Ati Peds

Front 1

An infant should ride in a rear facing car seat until..

Back 1

they weigh 20 lbs and are 1 year old.

Front 2

A 4 year old with iron deficiency anemia should be encouraged to eat

Back 2

liver; dark, leafy green vegetables, whole grains

Front 3

Cool humidity helps a child with an Upper Resp Infx breathe by..

Back 3

decreasing respiratory tract edema

Front 4

Natural (innate) immunity

Back 4

present at birth. Examples include barriers against disease, such as skin and mucous membranes, and bacteriocidal substances of body fluids, such as intestinal flora and gastric acidity.

Front 5

Naturally acquired active immunity

Back 5

the immune system makes antibodies after exposure to the disease. It requires contact with the disease.

Front 6

Naturally acquired passive immunity

Back 6

no active immune process is involved. The antibodies are passively received through placental transfer by immunoglobuling

Front 7

Artificially acquired active immunity

Back 7

medically engineered substances are ingested or injected to stimulate the immune response against a specific disease. Immunizations are an example of this kind of immunity.

Front 8

artificially acquired passive immunity

Back 8

antibodies are injected without stimulating the immune response. Examples include tetanus antitoxin, hepatitis B immune globulin, and varicella zoster immune globulin.

Front 9

hemophelia - neonate

Back 9

s/s: prolonged bleeding after circumcision, immunizations, or minor injuries; multiple bruises without petechiae; peripheral neuropathies from bleeding near peripheral nerves; bleeding into the throat, mouth, and thorax; and hemarthrosis.

Front 10

Developmental-School age hospitalization

Back 10

School-age children engage in fantasy play and daydreaming. They are also able to participate in his care.

Front 11

Developmental-Pre-School hospitalization

Back 11

doll play is helpful

Front 12

Developmental-Toddler hospitalization

Back 12

enjoys push-pull toys and games of peek-a-boo.

Front 13

Reye's Syndrome

Back 13

defined as toxic encephalopathy, characterized by fever, profoundly impaired consciousness, and disordered hepatic function. Intractable vomiting occurs during the 1st stage, but rhinorrhea usually precedes the onset of the illness.
Reye's syndrome does not affect the spleen, but causes fatty degeneration of the liver. Hyperactive reflexes occur with CNS involvement. Malaise, cough, and sore throat are viral symptoms that commonly precede the ilness.

Front 14

Successful management of Reye's Syndrome

Back 14

Early dx and therapy are essential r/t rapid clinical course and its high mortality. Reye's syndrome is assoc w/a viral illness, and antibiotic therapy isn't crucial to preventing the initial progression of the illness. Isolation is not necessary r/t the disease is not communicable.

Front 15

After a child has a cardiopulmonary arrest, what drug would the RN expect to administer during the initial phase of treatment?

Back 15

Dopamine as an infusion to increase cardiac output and maintain BP.

Front 16

SARS Transmission

Back 16

The transmission of SARS isn't fully understood, so all personal protection must be in place for droplet, airborne, contact precautions. Gown, eye protection, mask and gloves.

Front 17

Earliest sign of Heart Failure in Infants

Back 17

Tachycardia (sleeping HR > 160) as a direct result of sympathetic stimulation.

Front 18

Epidural Hematoma

Back 18

Causes an initial loss of consciousness followed by transient consciousness leading to unconsciousness

Front 19

Esophogeal Atresia

Back 19

Cyanosis occurs when fluid from the blind pouch is aspirated into the trachea. increased drooling is common along w/coughing, sneezing and choking.

Front 20

A 10 y/o child w/Rheumatic Fever must have his HR measured while awake and while sleeping. Why?

Back 20

Tachycardia may be a sign of HF. Mild tachycardia can be detected more easily during sleep than during the day when activity can cause an increase.

Front 21

neonates of a mother with Diabetes born with hypoglycemia. Does this mean the baby has diabetes?

Back 21

No. The hypoglycemia is transient r/t the baby's insulin production responding to the mom's BG. There is no evidence suggesting that infants of diabetic mothers have an increased risk of having diabetes.

Front 22

NEC Necrotizing enterocolitis

Back 22

Clinical s/s:
Lethargy, vomiting, unstable temp, abdomen distention and gastric retention

Front 23

Turner Syndrome

Back 23

absence of one of the X chromosomes.
Webbed neck, posterior hairline, widely spaced nipples, and edema of the hands/feet at birth.
Often dx in the preschool child r/t growth is restricted at about 4 y/o. Dx at puberty r/t to 3 features: short stature, delayed sexual development, and amenorrhea; generally infertile.
Linear growth and secondary sex characteristics can be tx with estrogen therapy and growth hormone.

Front 24

Digoxin for CHF in infants

Back 24

rarely is an infant given more than 1 mL of Digoxin.

Front 25

Digoxin Toxicity

Back 25

s/s
bradycardia, anorexia, N/V. Dysrhythmias may occur with digoxin toxicity. To detect dysrhythmias, take apical pulse for 1 min. and compare with radial pulses. (Can be completed by 1 nurse.)

Front 26

Myelomeningocele repair
PreOp

Back 26

keep NB's legs in abduction, place them prone and put a moist, sterile dressing on the sac and tell parents to avoid touching it.
The NB needs gentle tactile stimulation to promote normal growth and development.

Front 27

Hypopituitarism medication

Back 27

These kids often have a deficient secretion of GH (somatotropin).
The definitive tx is daily injections of GH

Front 28

Age appropriate activities

Back 28

Adolescent - arrange or encouraging visits from peers
School Age - providing a book of riddles
Preschool - giving the child a large piece puzzle
Toddler- using puppets to entertain the child.

Front 29

Head Injury

Back 29

HOB 30 degrees
NPO if he's vomiting and can't stay awake
IV fluids to maintain fluid/electrolyte balance.
No suctioning, r/t can ↑ ICP

Front 30

Digoxin (Lanoxin)

Back 30

■■ Improves myocardial contractility
■■ Nursing Actions
☐☐ Monitor the pulse and withhold the medication as ordered. Generally if
an infant’s pulse is less than 90/min, the medication should be withheld.
In children, the medication should be withheld if the pulse is less than 70/
min.
☐☐ Monitor for toxicity as evidenced by bradycardia, dysrhythmias, nausea,
vomiting, or anorexia.
☐☐ Monitor serum digoxin levels.

Front 31

Suctioning a child with a trach

Back 31

no more than 5 seconds to prevent hypoxia.
Hyperventilate with 100% Oxygen prior to suctioning.

Front 32

Hypoglycemia
Autonomic nervous system responses
Rapid onset

Back 32

Blood glucose level less than 70 mg/dL
• Hunger, lightheadedness, and shakiness
• Nausea
• Anxiety and irritability
• Pale, cool skin
• Diaphoresis
• Irritability
• Normal or shallow respirations
• Tachycardia and palpitations

Front 33

Hypoglycemia
Impaired cerebral function
gradual onset•

Back 33

Blood glucose level less than 70 mg/dL
Strange or unusual feelings
• Decreasing level of consciousness
• Difficulty in thinking and inability to
concentrate
• Change in emotional behavior
• Slurred speech
• Headache and blurred vision
• Seizures leading to coma

Front 34

Hyperglycemia

Back 34

Blood glucose levels usually greater than 250 mg/dL
☐☐ Thirst
☐☐ Frequent urination
☐☐ Hunger
☐☐ Skin that is warm, dry, and flushed with poor turgor
☐☐ Dry mucous membranes
☐☐ Soft eyeballs
☐☐ Weakness
☐☐ Malaise
☐☐ Rapid, weak pulse; hypotension
☐☐ Rapid, deep respirations with acetone/fruity odor due to ketones (Kussmaul
respirations)

Front 35

Diagnostic criteria for diabetes

Back 35

includes two findings (on separate days) of one of
the following:
☐☐ Symptoms of diabetes plus a casual plasma glucose concentration of greater
than 200 mg/dL (without regard to time since last meal)
☐☐ A fasting blood glucose greater than 126 mg/dL
☐☐ A 2-hour glucose of greater than 200 mg/dL with an oral glucose tolerance
test

Front 36

Glycosylated hemoglobin (HbA1c)

Back 36

The expected reference range is 4% to 6%, but an acceptable target for
children who have diabetes may be 6.5% to 8% with a total target goal of
less than 7%.

Front 37

nutritional guidelines
Diabetes

Back 37

Count grams of carbohydrates consumed.
■■ Recognize that 15 g of carbohydrates are equal to 1 carbohydrate exchange.
■■ Include fiber in the diet to increase carbohydrate metabolism and to help control
cholesterol levels.
■■ Avoid concentrated sweets.
■■ Use artificial sweeteners.
■■ Keep fat content below 30% of the total caloric intake.

Front 38

guidelines to follow when sick.
Diabetes

Back 38

■■ Monitor blood glucose levels every 3 to 4 hr.
■■ Continue to take insulin or oral antidiabetic agents.
■■ Consume 4 oz of sugar-free, non-caffeinated liquid every 0.5 hr to prevent
dehydration.
■■ Meet carbohydrate needs by eating soft foods if possible. If not, consume liquids
that are equal to the usual carbohydrate content.
■■ Test urine for ketones and report if abnormal (should be negative to small).
■■ Rest.

Front 39

guidelines to follow when sick.
Diabetes
Call the health care provider if:

Back 39

☐☐ Blood glucose is higher than 240 mg/dL.
☐☐ Fever higher than 38.9° C (102° F), fever does not respond to
acetaminophen (Tylenol), or fever lasts more than 12 hr.

Front 40

guidelines to follow when sick.
Diabetes
Call the health care provider if:

Back 40

☐☐ Disorientation or confusion occurs.
☐☐ Rapid breathing is experienced.
☐☐ Vomiting occurs more than once.
☐☐ Diarrhea occurs more than five times or for longer than 24 hr.
☐☐ Liquids cannot be tolerated.
☐☐ Illness lasts longer than 2 days.

Front 41

Teach the child measures to take in response to signs and symptoms of hypoglycemia,
(shakiness, diaphoresis, anxiety, nervousness, chills, nausea, headache, weakness,
confusion).

Back 41

☐☐ Treat with 15 to 20 g carbohydrates.
☐☐ Recheck blood glucose in 15 min.
☐☐ If still low (less than 70 mg/dL), give 15 to 20 g more of carbohydrates.
XX Examples – 4 oz orange juice, 2 oz grape juice, 8 oz milk, glucose
tablets per manufacturer’s suggestion to equal 15 g
☐☐ Recheck blood glucose in 15 min.
☐☐ If blood glucose is within normal limits, take 7 g protein (if the next meal is
more than an hour away).
XX Examples – 1 oz of cheese (1 string cheese), 2 tablespoons of peanut
butter, or 8 oz of milk
■■ If the child is unconscious or unable to swallow, administer glucagon SC or IM
and notify the health care provider. Administer liquid with glucose as soon as
tolerated. Watch for vomiting and take precaution against aspiration.

