treatment Treatments for CHD are focused on: ■ Reducing cardiac workload ■ Preventing and treating congestive heart disease ■ Supporting maximal growth, development, and nutrition ■ Providing shunts and/or bands to protect the lungs by decreasing pulmonary blood flow

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169 ■ Cardiac surgery may be performed to repair area of congenital anomaly ■ Some mild congenital heart defects may not require intervention ■ Symptoms of fluid overload are treated with diuretics

Nursing Care and Concerns ■ Educate parent/caregivers on signs and symptoms of respiratory distress and early signs of congestive heart failure ■ Educate family on need to report early signs and symptoms of infection ■ Secure a supportive relationship to increase adherence to treatment plans and optimize follow-up care ■ Teach family how to administer medications (e.g., accurate digoxin administration with predosing apical heart rate). Make sure the primary caregiver return demonstrates the accurate drawing up of all medications

Evidence-Based Practice Tips ■ Prophylactic antibiotics must be administered prior to dental procedures to prevent endocarditis ■ Avoid sudden temperature or altitude changes. Avoid dehydration

Croup Pathology Croup is a complex syndrome characterized by “barky” or “brassy” cough (croupy), hoarseness, inspiratory stridor, and respiratory distress from swelling and obstruction in larynx. The small airway diameter of infants and young children exacerbates symptoms. Croup syndrome includes epiglottitis, laryngitis, laryngotracheobronchitis (LTB), and tracheitis. Two predominate conditions are spasmodic croup and LTB.

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Assessment Mild Croup ■ Barky cough without stridor or respiratory distress.

Severe Croup ■ Symptoms of respiratory distress: ■ Stridor ■ Cough ■ Retractions ■ Nasal flaring ■ Assess for symptoms progressing to cyanosis and complete obstruction

Treatment ■ Cool mist tent or humidified oxygen mask placed near child’s face. ■ Minimal disturbance to avoid anxiety and crying that might aggravate symptoms ■ Racemic epinephrine (nebulized) ■ Dexamethasone ■ Nebulized steroids ■ Heliox ■ If symptoms do not respond to treatment, consider bacterial tracheitis or retropharyngeal abscess

Nursing Care and Concerns ■ Keep child comfortable, reassure, provide support, prevent crying and agitation ■ Maintain cool mist and progress to humidified oxygen as needed ■ Keep child in position of comfort with head of bed elevated at least 30 degrees ■ Use a published croup scoring system to accurately document severity ■ Be vigilant with assessments and intervene if respiratory distress develops or if child begins to become fatigued by difficult breathing possibly requiring intubation ■ Educate family on the possibility of a long-lasting barky cough at night

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171 Evidence-Based Practice Tips ■ Stridor at rest indicates the need to seek medical care.

Cystic Fibrosis Pathology Cystic fibrosis is a genetic defect in the gene that produces the protein that regulates the movement of salt in and out of the cells. This results in thick, sticky secretions. The triad of clinical phenomena includes severe pulmonary disease, pancreatic disease, and infertility in women.

Respiratory Effects ■ Acute respiratory failure can occur with pneumonia ■ CF patients tend to have nasal polyps that can cause a triggering of infections of the sinus tracts ■ Air trapping of the lower airways leads to destruction of pulmonary parenchyma ■ CF may lead to decreased levels of the natural anti-inflammatory interleukin-10 (a cytokine), leading to severe lung inflammation after an infection ■ Hemoptysis can occur with coagulopathies from decreased absorption of vit K

Gastrointestinal Effects ■ Proteins and fat-soluble vitamins cannot be absorbed ■ With the faulty secretion of salt and water, stool material can become dehydrated

Assessment ■ ■ ■ ■ ■

Presence of thick, tenacious mucus and sputum Chronic sinusitis Weight loss Clubbing of fingers Steatorrhea

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PATHO A–G ■ Signs of respiratory distress: ■ Increased work of breathing ■ Tachypnea ■ Irregular breathing patterns ■ Pursed-lip breathing ■ Nasal flaring ■ Intercostal retractions ■ Use of accessory muscles ■ Clubbing of fingers respiratory acidosis

Treatment ■ Consistent and thorough pulmonary toileting: ■ Postural draining ■ Percussion or use of electronic vibrating vest device to produce and expectorate pulmonary secretions ■ Supplementary vitamins (A, D, E, K) ■ High-calorie diet ■ Prophylactic antibiotics, oral or aerosol ■ Pancreatic enzyme supplements ■ Possible lung transplantation with severe disease

Nursing Care and Concerns ■ Teach patient to prevent respiratory infections ■ Encourage patient to continue taking pancreatic enzymes to prevent wt loss ■ Meticulous pulmonary toileting ■ Emotional support with chronic disease

Evidence-Based Practice Tips ■ After six months of therapy, recombinant human deoxyribonuclease has been found to be associated with improvement in lung function ■ Stagnant mucus promotes bacterial infections in the lungs of children with cystic fibrosis. Since chronic infections produce lung disease, scarring, and fibrosis, aggressive removal of secretions is imperative

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173 Depression Depression during childhood has many known etiologies. Refer the child and family to appropriate mental health professionals for evaluation, intervention, and follow-up. Genetic factors play a role in more than 50% of diagnosed mood disorders. There are three types: 1. Major depressive disorders 2. Dysthymic disorders 3. Bipolar disorders

Assessment ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Energy level Racing thoughts Family history of mental illness School history Physical appearance, dress, grooming, hygiene, general health condition Play activities and level of involvement in comparison to peers in general Orientation to time, place, person, environment, and situation Attention, concentration, memory Substance abuse, alcohol, smoking Dysphoria Sleep disorders ranging from insomnia to hypersomnia Severe feelings of worthlessness

Pediatric Rapid Assessment for Depression Symptoms ■ Changes in sleep habits ■ Declining interest in activities of daily living (school, play, and hobbies) ■ Feelings of guilt ■ Changes in energy such as hyperactivity and fatigue ■ Poor concentration ■ Changes in appetite ■ Agitation or psychomotor retardation ■ Attempts or ideations of suicide

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Treatment ■ Treatment for mood disorders such as depression is based on severity, safety needs of the child, risk of suicide, and level of family involvement ■ Treatment includes antidepressant such as selective serotonin reuptake inhibitors

Nursing Care and Concerns ■ Provide support to families. Cultural factors play a large role in the family’s acknowledgment and acceptance of the diagnosis and compliance with the treatment regimen ■ It is imperative to maintain stable serum levels of mood disorder medications such as lithium. Educate the family on all aspects of medication administration, adherence, and lab studies

Evidence-Based Practice Tips ■ State laws vary on the requirement that parents or legal guardians must sign consent or offer verbal consent for a child of any age to undergo a psychiatric assessment. Check with state law. ■ If it is difficult to engage the child in conversation, use a topic such as “your top three wishes in the world,” or “future plans.” Asking the child to make drawings of his or her life, home, family, friends, school, and self may be helpful ■ Research has shown that 90% of teens who commit suicide have a diagnosis of depression, substance abuse, or another mental disorder. Early identification of depression and suicide risk, plus early interventions that include building resiliency, have been successful ■ Talking to or asking teens about suicide does not put the idea in their heads or lead to an increased risk that they will commit suicide or attempt suicide ■ The benefits of antidepressants are much greater than the risk of suicide ideation or attempt

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175 Developmental Hip Dysplasia Pathology Hip dysplasia is an abnormal connection between the femoral head and the acetabulum, leading to instability and abnormal movement. Three patterns of abnormal structuring can occur: 1. Preluxation: The hip joint is shallow and structures slip 2. Subluxation: Incomplete hip dislocation and partial dislocation of the femoral head 3. Dislocation: Complete dislocation of the hip joint In one-sided dysplasia, the left hip is more frequently affected than the right.

Assessment ■ Ortolani’s sign: Movement to reduce dislocated hip by flexing the thigh then abducting the thigh while lifting the femoral head into place ■ Barlow’s sign: Considered the most important test to examine the newborn hip. While stabilizing the opposite hip, the affected hip is flexed and adducted to assess for a dislocation while feeling the movement ■ Unequal gluteal folds in infants while lying supine ■ Shortening of limb on affected side while older child is standing up ■ Waddling gait in ambulatory child indicates a bilateral condition ■ Ultrasound and/or radiography definitively determine a dislocation and its severity

Treatment Treatment is based on interventions that provide abduction and flexion of the hip. If bracing/traction/corrective devices, such as a Pavlik harness, are not warranted, surgical interventions will be required to secure hip structures into place. Hip spica casting will be required postoperatively. Young infants are usually braced, while older infants require surgical reduction. Older children require open reduction with pelvic or femoral osteotomy.

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Nursing Care and Concerns ■ Provide education to family concerning the need to maintain young child in abduction position to encourage repair and healing ■ Assess skin every 2 hours for breakdown at sites of braces/harnesses or any corrective devices

Evidence-Based Practice Tip ■ The earlier the interventions are initiated to reduce the hip dysplasia, the greater the chance of preventing progressive deformities

Diabetes Insipidus and Syndrome of Inappropriate Antidiuretic Hormone Pathology These two conditions produce opposite symptoms. Diabetes insipidus (DI) is caused by a lack of antidiuretic hormone. Syndrome of inappropriate antidiuretic hormone (SIADH) is a condition of the excessive production of vasopressin or antidiuretic hormone (ADH).

Diabetes Insipidus May result from head trauma or space-occupying brain lesions. With the reduced secretion of ADH, DI leads to extreme dehydration as there is a tremendous loss of body fluids. The child exhibits large amounts of urine output.

Labs with DI ■ ■ ■ ■ ■

Increased serum sodium Increased serum osmolality Low urine sodium and potassium Low urine osmolality Low urine specific gravity (<1.005) with high UOP

Syndrome of Inappropriate Antidiuretic Hormone May result from head trauma or brain tumor. Usually transient but can be life threatening. With the increased secretion of ADH, excess water is held in the intravascular space, leading to low urine outputs, expanded fluid volume levels, dilutional serum sodium levels, and high urine osmolality.

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177 Labs with SIADH ■ ■ ■ ■ ■

Low serum sodium Low serum osmolality High urine sodium and potassium High urine osmolality High urine specific gravity (>1.020) with low UOP

Assessment ■ Decreased urine output ■ Weight gain ■ Hyponatremia with weakness, irritability, and lethargy

Treatment ■ Administration of prescribed medications

Nursing Care and Concerns ■ Ensure adherence to fluid restrictions if ordered ■ Implement seizure precautions when electrolyte imbalances are present

Diabetes Type 1 Pathology Type 1 diabetes mellitus is thought to be an autoimmune disease that results in insulin deficiency (insulinopenia) and hyperglycemia. Cardinal signs are polyuria, polydipsia, polyphagia (the 3 Ps), and fatigue. Treatment consists of stabilizing blood glucose levels, preventing weight loss, promoting optimal growth and development, and preventing hypoglycemia and diabetic ketoacidosis.

Assessment ■ Blood glucose checks at regular intervals: before meals and at bedtime ■ Three Ps ■ Anorexia

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PATHO A–G ■ ■ ■ ■ ■ ■ ■

Fatigue Wt loss Dehydration Frequent infections Nausea Weakness Urinalysis for glucose, pH, and ketones

Treatment ■ Maintain stable blood glucose levels by the administration of insulins as ordered: ■ Rapid acting: Such as Lispro-H (Humalog) ■ Intermediate acting: Such as NPH or Lente ■ Long acting: Such as Ultralente ■ Some newly diagnosed cases will need a continuous IV infusion of regular insulin at 0.1 U/kg/hour. Institutional policies may dictate that this infusion take place in an intensive care unit ■ Treat periods of dehydration and electrolyte imbalances ■ Low sugar diets ■ American Diabetes Association (ADA) carbohydrate-counting diets with corresponding insulin administration (check institutional policy on diets for type 1 diabetic children)

Nursing Care and Concerns ■ Educate child (if developmentally appropriate) to understand the disease process and to assess blood glucose levels ■ Teach family signs and symptoms of hyperglycemia and hypoglycemia ■ Demonstrate insulin administration and rotation of subcutaneous (SQ) sites for injection ■ Refer patient and family to diabetic clinical to be followed by diabetic educator ■ Teach family to carry quick source of carbohydrate for periods of hypoglycemia

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179 Evidence-Based Practice Tips ■ Approximately 25% of children with type 1 diabetes will initially present with ketoacidosis (DKA). ■ The course of treatment for a newly diagnosed child typically includes recovery from DKA, followed by transitional period to stabilize blood glucose levels, followed by aggressive teaching and follow-up care

Diabetes Type 2 Pathology In type 2 diabetes mellitus, either the body does not produce enough insulin, or the cells do not use the insulin that is produced. Also called non-insulin-dependent diabetes mellitus (NIDDM). Associated with the rise of childhood obesity rates, type 2 DM is on the rise. Treatment centers on increasing exercise and reducing the child’s weight. Some children require insulin injections to stabilize hyperglycemia during infections and illnesses.

Assessment ■ See Diabetes type 1 ■ Assess child’s blood glucose history for need for oral meds versus SQ insulin injections

Treatment ■ Oral hypoglycemic meds ■ Low-sugar diet/ADA diet ■ Weight loss programs, exercise

Nursing Care and Concerns ■ Assess child for signs of hyperglycemia and hypoglycemia ■ Create a supportive relationship with family to encourage adherence to weight loss plan ■ Encourage family to carry source of carbohydrate for periods of sudden hypoglycemia

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PATHO A–G ■ Be aggressive with teaching and follow-up care. With increasing obesity rates, children with type 2 DM are moving to type 1 and requiring insulin

Epiglottitis Pathology Epiglottitis is an inflammation of the epiglottis. It is considered a pediatric emergency because the child is at risk for complete airway obstruction. Edema may progress rapidly if bacterial cause is not treated promptly. Most frequent etiology is Haemophilus influenzae type b (HIB). Onset is usually abrupt and child presents as acutely ill with severe respiratory distress.

Assessment ■ Drooling with inability to swallow from edema ■ Tripod breathing positions (jaw thrusted out and leaning forward on hands) ■ Hoarse voice ■ Stridor

Treatment ■ Prepare emergency intubation equipment and be prepared for complete airway obstruction ■ IV antibiotics such as cephalosporins (blood cultures should be drawn) ■ IV hydration ■ NPO status ■ Rest and careful observation

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181 Nursing Care and Concerns Epiglottitis is a life-threatening condition: Do not leave child. ■ Do not use tongue blade to assess throat as this may lead to immediate increase in swelling and complete respiratory obstruction ■ Delay invasive diagnostic procedures until all emergency support and equipment are prepared ■ Have endotracheal intubation and cricothyroidotomy emergency equipment set up ■ Assess gas exchange and support child with oxygen therapy as needed ■ Assist family in controlling for fear, anxiety, and crying as this will increase symptoms and feelings of distress ■ Administer first dose of antibiotic immediately after airway is secured

Evidence-Based Practice Tips ■ Corticosteroids can help reduce airway edema in the first 24 hours after diagnosis ■ Any manipulation of the child (airway assessment, IV placement, venipuncture) may lead to complete airway obstruction. Intubate immediately ■ Keeping parents with child at all times alleviates anxiety during acute epiglottitis and may decrease the chance of complete obstruction ■ Blow-by oxygen less obtrusive and causes less anxiety than other delivery methods

Failure to Thrive Pathology Failure to thrive (FTT) exists when a child’s measured weight and height (physical growth) is considered significantly less than normal. Growth retardation may be accompanied by delayed developmental and emotional functioning. FTT is associated with families living in poverty. There are two main types:

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PATHO A–G 1. Organic FTT: There is an identifiable underlying medical condition 2. Nonorganic FTT: There is no identifiable underlying medical condition, and the condition is therefore associated with psychosocial factors. Typically found in children less than <5 yr (most often infants) with difficult parent/child relationships

Assessment ■ Failure to meet expected ht and wt for age; less than 5th percentile on national growth charts (some references say consistently below the 3rd percentile) ■ Assess parent/caregiver’s nutritional knowledge ■ Failure of parent/caregiver to offer and provide adequate calories for growth ■ History of poor eating habits or difficult feedings ■ Sleep disturbances ■ Vomiting ■ Loss of subcutaneous fat ■ Recurrent infections ■ Reduced muscle mass and tone ■ Dermatitis ■ Marasmus ■ Kwashiorkor ■ Assess for concurrent gastroesophageal reflux, urinary tract infection (UTI), hypothyroidism, cognitive delays, in-born errors of metabolism, poisoning, and malignancy ■ Assess for learning delays, language delays, and behavior problems

Treatment ■ Appropriate feeding environment: ■ No stress ■ Slow introduction of food ■ Allow 30 minutes for mealtimes ■ Provide encouragement and support ■ Never force-feed and have child eat with others

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183 ■ Do not offer low-calorie beverages; limit water consumption ■ Provide high-calorie supplement and formulas that provide >20 calories per oz ■ Rule out medical conditions leading to FTT ■ Prevent associated complications such as vitamin deficiencies, dehydration, electrolyte imbalances, and anemia

Nursing Care and Concerns ■ Secure assistance from nutritionist for screening, education, and support ■ Attempt to use consistent nursing caregivers who learn the child’s routines and feeding needs ■ Provide calm, persistent, face-to-face feeding environments; smile at child and show how relaxed you are. Never communicate disappointment regarding intake, never scold or punish. Include parents/caregivers in creating a plan of care ■ Provide nasogastric (NG), nasojejunal (NJ) or gastrostomy feeds as ordered

Evidence-Based Practice Tips ■ FTT has been found to be associated with maternal depression. Mothers should be screened for this condition and referred for treatment if necessary ■ Following the child’s eating rhythms (movements from plate to spoon, to mouth, to chewing and swallowing) assists with increased consumption

Gastroenteritis Pathology Gastroenteritis is an inflammation of the mucous membranes lining the stomach and intestines resulting from viral or bacterial infections or toxins. The enterotoxins produced by infectious agents or the cytotoxins damage the intestinal lining, producing inflammation. Fluid loss and electrolyte losses result from decreased intake, vomiting, and diarrhea.

