Nursing: Pediatric

Sensorimotor (birth-2 years): learns through senses and motor activity, develops object permanence (~8-9 months), separation anxiety peaks 10-18 months. Preoperational (2-7 years): egocentric thinking, magical thinking, animism (objects are alive), cannot understand another's perspective, beginning symbolic/pretend play. Concrete operational (7-11 years): logical thinking about concrete events, understands conservation (quantity stays same despite shape change), classifies and orders objects. Formal operational (11+ years): abstract thinking, hypothetical reasoning, idealism. Nursing application: use developmentally appropriate explanations and activities.

Trust vs Mistrust (birth-1 year): consistent caregiving → trust; nursing: encourage parental presence, meet needs promptly. Autonomy vs Shame/Doubt (1-3 years): toddler seeks independence; nursing: offer choices, allow self-feeding, expect ritualistic behavior. Initiative vs Guilt (3-6 years): preschooler explores, imaginative play; nursing: encourage questions, therapeutic play for procedures. Industry vs Inferiority (6-12 years): school-age focuses on accomplishment; nursing: praise efforts, allow participation in care, encourage peer interaction. Identity vs Role Confusion (12-18 years): adolescent forming identity; nursing: provide privacy, respect autonomy, peer support, confidentiality within legal limits.

Newborn: HR 120-160, RR 30-60, BP 60-80/40-50. Infant (1-12 mo): HR 100-160, RR 24-40, BP 72-104/37-56. Toddler (1-3 yr): HR 90-150, RR 22-34, BP 86-106/42-63. Preschool (3-5 yr): HR 80-140, RR 20-30, BP 89-112/46-72. School-age (6-12 yr): HR 70-120, RR 18-26, BP 97-120/57-80. Adolescent (12-18 yr): HR 60-100, RR 12-20, BP 110-135/65-85. KEY: in children, the FIRST sign of shock is tachycardia (not hypotension). Hypotension is a LATE/ominous sign — indicates decompensated shock. Always assess for age-appropriate values.

Birth: Hep B (first dose). 2 months: DTaP, IPV, Hib, PCV13, Rotavirus, Hep B (2nd). 4 months: same as 2 months (no Hep B). 6 months: DTaP, IPV (may be given), Hib, PCV13, Rotavirus (3rd dose if RotaTeq), Hep B (3rd), influenza (annually starting at 6 months). 12-15 months: MMR (1st), Varicella (1st), Hep A (1st), Hib (booster), PCV13 (booster). 4-6 years: DTaP, IPV, MMR (2nd), Varicella (2nd). 11-12 years: Tdap, HPV (series), Meningococcal ACWY. Live vaccines (MMR, Varicella, Rotavirus, LAIV): contraindicated in immunocompromised patients and pregnancy. Egg allergy: flu vaccine can still be given (ACIP). If fever >104°F or seizure after prior dose: consult provider.

Croup (laryngotracheobronchitis): viral (parainfluenza #1 cause), ages 6 months-3 years, gradual onset, low-grade fever, barky/seal-like cough, inspiratory stridor, hoarse voice, steeple sign on X-ray (subglottic narrowing). Treatment: cool mist humidity, nebulized racemic epinephrine (observe 2-4 hrs for rebound), oral dexamethasone 0.6 mg/kg single dose. Epiglottitis: bacterial (H. influenzae type B — rare with Hib vaccine), ages 3-7 years, rapid onset (hours), HIGH fever, drooling, dysphagia, 'hot potato'/muffled voice, tripod positioning, thumb sign on lateral X-ray (swollen epiglottis). EMERGENCY — do NOT examine throat (can cause complete obstruction). Treatment: secure airway first (intubation/tracheostomy in OR), IV antibiotics (ceftriaxone). Note: Evidence does not support mist therapy; current practice favors dexamethasone and nebulized epinephrine.

Most common cause of bronchiolitis in infants (<2 years). Peak season: November-March. Transmission: contact (lives on surfaces up to 6 hrs). Assessment: starts as URI (rhinorrhea, cough, low-grade fever) → progresses to wheezing, tachypnea, retractions, nasal flaring, poor feeding, irritability. Diagnosis: rapid antigen testing (nasal washing). Treatment: supportive — O2 (maintain SpO2 >90%), hydration (IV fluids or frequent small feedings), nasal suctioning, humidified O2. No routine bronchodilators or steroids (limited benefit). Prevention: palivizumab (Synagis) monthly IM during RSV season for high-risk infants (preterm <29 weeks, BPD, CHD). Nirsevimab (Beyfortus) — single dose for all infants. Isolation: contact precautions + standard. Hand hygiene is #1 prevention.

