Peds

 Active immunity – develops naturally after an initial infection or exposure to antigens, or artificially after a
vaccination.
 Attenuated vaccines – derived from microorganisms or viruses whose virulence has been weakened.
 Inactivated vaccines – contain killed microorganisms.
 Passive immunity – acquired immunity that occurs artificially through injection or is acquired naturally as the
result of antibody transfer through the placenta to a fetus or via colostrum to an infant; not permanent and
does not last as long as active.
 Prodromal – pertaining to early symptoms that mark the onset of a disease.

Integumentary

 Ezcema – redness, scaliness, itching. Apply cool compresses, antihistamines, cortocosteriods.

 Impetigo – D2 GBS, during hot humid months. Topical AB.
 Lice/Pediculosis Capitis – can survive 48 hours away from host, metal comb cleaned in boiling water; clothing
and bedding changed and washed daily and dryer for 20 min.
 Scabies – itch mite, permethrin (Elimite).
 Burn injuries
o Burns involving more than 10% BSA require fluid; check VS – HR, output, cap refill, and sensorium
status.
o Crystalloid solutions initially – albumin, plasma-lyte, fresh frozen plasma to maintain plasma volume.

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Hematological

 Sickle Cell – HbG A is replaced by abnormal HbG S; O2, blood, analgesics, high calorie & protein diet
with folic acid; risk – parent heterozygous for HbG S.
 Iron Deficiency Anemia – depletion of iron stores L2 decreased HbG in RBC; pallor, weakness & fatigue,
low HbG and Hct; iron fortified foods/formula, Z-track IM iron, iron with multivitamin, OJ, vit C but NOT
with milk or antacids. S/E: black stools, constipation, bad aftertaste.
 Aplastic anemia – deficiency of erythrocytes.
 Hemophilia – group of bleeding disorders D2 deficiency of coagulating proteins.
o Factor VIII deficiency – A/Classic
o Factor IX deficiency – B/Christmas
o X-linked recessive disorder; females pass to the affected male and rarely the female, may have
hemophilia if both their mother and father have the gene.
o S/S: abnormal bleeding and easily bruised.
o NIC: replacement of the missing clotting factor, DDVAP, control bleeding by immobilizing,
elevating, ice, and pressure for 15 minutes.
o Tell child to wear protective padding when playing sports.
 Von Willebrand’s – bleeding disorder affecting males and females, missing protein called von wille.
o Bleed from mucous membranes.
o S/S: epistaxis, gum bleeding, easy bruising, excessive menstrual bleeding.
o NIC: admin clotting factors, safety and prevention of bleeding.
 B-Thalassemia Major – reduced production of hemoglobin, recessive (both parents must have),
Mediterranean descent – greek, Italian, Syrian.
o S/S: frontal bossing (big bumpy forehead), wide set eyes with flattened nose, greenish yellow skin
tone, hepatosplenomegaly, severe anemia.
o NIC: HgB replacement therapy by blood transfusions, splenectomy, monitor for iron overload.
 Iron overload antidote – deferoxamine (desferal) or exjade.

Oncological Pg. 430

 Leukemia – malignant increase in immature leukocytes in bone marrow, depressing bone marrow,
causing anemia D2 decreased erythrocytes, infection from neutopenia, and bleeding from
thrombocytopenia/decreased platelets.
o Acute lymphocytic leukemia is the most common in children, more common in boys than girls
after 1 year.
o S/S: fever, pallor, hemorrhage (petechiae), bone and joint pain, pathological fractures.
o Child has high, normal, or low WBC count depending on presence of infection.
o Decreased HgB, HcT, Platelets.
o NIC: chemotherapy, radiation, hematopoetic stem cell transplant.
o Bathe daily with antimicrobial soap, avoid raw fruit&veg, away from crowds&sick people, measure
abdominal girth – increase may show hemorrhage.
o Hair loss may occur, regrows in 3-6 months.
o MONITOR FOR INFECTION.
 Hodgkin’s – type of lymphoma, malignancy of lymph node or chain of nodes that metastasizes to the
spleen, liver, bone marrow, lungs, and mediastinum.
o Dx: Reed Sternberg cells in lymph.
o S/S: painless englarged lymph, sentinel node in kids is by left clavicle, CT scan shows
metastasis.
o NIC: monitor for pancytopenia = reduction in the number of red and white blood cells, as well as
platelets – shortage of all blood cells.
 Wilm’s Tumor/Nephroblastoma – 3 years, most common intraabdominal & kidney tumor of childhood; will
see swelling/mass in abdomen, retention and/or hematuria, DO NOT palpate abdomen during
assessment, bathing, moving – rupture of tumor can spread cells via bloodstream.
 Neuroblastoma – by 10 years, most commonly at the adrenal gland, urine for vanilly, epi/nore for
suspicion of tumor, firm and nontender mass @ midline abdomen, retention or frequency.
 Osteosarcoma – most common bone cancer in children (AKA osteogenic sarcoma), found in
METAPHYSIS of long bones, lower extremities, most common site – femur, 10-25 years, bone pain, Sx to
remove affected tissue or amputation.
o Localized pain, limping, palpable mass, fractures at tumor site.
 Brain Tumors – Infratentorial is most common in cerebellum/brainstem, supratentorial – cerebrum.
o Child will feel a headache that is worse on awakening and improves during the day, vomiting,
ataxia = uncoordinated movement, seizures, behavorial changes, clumsiness, diplopia, facial
weakness.
o Favorite hat for shaved head, post op monitor for *meningitis = opisthotonos, Kernig’s, &
Brudzinski’s (abnormal positioning – arched back, knee can’t straighten with back pain, & head lift
makes knees bend.)
o Monitor for increased ICP.
o Unequal pupils – brain stam herniation.
o CSF – drainage = glucose dipstick.
 IICP – infants: fontanel bulging, Macewen’s sign (cracked pot on percussion), high pitched cry, irratibility,
setting sun sign (eyes appear to only look downwards).
 o Children: headache, forceful vomiting, diplopia (blurred vision), seizures.
o Behavioral: decline in school, increased sleeping, restlessness.
o Late: bradycardia, decreased response to painful stimuli, DECEREBRATE (extension) or
DECORTICATE (flexion) posturing, Cheyne Stokes respirations (periodic respiration, with cycles
of respiration that are increasingly deeper then shallower), papilledema (optic disk swelling),
alterations in pupil size and reaction, coma.