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PATHO A–G Major Causes ■ ■ ■ ■ ■ ■ ■ ■ ■

Rotavirus Norwalk virus Enteric adenovirus Salmonella Shigella Escherichia coli Yersinia Cryptosporidium Giardia lamblia

Assessment ■ Severity of dehydration: ■ Sunken eyes ■ Skin turgor ■ Wt loss ■ Dry mucous membranes ■ Decreased UOP ■ Electrolyte imbalances ■ Fever ■ Diarrhea ■ Vomiting ■ Stool characteristics: ■ Watery ■ Bloody ■ Profuse amounts ■ Explosiveness ■ Pus ■ Abnormal color or odor ■ Abdominal pain and cramping ■ Febrile seizures

Treatment ■ Rehydration orally or via IV if unable to hold down fluids ■ Use of oral electrolyte solutions (Pedialyte) in frequent small volumes ■ Continue breastfeedings as tolerated

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185 ■ In the presence of shock, fluid resuscitation via IV boluses (20 cc/kg repeated) ■ Advance diet as tolerated with easily digested foods ■ BRAT diet may be ordered (bananas, rice, applesauce, and toast) ■ Antibiotics and antiemetics are rarely used unless there is a definitive diagnosis of Shigella, E. coli, or Salmonella

Nursing Care and Concerns ■ ■ ■ ■ ■

Maintain strict universal precautions Dispose of excreta carefully to prevent contamination Daily weights Assess skin breakdown around anus; may require ointments Change diapers frequently and maintain strict I & 0 calculations

Evidence-Based Practice Tips ■ Complex carbohydrates are best tolerated as child’s diet is advanced from NPO to clear liquids to regular food

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PATHO H–Q

Hemophilia Pathology Hemophilia is a term used for a group of genetic disorders leading to a deficiency of blood-clotting factors, primarily in males. This places the child at risk for uncontrolled bleeding. Factor VIII deficiency (hemophilia A) and factor IX deficiency (hemophilia B or Christmas disease) are the two most common. Severity of the bleeding condition is dependent on the actual amount of the factor produced. In all conditions there is an impaired ability to form a fibrin clot leading to abnormal and unexpected bleeding. The condition may be identified as early as in the newborn period, with bleeding from circumcision, severe cephalohematoma, or even during the cutting of the umbilical cord. Children present with easy bruising, bleeding from cuts and wounds, epistaxis, and hemarthrosis. There are three types of hemophilia: 1. Mild: Bleeding is only associated with severe trauma 2. Moderate: Bleeding is associated with minor trauma 3. Severe: Bleeding occurs spontaneously

Assessment ■ Assess child for painful joints, bruising, bleeding in mouth, nose, or rectum ■ Assess child with severe hemophilia for symptoms of intracranial bleeds ■ Assess teen girls for excessive menstrual flow

Diagnostic Testing ■ Laboratory diagnostics of complete blood count (CBC), DNA testing, and coagulation studies will reveal condition ■ Assess PT, PTT, platelets, thrombin clotting time, and bleeding times

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187 Treatment ■ Administration of missing clotting factors for severe cases and desmopressin (DDAVP) for mild to moderate hemophilia A ■ Cryoprecipitate and fresh frozen plasma may be administered ■ Children should continue to have regular immunizations

Nursing Care and Concerns Educating all family members on the prevention of injuries and the presence of bleeding is essential. Clinical signs and symptoms of bleeding should be taught, including headaches, blurred vision, swelling of joints, tenderness, vomiting, lethargy, and seizures. Immediate joint immobilization, administration of ice packs, elevation and pressure should be reinforced. ■ Child’s school nurse and teachers must be involved with care and able to intervene if injury occurs. Child should be included in physical activity but rigorous contact sports must be avoided ■ Teaching all caregivers, and child if developmentally appropriate, to accurately administer clotting factors after injury to stop bleeding is life saving. This includes storage, reconstitution, and administration of the factor ■ Recommend using soft toothbrushes. Do not take rectal temps or perform digital rectal examinations. Avoid IM injections and pad side rails to prevent injury ■ Refer family to the National Hemophilia Foundation (www.infonhf.org)

Evidence-Based Practice Tips ■ Avoid all aspirin or aspirin-containing medicines ■ Childhood obesity is associated with joint stress and should be avoided via teaching, support, and interventions ■ Aggressive treatments of bleeding episodes prevent permanent crippling from hemarthrosis

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PATHO H–Q

Hirschsprung’s Disease Pathology Hirschsprung’s disease is considered a congenital aganglionic megacolon of the rectum or rectosigmoid, presenting as the absence of peristalsis and, therefore, absence of normal bowel evacuation. The aganglionic section of the bowel is due to the absence of autonomic parasympathetic ganglion cells, leading to the lack of nerve interventions and lack of propulsive movements of bowel. Feces accumulate directly above the area of the aganglionic segment, and the bowel above the aganglionic section then dilates. Etiology is unknown but may be associated with viral infections, intestinal polyps, or lymphoma. The condition typically presents in the newborn. Hirschsprung’s disease can be life threatening if intestinal distention and ischemia leads to enterocolitis. Transverse colon

Aganglionic portion of colon Rectum

Sigmoid colon, proximal to lesion, greatly distended

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189 Assessment The neonate presents with lack of stool passage or explosive stools that may be ribbon-like. Possible findings include: ■ ■ ■ ■ ■ ■

Abdominal distention Bilious vomiting Liquid or ribbon-like stools Palpable fecal mass Failure to thrive and weight loss Constipation

Assess for signs of dehydration: Pallor, dry mucous membranes, sunken eyes, and increased capillary refill time. Assess for presence of enterocolitis: Explosive, bloody diarrhea; lethargy; temperature instability; metabolic acidosis; and hypovolemic shock.

Treatment Surgical procedures may be performed in two or three steps; a temporary colostomy to divert fecal contents and allow the bowel to resume expected tone, then a rectal pull-through procedure is performed to remove the entire aganglionic segment of bowel along with the reversal of the temporary colostomy. Reversal of colostomy may not occur for 3 to 4 months after pull through.

Nursing Care and Concerns ■ Preoperatively assess child for nutritional status, weigh patient daily, and monitor I & O. Provide family emotional support and educate on the plan of care. Do not take rectal temperatures or use suppositories ■ Prepare child and family for surgery. Treat symptoms of pain and discomfort. Monitor for complications such as perforation ■ Provide postoperative care, which includes monitoring strict intake and output, including the nasogastric (NG) tube; monitor for pain, keep wound clean and dry to prevent infection. Do not use a rectal thermometer or suppositories. Educate the parents on procedures and care

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HIV/AIDS Pathology AIDS is caused by the human immunodeficiency virus (HIV). The virus targets the immune system CD4+ T-helper lymphocytes as well as macrophages and B-lymphocytes. AIDS is considered a multisystem disease producing gradual immunodeficiency. The virus is transmitted only via direct contact with blood, blood products, body fluids (semen, vaginal secretions, and breast milk), sexual contact, IV drug use, and prenatal vertical transmission from mother to child prenatally. Casual contact does not spread the virus. Most infected children become symptomatic within the first 6 to 9 months of life. Clinical findings include: ■ ■ ■ ■ ■

Lymphadenopathy Low birth weight Failure to thrive Oral thrush Recurring upper respiratory infections

Classification of AIDS Patients ■ Category N: No symptoms present ■ Category A: Mild symptoms including dermatitis, parotitis, otitis media, and lymphadenopathy ■ Category B: Moderate symptoms including cardiomyopathy, hepatitis, chronic diarrhea, meningitis, pneumonia, sepsis ■ Category C: Severe symptoms including multiple or recurrent bacterial infections, cytomegalovirus (CMV), HIV encephalopathy, lymphoma, sarcoma, and wasting syndrome

See CDC.org or further information.

Assessment ■ ■ ■ ■

Fever Fatigue Myalgia Night sweats

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191 ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Wt loss Diarrhea Respiratory infections Skin lesions/infections/inflammations Oral thrush Diaper rashes FTT Neutropenia Thrombocytopenia Anemia Developmental delays

Diagnostic Testing In pediatrics, the following tests are used to diagnose HIV: ■ ■ ■ ■ ■ ■ ■

ELISA Western blot HIV antigens HIV cultures CD4/CD8 ratios Polymerase chain reactions CBC

Treatment ■ Supportive care to treat infections ■ Combinations of antiviral drugs are used to slow the replication of the virus ■ Prophylactic antibiotics are used to prevent infections

Nursing Care and Concerns ■ Assess family’s knowledge of HIV/AIDS and provide several forms of education, including conference sessions, handouts, educational movies ■ AIDS is considered life threatening. Families need lots of support, education, and follow-up care

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PATHO H–Q ■ Prevent the child from being exposed to infectious agents in the hospital, clinic, and at home and use strict hand washing for patient encounters ■ Assess adherence to medication regimen ■ Assess child’s pain on a regular basis and provide interventions to increase comfort ■ Provide nutritional support to prevent wt loss ■ Assess for opportunistic infections ■ Educate family on transmission of the virus and use of appropriate universal precautions to reduce spread of the virus ■ Children should attend school ■ Support child’s developmental milestones and achievements ■ Refer family for child life, social services, and spiritual care ■ Since there is no cure, support child’s quality of life

Evidence-Based Practice Tips ■ All scheduled immunizations should be administered, but live vaccines should be replaced by attenuated ■ Administration of AZT to a pregnant woman before birth has been shown to reduce transmission of virus to the newborn during delivery

Hydrocephalus Pathology Hydrocephalus is a condition that results from the increased production, lack of reabsorption, or lack of outflow of cerebral spinal fluid (CSF) within the cranial vault. With the obstructed outflow, the child experiences a rise in intracranial pressure and a dilatation of the ventricular system proximal to the obstruction. The condition leads to ventricular dilatation and enlargement of child’s head circumference. Hydrocephalus is associated with tumor, vascular malformations, abscesses, cysts, hemorrhages, meningitis and trauma. There are two types: 1. Communicating hydrocephalus: Obstructed arachnoid villa with resulting lack of reabsorption of the CSF. 2. Noncommunicating hydrocephalus: Obstructed flow of CSF within the ventricular system from the presence of tumor or a congenital malformation.

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193 Assessment ■ Head circumference that is out of the expected range for a child’s age (>95th percentile) ■ Bulging fontanels ■ Distended scalp veins ■ Sunset eyes (appears downturned) ■ Poor feeding behaviors ■ Vomiting (may be projectile) ■ Irritability ■ Lethargy ■ Seizure ■ High-pitched cry

Treatment Treatment of hydrocephalus involves the placement of a temporary or permanent shunt to provide an exit for flow of CSF. Typically, the shunt is placed to drain excessive or obstructed CSF from ventricles to the peritoneal cavity from which it is then reabsorbed and excreted. The shunt is a straight, Silastic catheter placed in the right ventricle via a burr hole. The drainage is then either managed via a permanent extraventricular shunt or temporary shunt via a connection system to an external collecting system (child will be in the pediatric ICU).

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Nursing Care and Concerns ■ Provide meticulous postoperative care: Child is placed in a flat position on the nonoperative side; prevent pain or discomfort that would induce crying; assess for seizures ■ Assess for complications with the shunt system, such as sudden change in child’s clinical symptoms associated with sudden increase in intracranial pressure (ICP) ■ Assess for and prevent infections to shunt ■ Follow orders for shunt maintenance ■ Measure head circumference ■ Teach the parents signs and symptoms of ICP

Hyperbilirubinemia Pathology Hyperbilirubinemia is a condition of the neonate in which there is an increase in the breakdown of red blood cells (RBCs) releasing bilirubin. Child presents with jaundice from lipid-soluble unconjugated or indirect bilirubin in tissues. If there is a decrease of lipid-soluble bilirubin binding with albumin that should travel to liver for processing, then jaundice occurs. Conjugated bilirubin is water-soluble and has been processed by the enzyme glucuronyl transferase and is typically excreted through the infant’s urine and bile. Hyperbilirubinemia of the newborn most often occurs when there is a physiological immaturity of the liver functions or when there is an increased destruction of the RBCs. Typical onset is by 3 days of age. For normal newborns without a diagnosis of hyperbilirubinemia, slightly elevated levels decrease without interventions by the 10th day of life. Jaundice can be identified not only in the tissues but also the sclera, mucous membranes, and by the presence of dark urine. There are two types of hyperbilirubinemia: 1. Indirect hyperbilirubinemia: Transient, physiological, or breastfeeding jaundice 2. Direct hyperbilirubinemia: Biliary obstruction, metabolic disorders, neonatal hepatitis syndrome

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195 Assessment ■ Jaundice: Apply light pressure over bony prominences to blanch the skin. The yellow color of the jaundiced tissues will be evident. ■ Poor feeding behaviors, poor breastfeeding ■ Lethargy ■ Encephalopathy, which is the deposition of unconjugated bilirubin in the brain tissues; also called kernicterus

Diagnostic Testing ■ Laboratory values are followed on a regular basis as part of ongoing assessment of the child’s status: Elevated indirect bilirubin levels will dictate length of stay under bili lights (can be drawn by heel stick) ■ Hyperbilirubinemia is determined by values that exceed the expected ■ Many institutions determine values over 13 mg/dL to be elevated

Expected Bilirubin Values ■ ■ ■ ■

Cord: <2 mg/dL 0–1 day: <6 mg/dL 1–2 days: <8 mg/dL 3–7 days: <12 mg/dL

Treatment Hyperbilirubinemia is treated with bili light phototherapy. This therapy draws the bilirubin from the tissues to then be secreted. Time under the lights is determined by serial bilirubin laboratory draws.

Nursing Care and Concerns ■ Provide support for the new parents who are experiencing anxiety from their infant maintained under the phototherapy lights. Provide regular time intervals for holding, bonding, and feeding ■ Because protein binds with the conjugated bilirubin, the infant must be provided sufficient breast milk or formula. Work with the interdisciplinary team to determine adequate intake. Child may be lethargic and difficult to feed

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PATHO H–Q ■ Make sure the infant’s eyes are covered with protective shield devices while under the intense bilirubin lights. Teach the parents about the importance of this safety measure ■ Assess hydration status, because the infant is at risk for dehydration ■ Bili lights are continued until there is an acceptable pattern of reduction in total bilirubin levels. Some physicians may want to check for rebound effects and will monitor the child for 6 to 8 hours after the removal of phototherapy.

Idiopathic Thrombocytopenic Purpura Pathology Idiopathic thrombocytopenic purpura (ITP) is an acquired hemorrhagic condition in which circulating platelets are reduced. ITP typically follows a viral infection such as an upper respiratory infection or childhood communicable disease, but the etiology may be unknown. The condition occurs secondary to the production of antiplatelet antibodies from the spleen, which radically reduces the child’s circulating platelets. The typical presentation is bruising and bleeding into the tissues (purpura), petechiae or pinpoint bruising, bleeding of the mucous membranes, or blood found in the child’s urine or stool.

Assessment ■ Assess for signs of bleeding in any system

Diagnostic Testing ■ Monitor CBC and platelet counts. Report drops in level or levels below 20,000/mm3 ■ Assess coagulation studies ■ A bone marrow biopsy may be performed to rule out leukemia or other conditions

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197 Treatment ■ Oral or IV corticosteroids ■ Administration of intravenous immunoglobulins (IVIg) ■ Anti-D antibody in one dose for children with Rh D positive blood type, no mucosal bleeding, no infections, and normal white blood count (WBC)

Nursing Care and Concerns The administration of IVIg requires meticulous dosage calculation and medication administration. Nurses should work closely with the pharmacy to determine rate and total volume required by the child’s height and weight. Calculations should be double-checked by two nurses. Infusions start slowly and are increased every 15 minutes after repeated vital sign (VS) checks to monitor for hypotension and reactions. Carefully document all assessments and report any change of clinical condition immediately.