Front 42

Teach the child and parents signs and symptoms of hyperglycemia (hot, dry skin and
fruity breath) and measures to take in response to hyperglycemia.

Back 42

■■ Encourage oral fluid intake.
■■ Administer insulin as prescribed.
■■ Restrict exercise when blood glucose levels are greater than 250 mg/dL.
■■ Test urine for ketones and report if findings are abnormal.
■■ Consult the health care provider if symptoms progress.

Front 43

Insulin lispro
(Humalog)

Back 43

Rapid acting
Onset Less than 15 min
Peak 0.5 to 1 hr
Duration 3 to 4 hr

Front 44

Regular insulin
(Humulin R)

Back 44

Short acting
ONset 0.5 to 1 hr
Peak 2 to 3 hr
Duration 5 to 7 hr

Front 45

NPH insulin
(Humulin N)

Back 45

Intermediate acting

Onset 1 to 2 hr
Peak 4 to 12 hr
Duration 18 to 24 hr

Front 46

Insulin glargine
(Lantus)

Back 46

Long acting
Onset 1 hr
Peak - none
Duration 10.4 to 24 hr
Do not mix insulin glargine (Lantus) with other insulins due to
incompatibility.

Front 47

When mixing a rapid- or short-acting insulin with a longer-acting
insulin,

Back 47

draw up the shorter-acting insulin into the syringe first and
then the longer-acting insulin (this reduces the risk of introducing the
longer-acting insulin into the vial of the shorter-acting insulin).

Front 48

Diabetic ketoacidosis (DKA)

Back 48

Assess subjective and objective data for a blood glucose level greater than
300 mg/dL.
☐☐ Reports of nausea, vomiting, and/or abdominal pain (DKA/metabolic
acidosis)
☐☐ Reports of frequent urination, thirst, and hunger
☐☐ Reports of confusion
☐☐ Change in mental status
☐☐ Signs of dehydration (e.g., dry mucous membranes, weight loss, sunken
eyeballs resulting from fluid loss such as polyuria)
☐☐ Kussmaul respiration pattern, rapid and deep respirations, fruity scent to the
breath (DKA/metabolic acidosis)

Front 49

Nursing Actions
Diabetic ketoacidosis (DKA)

Back 49

■■ Provide rapid isotonic fluid (0.9% sodium chloride) replacement to maintain
perfusion to vital organs. Often large quantities are required to replace losses.
Monitor the child for evidence of fluid volume excess.
■■ Follow with a hypotonic fluid (0.45% sodium chloride) to continue replacing
losses to total body fluid.
■■ When serum glucose levels approach 250 mg/dL, add glucose to IV fluids to
minimize the risk of cerebral edema associated with drastic changes in serum
osmolality.
☐☐ Administer Regular insulin 0.1 unit/kg as an IV bolus dose and then follow
with a continuous intravenous infusion of regular insulin at 0.1 unit/kg/hr.
■■ Monitor glucose levels hourly.
■■ Monitor serum potassium levels. Potassium levels will initially be elevated.
With insulin therapy, potassium will shift into cells and the child will need to
be monitored for hypokalemia. Provide potassium replacement therapy in all
replacement IV fluids as indicated by lab values. Make sure urinary output is
adequate before administering potassium.
■■ Administer sodium bicarbonate by slow IV infusion for severe acidosis (pH of less
than 7.0). Monitor potassium levels because a correction of acidosis that occurs
too quickly may lead to hypokalemia.

Front 50

Hypoglycemia
◯◯ Decreased level of consciousness
◯◯ Nursing Actions

Back 50

■■ Follow facility protocol for hypoglycemia.
■■ Administer 50% glucose IV bolus for unresponsive clients.
■■ Follow with a snack of 15 to 20 g of carbohydrates as tolerated.
■■ Monitor blood glucose levels every hour.

Front 51

IM injections

Back 51

In comparison to adults, medications administered by IM injection are absorbed more
slowly in newborns, but faster in infants.
■■ The vastus lateralis site is usually the recommended site for infants and children
less than 2 years of age (it can accommodate fluid up to 2 mL).
■■ After age 2, the ventral gluteal site can be used (it can accommodate fluid up to
2 mL).
■■ The deltoid site has a smaller muscle mass and can only accommodate up to
1 mL of fluid.

Front 52

Variations in Med Admin
kids vs.adults

Back 52

Newborns and young infants may have intense and prolonged responses to
medications.
◯◯ A limited protein-binding capacity may lead to high concentrations of free drugs.
◯◯ Newborns are highly sensitive to medications that affect the CNS and are metabolized
by the liver.
◯◯ Newborns have limited renal excretion abilities. Therefore, they must have reduced
dosages of medications that are eliminated by the renal system.
◯◯ Starting at 1 year of age, children’s pharmacokinetic responses to medication will start
to be similar to those of adults, with the exception of faster metabolism until age 12.
●● Organ system immaturity is the greatest factor that affects medication response in children.

Front 53

◯◯ Strategies for administering oral medications to infants

Back 53

■■ Do not mix a medication with formula because the infant may not take all of the
formula, which will result in the infant not receiving the full dose of medication.
This may also alter the taste of the formula, which may cause the infant to refuse
to drink it in the future.
■■ Hold the infant in a semi-upright or semi-Fowler’s position to prevent aspiration.
■■ Use a medicine cup once the infant is able to drink from a cup.
■■ Place the medication into nipples from which the infant can suck.

Front 54

Administering oral medications via a feeding tube or a gastrostomy tube

Back 54

■■ Check tube placement before administering any medication.
■■ Use liquid forms of medications.
■■ Check the compatibility of medications before mixing.
■■ Do not mix medications with enteral feedings.
■■ Flush the tubing with warm water before and after each medication. Amount
of flush solution depends on the length and gauge of tubing. Determine this
amount, which is usually 1.5 times the tubing volume, before administering
medication.

Front 55

Epistaxis
Nursing Care

Back 55

◯◯ Have the child sit up with the head tilted slightly forward to promote draining of
blood out of the nose instead of down the back of the throat. Swallowing blood can
promote coughing and lead to nausea, vomiting, and diarrhea.
◯◯ Apply pressure to the lower nose, or instruct the child to use her thumb and forefinger
to press the nares together for 5 to 10 min.
■■ Inform the family that bleeding may last 20 to 30 min
■■ Instruct the child and family to seek medical care if bleeding lasts longer than
30 min or is caused by an injury/trauma.

Front 56

s/s Iron Deficiency Anemia

Back 56

◯◯ Shortness of breath
◯◯ Tachycardia
◯◯ Dizziness or fainting with exertion
◯◯ Pallor
◯◯ Nail bed deformities
◯◯ Fatigue, irritability, and muscle weakness
◯◯ Impaired healing, loss of skin elasticity, and thinning of hair
◯◯ Abdominal pain, nausea, vomiting, and loss of appetite
◯◯ Low-grade fever
◯◯ Systolic heart murmur and/or heart failure

Front 57

Normal values
Hgb/Hct

Back 57

Age 2 months Hgb 9.0 to 14.0 g/dL Hct 28% to 42%
Age 6 to 12 years Hgb 11.5 to 15.5 g/dL Hct 11.5 to 15.5 g/dL
Age 12 to 18 years Hgb 13.0 to 16.0 g/dL (male)
12.0 to 16.0 g/dL (female) Hct 37% to 49% (male)
36% to 46% (female)

Front 58

Iron Supplements

Back 58

☐☐ Give 1 hr before or 2 hr after milk or antacid to prevent decreased
absorption.
☐☐ Gastrointestinal side effects (diarrhea, constipation, nausea) are common at
the start of therapy. These will decrease over time.
☐☐ Administer iron supplements on an empty stomach. However,
administration may not be tolerated during initial treatment and may be
given after meals.
☐☐ Give vitamin C to help increase absorption.
☐☐ Use a straw with liquid preparation to prevent staining of teeth. After
administration, the child should rinse his mouth with water.
☐☐ Evenly distribute doses throughout the day to maximize RBC production by
providing bone marrow with a continuous supply of iron.
☐☐ Use a Z-track into deep muscle for parenteral injections. Do not massage
after injection.

Front 59

Dietary sources of iron

Back 59

☐☐ Infants – Cereal and iron-fortified formula
☐☐ Older children – Dried legumes; dried fruits; nuts; green, leafy vegetables;
iron-fortified breads; iron-fortified flour; poultry; and red meat

Front 60

Sickle cell disease (SCD)

Back 60

a group of diseases in which there is abnormal sickle hemoglobin
S (HbS).
●● Manifestations and complications of sickle cell anemia are the result of RBC sickling, which
leads to increased blood viscosity, obstruction of blood flow, and tissue hypoxia.
◯◯ Manifestations of sickle cell anemia are not usually apparent before 4 to 6 months of
age, due to the presence of fetal Hgb in infants.
■■ The RBCs have the ability to develop a sickled shape. This is usually precipitated
by increased oxygen demands (infection, emotional stress, pain) or decreased
levels of oxygen (pulmonary infections, high altitude).
●● Tissue hypoxia causes tissue ischemia, which results in pain.
●● Increased destruction of RBCs also occurs.
●● Sickle cell crisis is the exacerbation of sickle cell anemia.
●● Sickle cell anemia is usually diagnosed soon after birth. If not, toddlers or preschoolers will
present in crisis following an infection of the respiratory or GI tract.

Front 61

Sickle cell disease (SCD)
Subjective and Objective Data

Back 61

◯◯ Family history of sickle cell anemia or sickle cell trait
◯◯ Reports of pain, crisis, and management
◯◯ Shortness of breath/fatigue
◯◯ Tachycardia
◯◯ Pallor or jaundice
◯◯ Nail bed deformities
◯◯ Lethargy, irritability, and muscle weakness
◯◯ Impaired healing, loss of skin elasticity, and thinning of hair
◯◯ Abdominal pain, nausea, vomiting, and loss of appetite
◯◯ Low-grade fever
◯◯ Systolic heart murmur and heart failure

Front 62

Sickle cell disease (SCD)
Vaso-occlusive crisis
(painful episode) Manifestations

Back 62

• Acute
◯◯ Severe pain, usually in bones, joints, and abdomen
◯◯ Swollen joints, hands, and feet
◯◯ Anorexia, vomiting, and fever
◯◯ Hematuria
◯◯ Obstructive jaundice
◯◯ Visual disturbances
• Chronic
◯◯ Increased risk of respiratory infections and/or osteomyelitis
◯◯ Retinal detachment and blindness
◯◯ Systolic murmurs
◯◯ Renal failure and enuresis
◯◯ Liver failure
◯◯ Seizures
◯◯ Deformities of the skeleton

Front 63

Sickle cell disease (SCD)
Sequestration crisis
Manifestations

Back 63

• Excessive pooling of blood in the liver (hepatomegaly) and spleen
(splenomegaly)
• Tachycardia, dyspnea, weakness, pallor, and shock

Front 64

Sickle cell disease (SCD)
Aplastic crisis
Manifestations

Back 64

Extreme anemia as a result of decreased RBC production

Front 65

Sickle cell disease (SCD)
Hyperhemolytic crisis
Manifestations

Back 65

Increased rate of RBC destruction leading to anemia, jaundice, and/
or reticulocytosis

Front 66

Sickle cell disease (SCD)
Nursing Care
Pain Management

Back 66

■■ Treat mild to moderate pain with acetaminophen (Tylenol) or ibuprofen (Advil).
Manage severe pain with opioid analgesics.
■■ Apply comfort measures, such as warm packs to painful joints.