Middle ear infection — peak age 6-24 months. Risk factors: bottle propping, daycare, pacifier use after 6 months, secondhand smoke, cleft palate. Assessment: ear pain (tugging in infants), fever, irritability, decreased hearing, bulging red/yellow tympanic membrane, possible otorrhea (drainage). Treatment: amoxicillin 80-90 mg/kg/day x10 days (first-line for <2 years or severe). Observation option for >2 years with mild unilateral symptoms. Pain management: ibuprofen/acetaminophen, warm compresses. Tympanostomy tubes if recurrent (3+ episodes in 6 months or 4+ in 12 months). Prevention: breastfeeding, upright feeding, avoid smoke exposure, pneumococcal vaccine. Teaching: complete full antibiotic course.

Hypertrophy of pyloric sphincter → gastric outlet obstruction. Onset: 2-8 weeks of age, more common in firstborn males. Assessment: projectile vomiting (non-bilious, immediately after feeding), hungry immediately after vomiting (hungry vomiter), palpable olive-shaped mass in RUQ, visible peristaltic waves left to right, dehydration, weight loss. Metabolic alkalosis (loss of HCl → elevated pH, HCO3). Diagnosis: ultrasound (gold standard) — pyloric muscle thickness >4 mm, length >16 mm. Treatment: pyloromyotomy (Ramstedt procedure). Pre-op nursing: correct dehydration and electrolyte imbalances (IV fluids with K+ replacement), NPO. Post-op: advance feedings gradually (small, frequent, start with electrolyte solution → formula/breast milk), monitor I&O, position upright after feeding.

Telescoping of one bowel segment into another — most common at ileocecal junction. Peak age: 3-36 months (usually 5-10 months), more common in males. Assessment: sudden severe colicky abdominal pain (infant draws knees to chest, screams, then relaxes — episodic), 'currant jelly' stools (blood and mucus — late sign), sausage-shaped mass in RUQ, vomiting, lethargy between episodes, dance sign (empty RLQ). Diagnosis: ultrasound (target/donut sign). Treatment: non-surgical reduction with air or barium enema (therapeutic and diagnostic) — successful in ~90%. If unsuccessful or perforation suspected: surgical reduction. Nursing: NPO, NG tube, IV fluids, monitor for peritonitis (fever, guarding, rigidity, absent bowel sounds), post-reduction: observe for recurrence (10% risk).

Steps: 1. Determine child's weight in kg (lbs ÷ 2.2). 2. Calculate safe dose range (mg/kg/dose or mg/kg/day × weight). 3. Compare prescribed dose to safe range. 4. If safe, calculate volume to administer. Example: Child weighs 22 lbs (10 kg). Amoxicillin ordered 400 mg PO q8h. Safe range: 25-45 mg/kg/day. Low: 25 × 10 = 250 mg/day ÷ 3 doses = 83 mg/dose. High: 45 × 10 = 450 mg/day ÷ 3 doses = 150 mg/dose. Ordered: 400 mg × 3 = 1200 mg/day = 120 mg/kg/day → EXCEEDS safe range → HOLD and clarify with provider. Always verify: right patient, right weight, right calculation.

Mild (3-5% weight loss): slightly dry mucous membranes, slightly decreased urine output, normal skin turgor, alert. Moderate (6-9%): dry mucous membranes, decreased urine output (dark, concentrated), tachycardia, decreased tears, sunken fontanels (infants), decreased skin turgor (tenting >2 sec), irritable or lethargic. Severe (≥10%): very dry/parched mucous membranes, markedly decreased/absent urine output, tachycardia, weak/thready pulse, hypotension (late), markedly sunken fontanels and eyes, very poor skin turgor, lethargic/obtunded, mottled/cool extremities. Treatment: mild → ORT (oral rehydration therapy — Pedialyte); moderate → ORT or IV NS/LR bolus 20 mL/kg; severe → immediate IV NS or LR bolus 20 mL/kg, may repeat x3, monitor for overload. Daily weights, strict I&O.