Metabolic/Endocrine

 Temp norm = 36.4-37 C/97.5-98.6 F, fever is anything above 38 C/100.4 F.

 Phenylketonuria – recessive genetic disorder CNS damage from toxic levels of phenylalamine in the
blood.
o Phenylalamine >20 mg/dl, normal is 1.2-3.4 in newborns then 0.8-1.8 mg.
o S/S: digestive problems, vomiting, seizures, musty odor urine, mental retardation, in older
children – eczema, hypertonia, hypopigmentation of hair, skin, and irises, hyperactive behavior.
o NIC: screen at birth after first feeding, if Dx restrict phenylalamine: high protein (meat and dairy)
and aspartame avoided.
 Diabetes Mellitus:
o Type 1 – destruction of pancreatic beta cells; absolute insulin deficiency.
o Type 2 – insulin resistance, body fails to use insulin properly.
o Normal 70-110 mg/dL.
o S/S: polyuria, polydipsia, polyphagia.
 Slow wound healing.
 Vaginitis in adolescent girls.
 Fruity odor to breath.
 Weight loss, hyperglycemia.
 Lethargy, dehydration, headaches.
o Long term effects
 Slow growth, delayed maturation.
 Recurrent infections, neuropathy.
 Retinal and renal disease.
o Complications
 Hypo/Hyper glycemia
 DKA
 Coma
 Hypo/Hyper kalemia

 DKA: severe insulin deficiency, develops over days, Dx: 300 sugar and urine & serum ketone testing is
positive.
  S/S: hyperglycemia, Kussmaul’s respirations = labored or hyperventilation characterized by a
consistently deep and rapid respiratory pattern, acetone/fruity breath, increasing lethargy and
decreasing LOC.
1.) INSULIN DEFICIENCY: impaired metabolism of fats, proteins, carbohydrates.
2.) HYPERGLYCEMIA: fatigue, hunger, weight loss.
3.) POLYURIA: cellular starvation.
4.) Ketones: produced in response to cellular starvation, cannot nourish cell because of absence
of insulin.
5.) KETOACIDOSIS.
 Fat should be <30%.
 Tell child to carry glucose tablets at all times to treat hypoglycemia.
 GLUCAGON if unable to eat; unconscious, IM or SC.
 Foods for Hypo: ½ cup of juice/soda, 8oz milk, small box of raisins, 3-4 hard candies, 4 sugar cubes, 1
tbl sugar, 1 candy bar, 1 tsp honey, 2-3 glucose tabs.
 Hypoglycemia, give 10-15g CHO, retest in 15 minutes, give another 10-15g CHO.
 Always have a spare bottle of insulin.
 Exta 10-15g of CHO per 30-45 minutes of exercise.
 HgBA1C every 3 months, <7% is good.
 NIC to lessen pain of glucose stick – run warm water over the finger, ring finger or thumb on the side of
the finger pad.
 Urine testing for ketones and glucose, the 2nd voided urine specimen; done especially when the child is
ill or when blood glucose is consistently above 200.
 Sick Day Rules:
o Always give insulin.
o Blood glucose q 4 hours.
o Urinary ketones with each void.
o Encourage liquids and rest.