Front 67

Hirschsprung’s disease

Back 67

congenital aganglionic megacolon, is a structural anomaly of the (GI) tract that is caused by lack of ganglionic cells in segments of the colon and results in mechanical obstruction.
◯◯ Stool accumulates due to lack of peristalsis in the noninnervated area of the bowel (usually rectosigmoid), causing the bowel to dilate.
◯◯ Hirschsprung’s disease is usually diagnosed in infants, but chronic milder symptoms may occur in late childhood.
• Newborn
◯◯ Failure to pass meconium within 24 to 48 hr, refusal to
eat, episodes of vomiting bile, and abdominal distention
• Infant
◯◯ Failure to thrive, constipation, abdominal distention, episodes of vomiting and diarrhea
• Older child
◯◯ Constipation, abdominal distention, visible peristalsis, ribbon-like stool, palpable fecal mass, and a malnourished appearance

Front 68

Meckel’s diverticulum

Back 68

a complication resulting from failure of the omphalomesenteric
duct to fuse during embryonic development.
◯◯ The diverticulum may be up to 4 inches in length and is found in the small intestine.
• Abdominal pain, bloody stools without pain, bright red mucus in infant stools

Front 69

Intussusception

Back 69

the telescoping of the intestine over itself. This usually occurs in infants and young children up to 5 years of age, but it is most common between 5 and 9 months of age.
• Normal comfort interrupted by periods of sudden and acute
pain
• Palpable, sausage-shaped mass in the right upper quadrant of the abdomen and/or a tender, distended abdomen
• Stools that are mixed with blood and mucus that resemble the consistency of red currant jelly

Front 70

GER(D)

Back 70

GER(D) is more likely to occur in premature infants and infants born with congenital defects (neurologic disorders, esophageal disorders, hiatal hernia, cystic fibrosis, cerebral palsy).
• Infant
◯◯ Excessive spitting up or forceful vomiting, irritability,
excessive crying, blood in stool or vomitus, arching of
back and stiffening
◯◯ Apnea or apparent life-threatening event
• Older child
◯◯ Reports of heartburn, abdominal pain, difficulty
swallowing, chronic cough, and Sandifer syndrome (in
which there is repetitive stretching and arching of head
and neck that may mimic seizure activity)

Front 71

Hypertrophic pyloric stenosis

Back 71

• Vomiting that often occurs 30 to 60 min after a meal and becomes projectile as obstruction worsens An increased
BUN level may indicate dehydration.
• Constant hunger
• Olive-shaped mass in the right upper quadrant of the abdomen and possible peristaltic wave that moves from left to right when lying supine
• Failure to gain weight and signs of dehydration, such as skin that is dry and/or pale, cool lips, dry mucous membranes, decreased skin turgor, diminished urinary output, concentrated urine, thirst, rapid pulse, sunken eyes, and decreased blood pressure

Front 72

Laboratory Tests
GI/Structural/inflammatory Disorders

Back 72

■■ Serum electrolyte levels will be consistent, with changes occurring due to
vomiting and resulting in:
☐☐ Decreased sodium and potassium levels
☐☐ Increased pH and bicarbonate caused by metabolic alkalosis
■■ An elevated BUN indicates dehydration.
■■ A CBC may show an elevated WBC count greater than 10,000/mm3 with a shift to
left (increased immature neutrophils, referred to as bands), as well as an elevated
C-reactive protein, but this may not be specific to the diagnosis.

Front 73

Cleft palate repair

Back 73

- Change the infant’s position frequently to facilitate breathing.
The infant may be placed on the abdomen in the immediate
postoperative period.
- Maintain intravenous fluids until the infant is able to eat and
drink.
- Monitor packing, which is usually removed in 2 to 3 days.
- Avoid placing objects (tongue depressor, pacifier) in the infant’s
mouth after cleft palate repair.
-Avoid using objects for feeding (forks, spoons, pacifiers, straws)
that could harm the cleft palate repair.
- Avoid foods that could damage the palate repair.
- The infant may be discharged on a soft diet.

Front 74

Cleft palate repair
Client Education
☐☐ Preoperative

Back 74

Support the mother’s decision to continue breastfeeding her infant.
Instruct her to place the breast fully into the newborn’s mouth,
making a seal. Assist her to be open to alternatives, such as using breast
milk placed in special feeding devices, if necessary.
- Provide instruction to promote feeding. Teach the parents to use an
enlarged nipple, stimulate the infant’s suck reflex, and ensure that
the infant swallows appropriately. To prevent choking and coughing,
steady gentle pressure should be held on the bottom of the bottle.
- Teach parents to limit feedings to 20 to 30 min to prevent fatigue. Also
teach parents to allow the infant to rest frequently after each feeding.
- Identify alternate feeding devices (special nipples for bottles).
- Teach parents to feed the infant in an upright position.
- Teach parents to burp the infant more frequently due to the amount
of air swallowed. This will help prevent aspiration and abdominal
distention.

Front 75

Cleft palate repair
Postoperative

Back 75

Inform the parents that the infant may require elbow restraints for
4 to 6 weeks. Instruct the parents in the proper use of the restraints
and to periodically remove them one at a time to allow for exercise.
■■ Feed the infant in an upright position.
■■ Burp the infant often.
■■ Use a bulb syringe to suction oral and nasopharyngeal secretions.

Front 76

Appendicitis

Back 76

Pain is usually most intense in the right lower quadrant, over McBurney point, which is
halfway between the anterior superior iliac crest and the umbilicus.
Increased WBCs with an increased neutrophil count may indicate appendicitis.

Front 77

nursing interventions
Ruptured appendix → peritonitis

Back 77

Administer IV pain medications and antibiotics.
Monitor vital signs per facility protocol.
Provide nasogastric tube maintenance until bowel motility returns.
Provide postoperative activity (turning, initiating deep breathing, moving extremities, ambulating) as ordered.
Support coping mechanisms of the child and family.
Provide teaching for the child and family.
Provide surgical wound care.

Front 78

Discharge instructions for NB w/cleft lip/palate and mom who wants to breastfeed.

Back 78

Provide a quiet, calm environment for feeding. Hold the newborn upright while feeding to prevent choking. Burp the newborn frequently because the newborn swallows a lot of air while eating. If breastfeeding, place the breast fully into the newborn’s mouth, making a seal. If bottle feeding, use a specialized nipple or a large syringe attached to rubber tubing.
Instill the formula slowly, observing that the newborn is swallowing. Do not be afraid
if milk comes through the newborn’s nose. This is okay because the cleft palate opens
directly into the nasal cavity. Don’t tire the newborn. Eating can be difficult and stressful.
Limit feeding times to 20 to 30 min. Also, teach parents to observe for ear infections and encourage speech attempts and any activities that will increase bonding, such as cuddling or talking to the newborn.

Front 79

Head Injury
Signs of increased intracranial pressure (ICP) and brainstem involvement

Back 79

☐ Severe headache
☐ Deteriorating level of consciousness, restlessness, irritability, and agitation
☐ Dilated and fixed, constricted and fixed, slow to react, or nonreactive pupils
☐ Alteration in breathing pattern, such as deep, fast, and intermittent gasping
respirations
☐ Abnormal posturing
- Decorticate (dysfunction of the cerebral cortex) – Demonstrates the arms, wrists, and fingers flexed and bent inward onto the chest and the legs extended and adducted
- Decerebrate (dysfunction at the midbrain) – Demonstrates a backward
arching of the head and arms with legs rigidly extended and toes pointing downward
- Flaccidity – Demonstrates no muscle tone
☐☐ A child who is comatose and has asymmetric pupils or one pupil that is
dilated and nonreactive is a medical emergency.
☐☐ Cushing’s reflex is a late sign characterized by severe hypertension with
widening pulse pressure (systolic – diastolic) and bradycardia.

Front 80

Glasgow Coma Scale (GCS)

Back 80

☐☐ GCS scores of 8 or less are associated with severe head injury and coma.
☐☐ GCS scores between 9 and 12 indicate moderate head injury.
☐☐ GCS scores of 13 or greater reflect minor head trauma.

Front 81

Laboratory Tests
Head Injury

Back 81

■■ Arterial blood gases (ABGs)
■■ Alcohol level and drug screen
■■ CBC with differential

Front 82

Head Injury
Diagnostic Procedures

Back 82

■■ Cervical spine films
☐☐ Rule out cervical spine injury.
■■ Computerized tomography (CT) and/or magnetic resonance imaging (MRI) of
head and/or neck
☐☐ May be performed with and without contrast if indicated
■■ Measurement of ICP
☐☐ The expected reference range is 10 to 15 mm Hg.
☐☐ Client Education
XX Provide support to the child and family.

Front 83

Head Injury
Nursing Care

Back 83

◯◯ Ensure the child’s spine is stabilized until spinal cord injury is ruled out.
Maintaining body alignment will prevent increased ICP,and pillows should be avoided because they may cause hyperflexion of the child’s neck.
Suctioning should not be performed routinely, but on an as needed basis.
◯◯ Monitor the child’s vital signs, level of consciousness, pupils, ICP, motor activity,
sensory perception, and verbal responses at frequent intervals. Use the Glasgow Coma Scale as indicated.
◯◯ Maintain a patent airway. Provide mechanical ventilation as indicated.
◯◯ Administer oxygen as indicated to maintain an oxygen saturation level greater than 95%.
◯◯ Hyperventilate the child to keep the PaCO2 between 30 and 35 mm Hg (this reduces cerebral blood flow).
◯◯ Maintain c-spine stability if indicated.
◯◯ Implement actions that will decrease ICP.
◯◯ Restrain extremities as indicated to prevent pulling on tubes.
◯◯ Implement measures to prevent complications of immobility (turn every 2 hr,
maintain footboard and splints). Specialty beds may be used.
◯◯ Insert and maintain an indwelling urinary catheter.
◯◯ Administer stool softener to prevent straining (Valsalva maneuver).
◯◯ Report to the provider the presence of CSF from nose or ears.
◯◯ Provide a calm, restful environment (limit visitors, minimize noise).
◯◯ Use energy conservation measures. Alternate activities with rest periods.
◯◯ Implement seizure precautions.
◯◯ Monitor fluid and electrolyte values and osmolarity to detect changes in sodium
regulation, the onset of diabetes insipidus, or severe hypovolemia.
◯◯ Provide adequate fluids to maintain cerebral perfusion. When a large amount of IV
fluids is ordered, monitor the child carefully for excess fluid volume, which may
increase ICP.
◯◯ Maintain the child’s safety (side rails up, padded side rails, call light within reach).
◯◯ Provide nutritional support (total parenteral nutrition, enteral nutrition).
◯◯ Maintain ongoing communication with the child.
◯◯ Instruct the family on effective ways to communicate with the child (touching,
talking, assisting with care as appropriate).