Evidence-Based Practice Tips ■ The rapid initiation of IVIg reduces the length of hospitalization and the possibility of a splenectomy

Increased Intracranial Pressure Pathology The child’s brain is enclosed in a rigid cranial vault. Under normal circumstances, a child’s ICP stays constant. Compensatory mechanisms include alterations between CSF, blood flow, brain tissue fluids, and meninges. If one compensatory mechanism increases, there must be a reduction of another. If ICP is not corrected, decreased perfusion and increasing edema can lead to loss of cerebral arterial perfusion and, if left untreated, brain cell death. A number of injuries and conditions cause the pressure of the intracranial tissues to increase: ■ Presence of a space-occupying lesion, such as tumor or foreign object ■ Intracranial bleeds ■ Trauma

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PATHO H–Q ■ ■ ■ ■ ■ ■ ■ ■

Meningitis Water intoxication Cysts Abscesses AV malformations (arterial-venous malformation of vessels) Obstructive hydrocephalus Overhydration in the treatment of diabetic ketoacidosis (DKA) Presence of a shunt

Increasing pressure within the bony cranium leads to compression of tissues and vital areas such as the brainstem. Progressive deterioration occurs as intracranial pressure increases. If herniation is suspected, rapid sequence intubation is imperative.

Assessment ■ Neurological status: Altered level of consciousness and altered mental status ■ Vomiting ■ Cushing’s response: ■ Hypertension ■ Bradycardia ■ Bradypnea ■ Bulging anterior fontanels and/or increasing head circumference ■ Retinal hemorrhage ■ Seizures ■ High-pitched cry ■ Sunset eyes ■ Diplopia ■ Unequal pupils ■ Occipital headaches ■ Neck pain ■ Vomiting (including projectile vomiting) ■ Visual disturbances ■ Decreased level of consciousness ■ Decerebrate or decorticate posturing

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199 Treatment ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Secure ABCs Provide C-spine stabilization Assess for need of neurosurgical interventions Consider rapid sequence intubation as needed Treat seizures if present Elevate the head of bed (HOB) at least 30 degrees Do not use hypotonic IV solutions: fluid shifts from intravascular space to extravascular space will increase ICP Avoid prolonged bag and mask ventilation Consider steroids to reduce inflammation Consider mannitol to induce dieresis Transfer to ICU

Lidocaine blunts ICP spikes. Thiopental and propofol cause peripheral vasodilatation.

Nursing Care and Concerns ■ ■ ■ ■ ■ ■

Assess for early signs of neurological change and increasing ICP Keep HOB elevated Prevent over- or underhydration Monitor strict I&O Prevent skin breakdown Monitor for diabetes insipidus (DI) and syndrome of inappropriate antidiuretic hormone (SIADH)

Evidence-Based Practice Tips ■ Deep respiratory suctioning and chest percussion increases ICP

Inflammatory Bowel Syndrome Pathology Inflammatory bowel syndrome (IBS) is a group of bowel disorders that are considered idiopathic and chronic, mainly surfacing during adolescence. Two of the most common are Crohn’s disease and ulcerative colitis.

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PATHO H–Q Crohn’s Disease Crohn’s disease is a chronic inflammatory disorder involving any region of the GI tract, from the mouth to the anus. Tending to be eccentric and segmental, skip areas of normal bowel are present. The disease involves all layers of the intestine walls. Children may present with cramping pain, abdominal pain, bloody stools, diarrhea, urgency to stool, fever, fatigue, decrease in appetite, and weight loss. Diagnostic confirmation is with history, physical examination, laboratory studies, and endoscopic or colonic scoping with or without biopsies. Treatment consists of nutritional therapy, oral corticosteroids, aminosalicylates, and surgery as the last resort. Possible complications to watch for are intestinal obstruction, perforation, sepsis, hemorrhage, fistulas, strictures, and toxic megacolon.

Ulcerative Colitis A chronic inflammatory disorder of the colon and rectal mucosa with varying degrees of ulceration, bleeding, and edema. Children usually present with diarrhea, rectal bleeding, abdominal pain, stool urgency with a gradual progression of symptoms. Other symptoms may include electrolyte imbalances, anorexia, weight loss, fatigue, fever, and pallor. Diagnosis is confirmed with history, physical, laboratory studies for anemia, leukocytosis and increased sedimentation rate, and colonoscopy. Treatment is not curative but focuses on control of symptoms. Aminosalicylates and oral corticosteroids are used to decrease inflammation. Nutritional support is needed to correct nutrient deficits, to promote energy, and to promote normal growth. Surgical treatment is initiated if medical and nutritional therapies fail.

Intussusception Pathology Intussusception is the telescoping or invagination of a segment of bowel into a section just adjacent to it, causing an obstruction. It comes on suddenly, with severe colicky pain occurring at frequent intervals. The area most affected is the right upper quadrant at the juncture of the small intestine and the cecum. Typically, the condition presents in children between 3 months and 5 years old.

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201 Assessment Assessment of the patient may reveal intermittent pain that may cause the child to present in a fetal position, or with legs flexed, crying loudly. Palpation may show evidence of a distended and tender abdomen with a palpable sausage-like mass. Other possible findings include emesis of gastric content and “currant jelly-like” stools containing mucus and blood. Lethargy presents in the infant as the child becomes weaker.

Treatment Treatment involves the insertion of an NG tube to decompress the intestines and minimize vomiting. A nonsurgical reduction of the area of the intussusception includes the use of air, barium, and water-soluble contrast. If these interventions fail, then surgery must be performed. These are emergency procedures. Untreated intussusceptions are considered life threatening secondary to necrosis that can develop from lack of blood flow, hemorrhage, perforation, and shock. The more time that passes before medical interventions, the more acute the child presents with weakness, lethargy, abdominal distention, shock, and the possibility of death.

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Kawasaki Disease Pathology Kawasaki disease is considered a condition of multisystem vasculitis leading to acute febrile illness requiring hospitalization. May lead to cardiac involvement in which vasculitis of the coronary artery occurs. Peaks in the winter months and is almost always seen in children younger than 8 years old. Infants diagnosed with Kawasaki must be closely monitored for cardiac damage. Etiology is unknown. One quarter of all children with Kawasaki disease left untreated will experience coronary artery aneurysms and dilatation.

Assessment ■ ■ ■ ■ ■ ■ ■ ■

Fevers lasting more than 5 days Strawberry-looking tongue and red, cracked lips Rash (polymorphous exanthem) Swelling of hands and feet Extreme irritability Arthritis, uveitis, aseptic meningitis, carditis Irritation and redness of the eyes Swollen lymph nodes

Phases ■ Acute: 8 to 15 days in length; characterized by abrupt fevers, rashes, strawberry tongue edema ■ Subacute: 10 to 25 days in length; characterized by desquamation of the toes and fingers, fevers resolved ■ Convalescent: Variable, all clinical symptoms resolved and laboratory tests back to normal

Diagnostic Testing ■ ■ ■ ■

Sedimentation rate C-reactive protein Urinalysis (UA) Platelet count

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203 Treatment ■ Aspirin therapy: 80–100 mg/kg/day divided into q 4–6 hour doses ■ High-dose intravenous gamma globulin: 2 g/kg over 8–12 hours

Nursing Care and Concerns ■ Monitor cardiac status: I&O, daily weights ■ Provide symptomatic relief for fever, rash, and oral care

Evidence-Based Practice ■ Children’s left ventricle function should be followed by serial echocardiography. Longer-term follow-up is required for children who demonstrate abnormalities ■ For children in their second decade, stress testing should be performed every 2 years to help guide activity restrictions. Endurance training for contact sports should be discouraged

Lead Poisoning (Plumbism) Pathology Lead poisoning occurs with the accumulation of lead in the child’s blood. Toxicity occurs when the level is above 10 mcg/dL in capillary testing or above 10 mcg/dL in venous samples. The presence of lead in the brain tissues increases vascular permeability, thus leading to fluid shifts resulting in encephalopathy and increased ICP. Central nervous system damage and renal toxicity are serious complications and lead to hyperactivity, aggression, irritability, cognitive impairment, brain damage, seizures, and death. High lead levels interfere with RBC production and lead to overall anemia. Toddlers and preschoolers are at greatest risk for lead poisoning due to their play, teething, mouthing of objects, and developmental level. Typically children experience lead poisoning slowly over a period of time and the ingestion of the lead material cannot be excreted.

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PATHO H–Q CDC and Prevention Classification of Lead Poisoning Risk ■ Class 1 (low risk) under 9 mcg: Retest every 24 months for children ages 6 to 35 months who are considered low risk; retest every 6 months for those ages 6 to 35 months who are considered high risk ■ Class IIa (rescreen) 10 to 14 mcg: Retest early; continue retesting yearly for children older than age 36 months until they are age 6 years ■ Class IIb (moderate risk) 15 to 19 mcg: Retest every 3 to 4 months for children ages 6 to 35 months ■ Class III (high risk) 20 to 44 mcg: Retest every 3 to 4 months; begin home abatement program ■ Class IV (urgent risk) 45 to 69 mcg: Initiate medical therapy and environmental remediation ■ Class V (urgent risk) greater than 70 mcg: Immediately treat with chelating agent

See www.cdc.org for more information

Assessment Assess the child’s exposure to lead-based paint chips (used prior to 1970 in older homes), industrial lead dust, auto exhaust, lead-based ceramic pottery, cultural medical remedies that contain lead, and contaminated water or air. Also assess child for severity of symptoms: ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Lethargy Irritability Fatigue Headache Weight loss Vomiting Anemia Colic Behavior difficulties Learning difficulties Paralysis Seizures Encephalopathy Coma Death

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205 Diagnostic Testing ■ Diagnostics will include a CBC, UA, renal panel, iron level

Treatment Treatment focuses on the safe removal of lead from the blood with IV or IM calcium disodium edentate (Ca EDTA) or deep IM British anti-lewisite (BAL or dimercaprol) or oral Succimer. Follow institutional policy carefully concerning IV lead poisoning treatment as often frequent assessments and VS are warranted during the infusion. Side effects of IV chelation infusions include: ■ ■ ■ ■

Hypertension and tachycardia Nausea, vomiting, diarrhea Burning sensations in the mouth Muscle weakness

Nursing Care and Concerns ■ Corroborate histories from different family members to confirm type/dose/extent of toxic exposure ■ Families must be taught how to rectify the toxic lead exposure by evaluating the child’s home environment, tableware, cultural practices Treatment will only be successful if the child’s exposure is terminated ■ Family education concerning lead exposure and possible contamination is the priority treatment for levels found between 10 and 19 mcg/dL Nurses are key players in this necessary education. A child’s exposure occurs due to three factors: Drinking contaminated water, breathing lead dust or ingesting contaminated food or nonfood substances ■ If a large number of children in a community have tested positive, notify and refer to local public health department for follow-through ■ Question the family about pica behaviors. Provide education ■ Check for previous peanut allergies before the transfusion of Dimercaprol (BAL)

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PATHO H–Q Evidence-Based Practice Tips ■ Young children should be routinely screened for lead levels at 1 year unless considered high risk before that time ■ Lead levels found >70 should always be considered a medical emergency and warrant hospitalization. At this level, encephalopathy should be highly suspected and treated immediately ■ Encephalopathy associated with lead poisoning may not have a prodromal period and may be seen as unusually behavioral changes in the child. Any nonspecific change in behavior or unexplained behavior should prompt care providers to suspect lead poisoning

Meningitis Pathology Meningitis is the acute inflammation of the meninges, the layer of tissue surrounding the brain and spinal cord. As organisms invade the meninges, the cerebral spinal fluid spreads the infectious agent to the brain and adjacent tissues. Neonates have the poorest prognosis and the greatest chance for neurological sequelae. There are five types of meningitis: 1. Bacterial meningitis via direct invasion or indirect invasion from infections from other body sites (teeth, sinuses, lungs, and tonsils) 2. Viral meningitis such as from enteroviruses 3. Fungal meningitis 4. Chemical agents causing inflammation of the meninges 5. Aseptic meningitis caused by enteroviruses Most common infectious agents in childhood include: ■ Neisseria meningitidis (meningococcal meningitis) ■ Streptococcus pneumoniae (pneumococcal meningitis)

Most common infectious agents in infancy are: ■ Escherichia coli ■ B Streptococcus

The most serious and life-threatening form of meningitis is meningococcal meningitis in which the child presents critically ill with a rapidly progressive

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207 clinical picture of shock, purpura, reduced level of consciousness, and disseminated intravascular coagulation (DIC), which may result in death within 24 hours or have lasting effects of poor peripheral perfusion leading to limb loss. Long-term complications associated with meningitis include: ■ ■ ■ ■ ■ ■

Cerebral edema Deafness Hydrocephalus Chronic seizure disorders Blindness Increased secretion of antidiuretic hormone (SIADH)

Assessment ■ Assess for primary infections such as otitis media, respiratory tract infections, and sinusitis ■ Assess for classic symptoms: ■ Subnormal temperatures or low-grade fevers ■ Irritability, increased crying ■ Poor feeding, poor suck ■ Bulging fontanels in infants and increased head circumferences ■ Headaches ■ Vomiting and/or diarrhea ■ Symptoms of increased intracranial pressure ■ SIADH ■ Photophobia ■ Nuchal rigidity ■ Positive Kernig’s sign ■ Positive Brudzinski sign ■ Seizures ■ Sepsis ■ Shock

In severe cases, assess for involuntary arching of back and neck.

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Diagnostic Testing Laboratory values from lumbar punctures include: ■ Increase WBC ■ Decreased serum glucose with bacterial infections and increased with viral ■ High protein levels

Treatment ■ Meningitis is considered an emergency and antibiotics are started immediately after blood cultures/lumbar puncture/UA are obtained. ■ Typically 4th generation cephalosporins, ampicillin, or gentamicin are used ■ Children of all ages should be kept in strict respiratory isolation for the first 24 hours or for the first 3 doses of antibiotics deemed sensitive to the infectious organism (Follow institutional policy closely)

Nursing Care and Concerns ■ Isolate child with suspected meningitis immediately, regardless of infectious agent ■ Prepare child and family for lumbar puncture and several laboratory tests ■ Place IV immediately and administer first dose of antibiotics as soon as ready ■ Restrict fluids as ordered for SIADH ■ Provide an environment free of excessive noise and bright lights ■ Monitor for changes in VS and provide pain relief

Evidence-Based Practice Tips ■ The immunization for Haemophilus influenzae b (HIB) has greatly reduced the incidence of HIB meningitis. Teaching families about the important of immunizations is needed to keep the incidence down ■ Do not start antibiotics until specimens are obtained, because if blood culture specimens are contaminated with IV antibiotics, cultures will not be accurate. Follow orders carefully and check institutional policies

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209 Nephrotic Syndrome Pathology Nephrotic syndrome is an idiopathic (95%) symptom complex that is characterized by four major presentations: 1. 2. 3. 4.

Proteinuria Hyperlipidemia Hypoalbuminemia Generalized edema

The most common type is minimal change nephrotic syndrome, also called nephrosis, which responds well to corticosteroids and is self limiting. Clinical presentation of symptoms usually follows an infectious disease process, usually viral in nature, such as an upper respiratory infection. The clinical symptoms are caused by either glomerular damage or by increased permeability to protein leaking through the glomerular membrane, resulting in a loss of serum protein to the urine.