GI Disorders

 Vomiting – met. Alkalosis, aspiration causing pneumonia, may be pyloric stenosis, oral rehydration
small amounts slowly.
 Rotavirus – common cause of severe diarrhea in 3-24 months, children younger than 3 months still
have maternal antibodies.
 Cleft lip/palate:
o Causes: hereditary, rubella, radiation, teratogenic factors.
o Cleft lip repair precedes palate, 3-6 months, palate 6 to 24 months to allow for normal growth.
o Increased risk for otitis media which may L2 hearing loss.
o Feeding: infant upright and direct formula to the sida abd back of the mouth to prevent
aspiration, small amounts and burp frequently, ESSR feeding – enlarge the nipple, stimulate
sucking, swallow, rest to allow the infant to finish swallowing.
 o Post cleft lip Sx: NO prone or side lying same side as repair, clean line with NS, elbow
restraints.
o Post palate: child must not brush their own teeth, avoid hard foods – toast/cookies.
 Esophageal atresia and tracheoesophageal fistula:
o Esophagus terminates before it reaches the stomach ending in a blind pouch or a fistula is
present that forms an unnatural connection with the trachea.
o Causes oral intake to enter the lungs or large amounts of air to enter the stomach; severe
abdominal distention can occur.
o S/S: frothy saliva in the nose, mouth, and excessive drooling; 3C’s – coughing, choking, and
unexplained cyanosis; regurgitation and vomiting; abdominal distention; resp distress during
and after feeding.
o NIC: leakage from anastomotic will show as purulent drainage from chest tube, takes 5-7 days
for anastamosis to heal and start feeding; nonnutritive sucking with a pacifier who can handle
the secretions and is NPO.

 GERD – backflow of gastric contents into the esophagus D2 relaxation of lower esophageal/cardiac
sphincter.
o S/S: poor weight gain, passive regurgitation, hematemesis, heartburn in older children, anemia
from blood loss.
o NIC: monitor for aspiration, have suction at bedside.
o Position infants supine, only prone while awake. Older than 1 year position with HOB elevated.
o Small, frequent feedings; thicken formula with rice cereal, for toddlers give solids first then
fluids; avoid fatty and spicy foods, tomatoes, citrus, soda; avoid vigorous play after eating and
avoid eating just before bedtime.
o Antacids for symptom relief, Proton Pump Inhibitors and Histamine H2 Receptor Blockers to
decrease gastric acid secretion.
 Pyloric Stenosis – hypertrophy/narrowing of the pylorus narrowing the canal between the stomach and
duodenum.
 o S/S: PROJECTILE VOMITING, OLIVE SHAPED MASS (RUQ), dehydration, met. Alkalosis,
peristaltic waves are visible from left to right after feeding.
o NIC: strict i&o, daily weights.
o Pyloromyotomy: incision through muscle fibers of pylorus, preop = NPO and prepare for
stomach decompression, postop = gradually increase feeding, burp frequently and handle
infant minimally after feeding.

 Lactose Intolerance – missing lactase, the enzyme in the small intestine that breaks down lactose.
o S/S: abdominal distention, diarrhea and flatus, crampy abdominal pain, colic.
o NIC: Supplement vitamin D that isn’t being received, hard cheese, yogurt, cottage cheese are
okay because they contain inactive lactase enzyme.
 Celiac Disease – gluten allergy, wheat, barley, rye, oats causing accumulation of glutamine which is
toxic to intestinal cells.
o S/S: acute/insidious diarrhea, steatorrhea, muscle wasting in buttocks/extremities, vomiting.
o Celiac crisis: D2 fasting, infection, or gluten intake = profuse watery diarrhea/vomiting.
o NIC: substitute corn, rice and millet as grain sources, supplements of iron, folic acid, fat soluble
A, D, E & K vitamins.
 Appendicitis – inflammation of appendix, perforation may occur within hours L2 peritonitis, sepsis,
septic shock, then death.
o S/S: pain in RLQ and MCBURNEY’S POINT, side lying with abdominal guarding to relieve pain,
low grade fever.
o Peritonitis – fever, progressive abdominal distention.
o Perforation is seen by the sudden relief of pain then a subsequent increase in pain.
o Appendectomy – Pre Op: Right side lying or low to semi fowlers, ice 20-30 minutes every hour,
avoid heat, NPO. Post Op: NPO until bowel function has returned.
o Penrose Drain = kept from falling into incision with safety pEn; given if perforation.
 Hirschsprung’s Disease – congenital AGANLIONOSIS/MEGACOLON; absence of ganglionic (nerve)
cells L2 blockage of the large intestine due to improper muscle movement in the bowel. May L2 chronic
constipation or enterocolitis = inflammation of the digestive tract, involving enteritis of the small
intestine and colitis of the colon.
 o S/S: failure to pass stool 1st 48 hours after birth, distended abdomen, refusal to suck, bile
stained vomit. In older children – RIBBON LIKE STOOLS, foul smelling stools, constipation
alternating with diarrhea, failure to gain weight.
o NIC: LOW FIBER, HIGH CAL, HIGH PROTEIN, stool softeners, measure ab. Girth daily.
o Stoma should be red and moist.