Front 84

actions that will decrease ICP.

Back 84

■ Keep the head of the bed elevated to 30°, which will also promote venous
drainage.
■■ Avoid extreme flexion, extension, or rotation of the head and maintain in
midline neutral position.
■■ Keep the child’s body in alignment, avoiding hip flexion/extension.
■■ Minimize endotracheal or oral suctioning.
■■ Instruct the child to avoid coughing and blowing her nose, because these
activities increase ICP.

Front 85

Medications
Head Injury

Back 85

◯◯ Corticosteroids – Dexamethasone (Decadron) and methylprednisolone (Solu-Medrol)
■■ Decrease cerebral edema
■■ Nursing Considerations
☐☐ Monitor for signs of infection.
◯◯ Mannitol (Osmitrol)
■■ Osmotic diuretic used to treat cerebral edema
■■ Nursing Considerations
☐☐ Administer intravenously to treat acute cerebral edema.
☐☐ Insert an indwelling urinary catheter to monitor fluid status and renal
function.
◯◯ Phenytoin (Dilantin)
■■ Used to prevent or treat seizures that may occur
■■ Nursing Considerations
☐☐ Monitor therapeutic medication levels.
☐☐ Check for medication interactions.
◯◯ Analgesics – Morphine sulfate and fentanyl citrate (Sublimaze)
■■ Control pain and restlessness.
■■ Nursing Considerations
☐☐ Use opioids if the child is receiving ventilation.
☐☐ Avoid the use of opioids due to their CNS depressant effect that will make
neurologic assessment difficult.

Front 86

Head Injury Complications
●● Brain Herniation

Back 86

◯◯ Clinical signs include fixed, dilated pupils; deteriorating level of consciousness;
Cheyne-Stokes respirations; hemodynamic instability; and abnormal posturing.
◯◯ With treatment, severe neurologic impairment usually persists.
◯◯ Nursing Actions
■■ This situation should be prevented before treatment is needed.
■■ Close monitoring of the child’s vital signs and neurologic status will allow early
reporting of changes in the Glasgow Coma Scale score, an increase in the blood
pressure, and alterations in respiratory pattern and effort.
■■ Early treatment of increased ICP should be implemented.
■■ Emergent treatment includes administration of mannitol (Osmitrol) and possible surgical (debulking) treatment.

Front 87

Human growth hormone (GH)

Back 87

somatotropin, is a naturally occurring substance that is
secreted by the pituitary gland.
●● GH is important for normal growth, development, and cellular metabolism.
●● A deficiency in GH prevents somatic growth throughout the body.
●● Other hormones that work with GH to control metabolic processes include
adrenocorticotropic hormone (ACTH), thyroid stimulating hormone (TSH), and the
gonadotropins (follicle-stimulating hormone [FSH] and luteinizing hormone [LH]).

Front 88

Achondroplasia

Back 88

a genetic disorder that causes nonproportional (short-limbed) dwarfism.
◯◯ Besides short stature, achondroplasia causes a relatively long trunk with shortened upper parts of arms and legs, large head with prominent forehead, flattened bridge of
the nose, shortened hands and fingers, and decreased muscle tone.
◯◯ Children who have achondroplasia tend to have physical disabilities, such as scoliosis, breathing difficulties (due to small chests), and lower back pain.
◯◯ Achondroplasia is not successfully treated with GH.

Front 89

Objective Data
Growth Hormone Deficiency

Back 89

■■ Short stature with growth during the first year within expected percentile ranges
☐ A decrease in percentiles usually starts by the second year and may be as low
as the fifth percentile.
☐ Height is usually more delayed than weight, which appears appropriate.
■■ Normal skeletal proportions
■■ Delayed eruption of permanent teeth
■■ Underdeveloped jaw, resulting in overcrowding of teeth

Front 90

Medications
Growth Hormone Deficiency

Back 90

◯◯ Somatropin
■■ Used as a human growth hormone that is a replacement for deficiency in growth
hormones
■■ Nursing Considerations
☐☐ Administer the medication via subcutaneous injections.
☐☐ Use cautiously in children who are receiving insulin.
Client Education
■■ Teach the child and parents how to administer medication by subcutaneous
injection for home use.
■■ Instruct the child and parents that GH should be administered 6 to 7 days a week.
■■ Inform the child and parents that GH is usually continued until bone maturation
takes place. This may be 16 years of age or older for boys and 14 years of age or
older for girls.
■■ Encourage the child and family to seek evaluation during early adulthood.
Children with GH deficiency in childhood should be evaluated in early
adulthood to determine the need for continued replacement therapy.

Front 91

Growth Hormone Deficiency
diagnostic tests

Back 91

X-rays of wrist and hand - Determines bone age
IGF-1 - Determines GH level
MRI - Identifies pituitary gland tumor
GH stimulation - Measures effect of glucose on GH

Front 92

cardiac tamponade s/s

Back 92

muffled heart sounds, hypotension, a narrowing pulse pressure, and sudden cessation of chest tube drainage..
Cardiac tamponade occurs when a large volume of fluid interferes w/ventricular filling and pumping and collects in the pericardial sac.

Front 93

A nurse is monitoring fluid and electrolyte balance in a child after cardiac surgery requiring cardiopulmonary bypass. Which finding is expected?

Back 93

body excretes aldosterone and ADH in response to cp bypass. This in-turn ↑ Na+ levels, ↓ K+ levels, ↑ water retention, and ↓ u/o.

Front 94

Pain Scales

Back 94

Age 2-7 = FLACC Scale
3-13 = OUCHER Scale

Front 95

Varicella (chickenpox)/
varicella-zoster virus

Back 95

SPREAD
• Direct contact
• Droplet
• Contaminated objects
INCUBATION
14 to 21 days
COMMUNICABILITY
One day before to
6 days after first
lesions appear

Front 96

Rubella (German
measles)/rubella virus

Back 96

SPREAD
• Direct contact
• Droplet
INCUBATION
14 to 21 days
COMMUNICABILITY
7 days before to
5 days after rash

Front 97

Rubeola
(measles)/rubeola virus

Back 97

SPREAD
• Direct contact
• Droplet
INCUBATION
10 to 21 days
COMMUNICABILITY
4 days before to 5
days after rash

Front 98

Pertussis (whooping
cough)/Bordetella
pertussisv

Back 98

SPREAD
• Droplet
INCUBATION
6 to 20 days
COMMUNICABILITY
Catarrhal stage before paroxysms

Front 99

Erythema infectiosum
(fifth disease)

Back 99

SPREAD
• Respiratory secretions and blood
INCUBATION
4 to 21 days
COMMUNICABILITY
Unknown

Front 100

Mumps/paramyxovirus

Back 100

SPREAD
• Direct contact
• Droplet
INCUBATION
14 to 21 days
COMMUNICABILITY
Immediately before and after swelling

Front 101

Epstein-Barr (EBV) virus (EBV), also known as infectious mononucleosis)

Back 101

SPREAD
• Direct contact
INCUBATION
4 to 6 weeks
COMMUNICABILITY
Unknown

Front 102

Pancytopenia

Back 102

◯◯ Bone marrow depression resulting in anemia, neutropenia, and/or thrombocytopenia
◯◯ Nursing Actions
■■ Monitor vital signs and report them to the health care provider. Report a
temperature greater than 37.8° C (100° F).
■■ Monitor for signs of infection (lung congestion; redness, swelling, and pain
around IV sites) and lesions in the mouth, and monitor the client’s wound site
and immunization status.
■■ Administer antimicrobial, antiviral, and antifungal medications as prescribed.

Front 103

Pancytopenia
Nursing Actions

Back 103

■■ Encourage the child to avoid crowds while undergoing chemotherapy.
■■ Instruct the child to avoid fresh fruits and vegetables.
■■ Avoid invasive procedures (injections, rectal temperatures, catheters). Apply
pressure to puncture sites for 5 min.
■■ Monitor for signs of bleeding.
■■ Avoid aspirin/NSAIDs.
■■ Administer filgrastim (Neupogen), a granulocyte colony-stimulating factor that
stimulates WBC production, subcutaneously daily.
■■ Monitor the child for headache, fever, and mild to moderate bone pain.
■■ Administer epoetin alfa (Procrit) subcutaneously two to three times per week as
prescribed to stimulate RBC formation.
■■ Monitor blood pressure.
■■ Administer oprelvekin (Interleukin-11, Neumega) subcutaneously daily as
prescribed to stimulate platelet formation.

Front 104

side effects of chemotherapy and radiation therapy
●● Anorexia, nausea, vomiting

Back 104

◯◯ Nursing Actions
■■ Avoid strong odors. Provide a pleasant atmosphere for meals.
■■ Suggest and assist in selecting foods/fluids.
■■ Provide small, frequent meals.
■■ Administer antiemetics as prescribed, usually before meals.

Front 105

side effects of chemotherapy and radiation therapy
●● Alteration in bowel elimination

Back 105

◯◯ Diarrhea is a result of radiation to the abdominal area. Some chemotherapeutic agents
may cause constipation. If mobility and nutrition decrease, the child is more likely to
develop constipation.
◯◯ Nursing Actions
■■ Provide meticulous skin care.
■■ Provide a nutritious diet.
■■ Determine if certain foods or drinks (high fiber, lactose rich) worsen the child’s
condition.
■■ Monitor intake and output and daily weight.

Front 106

side effects of chemotherapy and radiation therapy

Stomatitis and dry mouth

Back 106

◯◯ Nursing Actions
■■ Provide a soft toothbrush and/or swabs.
■■ Lubricate the child’s lips.
■■ Give soft, nonacidic foods. A puréed or liquid diet may be required.
■■ Provide analgesics.
◯◯ Client Education
■■ Encourage the parents and child to visit a dentist before therapy.
■■ Encourage the use of mouth washes, such as 1 tsp salt mixed with 1 pint of water
or 1 tsp baking soda mixed with 1 quart of water.