Assessment ■ ■ ■ ■ ■ ■ ■ ■ ■

Vital signs: Normal or slightly decreased blood pressure Shiny skin and prominent veins due to edema Abdominal pain Anorexia Fatigue Decreased urine output Frothy, foamy, dark yellow urine with high specific gravity Assess for fluid volume deficit Assess for complications such as renal failure, sepsis, peritonitis, pneumonia ■ Laboratory values will demonstrate decreased serum albumin (<2 g/dL), increased hemoglobin and hematocrit from hemoconcentration, increased platelet count, increased erythrocyte sedimentation rate, decreased serum sodium, and variable values on other electrolytes

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Treatment ■ Corticosteroid therapy has been found to be the only effective treatment ■ If resistance to steroids occurs, immunosuppressive agents are given

Nursing Care and Concerns ■ Weigh patient daily on same scale; monitor daily abdominal girths ■ Maintain strict accurate account of I&O and monitor urine specific gravity ■ Dipstick urine for blood and protein ■ Prevent skin breakdown in the presence of generalized edema: initiate and post above the child’s bed a specific turning/repositioning schedule ■ Prevent infection ■ Provide low- or no-salt diet during the presence of generalized edema ■ Provide high-protein, high-potassium diet (work with nutritionist) ■ Monitor closely for respiratory/pulmonary involvement: Crackles, work of breathing (WOB) ■ Educate family about the chance of relapse

Evidence-Based Practice Tips ■ Weight loss from anorexia may be masked by increasing generalized edema. Monitor nutritional status carefully. Refer to nutritional services

Poisoning Pathology Children are at risk for ingesting toxic substances across childhood. Crawling infants, active toddlers, and curious preschoolers are at extreme risk. Adolescents are at risk for suicide attempts that lead to poisoning. Common toxic exposures leading to poisoning include: ■ ■ ■ ■ ■

Acetaminophen or salicylate toxicity or overdose Iron or lead Carbon monoxide Opioids, narcotics, benzodiazepines, barbiturates Cardiac medications, such as calcium channel blockers and digoxin

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211 ■ Alcohol ■ Anticholinergics, such as antihistamines, toxic plants, muscle relaxants, and tricyclic antidepressants

Assessment and Treatment Suspected Overdose/Poisoning Management: Four Step Process Step One: Assess the Child ■ Ensure ABCD (airway, breathing, circulation, disability/mini-neurological examination) ■ Apply pulse oximetry ■ Administer oxygen and support/protect airway (may need endotracheal tube [ETT]) ■ Place on cardiac monitor ■ Take VS ■ Obtain IV access ■ Call poison control center for guidance at 1-800-222-1222 ■ Ask family/caregiver to provide chemical name and time since ingestion or exposure if able ■ Obtain blood laboratory draws and urine specimens

Step Two: Terminate Exposure ■ Ingested poison: Empty mouth of pills, plant parts, or other material ■ Do not induce vomiting until informed to do so by Poison Control Center ■ Do not administer Ipecac syrup ■ Poison in eyes: Flush eyes continuously with normal saline (or room temperature water at home) for 15–20 minutes ■ Inhaled poison: Get child to fresh air immediately ■ Poison on skin: Remove all clothing that is contaminated and begin flushing the skin with water and soap

Step Three: Identify the Poison ■ Question the child and witnesses ■ Look for environmental clues, such as empty containers, nearby spills, odor on breath; save all evidence of poison, such as containers, vomitus, urine

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PATHO H–Q ■ Be alert to signs and symptoms of potential poisoning in absence of other evidence, including symptoms of ocular or dermal exposure ■ Call Poison Control Center or other competent emergency facility for immediate advice regarding treatment

Step Four: Prevent Poison Absorption ■ Place child in side-lying position ■ Administer drug antidote, activated charcoal PO or NG ■ Child may require whole bowel irrigation with polyethylene glycol electrolyte solution; cathartic such as magnesium citrate or sulfate, or sorbitol) or perform gastric lavage ■ Monitor for shock, seizures, and arrhythmias ■ Conduct a complete physical examination of all systems

Nursing Care and Concerns ■ Provide diligent support for the interdisciplinary team in the response and treatment of a child experiencing a poisoning ■ Contact and include social services, pharmacy, and Child Protective Services if poisoning is suspected to be intentional ■ Corroborate histories from different family members to confirm type, dose, extent of toxic exposure ■ Maintain suicide precautions ■ Maintain seizure precautions ■ Obtain 24-hour sitter if indicated for child and family ■ Prevent further injury ■ Initiate a formal and well-documented family education plan for: ■ Child safety tips for the home, including safe storage of chemicals, prescription medications and over-the-counter meds ■ Medication storage guidelines (never place meds in alternative containers)

Evidence-Based Practice Tips ■ Ipecac syrup is not recommended for use in acute care settings ■ Gastric lavage is not routinely recommended ■ Return demonstration of medication preparation and administration for caregivers taking home prescriptions is one way to ensure that overdose of even common meds like Tylenol is prevented ■ Activated charcoal is not effective in the treatment of heavy metal poisoning

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213 Oncology There are more than 250 types of childhood cancer. Cancer affects children across childhood, from infancy to adolescents. Care of a child with cancer takes specialized knowledge and concern. Children receiving treatments for cancer require meticulous nursing care to: ■ Prevent complications ■ Support and educate the family ■ Orchestrate an interdisciplinary approach

Cancer is a life-threatening disease that requires lengthy treatment plans. Close contact with the family, open communication, thorough teaching on side effects and infection prevention, and a holistic approach to the care of the child increases quality of life and prevents complications.

Pathology The cause of cancer remains unknown. Genetic factors result in the proliferation of cancer cells with the abnormal properties of: ■ Unregulated growth ■ Lack of contact inhibition in which cells continue to grow when they should stop, such as against bone or out of cavities ■ Metastasizing to surrounding tissue or distant sites

Assessment Presenting clinical signs and symptoms include: ■ ■ ■ ■ ■

Unresolving fevers Discomfort, pain, fatigue Anemia, petechiae Weight loss Lymphadenopathy

Diagnostic Testing ■ CBC with differentiation ■ Bone marrow biopsy

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Treatment ■ ■ ■ ■

Surgery Chemotherapy Radiation Bone marrow transplantation

Side Effects of Cancer Treatments ■ ■ ■ ■ ■ ■

Immunosuppression Infection Anemia, thrombocytopenia, neutropenia Nausea, vomiting, diarrhea, weight loss Mucositis, stomatitis, and ulcerations Alopecia

Chemotherapy drug-specific side effects include pulmonary fibrosis, hemorrhagic cystitis, and renal disease. Investigate specifics for each drug administered.

Nursing Care and Concerns ■ ■ ■ ■

Protection from infection during periods of immunosuppression Implementation of bleeding precautions Interventions for prevention of wasting syndrome/cachexia Education on care of central lines, transfusion therapy, and symptom control ■ Support for family functioning, processing information, and emotional reactions. Anticipate anger, grief, and support coping. Support siblings ■ Provide distraction, play therapy ■ Support child’s connection with school officials The two most commonly found forms of cancer in children are leukemia and brain tumors. These will be addressed here. For further information on childhood cancer specifics concerning types, pathology, and treatments, please see: ■ Association of Pediatric Hematology and Oncology Nursing (APHON) www.aphon.org ■ American Cancer Society at www.cancer.org ■ American Academy of Pediatrics at www.aap.org

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215 Leukemia Leukemia is the most common form of cancer in childhood. Leukemia represents a group of malignancies that invade the bone marrow, lymphatic system, and may cause tumors throughout the body. There are two main categories of leukemia that refer to the cells of origin; acute lymphoblastic leukemia (ALL) and acute myelogenous leukemia (AML) also called acute nonlymphoid leukemia (ANLL). Leukemia causes bone marrow dysfunction leading to anemia, thrombocytopenia, and neutropenia. The unrestricted production and release of dysfunctional, immature WBCs into the circulation causes impaired circulation and immunosuppression. Treatment focuses on the eradication of the production of leukemic cells via chemotherapy, radiation and bone marrow transplantation. Prevention of leukemic cell lysis syndrome is imperative; it is life threatening and leads to hyperuricemia, hyperkalemia, and hyperphosphatemia.

Nursing Care and Concerns Administer chemotherapy accurately with a focus on symptom management and complication prevention. Assess for specific complications associated with each chemotherapy drug such as cardiomyopathy, and pulmonary fibrosis. Early identification of fevers during neutropenia with subsequent aggressive antibiotics is an essential nursing function.

Evidence-Based Practice Tips Early identification of the following complications saves lives during aggressive cancer treatment in children: Blood transfusion reactions Central line infections Hyperleukocytosis Sepsis associated with neutropenia Superior vena cava syndrome Tumor lysis syndrome Typhlitis

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Brain Tumors Brain tumors are the most common solid tumor found in childhood. There are four types: 1. 2. 3. 4.

Astrocytoma Glioma Ependymoma Medulloblastoma

Assessment focuses on symptoms associated with the presence of tumor in brain tissue. Visual changes, gait changes, weakness, clumsiness, and seizures may be present. Assess for increasing cranial size, including bulging fontanels and open cranial sutures in infants. Treatments include surgical debulking and/or removal, radiation and chemotherapy. Nursing care focuses on preserving neurological function, providing symptom control, and supporting all family members. Postoperative care includes: ■ Keeping HOB up as ordered ■ Providing a quiet, dimly lit environment for healing ■ Assessing for pain, headache, symptoms of increasing intracranial pressure ■ Maintaining bandages over surgical site, preventing infection

Other childhood cancers include: ■ Neuroblastoma: Tumors of the neuroganglia ■ Retinoblastoma: Tumors of the retina in the eye ■ Wilms’ Tumor: Tumor of the kidneys

Orthopedics: Fractures and Traction Pathology The pathophysiology of fractures across the childhood is associated with several causes: ■ Indirect force or direct force in which bone is subjected to stress beyond what it can endure ■ Spontaneous fracturing associated with an underlying disease process (osteogenesis imperfect)

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217 ■ ■ ■ ■

Muscle contractions; intense and associated with seizures Child abuse Cancer; sarcomas Osteoporosis caused by immobilization

Most childhood fractures occur along the long bones. Types of fractures include: ■ Greenstick: Incomplete fracture on one side with buckling of bone on other ■ Compression: Two bones involved with compression between ■ Comminuted: Bone is splintered into several pieces ■ Spiral: Fracture is in a circular pattern ■ Compound: Considered open; skin is broken and bone may protrude ■ Simple: Considered closed; skin remains intact. Fracture is limited ■ Complete: Bone separates into two or more pieces ■ Incomplete: Partial fracture which extends through the width of the bone

The highest morbidity is associated with skull fractures and pelvic fractures. All fractures in a child younger than 18 months should include an assessment for child abuse. Fractures presenting in various stages of healing should be evaluated for child abuse.

Assessment ■ ■ ■ ■ ■

Tenderness at site, may be relieved with rest or immobility Guarding of limb associated with fracture Limited mobility Generalized swelling or deformity at the fracture site Decreased vascularity and neurological function distal from the site

Diagnostic Testing ■ ■ ■ ■

X-ray Bone scans Magnetic resonance imaging (MRI) Ultrasound

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Treatment ■ Treatments are focused on immobilizing the fractured limb or site, allowing the site to heal, and preventing complications, including deformity, nerve injury, compartment syndrome, and joint dysfunction ■ Open reduction, internal fixation (ORIF) surgical processes may be warranted ■ Traction, casting, and pinning may be required

Nursing Care and Concerns ■ Assess for pain and discomfort and provide interventions as required ■ Immobilize fractured site and maintain alignment ■ Monitor cast after application; plaster of Paris dries much slower than synthetic materials ■ Handle the drying cast with palms only, not fingers, to prevent denting ■ Assess for irritation and skin breakdown at site of cast ■ Assess and document CCSMT (circulation, color, sensation, movement and touch) ■ Assess for signs of compartment syndrome: Severe pain, pallor distal to fracture ■ Assess for signs and symptoms of infection at surgical site; check pins ■ Assess for fat emboli associated with large fractures that release bone substances into the blood vessels ■ Alleviate swelling with ice, elevation ■ Assess adequacy of diet for protein and vitamins to promote healing ■ Educate family on anticipatory guidance to prevent further accidents, injuries, and fractures.

If child is in traction: ■ ■ ■ ■ ■

Make sure alignment, pulleys, and ropes, are all secured Do not stop traction pull at any time as fracture can become worse Provide distraction and play therapy for extended bed rest Offer adequate fluids and high-fiber diet Encourage exercise and full range of motion for all extremities unaffected by traction or casting

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219 Pneumonia Pathology Pneumonia is the acute infection and inflammation of the lung parenchyma, such as the alveoli, alveolar sacs, ducts, and bronchioles. The condition, if severe, can impair gas exchange and lead to acute illness in children. Typically, pneumonia is classified according to the infectious agent or etiology if the culprit is chemical in nature, such as aspiration pneumonia of gastric acid. Major organisms include Streptococcus pneumoniae, group A Streptococcus, enteric bacilli, Haemophilus influenzae, and the respiratory syncytial virus (RSV). In older children, Mycoplasma pneumonia is most common. When lobular involvement occurs from bacterial pneumonia, it is considered consolidation. If viral in etiology, it is considered interstitial tissue inflammation. Viral pathogens that can cause pneumonia include parainfluenza, adenovirus, and influenza. Chemical pneumonia can occur from aspiration of stomach contents, foreign bodies, or food.

Assessment ■ ■ ■ ■ ■ ■ ■

High fevers and chills Chest pain Nausea, vomiting, anorexia, and diarrhea Nonproductive or productive cough Rhinitis Malaise Anxiety with air hunger

In infants, grunting, intercostal and subcostal retractions, and nasal flaring may be present ■ Circumoral cyanosis may be present in severe cases

Diagnostic Testing Laboratory studies include sputum collection for culture, CBC, blood cultures, strep titers (antistreptolysin-O [ASO] titers) Chest x-rays are used to confirm infiltrates or consolidation.

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Treatment ■ IV or oral antibiotics sensitive to causal agent such as penicillin G ■ Antibiotics are not used to treat viral pneumonia but may be ordered to prevent secondary infections in susceptible children with chronic diseases or immunosuppression ■ Severe cases may require a period of time on assisted ventilation

Nursing Care and Concerns ■ ■ ■ ■

Assess respiratory status frequently, and provide oxygen prn Assist with secretion removal Provide sips of favorite fluids to prevent dehydration Educate family on importance of antibiotic therapy and prevention of transmission

Evidence-Based Practice Tips ■ The administration of the immunization pneumococcal vaccine reduces pneumonia in high-risk children

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221 Respiratory Syncytial Virus Bronchiolitis Pathology Bronchiolitis is an illness of the lower respiratory tract, typically caused by a virus. When respiratory syncytial virus (RSV) is the cause, the walls of the small bronchi and bronchioles become inflamed with copious mucus secretion. The child’s symptoms include tachypnea, dyspnea, and hypercarbia in severely ill children. Death can occur with severely compromised infants. RSV bronchiolitis occurs most frequently in winter months, October through April, and is highly contagious via droplet transmission. Infants and young children with RSV can be roomed together during hospitalizations. Follow institutional protocol concerning bed assignments and distance between patients, which may be 3 feet or more.

Assessment Obtain a nasal specimen for rapid laboratory confirmation of RSV infection as soon as bronchiolitis is suspected. This can be performed by a simple nasal wash, bulb syringe technique, or by the use of a syringe attached to cut IV HL/SL tubing with 1 cc sterile saline for inoculation and aspiration. This will allow for immediate isolation and prevention of transmission to other hospitalized children. Symptoms include: ■ Chills, fever ■ Rhinorrhea: copious mucus production requiring frequent suctioning in infants ■ Persistent tight bronchiolitic cough ■ Retractions ■ Rhonchi, fine rales, crackles, and wheezing ■ Irritability ■ Difficulty sleeping due to dyspnea and mucus production

Treatment ■ High-risk infants and premature infants may require RespiGam (palivizumab) or RSV immune globulin (RSV-IVIg) to prevent severe

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■ ■ ■ ■

infections. Prophylaxis is initiated at the beginning of the high-risk season and continued until the season is over High-risk infants can experience apneic episodes and, therefore, should be monitored Child may respond to bronchodilators Children with preexisting lung disease may require steroids Severe illness (characterized by tachypnea, listlessness, apneic spells, and hyperexpanded chest) requires transfer to critical care/intensive care unit

Nursing Care and Concerns ■ ■ ■ ■ ■ ■

Provide close observation and place high-risk infants on monitor Keep acutely ill child NPO to prevent aspiration Provide source of hydration Suction frequently Providing humidified air may decrease symptoms Provide airway support and oxygenation as needed

Evidence-Based Practice Tips ■ Children younger than 2 years with bronchopulmonary dysplasia (BPD) requiring oxygen should receive RSV immunoprophylaxis

Reye’s Syndrome Pathology Reye’s syndrome is a nonspecific, noninflammatory encephalopathy with organ involvement. Death occurs due to brain tissue herniation in association with severe cerebral edema, sepsis, and shock. Reye’s syndrome is strongly associated with the use of salicylates (aspirin) to treat symptoms of varicella infections or influenza. The Academy of Pediatrics has issued warnings to parents and healthcare professionals to avoid using salicylates in children with possible varicella infections or influenza A or B. Reye’s syndrome is associated with six major clinical presentations: 1. Encephalopathy 2. Increased ICP

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223 3. 4. 5. 6.