 Intussusception – telescoping of bowels that L2 obstruction.

o S/S: Colicky abdominal pain, child in fetal position, vomiting, BILE STAINED FECAL EMESIS,
CURRANT JELLY LIKE STOOLS containing blood and mucus, tender and distended
abdomen, hypo/hyper active bowel sounds.
o NIC: Monitor for perforation, normal stools – has reduced itself, hydrostatic reduction – air/water
pressure onto part that is prolapsed.
 Abdominal Wall Defects
o Omphalocele – IN A SAC herniation of abdominal contents through umbilical ring encased in a
sac. Immediately after birth cover with sterile saline gauze then layer of plastic wrap to prevent
drying.
o Gastroschisis – WITHOUT SAC herniation of the intsting is lateral to the umbilical ring, no
membrane covers the exposed bowels, sterile saline gauze and abdomen loosely wrapped in
plastic, not the intestines – may lead to pressure and necrosis.
 Hernias – protrustion of bowels
o Umbilical - through the umbilicus that is usually reducible by finger.
o Inguinal – painless swelling, noticeable when infant cries/coughs.
o Incarcerated – when bowel becomes tightly caught up in hernial sac, requires immediate
surgery, may L2 gangrene.
o Non communicating hydrocele – residual peritoneal fluid is trapped with no communication to
the peritoneal cavity, disappear by 1 year.
o Communicating hydrocele – hernia that remains open from the scrotum to the abdominal cavity.
 o Post op: ice bags and scrotal support to relieve pain and swelling, no tub bathing until the
incision heals, avoid strenuous play/activities.
 Constipation – decrease milk and sugar intake, child to sit on toilet 20-30 minutes after breakfast and
dinner for 5-10 minutes.
 Encopresis – constipation with fecal incontinence.
 Enemas – monitor for hypernatremia and hyperphosphatemia < S/S: tetany, muscle weakness,
dysrhythmias, hypotension.
 IBS – alternating between constipation and diarrhea with undigested food and mucus in stool, self
limiting and aggravated by stress and emotions, anticholinergics may be Rx.
 Lead levels should be <10.
 Chelation therapy removes lead from the blood.
 Acetaminophen toxic dose is 150mg/kg, antidote = n-acetlycysteine – inactivated by charcoal.
o S/S: RUQ pain, jaundice, confusion, stupor, elevated liver enzyme and bilirubin, prolonged PT.
 Aspirin (acetylsalicylic acid) – acute 300-500mg/kg or 100mg/kg/day for 2+ days.
o Tinnitus, seizures, oliguria, hypokalemia, METABOLIC ACIDOSIS.
o Give charcoal to decrease absorption, sodium bicarbonate for met. acid., dialysis.
 Corrosives – no vomiting, give milk/water.

Ear, Eye, and Throat

 Strabismus – cross-eye or extreme squinting, normal until 4 months, underdeveloped ocular muscles.
May be given an eyepatch for the good eye to allow the bad eye to gain strength.
 Conjunctivitis – away from other people until AB have been given at least 24 hours, makeup should be
discarded and replaced.

 Otitis media – feed infants upright position to prevent reflux, children’s Eustachian tubes are shorter,
wider, and straighter. Encourage breast feeding the 1st 6 months of life.
 o S/S: rubbing, pulling at ear, purulent ear drainage, rolling head sie to side, red and bulging
tympanic membrane, hearing loss – chronic otitis media.
o NIC: lie with affected ear down, avoid chewing, local heat/cold, frequent cleaning.
o Myringotomy – laser incision with tubes places to keep tympanic membrane open to facilitate
drainage. Plugs with swimming, bathing, diving and submerging underwater isn’t allowed, no
nose blowing 7-10 days post op.
 Tonsillitis/Adenoiditis (pharyngeal tonsils) – mouth breathing with unpleasant odor, may cause
obstructive sleep apnea.
o PreOp – assess for loose teeth. PostOp – ice collar, ice chips, popsicles for sore throat, prone
or side lying for drainage, avoid citrus; red, brown, purple liquids which can look like blood if the
child vomits, avoid milk and ice cream which coat the throat causing child to clear throat, soft
foods in 1-2 days. No straws, forks, sharp objects into mouth. Mouth odor, slight ear pain, and
low grade fever may occur a few days post op.
 Epistaxis – septum is highly vascular.
o Sit upright and lean forward, continuous pressure for 10 minutes.
o Cold cloth to bridge of nose if bleeding persists and a cotton wad in nostril, petroleum jelly after
bleeding stops to prevent crusting and prevent child picking.

Respiratory Disorders

 Epiglottitis – bacterial form of croup.