Neonates/infants (0-1 year): NIPS (Neonatal Infant Pain Scale) — facial expression, cry, breathing, arms, legs, state of arousal (0-7 scale). FLACC (2 months-7 years or nonverbal): Face, Legs, Activity, Cry, Consolability — each scored 0-2 (total 0-10). Used for postoperative, procedural, and nonverbal patients. Wong-Baker FACES (3+ years): child points to face that matches pain (0 = no hurt, 10 = hurts worst). Numeric Rating Scale (8+ years): 0-10 self-report. CRIES (neonates, postoperative): Crying, Requires O2, Increased VS, Expression, Sleeplessness. Key principle: self-report is gold standard when possible. Always believe the child's report. Non-pharmacologic: distraction, comfort positioning, sucrose pacifier (neonates), therapeutic play.

Physical signs: bruises in various stages of healing, bruises in unusual locations (ears, neck, buttocks, torso — NOT shins/knees/forehead which are common in play), patterned injuries (belt marks, cigarette burns, immersion burns with clear demarcation — 'stocking/glove' pattern), spiral fractures in non-ambulatory children, retinal hemorrhages (shaken baby syndrome), torn frenulum (forced feeding). Behavioral signs: child — withdrawal, regression, excessive fear of parent, inappropriate sexual knowledge, not wanting to go home. Parent/caregiver — inconsistent or implausible history, delay in seeking care, blaming child, history doesn't match developmental ability (e.g., 'fell off couch' for infant with spiral femur fracture). Nursing: mandatory reporter — report SUSPICION (do not need proof). Document objectively (exact quotes, measurements, photos). Do not ask leading questions. Report to local CPS/law enforcement.

Autosomal recessive — abnormal hemoglobin S (HbS) causes RBCs to sickle under low O2 conditions → vaso-occlusion, ischemia, organ damage. Triggers for crisis: infection, dehydration, cold exposure, stress, hypoxia, high altitude. Types of crises: vaso-occlusive (most common) — severe pain in extremities, chest, abdomen, joints; splenic sequestration — spleen traps blood → hypovolemic shock (emergency in young children, teach parents to palpate spleen); aplastic crisis — parvovirus B19 → bone marrow suppression; acute chest syndrome — chest pain, fever, pulmonary infiltrate (leading cause of death). Nursing: hydration (1.5x maintenance), pain management (do NOT undertreat — use opioids for severe pain), O2 for hypoxemia (not routinely — can suppress erythropoiesis), blood transfusions, folic acid supplementation, penicillin prophylaxis (birth to 5 years — functional asplenia), hydroxyurea (increases HbF, reduces crises). Teach: avoid triggers, recognize signs of infection/splenic sequestration.

Autoimmune destruction of beta cells → absolute insulin deficiency. Presentation: polyuria, polydipsia, polyphagia WITH weight loss, fatigue, bedwetting (new onset). DKA at diagnosis in ~30%. DKA: blood glucose >250 mg/dL, pH <7.30, HCO3 <15, positive serum ketones, Kussmaul respirations (deep/rapid), fruity breath, N/V, abdominal pain, altered LOC. DKA treatment: IV fluids (NS bolus then 0.45% NS), insulin drip (0.1 units/kg/hr — do NOT bolus in peds), monitor glucose hourly, replace potassium (add K+ when <5.5 and patient is voiding), monitor for cerebral edema (headache, altered LOC, Cushing triad — most feared complication in pediatric DKA). Management: insulin therapy (MDI or pump), carb counting, blood glucose monitoring (goal A1C <7.0% (updated ADA 2022)), recognize hypo/hyperglycemia, sick day rules, school plan.

Classification: Intermittent — symptoms ≤2 days/week, ≤2 nights/month, FEV1 >80%. Mild persistent — >2 days/week (not daily), 3-4 nights/month. Moderate persistent — daily symptoms, >1 night/week, FEV1 60-80%. Severe persistent — throughout the day, nightly, FEV1 <60%. Step therapy: Step 1 (intermittent): SABA PRN only. Step 2: low-dose ICS. Step 3: low-dose ICS + LABA or medium-dose ICS. Step 4: medium-dose ICS + LABA. Step 5-6: high-dose ICS + LABA ± oral corticosteroids. Children <5: different guidelines (ICS preferred controller, no LABA <4 years). Teaching: use spacer with MDI (all ages), rinse mouth after ICS, asthma action plan (green/yellow/red zones), trigger avoidance, proper inhaler technique. Peak flow monitoring in children >5 years. Exercise-induced: SABA 15 min before activity.