Metabolic dysfunction Hepatic dysfunction Renal damage Fatty infiltration of the viscera

Assessment ■ ■ ■ ■ ■ ■

Hypoxia Seizures Hypoglycemia Coagulopathies Electrolyte imbalances Hyperthermia

Diagnostic Testing Glucose ■ Newborn >day: 50-90 mg/dL ■ Child: 60-90 mg/dL

Electrolytes ■ Sodium, child: 138–145 mmol/L ■ Potassium, child: 3.5–5.0 mmol/L ■ Chloride, child: 97–110 mmol/L

Ammonia ■ Child: 15–45 mcg/dL

Creatinine Phosphokinase ■ Child: 0.3–0.7 mg/dL

Lipase ■ 4–24 U/dL

Amylase ■ 0–44 Units/L

Bleeding Times ■ PT, child: 11–14 seconds ■ PTT, child: 21–35 seconds

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Staging of Reye’s Syndrome Stage I II (follows 5–7 days after stage I) III IV V

Symptoms Lethargic, vomiting, sleepiness, normal posture, brisk pupil reaction, purposeful response to pain stimuli Combative or stuporous, disoriented, normal posture, sluggish pupil reaction, purposeful or nonpurposeful response to pain stimuli Coma, decorticated, sluggish pupil reaction Coma, seizures, decelerate, sluggish pupil reaction Coma, apnea, flaccid, no pupil reaction

Source: National Institute of Health, www.nih.org

Treatment ■ Close observation in ICU ■ Drug treatment for osmotic diuresis, coagulopathies, and pain

Nursing Care and Concerns ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Monitor patient carefully for progression through stages Monitor for changes in neurological status; report immediately Assess for symptoms of GI bleeding, pancreatitis, liver failure Provide IV hydration with glucose Provide seizure precautions Monitor respiratory status Check pupils using Glasgow Coma Scale Elevate head of bed 30 to 45 degrees Keep child calm and free of discomfort; avoid crying Provide quiet environment Reinforce parent/caregiver education on need for long-term follow-up (auditory and speech disorders, motor and intellectual deficits)

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225 Scoliosis Pathology Scoliosis is a lateral curvature of the spine of greater than 10 degrees. The curvature can occur anywhere along the spine, although it is most commonly found in the thoracic area. Scoliosis is referred to as being functional, structural, or idiopathic: ■ Functional scoliosis: Related to a preexisting condition that affects the curvature of the child’s spine, such as limb length discrepancy ■ Structural scoliosis: A congenital deformity of the spine that may be related to myelomeningocele or failure of formation of wedge vertebrae ■ Idiopathic scoliosis: The most common form; occurs in otherwise healthy, neurologically intact children

It is rare to diagnosis a child with greater than a 20-degree curvature of the spine. Scoliosis is associated with cerebral palsy because these children may have neuromuscular weakness. This disorder is found much more readily in the female gender. Complications can be associated with the presence of scoliosis and include urinary difficulties and neurological problems.

Assessment Radiological screening is performed to determine the location and severity of degree of curvature. Screening of all school-age children is imperative. Although severe curvature can be associated with chronic pain, most scoliosis does not produce discomfort. ■ Asymmetry of hips, shoulders, breasts, flank, or scapulae viewed from behind with child bending forward ■ Unequal limb lengths ■ Malalignment of pelvis and trunk ■ Possible initial complaint of uneven pant legs or difficulty dressing and making clothes fit right

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Treatment Surgical ■ Posterior spinal fusion for curves greater than 40 degrees ■ Surgical placement of hardware such as rods and cables ■ Iliac crest bone chips may be used to position and immobilize the spine and reduce the need for further body casting

Nonsurgical ■ Milwaukee brace worn 23 hours/day ■ Orthoplast jacket, or thoracic lumbar sacral orthotic (TLSO)

Nursing Care and Concerns ■ Ensure postoperative pain control ■ Implement meticulous postoperative assessments and interventions to prevent paralytic ileum, bleeding, fluid and electrolyte imbalances, and respiratory complications ■ Use only two-person log rolling to ensure proper body alignment. Roll and reposition at least every 2 hours. Keep head flat if ordered. ■ Institute range-of-motion exercises ■ Instruct family on use of brace, precautions for use, time period brace is to be removed daily, and how to assess for skin breakdown ■ Encourage adolescent to verbalize concerns about body image and potential reactions from peers

Evidence–Based Practice Tips ■ Premenarchal girls with a lateral spinal curvature of 20 to 30 degrees are at risk for progression of the disease. Curves of less than 30 degrees rarely progress after the skeletal system matures. Scoliosis of greater than 50 degrees often progresses through adulthood

Seizure Disorders Pathology A seizure is a sudden but transient episode of abnormal neuronal activity consisting of repetitive electric discharges from brain cells. The nerve cells become hyperexcitable and the seizure threshold is surpassed.

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227 The term epilepsy denotes two or more seizures (unprovoked) during childhood regardless of type. Seizures are categorized as generalized, focal, partial (simple or complex), or absence. Body movements are described as: ■ Tonic: Rigid posture while muscles are in continuous state of contraction ■ Clonic: Rhythmic pattern of muscles alternating between contraction and relaxation ■ Tonic-clonic: Total body seizure of violent tonic pattern followed by clonic ■ Atonic: Child drops and falls and should always wear a helmet

Symptoms and clinical presentations vary depending on the anatomical location of the brain where the seizure originated.

Causes ■ Fevers (febrile seizures seen with a rapid increase in core body temperature, not necessarily at the height of the fever) ■ Anoxic periods or hypoxic brain injuries ■ Increased intracranial pressure ■ Genetic factors ■ Meningitis ■ Infectious diseases ■ Tumors ■ Toxins ■ Metabolic disorders ■ Head trauma ■ Abrupt withdrawal of anticonvulsant therapy

Types Generalized ■ Tonic-clonic: Loss of consciousness followed by tonic generalized stiffening, then clonic muscle spasms of upper and lower body. Child may lose urinary continence and may experience an aura. Sleep, lethargy, and confusion occur after seizure ■ Myoclonic: Sudden jerky movements of a muscle or group of muscles. Appears synchronous with jerking of the head, neck, upper arms, and legs. Child usually remains conscious ■ Absence: Child demonstrates an impaired awareness or responsiveness for a period of time. Often noted first by teacher in classroom environment. Child is usually alert after the seizure

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PATHO R–Z Focal or Partial ■ Simple partial: No loss of consciousness, motor signs include twitching of one side of the body, hand, and face ■ Complex partial: Impairment of consciousness, lip smacking, hand movements such as picking, chewing

Febrile ■ Rapid increase in temperature lowers child’s seizure threshold ■ Occurs only once per febrile state ■ Up to 4% of the general population less than 5 years old experiences at least one febrile seizure

Complications ■ ■ ■ ■ ■

Aspiration pneumonia Asphyxia Lacerations Fractures Cognitive impairment with severe anoxia

A seizure disorder is considered a brief malfunction of the brain unless the child experiences status epilepticus, in which seizure activity does not stop.

Assessment After seizure, assess child for the following: ■ ■ ■ ■

Loss of consciousness or change in awareness, alertness, or speech Hyperthermia Compromised airway or altered respiratory function Aura during preictal period; considered an unusual sensory experience, such as tastes, smells, feelings, or visualizations ■ Postictal state: Determine level of consciousness, orientation to person, time, place, and situation, sleep state

Diagnostic Testing ■ Electroencephalogram (EEG) to determine type and location of seizures

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229 ■ Lumbar puncture, CBC and toxic screens may be ordered to rule out toxic exposures and infectious processes

Treatment ■ Treatments consist of antiepileptic (anticonvulsant) therapy starting with single-drug and moving to multiple-drug therapy as indicated ■ It is imperative that a nurse assess therapeutic drug levels: ■ Phenytoin (Dilantin): 5–20 mcg/cc ■ Phenobarbital: 15–40 mcg/cc ■ Carbamazepine (Tegretol): 4–12 mcg/cc ■ Valproic acid ((Depakene): 50–120 mcg/cc ■ Ethosuximide (Zarontin): 40–100 mcg/cc ■ Clonazepam (Klonopin): 15–18 mcg/cc

Nursing Care and Concerns Never leave a child during a seizure! ■ Do not attempt to place a tongue blade or airway in a child’s mouth during a seizure, and do not try to restrain a child during a seizure ■ Ensure a safe environment after a seizure, including side-lying positioning and secretion clearance ■ Assess child for injury, bleeding, chipped teeth, and emotional reactions after ■ Reassure family members; witnessing a seizure is disturbing and frightening ■ Monitor for fluid imbalances ■ Maintain meticulous records of seizure activity, including precipitating factors, duration, type, presence of an aura, state of being, and consciousness after seizure ■ Assess for need for IV placement, IV fluids and oxygen after seizure ■ Meticulously document the seizure experience: Note the time the seizure activity started and ended, type of seizure, and movements

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PATHO R–Z If a Seizure History Is Known ■ Provide seizure precautions: Pad bed rails or crib rails ■ Educate entire family and all caregivers on the extreme importance of adhering to drug therapy to prevent seizures and monitoring serum levels of anticonvulsant medications to prevent undermedication or toxicity ■ Assess and support child’s emotional reaction, including body image changes and distress ■ Educate family on need to notify child’s school administration, teachers, and sports team coaches. ■ Educate the family on the need to promote as normal of a life as possible for the child reinforcing safety and a positive self image

Evidence-Based Practice Tips ■ Both genetic predispositions and lowered seizure thresholds in an immature brain are associated with the development of febrile seizures. If a parent’s medical history includes febrile seizures, teaching should include prevention of high fevers

Sepsis and Shock: Newborn and Child Pathology Newborns may present with acute shock secondary to an infection with E. coli, Listeria, herpes viruses, or Group B streptococcus. Newborns are particularly susceptible to sepsis due to their immature immune response. Shock is a clinical syndrome characterized by decreased cardiac output insufficient to meet the demands of the tissues.

Types of Shock ■ Cardiogenic: Pump failure leads to decreased cardiac output. Specific cardiac conditions such as supraventricular tachycardia and other tachydysrhythmias are common etiologies ■ Hypovolemic: Cardiac output is diminished because of decreased intravascular volume secondary to acute body fluid or blood loss. Acute viral gastroenteritis is a common etiology. Estimation of frequency and amount of diarrhea and vomiting is important. Infants and young children have a relatively low blood volume (80 cc/kg), so any loss requires rapid control

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231 ■ Distributive: A combination of decreased systemic vascular resistance and decreased cardiac output. The infant or child presents with vasodilation, resulting in hypovolemia. Etiology may be sepsis, anaphylaxis, and neurological injury ■ Obstructive: Impairment of cardiac filling due to tension pneumothorax, massive pulmonary embolus, or pericardial tamponade prevents the heart from pumping effectively

The challenge in the newborn period is to determine if the symptoms of shock associated with sepsis result from congenital heart disease, cardiac tissue damage, or a disseminated infectious disease. Older children with sepsis typically present with fevers, dehydration, and evidence of increasingly poor perfusion.

Assessment ■ Fevers and shaking chills in older children ■ Poor feeding behaviors ■ Hypotension (serial blood pressure readings are imperative to assess sepsis) ■ Tachycardia or bradycardia (sinus tachycardia = early compensation) ■ Petechiae ■ Pallor or cyanosis ■ Diminished femoral pulses ■ Prolonged capillary refill (assess nail beds and various areas of extremities) ■ Cold extremities ■ Decreased urinary output (must be maintained at >1 cc/kg/hour) ■ Altered sensorium, lethargy, impaired mental status ■ Decreased pain response

Diagnostic Testing ■ ■ ■ ■ ■

Arterial blood gases (ABGs) Electrolytes Complete blood count (CBC) with differential BUN Creatinine

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PATHO R–Z ■ ■ ■ ■ ■ ■

Culture of blood and urine Chest x-ray Electrocardiogram (EKG) Lumbar puncture C-reactive proteins Erythrocyte sedimentation rate (ESR)

Treatment ■ Blood or urine cultures that identify the infectious agent and subsequent administration of antibiotics (ampicillin, cefotaxime, ceftriaxone and/or gentamicin for bacterial infections, IV acyclovir for viral infections) ■ Correction of hypovolemia with 0.9% NS boluses (20 cc/kg), repeated as needed ■ Albumin (5%, 10–20 cc/kg) and PRBCs (10–15 cc/kg) may also be needed to support the newborn in shock ■ Cardiogenic shock may require PGE1 (0.05–0.2 mcg/kg/min), dopamine (10–15 mcg/kg/min), and epinephrine (0.05–0.5 mcg/kg/min)

Nursing Care and Concerns ■ Ensure airway, breathing, circulation (ABCs), provide oxygen if needed, monitor vital signs (VS) frequently, and report changes in clinical status immediately ■ Administer first dose of antibiotics within 60 minutes of the newborn’s fever, especially if child is symptomatic ■ Provide emotional support to family members

Evidence-Based Practice Tips ■ When a child presents with diabetic ketoacidosis (DKA)–associated polyuria, assume the child is dehydrated and assess for hypovolemia. Prevent hypovolemic shock. The child may present with >20% volume depletion ■ Any child with immunosuppression that demonstrates a single fever must have immediate cultures, antibiotics, and fluids. Do not administer antibiotics until all cultures have been obtained ■ If a child presents with fever and petechiae, suspect meningococcemia and initiate rapid evaluation and interventions. These children can deteriorate rapidly

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233 ■ If a child with sepsis presents with adequate oxygen saturations, do not assume the tissues have adequate oxygen delivery. Place the child on a supplemental source of oxygen until the child is stable

Sudden Infant Death Syndrome Pathology The National Institute of Child Health and Human Services defines sudden infant death syndrome (SIDS) as the sudden death of an infant younger than age 1 year that remains unexplained after a thorough case investigation, including autopsy, examination of the death scene, and review of the clinical history. ■ ■ ■ ■

The documented incidence of SIDS is greatest in the winter months SIDS is the most common cause of death before the age of 1 year SIDS occurs in one out of every 1000 live births in the United States There is a higher-than-average incidence of SIDS in infants of African American and Native American descents ■ The peak age for SIDS is between 2 and 3 months ■ Death most frequently occurs between midnight and 6 a.m. ■ The infant appears otherwise healthy, nourished, and appropriate in weight

Clinical Signs ■ Bloody mucus in the mouth or nares ■ Cyanosis of the nail beds and lips ■ Autopsy reports demonstrate inflammation in the upper respiratory tract, petechiae on the pleura, thymus, and pericardia, and pulmonary edema ■ Central nervous system abnormalities, such as delayed myelination or scarring in the tissues surrounding the respiratory control center within the brainstem, have been detected

Although the pathophysiology associated with SIDS is unclear, clinical findings are present in 80% of the cases. Lethal rebreathing of carbon dioxide is associated with SIDS, especially accompanied with prone sleeping positioning of the infant. Infectious agents are always carefully ruled out as well as respiratory tract abnormalities. Abnormality of the

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PATHO R–Z arousal responsiveness of the cardiorespiratory control center, which typically allows the child to maintain a breathing pattern, is another hypothesis.

Individual Risk Factors ■ ■ ■ ■ ■ ■

Prematurity Low birth weight Male gender Twin gestation Low Apgar scores Diagnosis of bronchopulmonary dysplasia

Environmental/Family Risk Factors ■ ■ ■ ■

Low socioeconomic status Low educational level of mother History of smoking, drug abuse, or high alcohol consumption in the house Maternal anemia

Infants at high risk for SIDS may be prescribed a home apnea monitoring system, which sounds an loud alarm if the infant demonstrates delayed breathing or bradycardia.

Assessment There are no assessments associated with SIDS. The child is brought into the health-care setting already dead with no response to emergency personnel’s efforts of advanced CPR. Paramedics are usually called to the scene and resuscitative efforts may continue until the child is brought to the emergency room.

Treatment There is no treatment for SIDS. Because the infant is otherwise healthy, there are no signs that SIDS is impending and no preventive treatment. The only prevention is parent education. Subsequent siblings in the high-risk categories may be home-monitored.