o S/S: cherry red edematous epiglottis, dysphonia (muffled voice), dysphagia, DROOLING,
RETRACTIONS, STRIDOR.
o NIC: no oral temp, NPO, NO SUPINE, heliox or epinephrine to decrease edema, cool mist
oxygen and high humidification.
 Laryngotracheobronchitis – most common form of croup, frequent in <5 years.
o S/S: Seal bark and brassy cough, stridor, low grade fever. Then continuous stridor, accessory
muscles, crackles and wheezing. Then anxiety, diaphoresis, anoxia and hypercapnia. Then
cyanosis, apneic episodes and cessation of breathing.
o NIC: Cool air vaporizer, avoid cough syrups which dry and thicken secretions, heliox.
 Bronchitis (AKA tracheobronchitis) – occurs with an URI. Dry hacking cough that worsens at night and
becomes productive in 2-3 days. Give cool humidified air, cough suppressant to promote rest.
 Bronchiolitis – thick mucus production.
 RSV – acute viral infection common cause of bronchiolitis, winter and spring, peak incidence @ 6
months. Isolate, suction.
 Pneumonia – viral more common than bacterial in kids, bacterial requires hospitalization- associated
with empyema = collection of pus in the space between the lung and the inner surface of the chest wall
(pleural space) and pleural effusion = buildup of fluid between the layers of tissue that line the lungs
and chest cavity, common in winter and fall.
 Asthma – chronic inflammatory disorder of the airways.
o Cell release of histamine leads to a bronchoconstrictive process, bronchospasm, and
obstruction.
 o Status asthmaticus – acute asthma attack, resp distress despite efforts.
o S/S: dyspnea, WHEEZING, chest tightness, cough, breathlessness especially at night and/or in
the early morning.
o Asthma attack – chest tightness, tired just before the attack; itching of neck or upper back,
rattling, frothy, clear, gelatinous sputum; retractions; HYPERRESONANCE of lungs; breath
sounds are coarse and loud – crackles, coarse rhonchi, inspiratory and expiratory wheezing;
lips turn dark red then cyanotic; speaks in short sentences.
o May be brought on by aspiring, NSAIDS, AB, B-Blockers, sulfite presevatives.
o Rescue Meds: Short acting Beta 2 agonists – bronchodilate; anticholinergics – relief of acute
bronchospasm; systemic corticosteriods – anti-inflammatory to reverse airflow obstruction.
o Long term/preventative meds: corticosteriods, anti allergy, nsaids, long acting B2 agonists,
LEUKOTRIENE MODIFIERS, MONOCLONAL antibody.
o NIC: Assess airway, humidified O2 by nasal cannula/face mask, admin rescue meds, IV line.
o Nebulizer (med mixed with saline then admin via machine)/MDI metered dose inhaler – use a
spacer for MDI with corticosteroid to prevent yeast infection in the mouth.
 Cystic Fibrosis – autosomal recessive trait disorder; exocrine gland dysfunction – mucus produced is
abnormally thick, tenacious, and copious causing obstruction of small passageways of the affected
organs – respiratory, gi, and reproductive.
o Pancreatic enzyme deficiency and sweat gland dysfunction L2 increased sodium and chloride
sweat concentrations. Sweat chloride test – 75 mg of sweat needed, normally sweat chloride
concentration is <40, >60 = + test, 40-60 should be retested.
o Chronic hypoxemia L2 pulmonary HTN L2 cor pulmonale.
o Meconium ileus is the earliest sign of C.F., stools are frothy and foul smelling, deficiency in
ADE&K.
o Can delay puberty in girls, girls often infertile and boys sterile.
o NIC: chest physiotherapy upon awakening and in the evening, especially with an infection;
flutter mucus device with a steel ball; huffing methods to expel secretions; bronchodialators,
lung transplants.
o GI – high cal, hi protein, ADE&K supplements, energy requirements are 20-50% more,
pancreatic enzyme replacement within 30 minutes of eating and given with all meals and
snacks, not given if NPO, enteric coated or sprinkled on small amount of food.
 SIDS – 2-3 months of age, less than 1 year, boys, Native Americans, African Americans, and
Hispanics.
o High risk: prone, soft bedding, non infant bed – sofa, overheating (thermal stress), cosleeping,
mother who smoked/substances during pregnancy, exposure to tobacco smoke after birth.
o S/S: apneic, blue, lifeless, frothy blood tinged fluid in nose and mouth, usually found in a
corner, disheveled bed with blankets over head, huddled in a corner.
o Prevention: placed supine, no stuffed animals in crib.
 Foreign Body Aspiration – Wheezing, stridor, cyanosis. Removal by endoscopy.
 TB – acid fast bacillus myco tuberculosis; inhalation of droplets from an individual with active TB.
o S/S: child may be asymptomatic, weight loss, anorexia, fever; dullness to percussion.
 o TST (TB Skin Test) – produces a positive reaction 2-10 weeks after the initial infection; after the
child reacts positively, they will forever react positively. Should not be done at the same time
as measles vaccine – false positive.
o Sputum culture – DEFINITIVE Diagnosis showing mycobateria in culture; because a child
usually swallows sputum, gastric washings – lavage from fasting stomach may be done in the
early morning before breakfast.
o NIC: 9 month isoniazid to prevent latent from becoming active, 12 months HIV (+).
o Active TB – Rifampin, isoniazid, and pyrazinamida daily for 2 months, then rifampin and
isoniazid twice weekly for 3 months.
o TB meds cause bodily fluids to turn orange.