Front 107

●● Age-Appropriate Activities
(Birth to 1 year)

Back 107

◯◯ Infants will have short attention spans and will not interact with other children
during play (solitary play). Appropriate toys and activities that stimulate the senses
and encourage development include:
■■ Rattles
■■ Mobiles
■■ Teething toys
■■ Nesting toys
■■ Playing pat-a-cake
■■ Playing with balls
■■ Reading books

Front 108

●● Immunizations
(Birth to 1 year)

Back 108

■■ Birth – Hepatitis B (Hep B)
■■ 2 months – Diphtheria and tetanus toxoids and pertussis (DTaP), rotavirus
vaccine (RV), inactivated poliovirus (IPV), Haemophilus influenzae type B (Hib),
pneumococcal vaccine (PCV), and Hep B
■■ 4 months – DTaP, RV, IPV, Hib, PVC
■■ 6 months – DTaP, IPV (6 to 18 months), PVC, and Hep B (6 to 12 months);
RotaTeq, an alternative formulation for RV, requires 3 doses that must be
completed by 32 weeks of age.
■■ 6 to 12 months – Seasonal influenza vaccination yearly; the trivalent inactivated
influenza vaccine (TIV) is available as an intramuscular injection.

Front 109

pulse oximetry

Back 109

The expected reference range for SaO2 is 95% to 100%. Acceptable levels may range
from 91 to 100%. Some illnesses may allow for an SaO2 of 85% to 89%.
◯◯ Results less than 91% require nursing intervention to assist the child to regain normal SaO2 levels. An SaO2 of less than 86% is a life-threatening emergency. The lower the SaO2 level, the less accurate the value.

Front 110

Chest Physiotherapy (CPT)

Back 110

the use of a set of techniques that include percussion, vibration,
and postural drainage. Gravity and positioning loosen respiratory secretions and move them into the central airways where they can be removed by coughing or suctioning to promote removal of excessive secretions from specific areas of the lungs.
●● Indications
◯◯ Client Presentation
■■ Thick secretions with an inability to clear the airway
■■ Contraindication – Decreased cardiac reserves, pulmonary embolism, or increased intracranial pressure
◯◯ Nursing Actions
■■ Schedule treatments 1 hr before meals or 2 hr after meals and at bedtime to
decrease the likelihood of vomiting or aspirating.
■■ Administer a bronchodilator medication or nebulizer treatment 30 min to 1 hr
prior to postural drainage if prescribed.
■■ Offer the child an emesis basin and facial tissues

Front 111

Chest Physiotherapy (CPT)
Intraprocedure

Back 111

◯◯ Nursing Actions
■■ Perform hand hygiene, provide privacy, and explain the procedure to the child
and parents.
■■ Ensure proper positioning of the child to promote drainage of specific areas of the
lungs.
☐☐ Apical sections of the upper lobes – Fowler’s position
☐☐ Posterior sections of the upper lobes – Side-lying position
☐☐ Right lobe – On the left side with a pillow under the chest wall
☐☐ Left lobe – Trendelenburg position
■■ Apply manual percussion by using cupped hand or a special device to clap
rhythmically on the chest wall to break up secretions.
■■ Place hands on the affected area, tense hand and arm muscles, and move the heel
of the hands to create vibrations as the child exhales to help remove secretions.
Have the client cough after each set of vibrations.
■■ Have the child remain in each postural drainage position for 10 to 15 min to
allow time for percussion, vibration, and postural drainage.
■■ Discontinue the procedure if the child reports faintness or dizziness.

Front 112

■■ Hypoxemia

Back 112

Early signs
• Tachypnea
• Tachycardia
• Restlessness
• Pallor of the skin and mucous membranes
• Elevated blood pressure
• Symptoms of respiratory distress (use of
accessory muscles, nasal flaring, tracheal
tugging, adventitious lung sounds)
Late signs
• Confusion and stupor
• Cyanosis of skin and mucous membranes
• Bradypnea
• Bradycardia
• Hypotension
• Cardiac dysrhythmias

Front 113

Oxygen hood – Small plastic
hood that fits over the
infant’s head

Back 113

• Use a minimum flow rate of 4 to 5 L/min to prevent carbondioxide buildup.
• Ensure that the child’s neck, chin, or shoulders do not rub against the hood.
• Secure a pulse oximeter to the child for continuous SaO2 monitoring.

Front 114

Oxygen tent – Large plastic tent that fits over the crib or bed and can provide oxygen
and humidity if prescribed

Back 114

• Use oxygen tents for children older than 2 to 3 months.
• Set the tent on a high flow rate to flood the tent with oxygen. Then, adjust flow meter to the desired amount prior to placing the child into the tent. Repeat if the tent has been opened for an extended period of time.
• An oxygen level greater than 30% to 50% FiO2 is hard to maintain, especially if the child is restless in bed.
• Keep the tent around the perimeter of the bed.
• Plan care to minimize how often the tent is opened.
• Monitor the temperature inside the tent to ensure that it is appropriate.
• Use plastic or vinyl toys, avoiding soft toys and toys that are mechanical or electrical.
• Keep the child warm and dry.

Front 115

Nasal cannula –

Back 115

Disposable plastic tube with two prongs
for insertion into the nostrils that delivers an oxygen concentrations of 24% to 40% FiO2 at a flow rate of 1 to 6 L/min
• Nasal cannulas are safe, easy to apply, and well tolerated.
• The child is able to eat, talk, and ambulate while wearing a cannula.
• Cannulas may be used by infants and older children who are cooperative.
• Assess the patency of the nares.
• Ensure that the prongs fit in the nares properly.
• A nasal cannula may cause skin breakdown and dry mucous membranes.
• Supply the child with a water-soluble gel if the nares are dry.
• Provide humidification for flow rates greater than 4 L/min.
• Prongs can become dislodged easily; therefore, monitor the child frequently.

Front 116

Pediatric face mask –
Pediatric-size mask that
covers the child’s nose and
mouth

Back 116

• Face masks are not tolerated well by children.
• Cooperation may be gained from an older child by giving an explanation of the need for therapy.

Front 117

Oxygen toxicity

Back 117

■■ Oxygen toxicity may result from high concentrations of oxygen (typically 50%),
long duration of oxygen therapy (typically greater than 24 to 48 hr), and the child’s degree of lung disease.
☐☐ Signs and symptoms include a nonproductive cough, substernal pain,
nasal stuffiness, nausea and vomiting, fatigue, headache, sore throat, and
hypoventilation.
■■ Nursing Actions
☐☐ Use the lowest level of oxygen necessary to maintain an adequate SaO2.
☐☐ Monitor ABGs and notify the health care provider if SaO2 levels rise outside
of the expected reference range.
☐☐ Use of an oxygen mask with continuous positive airway pressure (CPAP), bilevel positive airway pressure (BiPAP), or positive end-expiratory pressure
(PEEP) while a child is on a mechanical ventilator may decrease the amount
of oxygen needed.
☐☐ Decrease the amount of oxygen gradually.

Front 118

Endotracheal suctioning (ETS)

Back 118

☐☐ Set the suction pressure to no higher than 110 mm Hg for children, and
95 mm Hg for infants. Use the lowest amount of pressure possible.
☐☐ Test the suction setup by aspirating sterile water/0.9% NaCl solution from
the cup. If the unit is operating properly, continue with the procedure.
☐☐ Remove the bag or ventilator from the tracheostomy or endotracheal tube
and insert the catheter into the lumen of the airway. Advance the catheter
until resistance is met. The catheter should reach the level of the carina
(location of bifurcation into the mainstem bronchi).
☐☐ Pull the catheter back 0.5 cm (0.2 in) prior to applying suction to prevent
mucosal damage.
☐☐ Apply suction intermittently by covering and releasing the suction port
with the thumb for 5 seconds at a time.
☐☐ Apply suction only while withdrawing the catheter and rotating it with the
thumb and forefinger.
☐☐ Limit each suction attempt to no longer than 5 seconds to avoid hypoxemia
and the vagal response. Limit suctioning to two to three attempts.
☐☐ Reattach the BVM or ventilator and supply the child with 100% inspired oxygen.
-allow 30-60 seconds between sxning

Front 119

Children younger than 8 years of age must use an uncuffed endotracheal tube.

Back 119

■■ Provide adequate humidification and hydration to thin secretions and decrease
the risk of mucus plugging.
■■ Do not suction routinely, because this may cause mucosal damage, bleeding, and
bronchospasm.
■■ Assess/monitor the need for suctioning. Suction on a PRN basis when assessment
findings indicate the need to do so (audible/noisy secretions, crackles,
restlessness, tachypnea, tachycardia, and mucus in the airway).
■■ Maintain surgical aseptic technique when suctioning to prevent infection.
■■ Provide emotional support to the child and parents.
■■ Give frequent oral care, usually every 2 hr.
■■ For cuffed tubes, keep the pressure below 20 mm Hg to reduce the risk of tracheal necrosis due to prolonged compression of tracheal capillaries.
■■ Provide tracheostomy care every 8 hr.
☐☐ If necessary, suction the tracheostomy tube using sterile suctioning supplies.
☐☐ Remove old dressings and excess secretions.
☐☐ Apply the oxygen source loosely if the child’s oxygen saturation level
decreases during the procedure.
■■ Change nondisposable tracheostomy tubes every 6 to 8 weeks or per protocol.
■■ Reposition the client every 2 hr to prevent atelectasis and pneumonia.

Front 120

oxygen administration by age

Back 120

The most effective way to deliver oxygen to an infant is using a plastic oxygen hood. The toddler should be placed in a mist/oxygen tent, allowing him to play and move around without being restricted. The school-age child may be able to tolerate a face mask and should be encouraged to do so until her condition improves. The adolescent should be able to comply with directions given to maintain oxygen administration via nasal cannula.

Front 121

Acute glomerulonephritis (agn)
Acute poststreptococcal glomerulonephritis (APSGN)

Back 121

the most common of the
postinfectious renal diseases.
◯◯ APSGN is an antibody-antigen disease that occurs as a result of certain strains of the Group A ß-hemolytic streptococcal infection and is most commonly seen in children between the ages of 6 and 7.
◯◯ The exact mechanism of the pathophysiology for APSGN is not certain. It is believed that immune complexes develop and become trapped in the glomerular capillary loop at the basement membrane. This produces swelling and occlusion of the capillary lumen and results in alterations in the glomerular filtration rate.
◯◯ Renal manifestations usually occur 10 to 21 days post infection.
◯◯ Prognosis varies depending upon the specific cause, but spontaneous recovery
generally occurs after the acute illness. Recurrence is not common.

Front 122

Acute poststreptococcal glomerulonephritis (APSGN)
Physical Assessment Findings

Back 122

■■ Decreased glomerular filtration rate leading to decreased urine output
■■ Anorexia
■■ Pallor
■■ Vague reports of discomfort (headache, abdominal pain, dysuria)
■■ Dyspnea
■■ Orthopnea
■■ Moist crackles on auscultation
■■ Distended neck veins
■■ Periorbital edema
■■ Facial edema that is worse in the morning but then spreads to extremities and
abdomen with progression of the day
■■ Mild to severe hypertension
■■ Pale appearance, irritability, and lethargy (The child seems ill.)