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235 Nursing Care ■ Nursing care centers on the care of the shocked and grieving family. The death of an otherwise healthy infant is one of the greatest losses a family can experience ■ One nurse should stay with the family the entire time they are in the health-care setting and should provide therapeutic communication, support, and expert listening skills. The family may demonstrate anger, fear, remorse, and extreme emotional reactions ■ Parents who accompany a SIDS victim to the hospital should not leave until they have seen appropriate mental health professionals. Single parents should not be allowed to drive home from the ER alone. Mobilization of supportive family members and mental health professionals is imperative to assist the powerfully grieving family ■ Provide resources (write them down) and encourage family members to contact them: ■ American Sudden Infant Death Syndrome Institute at 1-800-232-SIDS ■ National Sudden Infant Death Syndrome Foundation at 1-800-638-7437. ■ Sudden Infant Death Syndrome Alliance at 1-800-221-7437 and www.sidsalliance.org ■ Make sure the staff of the hospital, particularly the emergency room staff, follows up with the family with a call and a sympathy card

Parent Education ■ Never place an infant to sleep in the prone position. See “Back to Sleep Campaign” at www.sidsalliance.org or www.californiasids.org ■ Provide the infant with a safe sleeping environment: ■ Make sure there are no fluffy pillows or heavy blankets in the bed that could cover the infant ■ Dress the infant in one layer more than the adult is wearing in the house. Do not overheat the infant while sleeping ■ There should be no space between the crib mattress and the crib rails. Only crib mattresses should be used to place an infant to sleep. The crib mattress must be firm and nonmoldable ■ Do not smoke in the house or anywhere near the child. This includes the home, car, or outside environment ■ All families that have risk factors should be encouraged to learn CPR

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PATHO R–Z Evidence-Based Practice Tips ■ The incidence of SIDS in 1 year was 0.74 deaths per 1000 live births, and a high association with intrauterine drug exposure was found ■ The use of home apnea monitors continues to be questioned by health-care providers, as it does not prevent SIDS ■ The incidence of SIDS has been reduced exponentially with the “Back to Sleep” parent education program. Education reduces SIDS rates ■ Infants with breathing pathologies and difficulties, as well as those with excessive vomiting, should continue to be placed supine, but should be placed on a firm mattress with the head of the bed elevated (American Academy of Pediatrics) ■ All new mothers should be encouraged to secure prenatal care and to breastfeed to support immune function

Suicide The incidence of childhood and adolescent suicide is on the rise in the United States. Suicide is the third most common cause of death in adolescents. Highest risk groups include teenagers, males, and those with singleparent households, and noncustodial living arrangements. Suicidal behaviors encompass a range of actions including ideation, gestures, attempts, and intentional death. Suicide methods can include firearms, over-the-counter medications, prescription medications, jumping from high places, hanging, drowning, inhaling carbon monoxide, and cutting. The following are associated with suicide ideation: ■ ■ ■ ■ ■ ■ ■

Social withdrawal from family, friends, and typical social activities Delinquent behaviors Eating disorders Sense of hopelessness and despair Family suicide, especially maternal suicide Substance abuse School failure

Take all threats seriously and secure professional mental health help! After a suicide gesture or attempt, obtain a detailed description from child and caregiver including reason, plans, methods, and rescue activity.

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237 Never leave a hospitalized suicide patient alone! Secure a sitter promptly for around the clock observation.

Evidence-Based Practice Tips ■ 90% of adolescents who commit suicide have a diagnosable psychiatric illness such as major depression, schizophrenia, or substance abuse. Assess teens carefully and mobilize professional treatment (Lieh-Lai, Ling-McGeorge, Asi-Bautista & Reid, 2001)

Swine Influenza (Novel H1N1) Pathology H1N1 is a new influenza virus first detected in April of 2009. Like other influenza viruses, H1N1 can lead to hospitalizations and death. This new virus is causing illnesses in what are typically flu-free summer months. The virus is called the “swine” flu because the genetic makeup resembles an influenza virus normally found in pigs. H1N1 is considered a “quadruple reassortant virus” because it consists of two genes that are found in pigs in Europe and Asia, and human and avian genes. “High risk” groups include: ■ ■ ■ ■

Those more than 65 years old Those at or less than 5 years old Pregnant women Persons with certain chronic illnesses, such as asthma, renal disease, hepatic disease, sickle cell anemia, and diabetes

The virus may be contagious from one day before symptoms start up to 7 days after the sickness occurs. The virus can cause infections up to 2–8 hours after being deposited onto an environmental surface. Strict hand washing procedures must be followed.

Assessment Typically flu-like symptoms include fever, aches, cough, headaches, chills, diarrhea, vomiting, and mucus production. Children with the following symptoms are considered an emergency and should be brought immediately to an appropriate health-care setting:

PATHO R–Z

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PATHO R–Z ■ ■ ■ ■ ■ ■ ■

Poor PO intake Cyanosis Tachypnea and dyspnea Decrease level of consciousness Highly irritable: Not wanting to be held or comforted Severe vomiting Flu-like symptoms that improve then return with higher fevers

Diagnostic Testing Nasal swabs are taken according to hospital protocol for the determination of the type of influenza the patient has.

Treatment Two medications have been approved for the prevention and treatment of H1N1: oseltamivir and zanamivir (www.cdc.gov). Chemoprophylaxis should occur with: ■ Children at or under 2 years old with direct contact with someone diagnosed with H1N1 ■ Confirmed first respondents or health-care professionals who have had a direct contact exposure

Nursing Care Patients need to be isolated while they are infectious. Avoid being within 6 feet of infected child unless giving direct care. Care providers must follow infectious disease protocols: ■ Wear mask (N95) (see PandemicFlu.gov for recommendations) ■ Wear gloves with close contact ■ Wear gown while handling infectious materials ■ Keep patient’s door closed ■ Do not allow siblings, family members, or parents to enter common rooms such as the playroom or communal kitchen ■ Follow strict hand washing procedures (15–20 seconds with soapy water or use alcohol-based hand sanitizers)

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239 Evidence-Based Practice Tips: ■ The CDC states that a voluntary H1N1 vaccine should be available during the fall of 2009 ■ Updated counts of numbers of infected are found at http://www.cdc.gov/h1n1flu/update.htm ■ One third of adults more than 60 years of age may have natural immunity. Research continues investigating whether older adults have existing antibodies against H1N1 ■ The largest confirmed cases thus far have been in people between 5 and 24 years old (www.cdc.gov)

Urinary Tract Infections Pathology Urinary tract infections (UTIs) are common throughout childhood. Bacterial invasion of the otherwise sterile urinary tract leads to symptoms of dysuria. A UTI may include the lower urinary tract (urethra or bladder), or the upper kidney structures (renal pelvis and renal parenchyma). The shorter length of the female child’s urethra (2 cm) and urinary stasis are the two most important factors associated with the development of UTIs. An alkaline pH is also associated with UTIs. Eschericlia coli remains the most common bacterial culprit.

Assessment ■ If an infant presents with fever of unknown origin, UTI should be ruled out ■ Infants may present with fussiness and vague symptoms. Older children may have very sudden onset of symptoms and fevers up to 104°F

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PATHO R–Z Assess for: ■ ■ ■ ■ ■

Pain on urination (an infant may scream when voiding in diaper) Vomiting, diarrhea, and abdominal pain Hematuria and pyuria Frequency, urgency to void Foul-smelling urine

Diagnostic Testing ■ Urinalysis with culture (do not start antibiotics until specimen is obtained) ■ CBC ■ Renal ultrasound, intravenous pyelogram (IVP) or voiding cystourethrogram (VCUG)

Treatment ■ Administration of appropriate antibiotic therapy sensitive to the microbe causing the UTI ■ Common drugs to treat UTIs are penicillins, cephalosporins, and sulfonamides

Nursing Care ■ Provide adequate fluids to keep febrile patient hydrated. May need 2x maintenance fluid intake ■ When collecting urine specimen, perform clean catch or sterile catheterization ■ Treat fever ■ Educate family on prevention of recurrent UTIs including developmentally appropriate interventions such as the following: ■ Infants: Thorough wiping of fecal matter with each diaper change to prevent infection. Female labia must be cleansed thoroughly after defecating. Infants should not be left in a diaper with feces for any period of time ■ Toddlers and preschoolers: As child is learning independent toileting, females must be taught to wipe from front to back to prevent

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241 cross contamination of feces into genital area. UTI may occur due to irritation from bubble bath soaps ■ Adolescents: Assess the teenager’s sexual activity history. UTIs may be associated with sexual activity and incomplete bladder emptying

Evidence-Based Practice Tip ■ When pushing fluids, do not offer child chocolate, caffeinated, or carbonated drinks as these have been shown to cause further bladder mucosa irritation

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Components of a Pediatric Health History ■ Name, age, sex, year in school ■ Address ■ Parents’ or legal guardian’s names, home phone number(s), cell phone number(s), e-mail addresses ■ Source of history ■ Date of admission/intake ■ Allergies ■ Previous medical diagnoses ■ Previous hospitalizations ■ Present illnesses ■ Birth history ■ Elimination patterns ■ Eating habits ■ 24-hour diet recall ■ Immunization history ■ Current medications ■ Vitamin supplements, herbs, alternative therapies and treatments, special diet ■ Sleep patterns ■ Language development ■ Socialization patterns ■ Parents’ employment, work history, current hours of work per week, schedule ■ Cognitive development

Body System Review for Pediatric Health History ■ ■ ■ ■ ■ ■

General appearance, language level, affect, vital signs Ht, wt, head circumference General appearance of skin, nails, and hair; skin integrity Head and neck Ears, eyes, nose and throat, including gums, tongue, teeth Cardiovascular

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243 ■ ■ ■ ■ ■ ■ ■

Lungs Sexuality/reproductive system Gastrointestinal (GI) Genitourinary (GU) Musculoskeletal, articular Neurological, motor, and mental status Emotional state: depression, anxiety, family processes

Pediatric Equipment Sizes: Quick Reference Guide Skills Device Blood pressure cuff Urinary catheter Chest tube Suction catheter IV gauge IM needle length Gastric tube Endotracheal tube

Neonate Newborn 5 Fr 10–14 6 24 0.5 5 3.0–3.5

1–3 yr Infant 8 Fr 14–20 6–8 24 0.5 8 3.5–4.5

3–10 yr Infant/child 8–10 FR 14–24 8 22 0.5 8–10 4–5

Useful Mnemonics ABCs Airway Breathing Circulation

ABCDEFG Airway Breathing Circulation Don’t Ever Forget Glucose (especially in a child experiencing seizures)

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10–14 yr Child 10–12 Fr 16–32 8–10 22 0.5–1.5 10–12 4.5–6.5

Adult Adult 12–16 28–38 10–12 20 1–1.5 12–16 6.5–7

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TOOLS ABCDE-COPI-ME (Linnard-Palmer, 2008) Airway (Open airway and assess patency) Breathing (Provide rescue breathing via bag/mask) Circulation (Assess pulse, provide chest compressions) Disability and need for defibrillation (Neuro status, monitor) Evaluate the need for transfer/advanced care (PALS and meds) Crash cart (bring to the child, open, set up, initiate equipment) Oxygen (select highest flow, attach to ambu bag) Place the patient on a back board (behind crash cart, rapidly) Intravenous sites, fluids, boluses and labs (calculate per kg) Move other patients and family out of the room, secure support, call supervisor, provide privacy Evaluate the patient frequently and tell the code team about the medical history and current events

SBAR: Guide for Communication Between Health-Care Team Members Situation Background Assessment Request

SCALE (Emergency Drugs) Sodium bicarbonate Calcium Atropine Lidocaine Epinephrine

LEAN (Drugs That Can Be Given Via the Endotracheal Tube) Lidocaine Epinephrine Atropine Naloxone

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245 CIAMPEDS*(Emergency Nursing Association Mnemonic for Triage and Assessment) Chief complaint Immunizations Allergies Medications Past medical history/parents impression of child’s condition Events surrounding the illness or injury Diet and diapers (last intake, patterns of intake, voiding patterns) Symptoms associated with the illness or injury * Used with permission from the Emergency Nursing Association.

Responsiveness Awake Voice Pain Unresponsive

Perioperative Care Preoperative Assessments Initiate a Preoperative Checklist Following Institutional Policy ■ Assess vital signs, oxygen saturation ■ Assess pertinent medical history that could affect surgical procedure, such as diabetes, asthma, chronic disease, recent exposure to infectious diseases ■ Assess current medication list; document last dose/time administered ■ Assess for allergies: Foods, medications, latex ■ Assess ht in cm and wt in kg, report to pharmacy for accurate medication calculations ■ Assess last food/drink consumed. Document exact time and content of last oral intake ■ Assess last stool and urination. Document quantity ■ Assess for symptoms: nausea, pain, fatigue, emotional distress, dyspnea and sleep deprivation. Use scales when appropriate; document

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TOOLS ■ Assess for consent for procedure and transfusion therapy if indicated ■ Assess for presence of loose teeth and report to surgical team ■ Assess for any metal in or on child’s body, including implants, hardware, screws, braces, infusion pumps, central venous catheters, contact lens, and hearing aids ■ Assess for need for presurgical laboratory tests or specimens ■ Assess for need for premedication ■ Maintain NPO status until notified by surgical team about orders for NPO requirement ■ Make sure child and family have accurate name bands on and security devices as required by institution ■ Call medical records for charts from previous hospitalizations, previous medical diagnostic test findings, or an advance directive if the child is older than 18 years ■ Make sure child’s main pediatrician has been notified of the hospitalization and pending surgery

Follow institutional policies, and maintain HIPAA parameters at all times. No medical information may be shared with anyone other than the immediate family or guardian. If there is a question about this, call admitting for a list of family members who have been granted the right to solicit the child’s clinical status or any information concerning the child’s hospitalization.

Preoperative Teaching Must be developmentally appropriate and suited for child’s comprehension. Request child life services to offer medical play and procedural preparation. The use of medical play dolls that are anatomically correct with incisions, IV access, and surgical tubes are highly effective. ■ ■ ■ ■ ■ ■ ■

Deep breathing exercises that will be expected after surgery Incentive spirometer use if indicated Expected presence of a surgical incision Description of wound size and location Expected drains, dressings, tubes, oxygen delivery devices Expected length of healing time Need to secure valuables (jewelry, electronic devices, and cell phones)

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247 ■ Symptom control and reassurance that needs will be taken care of: Introduce pain assessment tool that will be used ■ Place where family can stay during procedure and how/approximate time they will be contacted postoperatively on child’s condition

Postoperative Assessment ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Begin assessment as soon as patient arrives on the unit Assess ABCs Assess neurological status: Mental status and level of alertness Assess vital signs Assess for pain using the most appropriate pain assessment tool for developmental stage/age Assess need for oxygen Assess IV lines, pumps, and IV catheters Assess wound or surgical incision areas; document presence of drainage Assess for presence of drainage devices Assess for need for oral suction Assess safety: Crib rails up, side rails up (upper), rails padded as needed Position for comfort and optimal drainage of secretions as needed Assess need for elimination and/or presence of Foley catheter Provide emotional support for child and parents or caregivers

Postoperative Teaching ■ Expected sensations: Discomfort and need for verbal communication of pain level ■ When NPO status will be over and child can start clear liquids ■ When pacifier can be used ■ Expected length of recovery time ■ When child will be expected to get out of bed (OOB) and ambulate ■ How elimination will be accomplished ■ Time frame/schedule of pulmonary toileting (turn, cough, deep breathe [TCDB], incentive spirometery, suctioning prn) ■ Plan for care of surgical dressings, drains ■ Need for rest and limiting conversations/visiting hours and suggestions for quiet healing times/need for essential naps

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Tips for Successful Foley Catheter Care: Preventing Infection ■ Always ensure the use of a sterile field when placing a urinary catheter into a child of any age ■ Secure assistance for holding flashlight, securing the sterile field or for gentle restraining ■ Always choose the appropriate size for the child’s age and size ■ Always use a preconnected closed sterile urinary drainage system ■ Secure catheter in place with paper tape out of site of young child ■ Obtain urine specimens for the laboratory from the sample port using aseptic technique ■ Secure drainage bag at level lower that the child’s bladder level ■ Do not allow urine to pool in catheter tubing ■ Empty bag twice a shift to prevent overfilling ■ Perform daily perineal care especially with diapered child ■ Remove urinary catheter as soon as possible to prevent infection

Abbreviations Used in Pediatric Medication Administration: a.c. = Before meals a.d. = Right ear ad lib. = As desired by child a.s. = Left ear bid = Twice daily Caps. = Capsules Qd = Everyday Elix. = Elixir H = Hour h.s. = At bedtime IM = Intramuscular IV = Intravenous dEq. = Milliequivalent NPO = Nothing by mouth O.D. = Right eye O.S. = Left eye

O.U. = Both eyes p.c. = After meals PO = By mouth PR = Per rectum PRN = As needed qh = Every hour QID = Four times a day QOD = Every other day q.s. = Quantity sufficient sol. = Solution SQ = Subcutaneous STAT = At once, now, immediately susp. = Supension tab = Tablet tid = Three times a day

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249 Rapid Conversion Chart 1 mg = 1,000 mcg 1g = 1,000 mg 1 kg = 1000 g 1 oz = 30 cc 1 tsp = 5 cc 1 Tbs = 15 cc

1 Tbs = 3 tsp 1 kg = 2.2 lb 1 gr = 60 mg 1 cm = 10 mm 100 cm = 1 meter 1000 mm = 1 meter

Metric System Conversion From a larger unit to a smaller unit, move the decimal point one space to the right for each unit changed (1 gram to ___ miligrams) 1.000 g to 1000 mg. From a smaller unit to a larger unit, move the decimal point one space to the left for each unit changed (1500 cc to ___ liters) 1.500 to 1.5 liters.