Cardiovascular
 Heart Failure – inability of the heart to pump enough blood to meet the body’s metabolic and oxygen
demands. In infants and children, commonly caused by heart defects – shunt and/or obstruction. Goals
to remove excess fluid and sodium, decrease cardiac demands, improve tissue oxygenation, and
decrease oxygen consumption.
o S/S: tachycardia, tachypnea, profuse scalp diaphoresis – esp. in infants, sudden weight gain,
resp. distress.
o NIC: RR for 1 minute for resp distress, HR apical for 1 minute for dysrhythmias, strict i&o, daily
weights – 1lb/0.5kg = retention, monitor for facial/peripheral edema, elevate HOB Semi, provide
rest and decrease stimuli.
o Feed when hungry and soof after awakening – conserving energy and oxygen supply, admin
sedation during acute period to promote rest.
o DIGOXIN – apical HR for 1 full minute, <90-110 BPM, in infants and young children and <70 in
older children, DO NOT ADMIN. 1 hour before, 2 hours after feeding, do not mix with
food/fluids, if a dose is missed – within 4 hours give does, more than 4 hours do not give dose,
if vomit do not give second dose, give water or brush teeth after dose – cavity.
 o **Infants rarely receive more than 1mL/50mcg/0.05mg of digoxin.**
o Normal levels are 0.5-2.0 ng/dl, toxicity = >2 ng/dl.
o Ace Inhibitors
o Lasix – monitor for hypokalemia: inverted T waves, prominent U waves, muscle weakness,
cramping, confusion.
o Potassium rich foods – bananas, baked potato skins, peanut butter.
 Defects with Increased Pulmonary Blood Flow – intracardiac communication along the septum or an
abnormal connection between the great arteries allows lood to flow from the high pressure left side of
the heart to the low pressure right side of the heart. Typically show S/S of HF.
o ASD Atrial Septal Defect – opening between atria causing an increased flow of oxygenated
blood into the right side of the heart where deoxygenated blood usually flows.
 RA and RV enlargement.
 May be asymptomatic or develop HF.
 S/S of decreased CO: decreased peripheral pulses, exercise intolerance, hypotension,
oliguria, tachycardia, cool pale extremities.
 Tx: Closed during cardiac cath, open repair with cardiopulmonary bypass by
schoolage.
o Atrioventricular canal defect – incomplete fusion of endocardial cushions, common in Downs
Syndrome.
 S/S: MURMUR, CYANOSIS with crying, decreased CO.
o Patent Ductus Arteriosus – failure of the ductus arteriosus to close within the first weeks of life.
 S/S: MURMUR machine like, widened pulse pressure and BOUNDING PULSES are
present, ~HF, ~decreased CO.
 Tx: Indomethacin (Indocin) a prostaglandin inhibitor admin to close the PDA in
preemies and some newborns.

o VSD Ventricular Septal Defect – opening between the RV & LV. Many spontaneously close
during the first years of life in children having small-moderate defects.
 S/S: MURMUR, ~HF, ~decreased CO.
 Tx: Closed during cardiac cath, open repair with cardiopulmonary bypass.
 Obstructive Defects – blood exiting the heart meets an area of stenosis which impedes flow. Showing
S/S ~HF or may be asymptomatic with only a mild obstruction.
o Aortic Stenosis – narrowing of aortic valve causing resistance of blood from LV into aorta.
 Murmur, chest pain, dizziness.
o Coarctation of the aorta – narrow aorta near ductus arteriosus.
 BP high in upper extremities, low in lower extremities; bounding pulses in arms, weak
or absent femoral pulses; cool lower extremities.
 Dizziness, fainting, epistaxis.
o Pulmonary Stenosis – narrow at entrance of pulmonary artery.
 Right Ventricular HYPERTROPHY, decreased pulmonary blood flow, cyanosis,
murmurs.

 Defects with Decreased Pulmonary Flow

o Pressure on the right side of the heart increases exceeding pressure on the left side, allowing
desaturated blood to shunt right to left causing a desaturation in the left side of the heart and in
the systemic circulation.
o Tetralogy of Fallot – VSD, Pulmonary stenosis, Overriding aorta, and Right ventricular
hypertrophy.
  If pulmonary resistance is higher than systemic blood will shunt right to left, if systemic
is higher left to right.
 Murmur, cyanosis, blue “TET” spells when an infant cries, poops, eats – poor O2
supply.
 Children may squat, poor growth, clubbing of fingers = abnormal enlargement of distal
phalanges.
o Tricuspid Atresia – failure of the tricuspid valve to develop, there is no communication btwn RA
& RV.
 Cyanosis, tachycardia, dyspnea, clubbing in older children – chronic hypoxia.