Front 123

Acute poststreptococcal glomerulonephritis (APSGN)

Laboratory Tests

Back 123

■■ Throat culture to identify possible streptococcus infection (usually negative by
the time of diagnosis)
■■ Urinalysis – Proteinuria, smoky or tea-colored urine, hematuria, cell debris (red
cells and casts), elevated specific gravity
■■ Renal function – Elevated BUN and creatinine
■■ Antistreptolysin-O (ASO) titer – Positive indicator for the presence of streptococcal antibodies
■■ Antihyaluronidase (AHase), antideoxyribonuclease B (ADNase-B), and
streptozyme antibodies may be present.
■■ Serum complement (C3) – Decreased initially; increases as recovery takes place;
returns to normal at 8 to 10 weeks post glomerulonephritis

Front 124

Acute poststreptococcal glomerulonephritis (APSGN)

■diagnostic procedures

Back 124

■■ Chest x-ray
☐☐ Used to identify pulmonary complications, especially during the edematous phase
XX Pulmonary edema
XX Cardiac enlargement
XX Pleural effusions

Front 125

Acute poststreptococcal glomerulonephritis (APSGN)

●● Nursing Care

Back 125

◯◯ Monitor I&O.
◯◯ Monitor daily weights; weigh the child on the same scale with the same amount of
clothing daily.
◯◯ Monitor vital signs.
◯◯ Monitor neurologic status and observe for behavior changes, especially in children who have edema, hypertension, and gross hematuria. Implement seizure precautions if condition indicates.
◯◯ Encourage adequate nutritional intake within restriction guidelines. A regular diet
with elimination of high sodium foods will be appropriate for most.
■■ Restrict foods high in potassium during periods of oliguria.
■■ Provide small, frequent meals of favorite foods due to a decrease in appetite.
■■ Refer the child for dietary consultation if indicated.
◯◯ Manage fluid restrictions as prescribed. Fluids may be restricted during periods of edema and hypertension.
◯◯ Monitor skin for breakdown areas and prevent pressure sores.
■■ Encourage frequent turning and repositioning.
■■ Keep skin dry.
■■ Pad bony prominences and use a specialty mattress.
■■ Elevate edematous body parts.

Front 126

Nephrotic syndrome

Back 126

◯◯ In nephrotic syndrome, alterations in the glomerular membrane allow proteins
(especially albumin) to pass into the urine, resulting in decreased serum osmotic
pressure. The exact cause of glomerular alteration is not well understood and is
thought to be due to metabolic, biochemical, physiochemical, or immune-mediated causes.
◯◯ Nephrotic syndrome is characterized by hyperlipidemia, proteinuria,
hypoalbuminemia, and edema.
◯◯ Management of nephrotic syndrome is aimed at reducing the excretion of protein, reducing fluid retent

Front 127

Minimal change nephrotic syndrome (MCNS)

Back 127

■■ Peak incidence is between 2 and 7 years of age.
■■ Cause is unknown, but it may have a multifactorial etiology (immune-mediated,
biochemical).
◯◯ Secondary nephrotic syndrome (occurs after or is associated with glomerular damage due to a known cause).
◯◯ Congenital nephrotic syndrome (an inherited disorder).

Front 128

Nephrotic Syndrome
Subjective Data

Back 128

◯◯ Weight gain over a short period of days or weeks
◯◯ Poor appetite, possibly anorexia, nausea and vomiting, and diarrhea
◯◯ Decreased activity levels
◯◯ Irritability

Front 129

Nephrotic Syndrome
◯ Physical Assessment Findings

Back 129

■■ Weight gain
■■ Edema (facial/periorbital) is worse in morning and decreases as the day progresses
■■ Ascites and dependent edema (especially in the labia, scrotum, legs, and ankles)
■■ Dark, frothy urine, decreased urine output, and oliguria
■■ Normal or slightly elevated blood pressure

Front 130

nephrotic Syndrome
Labs

Back 130

■■ Urinalysis/24-hr urine collection
☐☐ Proteinuria – Protein greater than 3+ or 4+ (greater than 3.5 g in 24 hr)
☐☐ Hyaline casts
☐☐ Increased specific gravity
☐☐ Color change
■■ Serum chemistry
☐☐ Hypoalbuminemia – Reduced serum protein and albumin
☐☐ Hyperlipidemia– Elevated serum lipid levels
☐☐ Hemoconcentration– Elevated Hgb, Hct, and platelets

Front 131

Nephrotic Syndrome
Nursing care

Back 131

◯◯ Encourage nutritional intake within restriction guidelines. Salt and fluids may be restricted during the edematous phase. Increase protein in diet to replace protein
losses.
◯◯ Provide rest.
◯◯ Monitor I&O. Monitor urine for specific gravity and protein.
◯◯ Monitor daily weights; weigh the child on the same scale with the same amount of
clothing.
◯◯ Monitor edema and measure abdominal girth daily. Measure at the widest area, usually
at or above the umbilicus. Assess degree of pitting, color, and texture of skin.
◯◯ Monitor and prevent infection.
■■ Assist the child to turn, cough, and deep breathe to prevent pulmonary
involvement.
■■ Monitor vital signs, especially temperature, for changes secondary to infection.

Front 132

Nephrotic Syndrome
Medications - Corticosteroids

Back 132

◯◯ Corticosteroid – Prednisone (Deltasone)
◯◯ Nursing Considerations
■■ Administer for 7 to 21 days (based on response) and then taper over several
months with decreasing doses until discontinued.
■■ Monitor for infection.
◯◯ Client Education
■■ Educate the child and family to avoid large crowds (to decrease the risk of
infection).
■■ Instruct the family to administer the medication on alternate days after the first
4 weeks of therapy.
■■ Inform the child and family that using corticosteroids can increase appetite,
cause weight gain (especially in the face), and cause mood swings.

Front 133

Nephrotic Syndrome
Medications - Diuretics

Back 133

◯◯ Diuretic – Furosemide (Lasix)
■■ Eliminates excess fluid from the body
■■ Nursing Considerations
☐☐ Encourage the child to eat foods that are high in potassium.
☐☐ Monitor serum electrolyte levels periodically.

Front 134

Nephrotic Syndrome
Medications - 25% Albumin

Back 134

■■ Increases plasma volume and decreases edema
■■ Nursing Considerations
☐☐ Administer per protocol.
☐☐ Monitor I&O.
☐☐ Watch for anaphylaxis.

Front 135

Nephrotic Syndrome
Medications - Cyclophosphamide (Cytoxan)

Back 135

Cyclophosphamide (Cytoxan)
■■ Administer for children who cannot tolerate prednisone or who have repeated
relapses of MCNS.

Front 136

Nephrotic Syndrome
Complications

Back 136

◯◯ Steroid therapy increases the risk for infection.
■■ Common infections seen in children with nephrotic syndrome include
pneumonia, peritonitis, and cellulitis.

Front 137

Pediculosis (head lice)

Back 137

a contagious parasitic infestation.
◯◯ Pediculosis is transmitted through the sharing of personal items (hair brushes, combs,
hats) or when personal items are kept close together.
◯◯ Female lice lays eggs (nits) that attach to the hair follicles and hatch within
7 to 10 days.
◯◯ Lice can live up to 1 month on the host, but only 48 hr without the host.
◯◯ Movement and saliva of the lice cause pruritus.

Front 138

Infection/Causative Agents
Impetigo contagiosa bacteria
• Staphylococcus

Back 138

Manifestations
• Appears as a red macule that becomes a
vesicle and ruptures
• Has thick, crusted, amber-colored exudate
(honey-colored crust)
• Spreads easily
Management
• Use compresses of 1:20 aluminum acetate in water
(Burow’s solution) to remove crusted exudate.
• Use topical antibacterial or oral antibiotics.

Front 139

Infection/Causative Agents
Verruca (warts)
• Human papillomavirus

Back 139

Manifestations
• Appears as a well-circumscribed grey or
brown papule with rough papillomatous
texture
Management
• Use destructive therapy (may leave scarring). The condition may resolve without treatment.
• Avoid irritation (rubbing, scratching) to prevent spread.

Front 140

Infection/Causative Agents
Cold sores and fever blisters
• Herpes simplex virus type1

Back 140

Manifestations
• Appears as a group of vesicles on inflamed
skin, usually around the lips or genitalia
• Is accompanied by a painful burning
sensation
• Dries, exfoliates, and heals within
8 to 10 days
Management
Cold sores and fever blisters
• Herpes simplex virus type 1
Genital herpes
• Herpes simplex virus type 2
--• Use aluminum acetate in water during the weeping
stage. A topical or oral antiviral medication may be
used to lessen the duration and decrease the severity.
Lesions usually heal without scarring.
• Prevent secondary infection.

Front 141

Infection/Causative Agents
Tinea capitis (ringworm, head) – Fungus
• Trichophyton tonsurans
• Microsporum canis

Back 141

Manifestations
• Appears as circular, scaly patches with or
without areas of alopecia
• Begins in the scalp and possibly progresses to the neck or hairline
Management
• Administer oral griseofulvin (Grifulvin) for 6 to 8 weeks or oral terbinafine (Lamisil) for 2 to 4 weeks.
• Apply topical antifungal medications that are appropriate for the affected areas (clotrimazole [Lotrimin], miconazole [Monistat 7]).
• Use a selenium sulfide shampoo.

Front 142

Infection/Causative Agents
Tinea corporis (ringworm, body) – Fungus
• Trichophyton rubrum
• Trichophyton mentagrophytes
• Microsporum canis

Back 142

Manifestations
• Appears as circular, scaly, red patches
• Has a clear center that spreads peripherally to the edges of the lesion
Management
• Administer oral griseofulvin for several months.
• Use topical antifungal medications that are appropriate
for the affected areas (clotrimazole, miconazole). Apply 2.5 cm (1 in) past the edge of the lesion and continue
treatment for 1 to 2 weeks after resolution of the lesion.

Front 143

Infection/Causative Agents
Candidiasis (thrush) – Fungus
• Candida albicans

Back 143

Manifestations
• Appears as inflamed areas with white
exudate that peel and bleed easily
Management
• Apply nystatin (Mycostatin) ointment or solution to affected areas.

Front 144

Infection/Causative Agents
Pediculosis (lice) – Parasite
• Pediculus humanus capitis (head lice)
• Pediculus corporis (body lice)
• Pediculus pubis (pubic lice)

Back 144

Manifestations
• Begins with generalized itching on head or
genital area
• Progresses to visible lesions from
scratching, which can become infected
with bacteria or fungi
• Involves nits in hair that are visible, behind
ears, at base of scalp, and occasionally
in eyelashes and brows (With heavy
infestations, live lice may also be seen.)
Management
• Apply an over-the-counter or prescribed pediculicide
shampoo to the infected child and family according to
product instructions.
• Do not use hair products with conditioner prior to
treatment. Hair should not be rewashed for 1 to 2 days
following treatment.
• Use a comb designed to remove nits. Inspect hair every 2 to 3 days for 2 to 3 weeks.
• Treat the child again at specific intervals based on inspection results and the pediculicide product used.
• Wear clean clothing after treatment.
• Wash clothing, linens, combs, and hairbrushes worn or used 2 days prior to treatment in hot water (54° C [130° F]). Place clothing and linens in a dryer on high heat until dry.
• Dry clean clothes that are nonwashable.
• Nonwashable items should be sealed in a plastic bag for 2 weeks.
• Vacuum areas occupied by the infected child.