Preventing Medication Errors in Pediatrics: Tips for Care Upon arrival and admission to the pediatric unit, ask the parents or guardian to provide a list of all medications the child is currently taking. Request that the parents or guardian bring in all home medications (over-the-counter and prescriptive) in their original containers for confirmation. ■ Double-check all medication orders against the original order sheet ■ Make sure child has an accurate name badge with medical record number (many small children pull these off or they slip off infants) ■ Use three-check systems prior to administering medication (against order, accuracy of dose provided by pharmacy, against medication record number) ■ Follow institutional policy for double-checking dose calculation and final dose drawn up with two RNs ■ Report dose missing from unit/cassette/med drawer to pharmacy immediately and follow up within 30 minutes ■ Administer medications on time, stay organized ■ Document medication administration right after administering med

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TOOLS ■ Educate child (if developmentally appropriate) and parent about medication: dose, indication, side effects ■ Report any refusals by child or parent ■ Never leave medications at bedside ■ Never call medications candy and discourage parents from doing so ■ Do not mix medications in large volumes of juice, breast milk, or formula as the child may not take the entire amount ■ Report if child vomits after any medication administration: Do not re-administer unless instructed to do so by physician or pharmacist ■ Communicate effectively about child’s medications if the child leaves the unit to go to another department (diagnostics, surgery, transfer to ICU) ■ Make sure family has an accurate written list of discharge medications ■ Talk to the family about how they plan on filling discharge medications and about any concerns they have about logistics, administration, or finances/insurance coverage. Involve social worker if there is any indication that the family cannot/will not fill ordered discharge prescription

Bill of Rights for Children and Teens Children of all ages and their families have the right to: ■ ■ ■ ■ ■ ■ ■ ■ ■

Respect and personal dignity Supportive care Information presented in an understandable manner Quality health care Emotional support Care that respects the need to grow, play, and learn Make choices and decisions Accurate medication administration Safety in their environment

Helpful Web Sites Web Sites of Pediatric Professional Nursing Organizations ■ American Association of Colleges of Nursing: www.aacn.nche.edu ■ American Nursing Association: www.nursingworld.org/

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251 ■ Association of Pediatric Hematology and Oncology Nursing (APHON): www.aphon.org ■ American Association of Pediatric Nurse Practitioners: www.napnap.org/ ■ Emergency Nursing Association (ENA): www.ena.org ■ Society of Pediatric Nurses (SPN): www.pednurses.org/ ■ Intravenous Nurses Association: www.ins1.org.org/

Web Sites of Helpful Government Sites ■ ■ ■ ■ ■ ■ ■

Centers for Disease Control (CDC): www.cdc.gov Growth charts: www.cdc.gov/GrowthCharts Immunization information: www.cdc.gov Low-cost or free health-care services: www.hrsa.gov/help Medi-Cal: www.cms.hhs.gov/medicare Medicaid: www.cms.hhs.gov/medicaid National Institute of Health (NIH): www.nih.gov

Other Professional Organizations with Pediatric Resources ■ AIDS Information Hotline 1-800-CDC-INFO: www.cdc.org ■ American Academy of Allergy, Asthma, and Immunology: www.acaai.org ■ American Academy of Pediatrics (AAP): www.aap.org ■ American Lung Association: www.lungusa.org ■ Association of Pediatric Hematology and Oncology Nursing (APHON): www.aphon.org ■ Autism: www.autism.com ■ Cognitive Impairment: www.teachmorelovemore.org ■ Cerebral Palsy: www.ucp.org ■ Childhood Anxiety: www.adaa.org ■ Child Life Council (CLC): www.childlife.org ■ Childhood Depression: www.aacap.org ■ Cleft Lip: www.cleftline.org ■ Cystic Fibrosis: www.cff.org ■ Eating Disorders: www.nationaleatingdisorders.org ■ Institute for Family Centered Care: www.familycenteredcare.org ■ March of Dimes Birth Defects Foundation: www.marchofdimes.com ■ National Association for Colitis and Crohn’s Diseases: www.nacc.org.uk ■ National Down Syndrome Society: www.ndss.org ■ National Pediatric and Family HIV Resource Center: www.pedhivaids.org

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TOOLS ■ ■ ■ ■ ■ ■

National Safe Kids: www.safekids.org Pediatric HIV/AIDS: www.cniva.org Shriners Hospitals: www.shrinershq.org Sickle Cell Anemia www.sicklecelldisease.org UNICEF: www.unicef.org World Health Organization (WHO): www.who.int

References American Heart Association. www.americanheart.org American Heart Association. (2005). Handbook of Emergency Cardiovascular Care. American Heart Association, Dallas, TX, pp. 73–97. American Humane Organization. www.americanhumane.org Andreoni, C., & Klinkhammer, B. (2000). Quick Reference Guide for Pediatric Emergency Nursing. W. B. Saunders, Philadelphia, pp. 11–19, 21–30. Baker, C., & Wong, D. (1987). Q.U.E.S.T.: A process of pain assessment in children. Orthopedic Nursing, 6(1), 11–21. Behrman, R., Kleigman, R., & Jenson, H. (2001). Nelson Textbook of Pediatrics Pocket Companion (16th ed.). W. B. Saunders, Philadelphia, pp. 145–197. Betz, C., & Sowden, L. (2000). Mosby’s Pediatric Nursing Reference Guide (4th ed.). Harcourt Health Sciences Co, St. Louis, pp. 29–33. Davies, J., & Hassell, L. (2001). Children in the Intensive Care. A Nurse’s Survival Guide. Harcourt Publishers Limited, Edinburgh, pp. 1–12, 37–72. Grossman, S., & Grossman, L. (2005). Pathophysiology of cystic fibrosis: Implications for critical care nurses. Critical Care Nurse, 25(4), pp. 46–51. Hay, W. W. (2005). Current Pediatric Diagnosis and Treatment (17th ed.). Lange Medical Books/McGraw-Hill, New York, p. 309. Hockenberry, N., & Wilson, D. (2007). Wong’s Nursing Care of Infants and Children (8th ed.). Mosby Elsevier, St. Louis. Hockenberry MJ, Wilson D, and Winkelstein ML. (2005). Wong’s essentials of pediatric nursing, ed. 7. St. Louis, Mosby, p. 1259. James, H. E. (1986). Neurologic evaluation and support in the child with an acute brain insult. Pediatric Annals, 15, 16.

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253 Jennet, B., & Teasdale, G. (1977). Aspects of care after severe head injury. Lancet, 1, 878. Krechel, S. W., & Bildner, J. (1995). CRIES: A new neonatal postoperative pain measurement score: Initial testing of validity and reliability. Pediatric Anaesthis, 5, 53–61. Leih-Lai, M., Ling-McGeorge, K. A., Asi-Bautista, M., & Reid, C. (2001). Pediatric Acute Care (2nd ed.). Lippincott Williams & Wilkins, Philadelphia. Source: Merkel, S., Voepel-Lewis, T., Shayevitz, J., & Malviya, S. (1997). The FLACC: A behavioral scale for scoring postoperative pain in young children. Pediatric Nurse 23(3), 293-297. National Center for Children in Poverty. www.nccp.org Rebeschi, L., & Brown, M. H. (2006). The Pediatric Nurse’s Survival Guide. (3rd ed.). pp. 2–17. Thompson Delmar Learning, Cliffton Park, NY. Shelton, T. L., & Stepanke, J. S. (1994). Family-centered care for children needing specialized health and developmental services (3rd ed, pvii). Monograph produced for the Association for the Care of Children’s Health, Landmark Publications, Bethesda, MD. Siberry, G., & Iannone, R. (2000). The Harriet Lane Handbook: A Manual for Pediatric House Officer. (15th ed.) pp. 66–67, 86–93). Mosby, St. Louis. The Joint Commission on Accreditation of Healthcare Organizations, 2001, www.jointcommission.org/ Thompson, R., & Standford, G. (1981). Child Life in Hospitals: Theory and Practice. Charles C. Thomas Publishers, Springfield. IL. Wong, D. (1991). Pediatric Quick Reference Guide. Mosby, St Louis. Wong, D., Hockenberry, M., Wilson, D., Winkelstein, M., & Kline, N. (2003). Wong’s Nursing Care of Infants and Children (7th ed.). Mosby Elsevier, St Louis. pp.15–24.

Illustration Credits Pages 22, 31, 59–60, 107, 165–167, 169, 171, 193, 201, from Ward, SL & Hisley, SM: Maternal-Child Nursing Care: Optimizing Outcomes for Mothers, Children and Families. 2009. Philadelphia: FA Davis. Pages 28–29, 168, from Dillon, PM: Nursing Health Assessment: A Critical Thinking, Case Studies Approach. (ed. 2) Philadelphia: FA Davis. Pages 93–94, 102, 119–120, Holloway, B, Moredich, C & and Aduddell, K: OB Peds/Women’s Health Notes: Nurse’s Clinical Pocket Guide. 2006. Philadelphia: FA Davis.

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TOOLS Pages 95–96, 106, 110–111, 124, Wilkinson, JL & Van Leuven, K: Fundamentals of Nursing: Theory, Concepts & Applications. Vol. 1. 2007. Philadelphia: FA Davis. Page 100 Courtesy of Alaris Medical Systems, San Diego, CA. Page 112 from Persing,G: Entry-Level Respiratory Care Review: Study Guide and Workbook, ed 2. WB Saunders, Philadelphia, 1996, p.13, with permission. Page 137 from Cook Critical Care. Ellettsville, IN. Page 188 from Nugent, P & Vitale, B: Test Success: Test-Taking Techniques for Beginning Nursing Students (ed. 5). 2008. Philadelphia: FA Davis.

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255 Index Note: Page numbers followed by f refer to figures. Abbreviations, in medication orders, 248 ABCs, of resuscitation, 132–133 mnemonics incorporating, 243–244 Abuse (child abuse), 154–159 fractures due to, 217 shaken baby syndrome as form of, 141–142 Accident prevention, 17–19. See also Safety. Acidosis, 48 diabetic, 140–141 Acquired immunodeficiency syndrome (AIDS), 190–192 Acute care hospitalization diagnoses, 2 Acyanotic congenital heart disease, 162–165 Adolescent, 5 airway obstruction in, 134 communication with, 15 development of, 12–13 eating habits of, 67 growth of, 33 height of, 33 pain in, 57, 60. See also Pain. play by, 27 vital signs in, 28 weight of, 33 Adult, vs. child, 4–5 Adult nurses, child care by, 1–2 Aganglionic megacolon (Hirschsprung’s disease), 188f, 188–189

AIDS (acquired immunodeficiency syndrome), 190–192 Airborne precautions, 113 Airway, management of, in CPR, 132 obstruction of, 133–134 Alkalosis, 48 Alloimmunization, transfusion and, 84 Ambu bag, oxygen delivery via, 109 Aminoglycosides, 98 serum levels of, laboratory values for, 50 Analgesia, patient-controlled, pumps for, 103–104, 104f Analog scale, in pain assessment, 60 Anaphylactic reaction, 86, 135 Anemia, 143–145 Angiocath, 125 Anorexia, 68 Antibiotics, 97–98 serum levels of, laboratory values for, 50 Anticipatory guidance, and safety, 17–19 Antidiuretic hormone, inappropriate secretion of, 176–177 Antimicrobials, 97–98 serum levels of, laboratory values for, 50 Anxiety, 13, 145–146 Aorta, coarctation of, 164f Aortic stenosis, 163f Apnea monitoring devices, 119, 119f

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INDEX Arterial blood gases, 47 Assessment, 33–34 central line, 129–130 nutritional status, 61 abnormal laboratory values in, 64 pain, 56, 57 scales used in, 58–60, 59f, 60f postoperative, 247 preceding administration of medications, 89 preoperative, 245–246 systemic, 34–43, 62–63 for health history, 242–243 vital sign, 28–31 Asthma, 146–151 Atresia, pulmonary, 166f tricuspid, 166f Atrial septal defect, 162f Atrioventricular septal defect, 163f Attention-deficit hyperactivity disorder, 152–153 Autism, 153–154 AVP mnemonic, 245 Baby. See Child; Infant; Newborn. Bag delivery, of oxygen, 109 Behavioral restraints, 20–21 Binge eating, and vomiting, 69 Blood gases, arterial, 47 Blood pH, interpretation of, 47 Blood pressure, assessment of, 30, 30f Blood products, 78 half-life of, 82 Blood specimen, collection of, 51 Blood transfusion. See Transfusion. Blood volume, 78 Blood warmers, 81 Blow-by oxygen delivery, 109

Body height, 32, 33 Body surface area, calculation of, 92 Body systems, child, 4–5 assessment of, 34–43, 62–63 for health history, 242–243 vs. adult body systems, 4–5 Body temperature, assessment of, 28, 121 Body weight, 32, 33, 61 dosage calculation based on, 92 excessive, 45–47 loss of, 46–47 Bowel disease, inflammatory, 199–200 Brain tumors, 216 Breastfeeding, 64–65, 66f Breathing, in CPR, 132–133 Bronchiolitis, 221 respiratory syncytial virus infection and, 221–222 Broviac catheter, 127 Bulb syringe, suctioning via, 122, 122f Bulimia, 69 Burn patients, fluid resuscitation for, 71–72 Calorie requirements, across childhood, 63 Cancer, 213–216 Cannula, nasal, oxygen delivery via, 108, 110f Cardiogenic shock, 135, 230 Cardiopulmonary resuscitation (CPR), 132–133 Cardiovascular system, assessment of, 34–35, 63 congenital disease of, 161–169, 162f–167f

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257 Catheter(s), Broviac, 127 central venous, peripherally inserted, 128 Foley, 107, 248 Hickman, 127 suction, 123 tunneled, 127, 127f Catheterization, urinary, 106, 107 and specimen collection, 107, 107f Cat-scratch fever, 115 Central lines, 125–130 Central venous catheter, peripherally inserted, 128 Cephalosporins, 97 Chemical restraints, 21 Chest sites, for apnea monitoring, 119, 119f for ECG monitoring, 120, 120f Chest tube drainage, 105–106, 106f Child, 5. See also Infant. abuse of, 154–159 fractures due to, 217 shaken baby syndrome as form of, 141–142 adolescent. See Adolescent. airway obstruction in, 134 assessment of, 33–34 systemic, 34–43, 62–63 for health history, 242–243 calorie requirements of, 63 care of, adult nurses in, 1–2 emotional factors in, 13 sites of, 3 choking in, 134 communication with, 14–15 critically ill, response to, 131–134 development of, 7–13 sensory, 43 theories of, 7–8 eating habits of, 67

growth of, 32–33 assessment of, 62 height of, 32, 33 hypoglycemia in, 140 infant. See Infant. interventions for, 25 newborn. See Newborn. pain in, 53, 57. See also Pain. play by, 26, 27 preschool. See Preschooler. school-age. See School-age child. special-needs, play by, 27 toddler. See Toddler. vital signs in, 28 vs. adult, 4–5 weight of, 32, 33, 61 Child life interventions, 25 Choking, 133–134 CIAMPEDS mnemonic, 245 Circulation, in CPR, 133 Cleft lip, 159–160 Cleft palate, 160–161 Coarctation of aorta, 164f Cognitive assessment, 39 Cognitive development, 7–8 Colitis, ulcerative, 200 Coma, Glasgow scale for, 42 Communicating hydrocephalus, 192 Communication, with child, 14–15 Compensated shock, 135 Congenital heart disease, 161–169, 162f–167f Conjunctivitis, 115 Contact precautions, 113 Convulsions, 226–230 CPR (cardiopulmonary resuscitation), 132–133 Crash cart, in CPR, 133 Crib tent, oxygen delivery via, 112f CRIES assessment tool, in rating pain, 59

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INDEX Critically ill child, response to, 131–134 Crohn’s disease, 200 Croup, 169–171 Curvature of spine, 225–226 Cyanotic congenital heart disease, 165–167 Cystic fibrosis, 171–172

Drowning, near, 141 Ductus arteriosus, patent, 163f Dysplasia, developmental, of hip, 175–176

Ear(s), infection of, 115 Early asthma reactions, 148 Eating disorders, 68–69 Eating habits, 66–67 Electrocardiographic monitoring, Death, sudden, of infant, 233–236 chest, 120, 120f Dehydration, 43–44, 70 Electrolytes, 73 Deltoid muscle injection site, 93f reference values for, 49, 73 Depression, 173–174 Emergency skills, 131–142 Development, 7–13 Emotional assessment, 40 sensory, 43 Emotional factors, in care of chiltheories of, 7–8 dren, 13 Developmental hip dysplasia, End-expiratory pressure, positive, 175–176 109 Diabetes insipidus, 176 Endocrine system, assessment of, Diabetes mellitus, 177–180 38 ketoacidosis in, 140–141 Enteric precautions, 113 type 1 (insulin-dependent), Enteritis, rotaviral, 115 177–179 Environmental safety, 16 type 2 (non–insulin-dependent), Epiglottitis, 180–181 179–180 Diabetic ketoacidosis (DKA), 140–141 Epilepsy, 227 Equipment safety, 16–17 Diet, specialty, for infant, 76, 77 Equipment sizes, 243 Diphtheria, immunization against, Erikson, E., on cognitive develop117 ment, 7–8 Direct hyperbilirubinemia, 194 Eye(s), assessment of, 62 Distraction, and play, 25 Distributive shock, 231 DKA (diabetic ketoacidosis), 140–141 Face mask, oxygen delivery via, 108, Documentation, of immunization, 111f 118 Faces scale, in pain assessment, of transfusion, 80–81 58–59, 59f Dorsogluteal injection site, 94f Failure to thrive, 181–183 Dosage calculations, 92 Fallot’s tetralogy, 165f Drainage, chest tube, 105–106, 106f Family, 3 Droplet precautions, 113 Family-centered care, 5–7