 Mixed Defects
o Transposition of the great arteries/vessels – pulmonary artery leaves the LV an the aorta
leaves the RV, there is no communication between the systemic and pulmonary system.
 Severely cyanotic at birth, cardiomegaly.
 PG E1 given to keep ductus arteriosus open and mix blood temporarily.
 Tx: Balloon atrial septostomy.
 Reverse Trendelenberg’s to decrease work of breathing.
 Rheumatic Fever – inflammatory autoimmune after a Group A B-Hemolytic Strep URI, affects
connective tissues of the heart, joints, and skin.
o Affects MITRAL valve.
o S/S: low grade fever that spikes in afternoon, elevated anti-streptolysin O titer, elevated ESR
erythrocyte sedimentation rate, elevated C-reactive protein.
o Aschoff bodies/lesions found in heart, vessels, brain, & serous surfaces of joints & pleura.
o NIC: Alternate heat/cold therapy on joints, bed rest for child with carditis, antibiotics, salicylates
and anti-inflammatory agents, seizure precautions for chorea.
o The use of aspirin is not usually recommended in children under the age of 16 as there is a
very small risk of causing Reye’s syndrome – a potentially fatal condition that can cause liver
and brain damage.
o However, an exception is usually made for rheumatic fever, as most children are only required
to take a low-dose aspirin for one to two weeks, and it has proved extremely successful in
relieving symptoms. Most health professionals believe the benefits of aspirin in the treatment of
rheumatic fever far outweigh the risks.
o Jones Criteria Dx: 2 major/1 major + 2 minor.
 Major: Chorea, arthralgia, carditis, erythema marginatum, SC nodules.
 Minor: Fever, arthralgia, elevated ESR/positive C-reactive protein, prolonged PR.
  Kawasaki Disease – AKA lymph node syndrome; may cause aneurysms.
o S/S: Acute - fever, conjunctival hyperemia, red throat, swollen hands, rash, enlargement of
cervical lymph nodes. Subacute – cracking lips and fissues, desquamation of skin on the tips of
fingers and toes, thrombocytosis.
o Aspirin, room temp foods.
 Aspirin toxicity: tinnitus, headache, bruising, vertigo. No aspirin if child has chicken pox or the flu – may
L2 Reye’s Syndrome = sudden (acute) brain damage and liver function.

Urinary

 Enuresis – by age 5 should be able to sense fullness and control voiding.

o Primary enuresis – usually outgrown unless there is a delay in the maturation of CNS, never
was a period of being dry.
o Secondary/acquired enuresis – after a period of being dry, the child develops enuresis.
 Assess for UTIs.
 Diurnal – daytime, nocturnal – nighttime.
 May complain of urgency, dysuria, or frequency.
o NIC: limit fluids at night, make child clean bed, void before bed, meds – TCAs, antidiuretics,
antispasmodics.
 Cryptorchidism – one or both testes fail to descend via inguinal canal into the sac.
o HCG may be given to stimulate testosterone in the older child.
o Sx by 1-2 years if do not descend.
 Epispadias – urethra on top/dorsal penis
 Hypospadias – urethra on bottom/ventral penis,
o Sx for both done 16-18 months, before toileting. Circumcision NOT performed, foreskin may be
used in repair.
 1 hour no voiding – may be kinks in urinary diversion or sediment.
 Admin pain meds for bladder spasms – anticholinergics.
 No tub bath until urethral stent is removed.
 Bladder exstrophy – bladder is outside the body via a hole in the lower ab wall – no petroleum jelly.

Neuro/Cognitive

 Cerebral Palsy – impaired movement/posture D2 abnormality in the extra/pyramidal motor system.

o Most common – spastic: upper motor muscle weakness.
o S/S: extreme irritability and crying, stiff/rigid arms/legs, persistence of infantile reflexes,
opsithonos.
o NIC: safety, upright after meals.
 Head Injury/IICP – earliest indication of improvement/deterioration of neuro condition is child’s LOC.
o S/S: Early – infant: irritability, high pitched cry, Macewen’s sign (cracked pot sound on
head), setting sun; child: headache, nausea, diplopia, seizures.
 o S/S: Late – significant decrease in LOC, bradycardia, alteration in pupil size and
reactivity, decorticate = adduction of arms at shoulders, arms flexed, fists, legs adducted,
decerebrate = rigid extension and pronation of arms and legs, cheyne-stokes RR =
abnormal pattern of breathing characterized by progressively deeper and sometimes
faster breathing, followed by a gradual decrease that results in a temporary stop in
breathing - apnea, coma.