Acyanotic (left-to-right shunt — increased pulmonary blood flow): ASD (atrial septal defect), VSD (ventricular septal defect — most common CHD), PDA (patent ductus arteriosus). Symptoms: HF symptoms, frequent respiratory infections, poor growth, murmur. VSD: loud harsh systolic murmur at LSB. PDA: continuous 'machinery' murmur, bounding pulses. PDA treatment in preterm: indomethacin or ibuprofen (close ductus). Cyanotic (right-to-left shunt — decreased pulmonary blood flow): Tetralogy of Fallot (most common cyanotic CHD), Transposition of great arteries (TGA), Truncus arteriosus. Tetralogy of Fallot (4 defects): VSD, overriding aorta, pulmonic stenosis, RV hypertrophy. Tet spells (hypercyanotic episodes): place in knee-chest position (increases SVR → forces blood to lungs). TGA: aorta and PA are switched — incompatible with life without mixing (PDA, ASD). Prostaglandin E1 (alprostadil) keeps PDA open until surgical repair.

Core principles: family is the constant in child's life, respect family diversity and culture, share honest and complete information, encourage family participation in care and decision-making, collaborate with families at all levels. Practical applications: open visitation, parental presence during procedures (offer — don't force), rooming-in, encourage parental participation in daily care (bathing, feeding), provide education at appropriate level, include family in care planning, sibling visitation, play therapy/child life specialist involvement. Parental coping: assess family's coping mechanisms, provide emotional support, connect with resources (social work, support groups, financial assistance). Atraumatic care: minimize physical and psychological distress — use EMLA cream before procedures, allow choices, therapeutic play, honest preparation.

1. Do NOT examine throat, do NOT lay child supine, do NOT take oral temperature, do NOT attempt blood draws or IVs initially — any agitation can cause complete airway obstruction. 2. Allow child to remain in position of comfort (usually sitting upright, leaning forward, tripod). 3. Keep parent at bedside (reduce anxiety). 4. Have emergency airway equipment at bedside (tracheostomy tray, intubation supplies). 5. Transport to OR for controlled intubation by anesthesia/ENT. 6. After airway secured: IV access, blood cultures, IV antibiotics (ceftriaxone or ampicillin-sulbactam), IV dexamethasone. 7. Contacts: prophylactic rifampin for household contacts if H. influenzae type B confirmed.

Acute vasculitis — leading cause of acquired heart disease in children in developed countries. Peak age: 6 months-5 years, more common in Asian descent. Diagnosis (5 of 6 criteria or 4 + coronary abnormalities): Fever ≥5 days PLUS ≥4 of: bilateral conjunctival injection (non-purulent), oral changes (strawberry tongue, red/cracked lips), cervical lymphadenopathy (≥1.5 cm, usually unilateral), polymorphous rash, extremity changes (erythema, edema → peeling of fingers/toes in subacute phase). Most serious complication: coronary artery aneurysm (echocardiogram at diagnosis, 2 weeks, 6-8 weeks). Treatment: IVIG (2 g/kg single dose within 10 days of onset) + high-dose aspirin (80-100 mg/kg/day in 4 doses during febrile phase → 3-5 mg/kg/day for 6-8 weeks — one of few times aspirin used in children). Monitor cardiac status, avoid live vaccines for 11 months after IVIG.

Cleft lip repair: usually at ~3 months (Rule of 10s: 10 weeks, 10 lbs, Hgb 10). Cleft palate repair: usually 9-12 months (before speech development). Pre-op: special feeding techniques — use squeeze bottles (Haberman, Pigeon), upright position, burp frequently, no standard nipple. Breastfeeding may be possible with cleft lip. Post-op cleft lip: elbow restraints (no hands to face), position on back or side (NOT on abdomen), clean suture line gently after feedings with water, avoid pacifiers, protect incision (Logan bow/steri-strips), pain management. Post-op cleft palate: avoid hard objects in mouth (no straws, spoons, pacifiers, tongue depressors), elbow restraints, feed with cup or side of spoon, soft diet, monitor for bleeding from palate. Long-term: speech therapy, dental care, ear infections (eustachian tube dysfunction), emotional support.

Massive proteinuria → hypoalbuminemia → decreased oncotic pressure → generalized edema (anasarca). Most common type in children: minimal change disease. Peak age: 2-6 years. Assessment: periorbital edema (first sign, especially AM), ascites, scrotal/labial edema, weight gain, decreased urine output, foamy/frothy urine, fatigue, pallor. Labs: proteinuria (3-4+, urine protein/creatinine ratio >2), hypoalbuminemia (<2.5 g/dL), hyperlipidemia, elevated hematocrit (hemoconcentration). Treatment: corticosteroids (prednisone — first-line, most respond), cyclophosphamide for steroid-resistant, albumin infusion for severe edema (followed by diuretic), sodium restriction, no fluid restriction unless severe hyponatremia. Nursing: daily weights, I&O, abdominal girth, monitor for infection (loss of immunoglobulins), skin care (edematous skin breaks down), no live vaccines during immunosuppression, urine dipstick monitoring at home.