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259 Febrile seizures, 228 Feces, collection of specimen of, 51 Feeding, of infant, 64, 65, 66, 76, 77 Fever, and seizures, 228 cat-scratch, 115 Fibrosis, cystic, 171–172 Fifth disease, 115 FLACC assessment tool, in rating pain, 59 Flu (influenza), 115 immunization against, 118 swine, 237–239 Fluid maintenance calculation, 69 Fluid resuscitation, 71–72 Focal seizures, 228 Foley catheters, 107, 248 Foreign object, airway obstruction by, 133–134 Formula feeding, of infant, 64, 76, 77 Fractures, 216–218 Freud, S., on sexual development, 8 Gastroenteritis, 183–185 Gastrointestinal system, assessment of, 36–37 Gastrostomy tube, administration of medications via, 91 Generalized seizures, 227 Genitourinary system, assessment of, 37–38 Giardia, 115 Glasgow coma scale, 42 Gluteal injection sites, 94f Growth, 32–33 assessment of, 62 Guidance, anticipatory, and safety, 17–19 Gums, assessment of, 63

Haemophilus influenzae type B, immunization against, 117 Hair, assessment of, 62 Health history, 242–243 Heart, assessment of, 34–35, 63 congenital disease of, 161–169, 162f–167f Height, 32, 33 Hematology values, 48–49 Hemophilia, 186–187 Hepatitis, Immunization against, 117, 118 Hickman catheter, 127 Hip, developmental dysplasia of, 175–176 Hirschsprung’s disease (aganglionic megacolon), 188f, 188–189 HIV (human immunodeficiency virus) infection, 190–192 H1N1 virus infection (swine influenza), 237–239 Hood system, for oxygen delivery, 109, 111f HPV (human papillomavirus) immunization, information source for, 118 Human immunodeficiency virus (HIV) infection, 190–192 Human papillomavirus (HPV) immunization, information source for, 118 Hydrocephalus, 192–194 Hyperactivity, attention deficit and, 152–153 Hyperbilirubinemia, 194–196 Hyperglycemia, 140–141 Hypertension, intracranial, 138–139, 197–199 Hypertonic dehydration, 44, 70 Hypertonic intravenous solutions, 72

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INDEX Hypoglycemia, 139–140 Hyponatremic dehydration, 44, 70 Hypotonic intravenous solutions, 72 Hypovolemic shock, 135, 230 Idiopathic thrombocytopenic purpura, 196–197 Immunity, assessment of, 38–39 Immunization, 115–118 Immunodeficiency, acquired, 190–192 Impetigo, 115 Implanted port, 126, 126f Inappropriate antidiuretic hormone secretion, syndrome of, 176–177 Increased intracranial pressure, 138–139, 197–199 Indirect hyperbilirubinemia, 194 Infant, 5. See also Child; Newborn. breastfeeding of, 64–65 positions for, 66f communication with, 14 death of, sudden, 233–236 development of, 9–10 feeding of, 64, 65, 66, 76, 77 growth of, 32 height of, 32 newborn. See Newborn. pain in, 53, 54, 57. See also Pain. play by, 26 premature, 5, 26 shaken, 141–142 specialty diets for, 76, 77 venous access in, 102f vital signs in, 28 weaning of, 64 weight of, 32, 61

Infection(s), 115 antimicrobials for, 97–98 serum levels of, laboratory values for, 50 immunization against, 115–118 precautions against, 112–114 prevention of, catheter care and, 248 sepsis/septic shock complicating, 135, 230–233 transfusion-transmitted, 82 Inflammatory bowel disease, 199–200 Influenza, 115 immunization against, 118 swine, 237–239 Injection sites, 93–96, 93f–96f Injury prevention, 17–19. See also Safety. Insulin-dependent diabetes mellitus (type 1 diabetes mellitus), 177–179 Intracranial pressure, increased, 138–139, 197–199 Intradermal injection sites, 96, 96f Intramuscular administration, of medications, 90 Intramuscular injection, 93f, 94f pain reduction during, 95 Intraosseous needle, 136–137, 137f Intravenous therapy, access for, 102f, 125–128, 125f–128f peripheral, 101, 125, 125f pumps used in, 99–100 solutions used in, 72 Intubation, oxygen delivery via, 109–110 Intussusception, 200–201, 201f Isonatremic dehydration, 44, 70

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261 Isotonic intravenous solutions, 72 IV therapy. See Intravenous therapy. Jugular line, 128f Kawasaki disease, 202–203 Ketoacidosis, diabetic, 140–141 Kidney failure, transfusion and, 84 Kohlberg, L., on moral development, 8 Laboratory values, 48–51 abnormal, poor nutritional status and, 64 Late asthma reactions, 148 Lead poisoning, 203–206 LEAN mnemonic, 244 Leg restraints, 22f Leukemia, 215 Lice, 115 Lip, cleft, 159–160 Liver panels, 49 Lyme disease, 115 Mask, oxygen delivery via, 108, 109, 111f Measles, immunization against, 118 Medication(s), administration of, 87 abbreviations used in orders for, 248 assessment preceding, 89 patients’ rights and, 86 routes of, 89–91 safety in, 17, 85, 249–250 anaphylactic reaction to, 86

antimicrobial, 97–98 serum levels of, laboratory values for, 50 dosages of, calculation of, 92 management of transfusion reaction with, 81 pain management with, 57–58 pharmacologic principles in relation to, 88–89 physiologic considerations and, 87–88 restraint facilitated via, 21 serum levels of, laboratory values for, 50–51 Megacolon, aganglionic, 188f, 188–189 Meningitis, 206–208 immunization against, 118 Mental status examination, 138 Metabolic acidosis, 48 Metabolic alkalosis, 48 Metabolic panels, 49 Methicillin-resistant Staphylococcal aureus (MRSA), precautions against, 114 Metric conversion, 249 Mitral stenosis, 165f Mnemonics, 243–245 Moral development, 8 MRSA (methicillin-resistant Staphylococcal aureus), precautions against, 114 Mummy wraps, 23f Mumps, immunization against, 118 Munchausen syndrome by proxy, 158–159 Musculoskeletal system, assessment of, 40–41, 63

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INDEX Nasal administration, of medications, 90 Nasal cannula (nasal prongs), oxygen delivery via, 108, 110f Nasal secretions, collection of specimen of, 52 Nasogastric tube, administration of medications via, 91 Near drowning, 141 Needle, intraosseous, 136–137, 137f Nephrotic syndrome, 209–210 Nervous system, assessment of, 41–43, 63 Neurogenic shock, 135 Neutropenia, precautions in presence of, 114 Newborn, 5 airway obstruction in, 134 growth of, 32 height of, 32 hypoglycemia in, 139 pain in, 56 play by, 26 resuscitation of, 137–138 sepsis in, 230 vital signs in, 28 weight of, 32 Noncommunicating hydrocephalus, 192 Non–insulin-dependent diabetes mellitus (type 2 diabetes mellitus), 179–180 Nonrebreathing mask, 108 Nontunneled line, 128 Novel H1N1 virus infection (swine influenza), 237–239 Numerical scale, in pain assessment, 60, 60f Nurse(s), adult, child care by, 1–2 pediatric, 1, 3 issues affecting, 2

professional organization of, 1 web sites helpful to, 250–252 responsibilities of, during transfusion, 79–80 Nutrition, parenteral, total, 73–75 Nutritional status, assessment of, 61 abnormal laboratory values in, 64 Obesity, 45–47 Obstructive shock, 231 Older infant, development of, 9–10 play by, 26 Olive tip suctioning, 122, 122f Oncology, 213–216 Oral administration, of medications, 89 Oral rehydration therapy, 71 Orthopedics, 216–218 Oucher assessment tool, in rating pain, 60 Overdose, 211 Oxygen delivery systems, 108–110, 110f–112f Oxygen saturation, assessment of, 31, 31f Pain, 53–60 assessment of, 56, 57 scales used in, 58–60, 59f, 60f control of, 54–56 during intramuscular injection, 95 via medications, 57–58 with PCA pumps, 103–104, 104f myths concerning, 53 untreated, consequences of, 54 Palate, cleft, 160–161

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263 Parenteral administration, of medications, 89–90 Parenteral nutrition, total, 73–75 Partial rebreathing mask, 108 Partial seizures, 228 Patent ductus arteriosus, 163f Patient-controlled analgesia (PCA), pumps used in, 103–104, 104f Patients’ rights, 250 and medication administration, 86 PCA (patient-controlled analgesia), pumps used in, 103–104, 104f Pediatric nurse(s), 1, 3 issues affecting, 2 professional organization of, 1 web sites helpful to, 250–252 PEEP (positive end-expiratory pressure), 109 Penicillins, 97 Perioperative care, 245–247 Peripheral intravenous therapy, 101, 125, 125f Peripherally inserted central venous catheter, 128 Pertussis, 115 immunization against, 117 pH, blood, interpretation of, 47 Pharmaceuticals. See Medication(s). Pharmacologic principles, 88–89 physiologic considerations and, 87–88 Piaget, J., on developmental milestones, 8 Play, 24–25 developmental aspects of, 26–27 therapeutic aspects of, 24–25 Plumbism, 203–206 Pneumonia, 219–220 immunization against, 118 Poisoning, 210–212 lead, 203–206

Port-a-Cath, 126 Positive end-expiratory pressure (PEEP), 109 Postoperative assessment, 247 Postoperative teaching, 247 Premature infant, 5 play by, 26 Preoperative assessment, 245–246 Preoperative teaching, 246–247 Preschooler, 5. See also Child. communication with, 14 development of, 11 growth of, 33 height of, 33 pain in, 57. See also Pain. play by, 27 weight of, 33 Prongs, nasal, oxygen delivery via, 108, 110f Pulmonary atresia, 166f Pulmonic stenosis, 164f Pulse, assessment of, 31 Pump(s), intravenous therapy, 99–100 patient-controlled analgesia, 103–104, 104f syringe, 100f, 100–101 Purpura, thrombocytopenic, idiopathic, 196–197 Quick mental status examination, 138 Rabies, 115 Rebreathing mask, partial, 108 Rectal administration, of medications, 91 Rehydration therapy, oral, 71 Renal failure, transfusion and, 84

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INDEX Respiration, 29. See also Respiratory entries. assessment of, 29 for distress, 131–132 patterns of, 29f, 30f Respiratory acidosis, 48 Respiratory alkalosis, 48 Respiratory distress, 131–132 Respiratory syncytial virus, 115 bronchiolitis due to, 221–222 precautions against, 114 Respiratory system. See also Respiration. assessment of, 35–36 medication administration via, 90–91 Restraint(s), 20–23 behavioral, 20–21 chemical, 21 methods of, during procedures, 22, 22f, 23, 23f Resuscitation, ABCs of, 132–133 mnemonics incorporating, 243–244 cardiopulmonary, 132–133 fluid, 71–72 neonatal, 137–138 Resuscitative mask, 109 Reye’s syndrome, 222–224 Rights, of patients, 86, 250 Rotavirus, 115 enteritis due to, 115 immunization against, information source for, 118 RSV. See Respiratory syncytial virus. Rubella, immunization against, 118 Safety, 16–19 anticipatory guidance and, 17–19 environmental, 16

equipment, 16–17 medication, 17, 85, 249–250 SBAR mnemonic, 244 Scabies, 115 SCALE mnemonic, 244 School-age child, 5. See also Child. communication with, 14 development of, 12 eating habits of, 67 growth of, 33 height of, 33 pain in, 57. See also Pain. play by, 27 vital signs in, 28 weight of, 33 Scoliosis, 225–226 Seizure disorders, 226–230 Sensory assessment, 43 Separation anxiety, 13 Septal defect, atrial, 162f atrioventricular, 163f ventricular, 162f Septic shock, 135, 230–233 Sexuality, assessment of, 39 developmental aspects of, 8 Shaken baby syndrome, 141–142 Shock, 135–136, 230–231 anaphylactic, 86, 135 cardiogenic, 135, 230 compensated, 135 distributive, 231 hypovolemic, 135, 230 interventions for, 136 neurogenic, 135 obstructive, 231 septic, 135, 230–233 uncompensated, 135 SIADH (syndrome of inappropriate antidiuretic hormone), 176–177 Side-tying, 22f

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265 SIDS (sudden infant death syndrome), 233–236 Single ventricle, 167f Skin, assessment of, 36, 62 Society of Pediatric Nurses, 1 Special-needs child, play by, 27 Specialty diets, for infant, 76, 77 Specimen collection, 51–52 urinary catheterization and, 107, 107f Spine, curvature of, 225–226 Sputum, collection of, 51 Staphylococcal aureus, methicillinresistant, precautions against, 114 Stenosis, aortic, 163f mitral, 165f pulmonic, 164f tricuspid, 164f Sterile suctioning, 122, 122f Stool specimen, collection of, 51 Stranger anxiety, 13 Subcutaneous administration, of medications, 90 Subcutaneous injection sites, 95f, 95–96 Sublingual administration, of medications, 89 Suctioning, 122f, 122–123 Sudden infant death syndrome (SIDS), 233–236 Suicide, 236–237 Surgery, assessment before, 245–246 assessment following, 247 teaching before, 246–247 teaching following, 247 Swine influenza (H1N1 virus infection), 237–239 Syndrome of inappropriate antidiuretic hormone (SIADH), 176–177

Syringe, bulb, suctioning via, 122, 122f Syringe pumps, 100f, 100–101 Systemic assessment, 34–43, 62–63 for health history, 242–243 Systemic differences, between adult and child, 4–5 Tantrums, 13 Teaching, postoperative, 247 preoperative, 246–247 Teeth, assessment of, 63 Temperature, assessment of, 28, 121 Tent system, for oxygen delivery, 109, 112f Tetanus, immunization against, 117 Tetracyclines, 97 Tetralogy of Fallot, 165f Thrombocytopenic purpura, idiopathic, 196–197 Toddler, 5. See also Child. communication with, 14 development of, 10 eating habits of, 67 growth of, 32 height of, 32 pain in, 57. See also Pain. play by, 26 vital signs in, 28 weight of, 32 Topical administration, of medications, 90 Total parenteral nutrition, 73–75 Tracheostomy, care of, 123–124 Tracheostomy equipment, 124, 124f Tracheostomy mask, oxygen delivery via, 109 Traction, 218

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INDEX Transdermal administration, of medications, 91 Transfusion, 78–84 alloimmunization risk in, 84 blood products used in, 78, 82 half-life of, 82 blood-type compatibility in, 79 blood warmers in, 81 calculation of amount of blood needed in, 78 documentation of, 80–81 errors in, 82 infections transmissible via, 82 nursing responsibilities during, 79–80 reaction to, 82–84 medications for, 81 renal failure associated with, 84 Tricuspid atresia, 166f Tricuspid stenosis, 164f Truncus arteriosus, 167f Tube(s), chest, drainage via, 105–106, 106f gastrostomy/nasogastric, administration of medications via, 91 Tuberculosis, 115 precautions against, 113 Tumor(s), 213–216 brain, 216 Tunneled catheter, 127, 127f Turn-cough–deep breathe maneuver, 130 Type 1 diabetes mellitus (insulindependent diabetes mellitus), 177–179 Type 2 diabetes mellitus (non–insulin-dependent diabetes mellitus), 179–180 Ulcerative colitis, 200 Uncompensated shock, 135

Universal precautions, 112, 113 Urinary catheterization, 106, 107 and specimen collection, 107, 107f Urinary tract infections (UTIs), 239–241 Urine, collection of, 51 catheterization and, 107, 107f Urogenital system, assessment of, 37–38 UTIs (urinary tract infections), 239–241 Vaccination, 115–118 Varicella, 115 immunization against, 118 precautions against, 114 Vastus lateralis injection site, 93f Venous access, 102f, 125–128, 125f–128f. See also Intravenous therapy. Ventilation, inadequate, 131–132 Ventilator, oxygen delivery via, 109–110 Ventral gluteal injection site, 94f Ventricle, single, 167f Ventricular septal defect, 162f Venturi mask, 108 Visual analog scale, in pain assessment, 60 Vital signs, 28–31 Vomiting, binge eating and, 69 Warmers (blood warmers), 81 Weaning, 64 Web sites, pediatric nursing–related, 250–252 Weight. See Body weight. West Nile virus, 115 Wong-Baker faces scale, in pain assessment, 58–59, 59f Wraps, mummy, 23f Young infant, play by, 26

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