o
o NIC: minimize crying, low stimuli, withhold sedatives before assessing, seizure
precautions = raise rails, pad rails, waterproof mattress.
o EPIDURAL HEMATOMA = asymmetrical pupils.
o Test drainage for glucose = CSF.
 Meningitis – infection of CNS, may be D2 systemic infections, trauma, infections of sinuses/ears.
o Dx: CSF from lumbar puncture – cloudy, increased pressure, decreased glucose,
elevated protein, increased WBC.
o H.influ type B, Strep Pneumoniae, Neisseria meningitidis, meningococcal meningitis =
droplet transmission via nasopharyngeal secretions – epidemic. Viral – mumps, herpes,
enterovirus.
o S/S: fever, chills, nuchal rigidity, Kernig’s (pain of leg when extended) & Brudzinski’s
(neck movement makes knees draw to chest), meningococcal – constant ear drainage,
perechia/pupura rashes, muscle/joint pain.
o NIC: respiratory isolation 24 hours after ab, ab immediately after lumbar, monitor for
hearing loss.
o Pneumococcal conjugate vaccine at 2 months.
 Hydrocephalus – imbalanced CSF absorption/production D2 trauma, hemorrhage, tumor, infections.
o Communicating – impaired absorption in subarachnoid space, no interference in
ventricular system.
o Non communicating – no CSF flow/obstruction to ventricular system.
o S/S: Infant – increased head circumference, bulging anterior fontanel.
o S/S: Child – behavior changes – irritability/lethargy, headache upon awakening,
nystagmus = fast involuntary eye movement.
o Late: high shrill cry and seizures.
o Sx – shunt. If ICP increases, elevate HOB 15-30 degrees, malfunction infant – loss of
appetite, headache, child – LOC alteration.
 Reye’s Syndrome – acute encephalopathy following viral illness (influenza, varicella) that causes
cerebral edema and fatty changes to the liver, Dx: liver biopsy.
o No aspirin, give Tylenol.
o S/S: virus 4-7 days before symptoms, fever, N & V, neuro deterioration, INCREASED
BLOOD AMMONIA LEVELS, lethargy – altered hepatic function.
 o NIC: rest, decrease stimuli, liver labs, monitor for impaired coagulation – prolonged
bleeding.
 Seizures – excessive and unorganized neuronal discharges in the brain.
o Generalized – tonic clonic, absense, myoclonic, atonic.
o Partial – depends on the area of the brain.
o Postseizure (postictal) – child is sleepy and disoriented.
o Seizure precautions: ensure patent airway, suction and O2 ready, lower to floor and
place side lying, loosen restrictive clothing, remove glasses.
 Neural Tube Defects – failure of neural tube to close during embryonic development.
o Spina bifida occulta – failure to close at lumbrosacral area, cords/nerves, not visible,
neuro defects not usually present.
o Spina bifida cystica – protrusion of spinal cord and/or meninges in a sac.
o Meningocele – sac of meninges and CSF in middling of the back, LS area, spinal cord
not involved, no neuro deficits.
o Myelomeningocele – sac of meninges, CSF, nerve roots, and a portion of the spinal cord,
sac/defect prone to leakage/rupture, neuro deficits are evident.
o S/S: flaccid paralysis of legs, altered bladder/bowel function, hip/joint deformities,
hydrocephalus.
o NIC: measure sac, monitor for IICP – hydrocephalus, cover sac with moist saline and
change whenever soiled, no diapering until repair, prone position, side position for
feeding.

*** Lower maternal serum AFP values have been associated with an increased risk for genetic conditions
such as trisomy 21 (Down syndrome) and trisomy 18. Risks for these syndrome disorders are only
provided with the use of multiple marker screening (QUAD / Quad Screen [Second Trimester] Maternal,
Serum). The AFP concentration in maternal serum rises throughout pregnancy, from the nonpregnancy
level of 0.20 ng/mL to about 250 ng/mL at 32 weeks gestation. If the fetus has an open neural tube defect
(NTD), AFP is thought to leak directly into the amniotic fluid causing unexpectedly high concentrations of
AFP. Subsequently, the AFP reaches the maternal circulation; thus producing elevated serum levels.
Other fetal abnormalities such as omphalocele, gastroschisis, congenital renal disease, esophageal
atresia, and other fetal distress situations such as threatened abortion and fetal demise also may show
AFP elevations. Increased maternal serum AFP values also may be seen in multiple pregnancies and in
unaffected singleton pregnancies in which the gestational age has been underestimated. ***

 ADHD – inattention, impulsivity, and overactivity. Meds = stimulants, S/E: appetite suppression, tics,
HTN, insomnia, nervousness, weight loss.
 Mental Retardation – extra chromosome 21/Trisomy 21.
o S/S: flat nasal bridge, simian hand crease, upward slanting eyes, epicathic fold,
folded/small ears.

Musculoskeletal

 Developmental Dysplasia of the Hip – mild to severe: acetabular/preluxation, subluxation, and

dislocation – of the femoral head.
o S/S: shortening of limb – Galeassi’s sign/Allis’s sign, unequal thigh rolls/gluteal folds,
positive Ortolani’s and Barlow’s.
 o Sx: Birth – 6 months: splints with Pavlik Harness – keeps hips and legs abducted, 6-18
months: reduction by traction with closed/open reduction, Spica cast – legs abducted.
 Idiopathic Scoliosis – lateral curvature.
o Braces – slow progression of curvature, not curative, worn 16-23 hours a day, Milwaukee
Brace.
o Spinal fusion – post op, monitor mesenteric artery syndrome – caused by mechanical
changes in the position of the child’s abdominal contents during Sx, S/S: emesis, ab
distention.
 Juvenille idiopathic arthiritis – often affecting girls, Tx is supportive – no cure.
o May show elevated ESR and leukocytosis.
o NIC: meds, ROM excercises, hot/cold packs, splinting affected joint in neutral psition
during painful episodes.
 Marfan Syndrome – disorder of connective tissue – skeletal, cardio, eyes and skin.
o S/S: tall and thind, slender fingers, curvature of spine, visual and cardiac problems.
o NIC: cardiac meds, avoid physical sports, AB before dental work – endocarditis.
 Fractures
o Elevate injured extremity, ice, neuro status assessment.
o 5 P’s – pain, pulses distal, pallor, paresthesia, and paralysis.
o Russell skin traction – before surgery to stabilize a fractured femur.

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