Front 145

Infection/Causative Agents
Scabies mite
• Sarcoptes scabiei

Back 145

Manifestations
• Appears as grayish-brown, threadlike
burrows with a black dot at the end (mite)
• Involves eczematous eruption in infants
• Is accompanied by intense itching that can
cause sores to become infected
• Appears as lesions in interdigital,
antecubital, popliteal, and inguinal areas
Management
• Apply topical medication from the child’s neck to his toes.
• Give the child clean clothes, towels, and bedding.
• Leave on the child’s skin for 8 to 12 hr.
• Bathe the child to remove the medication.

Front 146

Infection/Causative Agents
Lyme disease
• Borrelia burgdorferi

Back 146

Manifestations
• Has symptoms of viral-like illness
• Has three stages
◯◯ Stage 1 – Rash of red ring about
3 to 31 days after possible tick bite
◯◯ Stage 2 – Neurologic, cardiac, and
musculoskeletal involvement
◯◯ Stage 3 – Musculoskeletal pain in joints and supporting structures, as well as
neurological problems
Management
• Administer oral antibiotics. Use amoxicillin (Amoxil) for
children younger than 8 years of age and doxycycline
(Vibramycin) for children older than 8 years of age.
• Use erythromycin (E-Mycin) or cefuroxime (Zinacef) for
children who are allergic to penicillin.
• Treat for a period of 14 to 21 days.
• Monitor the child for up to 30 days following a tick bite. Instruct parents to seek medical care immediately if skin lesion or viral-type illness develops.

Front 147

Cerebral palsy (CP)

Back 147

a nonprogressive impairment of motor function, especially that of muscle control, coordination, and posture
●● CP is the most common permanent physical disability in children.
●● CP may cause abnormal perception and sensation; visual, hearing, and speech
impairments; seizures; and cognitive disabilities.
●● CP manifests differently in each child. Developmental outcomes vary and are dependent
on the severity of the injury. Many children with CP are able to perform most, if not all,
developmental tasks, and more than half will be able to work outside the home as adults.
Others will require complete care for their entire lives.

Front 148

Risk Factors
CP

Back 148

◯◯ The exact cause of CP is not known. Prenatal, perinatal, and postnatal risk factors
known to be associated with CP include:
■■ Existing brain anomalies, cerebral infections, head trauma (shaken baby
syndrome), and /or anoxia to the brain
■■ Premature birth
■■ Multiple births
■■ Extremely low or very low birth weights in newborns
■■ Inability of the placenta to provide the developing fetus with oxygen and
nutrients
■■ Interruption of oxygen delivery to the fetus during birth
■■ Kernicterus as a result of high levels of bilirubin in the neonatal period

Front 149

Cerebral palsy (CP)
Developmental early warning signs

Back 149

■■ Poor head control or absence of smiling in a 3-month-old infant
■■ Difficulty with dressing and diaper changes due to stiff arms or legs during
infancy and early childhood. The child may push away or arch his back.
■■ A floppy or limp body in infants.
■■ An inability to sit up without support in an 8-month-old infant
■■ Use of only one side of the body to play or move about
■■ Feeding difficulties (moving food from side to side with tongue, inability to
swallow safely).
◯◯ Painful muscle spasms
◯◯ Physical Assessment Findings
■■ Persistent primitive reflexes (Moro or tonic neck)
■■ Motor function showing muscle tightness or spasticity, involuntary movements,
and disturbance in gait or mobility

Front 150

Spastic CP

Back 150

XX Spastic CP is characterized by hypertonicity (muscle tightness or
spasticity); increased deep tendon reflexes; clonus; and poor control of
motion, balance, and posture.
XX Spastic CP may cause Impairments of fine and gross motor skills.
XX Spastic CP may present in all extremities (quadriplegia), similar parts of
the body (diplegia), three limbs (triplegia), one limb (monoplegia), or one side of the body (hemiplegia). It often causes affected limbs to be shorter and thinner.
XX Associated scoliosis may be present.
XX Gait may appear crouched with a scissoring motion of the legs with
intoeing and use of primarily the balls of the feet in a tip-toe fashion.
XX Spastic CP may present with contractures, especially the heel cord,
hips, or knees. Wrists and elbow are in a flexed position with clenching of the hand.
XX Flexor, adductor, and internal rotator muscles are more affected than the extensor and external adductor or rotator muscles.

Front 151

Dyskinetic CP

Back 151

XX Movements increase with stress but are absent with sleep. Normal deep
tendon reflexes are present with absence of clonus.
XX Speech may be impaired.

Front 152

Athetoid CP

Back 152

XX Findings include involuntary jerking movements that appear slow, writhing, and wormlike. These movements involve the trunk, neck, face, and tongue.

Front 153

Dystonic CP

Back 153

XX Slow, twisting movements occur that affect the trunk and extremities.

Front 154

Ataxic CP

Back 154

XX Evidence of wide-based gait and difficulty with coordination
XX Poor ability to do repetitive movements is a result
XX Difficulty with quick or precise movements (writing or buttoning a
shirt)
XX Jerky speech pattern is present

Front 155

Cerebral palsy (CP)
●● Nursing Care

Back 155

◯◯ Monitor developmental milestones.
◯◯ Evaluate the need for hearing and speech evaluations.
◯◯ Promote independence with self-care activities as much as possible. Assist the child to maintain a positive self-image and a high level of self-esteem.
◯◯ Determine the extent of family coping and support.
◯◯ Assess the family’s awareness of available resources.
◯◯ Assess the child’s developmental level and approach the child in a way that is
appropriate for the child’s developmental level, rather than chronological age.
◯◯ Communicate with the child directly, but include parents as needed.
◯◯ Help the child to use augmented communication, such as electronic devices for speech and other types of communication tools.
◯◯ Include the family in physical care of the hospitalized child with cerebral palsy.
■■ Ask the family about routine care and encourage them to provide it if
appropriate.
■■ Encourage the family to help verify the child’s needs if communication is
impaired.
◯◯ Maintain an open airway by elevating the head of the child’s bed (this is especially important if the child has increased oral secretions).
◯◯ Ensure suction equipment is available if required. Suction oral secretions as needed.
◯◯ Monitor for pain (especially with muscle spasms) using a developmentally appropriate
pain tool.

Front 156

Cerebral Palsy
●● Medications
◯◯ Baclofen (Lioresal)

Back 156

■■ Used as a centrally acting skeletal muscle relaxant that decreases muscle spasm
and severe spasticity
■■ Nursing Considerations
☐☐ Administer orally or intrathecally via a specialized, surgically implanted pump.
☐☐ Monitor effectiveness of the medication.
☐☐ Monitor for muscle weakness, increased fatigue, or less-common side effects
(diaphoresis, constipation).
■■ Client Education
☐☐ Educate the family about expected responses of medications.
☐☐ Reinforce with the family the side effects of medications, such as
drowsiness, and when to call the provider.
☐☐ Instruct the family to bring the child to see the provider every 4 to 6 weeks
to monitor effectiveness of therapy and to receive refills.

Front 157

Cerebral Palsy
●● Medications
◯◯ Diazepam (Valium

Back 157

■■ Skeletal muscle relaxant used to decrease muscle spasms and severe spasticity
■■ Nursing Considerations
☐☐ Use in older children and adolescents.
☐☐ Monitor for drowsiness and fatigue.
■■ Client Education
☐☐ Educate the family about expected responses to medications.
☐☐ Reinforce with the family the side effects of the medication and when to
call the provider.

Front 158

Spina bifida

Back 158

refers to defects in intrauterine closure of the boney spine. Spina bifida is further classified as spina bifida occulta and spina bifida cystica (meningocele or
myelomeningocele, which are visible defects in the spine with a saclike protrusion at any level of the spinal column at the midline of the back).
◯◯ In meningocele, the sac contains meninges and spinal fluid. Myelomeningocele contains meninges, spinal fluid, and nerves
◯◯ Diagnostic Procedures
■■ Maternal serum analysis
☐☐ Maternal serum should be tested for serum alpha-fetoprotein levels between
15 and 20 weeks of gestation (it is best to test between 16 and 18 weeks).
Elevated levels will require further testing, such as an amniocentesis.

Front 159

Spina Bifida
●● Risk Factors

Back 159

◯◯ Neural tube defects are caused by the failure of the neural tube to close in the first
3 to 5 weeks of gestation.
◯◯ Neural tube defects have been linked to insufficient folic acid in the maternal diet.
◯◯ An elevated a-fetoprotein (AFP) may indicate the presence of a neural tube defect.

Front 160

Spina Bifida
◯◯ Physical Assessment Findings

Back 160

■■ Inspect the sac at birth to determine whether it is intact.
■■ Inspect the lumbosacral area for dimpling. This may indicate spina bifida occulta.
■■ Ongoing assessments
☐☐ Assess for an increase in head circumference, which may occur rapidly with hydrocephalus until normal cranial growth is reached.
☐☐ Assess skin integrity for pressure sores caused by decreased sensation in the affected trunk and extremities.
☐☐ Identify allergies. Specifically assess for latex allergy.
☐☐ Assess cognitive development. This may be permanently delayed in some
children.
☐☐ Assess bladder/bowel functioning. Functioning is permanently affected in
all children with spina bifida.
☐☐ Monitor for manifestations of infection, including elevation of body temperature, nausea, vomiting, and fatigue.

Front 161

Spina Bifida
●● Medications
allergies

Back 161

◯◯ Oxybutynin chloride (Ditropan) and tolterodine (Detrol)
■■ These are antispasmodics that are used to improve bladder capacity and
continence.
■■ Client Education
☐☐ Educate the family about the need for proper and timely administration of
medications.
☐☐ Educate the family about the need for periodic monitoring of medication
levels.
●● Latex allergy
◯◯ The child has a high risk of allergy to latex. Allergy responses range from urticaria to wheezing, which may progress to anaphylaxis. There may also be an allergy to certain foods (bananas, avocados, kiwi, chestnuts).

Front 162

Spina Bifida
●● Increased intracranial pressure

Back 162

◯◯ Signs and symptoms
■■ Infants – High-pitched cry, lethargy, vomiting, bulging fontanels, and/or
widening cranial suture lines
■■ Children – Headache, lethargy, nausea, vomiting, double vision, decreased school
performance of learned tasks, decreased level of consciousness, and seizures
◯◯ Caused by shunt malfunction
◯◯ Nursing Actions
■■ Use gentle movements when performing range-of-motion exercises.
■■ Minimize environmental stressors (noise, frequent visitors).
■■ Assess and manage pain.

Front 163

Down syndrome

Back 163

a chromosomal abnormality.
●● Clinical manifestations of Down syndrome
◯◯ Hypotonicity, congenital heart defects, thyroid dysfunction, congenital
hypothyroidism, dysfunctional immune system, and high risk for leukemia
◯◯ The presence of cognitive defects with an IQ that will vary in range with an average of 50.
●● Risk Factors
◯◯ The exact etiology of Down syndrome is probably multifactorial. There is a higher
incidence in infants born to mothers who are older than 35 years of age.

Front 164

Down syndrome
◯◯ Diagnostic Procedures

Back 164

■■ Prenatal testing for a-fetoprotein in maternal serum – Low in the presence of
Down syndrome
■■ Chromosome analysis
☐☐ Prenatal testing, such as an amniocentesis, should be conducted for
chromosome analysis to confirm the genetic abnormality.
☐☐ Nursing Actions
XX Assist in the positioning of the child.
XX Provide support to the parents and child.
☐☐ Client Education
XX Teach the child what to expect with the procedure.

Front 165

Down syndrome
◯◯ Physical Assessment Findings

Back 165

■■ Small head
■■ Flattened forehead
■■ Low-set ears
■■ Upward slant to eyes
■■ Protruding tongue and narrow, high-arched palate
■■ Underdeveloped nasal bone (results in a flattened appearance to the nasal bridge)
■■ Hypotonia (decreased muscle tone)
■■ Transverse palmar crease
■■ Plantar space and wide space between the great toe and second toe
■■ Congenital heart defects (may be present)

Front 166

Down syndrome
Complications

Back 166

●● Respiratory infections
◯◯ Respiratory infections are common due to decreased muscle tone and poor drainage of
mucus because of hypotonicity and associated under-developed nasal bone.
◯◯ Nursing Actions
■■ Rinse the child’s mouth with water after feeding and at other times of the day
when it is dry. Mucous membranes are dry due to constant mouth breathing,
which also increases the risk for respiratory infection.
■■ Provide cool mist humidification and clearing of the nasal passages with a bulb
syringe as needed.
■■ Encourage exercise in older children.
**Reinforce the need for regular vaccinations.

Front 167

Juvenile idiopathic arthritis (JIA)

Back 167

a group of chronic autoimmune inflammatory diseases affecting joints and other tissues. There is chronic inflammation of the synovium of the
joints with effusion that leads to wearing down and damage to the articular cartilage.
●● Classifications of JIA include systemic arthritis, oligoarthritis, and polyarthritis with or
without rheumatoid factor.
●● No definitive diagnosis is available, but the onset of the disorder starts prior to 16 years of
age, and symptoms occur in one or more joints and last for 6 weeks or longer with no other
cause identified.
●● Peak incidence is between 1 and 3 years of age.
●● JIA is rarely life-threatening, and it may subside over time, but it can result in residual joint
deformities and altered joint function.

Front 168

Juvenile idiopathic arthritis (JIA)
Risk Factors/Subjective and Objective Data

Back 168

●● Risk Factors
◯◯ Susceptible individuals who have an autoimmune response to internal or external
triggers
●● Subjective and Objective Data
◯◯ Joint swelling, stiffness, redness, and warmth
◯◯ Mobility limitations
◯◯ Fever
◯◯ Rash
◯◯ Nodules under the skin
◯◯ Delayed growth and development
◯◯ Enlarged lymph nodes
◯◯ Visual changes and uveitis (inflammation in the anterior chamber of the eye)

Front 169

Juvenile idiopathic arthritis (JIA)
◯◯ Laboratory Tests

Back 169

■■ Erythrocyte sedimentation rate (ESR) – May or may not be elevated
■■ CBC with differential may demonstrate elevated WBCs, especially during
exacerbations.
■■ Antinuclear antibodies (ANA) indicate an increased risk for uveitis.
■■ Rheumatoid factor may or may not be present.

Front 170

Juvenile idiopathic arthritis (JIA)
●● Nursing Care

Back 170

◯◯ Encourage activity as tolerated.
◯◯ Teach parents to apply splints for nighttime sleep. Splints should be applied to knees, wrists, and hands to decrease pain and prevent flexion deformities.
◯◯ Encourage proper positioning with sleep. Encourage the use of electric blankets or sleeping bags for extra warmth.
◯◯ Provide firm mattress and discourage use of pillows under knees. Use no pillow or flat pillow for head.
◯◯ Encourage full range-of-motion exercises when pain and inflammation have subsided.
◯◯ Apply heat or warm moist packs to the child’s affected joints prior to exercise.
◯◯ Encourage warm baths.
◯◯ Identify alternate ways for the child to meet developmental needs, especially during periods of exacerbation.
◯◯ Encourage self-care by allowing adequate time for completion.
◯◯ Encourage a well-balanced diet that is high in fiber and contains adequate fluids to
prevent constipation from immobility.
◯◯ Encourage participation in school and contact with peers.
◯◯ Collaborate with the school nurse and teachers to arrange for care during the school day (medication administration, rest periods, extra time to get to classes, extra sets of books, split days).

Front 171

Juvenile idiopathic arthritis (JIA)
●● Medications

Back 171

◯◯ NSAIDs – Naproxen (Naprelan), ibuprofen (Motrin), and tolmetin sodium (Tolectin)
■■ NSAIDs control pain and inflammation.
■■ Nursing Considerations
☐☐ Instruct the child and family to administer NSAIDs as prescribed.
☐☐ Instruct the child and family that NSAIDs should be taken with food to
minimize gastric irritation.
■■ Client Education
☐☐ Teach the child and family to report changes in stool and GI discomfort or
increase in bruising immediately.
◯◯ Methotrexate (Rheumatrex)
■■ A cytotoxic disease modifying antirheumatic drug (DMARD) that slows joint degeneration and progression of rheumatoid arthritis when NSAIDs do not work alone
■■ Nursing Considerations
☐☐ Monitor liver function tests and CBC regularly.
■■ Client Education
☐☐ Teach adolescents to avoid alcohol.
☐☐ Discuss the use of effective birth control to avoid birth defects while taking
this medication.
◯◯ Corticosteroids
■■ Glucocorticoids provide symptomatic relief of inflammation and pain. They are
reserved for life-threatening complications, severe arthritis, and uveitis.
■■ Nursing Considerations
☐☐ Administer as eye solution, orally, or intravenously.
☐☐ Administer at the lowest effective dose for short-term therapy and then
discontinue by tapering the dose. An injection into the intraarticular space
may provide effective pain relief.
■■ Client Education
☐☐ Advise the child and family that weight gain, especially in the face, is a
common side effect.
☐☐ Monitor height and weight.
☐☐ Advise the family that an alteration in growth is a possible long-term
complication of corticosteroids.
☐☐ Advise the child to avoid exposure to potentially infectious agents.
☐☐ Advise the child and family to practice healthy eating habits.
◯◯ Etanercept (Enbrel)
■■ Etanercept is a tumor necrosis factor alpha-receptor blocker, another DMARD,
that is used when methotrexate is not effective for immunosuppressive action.
■■ Nursing Considerations
☐☐ Administer etanercept once or twice each week by subcutaneous injection.
■■ Client Education
☐☐ Educate about the potential for allergic reactions.
☐☐ Teach the child and family to avoid exposure to infectious agents.

Front 172

Muscular dystrophy (MD)

Back 172

a group of inherited disorders with progressive degeneration of
symmetric skeletal muscle groups.
●● Muscular dystrophy (MD) is the largest group of diseases that affects muscle function in children.
●● Loss of muscular strength is insidious.
●● Developmental milestones are likely to be met until the onset of the disease.
●● Onset of disease, pace of progression, and muscle group affected depend on the type of MD.
●● Duchenne (pseudohypertrophic) muscular dystrophy (DMD) is the most common form of MD. Inherited as an X-linked recessive trait, DMD has an onset between 3 and 7 years of age. Life expectancy with current technology for DMD reaches into early adulthood.
●● Management of DMD is symptomatic to assist with maintaining the highest level of
mobility and preventing complications as the disease progresses.

Front 173

Muscular dystrophy (MD)
◯◯ Physical Assessment Findings

Back 173

■■ Muscular weakness in lower extremities
■■ Muscular hypertrophy, especially in calves
■■ Mild delay in motor skill development
■■ Mobility with general muscle strength declining over time
■■ Unsteady, wide-based or waddling gait and loss of walking ability (usually by
age 12)
■■ Difficulty riding a tricycle, running, and rising from a seated position
■■ Mild cognitive delay with learning disabilities
■■ Cardiovascular complications (associated with the progression of DMD) – Weight loss, increased fatigue during usual ADLs, and orthopnea

Front 174

Muscular dystrophy (MD)
◯◯ Laboratory Tests

Back 174

■■ DNA analysis using peripheral blood, serum polymerase chain reaction (PCR) for
the dystrophin gene mutation, or muscle tissue biopsy
■■ Serum creatine phosphokinase (CK) – Elevated
■■ Electromyography (EMG) may also be used

Front 175

Muscular dystrophy (MD)
medications

Back 175

◯◯ Prednisone (Deltasone)
■■ Prednisone is a corticosteroid that increases muscle strength.
■■ Nursing Considerations
☐☐ Monitor for infection.
■■ Client Education
☐☐ Instruct the child and parents to avoid potentially infectious agents.
☐☐ Teach the child and family to practice healthy eating habits.

Front 176

Complications
●● Aspiration of oral secretions

Back 176

◯◯ Nursing Actions
■■ Keep the child’s head elevated.
■■ Keep suction available if copious oral secretions are present or the child has
difficulty with swallowing foods and/or fluids.
●● Potential for injury
◯◯ Nursing Actions
■■ Make sure the child’s bed rails are raised to prevent falls from the bed.
■■ Pad side rails and wheelchair arms to prevent injury.
■■ Secure the child in mobility devices, such as wheelchairs.
■■ Encourage the child to receive adequate rest to prevent injury at times of fatigue.
■■ Encourage the use of helmets, seat belts, and other safety equipment.

Front 177

Muscular dystrophy (MD)
Complications

Back 177

●● Respiratory compromise
◯◯ Respiratory muscles unable the child to maintain adequate respirations.
◯◯ Nursing Actions
■■ Help the child turn hourly or more frequently.
■■ Have the child use deep breathing and coughing.
■■ Suction as needed.
■■ Administer oxygen as prescribed.
■■ Use intermittent positive pressure ventilation and mechanically-assisted cough
devices if indicated.
■■ Administer antibiotics as prescribed.
◯◯ Client Education
■■ Discuss mechanical ventilation options with the child and parents.