Sources: paint in pre-1978 housing (#1 source), contaminated soil, water from lead pipes, imported toys/pottery, folk remedies. Screening: blood lead level (BLL) at 1 and 2 years (high-risk areas). CDC reference value: ≥3.5 mcg/dL (action level — previously 5). Assessment: often asymptomatic at low levels. Moderate levels: abdominal pain, constipation, irritability, learning difficulties, developmental delays. Severe (>70 mcg/dL): encephalopathy (seizures, coma, vomiting, ataxia) — medical emergency. Diagnosis: venous blood lead level (capillary screens must be confirmed). Treatment: remove source (environmental remediation). BLL 3.5-44: education, follow-up testing, nutritional counseling (adequate iron, calcium, vitamin C reduce absorption). BLL 45-69: chelation therapy with succimer (DMSA) oral. BLL ≥70: IV chelation (CaNa2EDTA ± dimercaprol/BAL), hospitalize. Nursing: assess home environment, nutrition, developmental screening.

Most common renal tumor in children. Peak age: 2-5 years. Assessment: painless abdominal mass (usually found incidentally by parent during bathing), abdominal swelling, hypertension (renin-mediated), hematuria (late), fever, malaise. CRITICAL NURSING ALERT: DO NOT PALPATE ABDOMEN — can cause rupture and tumor seeding. Place sign above bed: 'DO NOT PALPATE ABDOMEN.' Diagnosis: abdominal ultrasound/CT. Treatment: surgical nephrectomy (followed by chemotherapy ± radiation depending on stage). Nursing: handle gently, avoid abdominal pressure, pre-op assessment of remaining kidney function, post-op: monitor BP, I&O (remaining kidney function), assess for intestinal obstruction, protect from infection (chemotherapy). Prognosis: excellent with treatment (~90% survival for favorable histology). Monitor remaining kidney lifelong.

Non-progressive motor disorder from brain damage before, during, or shortly after birth. Risk factors: prematurity (#1), low birth weight, birth asphyxia, infections, kernicterus. Types: Spastic (most common, ~70-80%): increased muscle tone, hyperreflexia, scissoring gait. Dyskinetic/athetoid: involuntary writhing movements, fluctuating tone. Ataxic: poor balance, uncoordinated movements. Mixed: combination. Assessment: developmental delays (not meeting motor milestones), persistent primitive reflexes, abnormal muscle tone, feeding difficulties, intellectual disability (varies — may have normal intelligence). Nursing: multidisciplinary team (PT, OT, speech, ortho), prevent contractures (ROM exercises, bracing, positioning), nutritional support (may need G-tube), assistive devices, safety, seizure management (common comorbidity), skin integrity, family support, promote maximum independence. Medications: baclofen (spasticity), botulinum toxin (focal spasticity), anticonvulsants.

Most common surgical emergency in children. Peak age: 10-12 years. Assessment: periumbilical pain → localizes to RLQ (McBurney's point) within 12-24 hrs, anorexia, nausea, low-grade fever, rebound tenderness, guarding, positive psoas sign, positive obturator sign. Rovsing sign: pain in RLQ with palpation of LLQ. Younger children: more difficult to diagnose, higher perforation rate (difficulty verbalizing symptoms). Labs: elevated WBC (>10,000), left shift. Diagnosis: ultrasound (first-line in peds), CT if inconclusive. Nursing priorities: NPO, IV fluids, pain management (do NOT withhold analgesics — does not mask peritoneal signs per evidence), monitor for perforation signs (sudden relief of pain → then diffuse pain, high fever, rigid abdomen, absent bowel sounds). Post-appendectomy: advance diet when bowel sounds return, ambulate early, wound care, antibiotics if perforated.

Acyanotic (left-to-right shunt — oxygenated blood recirculates through lungs): VSD (most common CHD), ASD, PDA, coarctation of aorta. Symptoms: HF signs, frequent respiratory infections, failure to thrive, murmur. Cyanotic (right-to-left shunt — deoxygenated blood enters systemic circulation): Tetralogy of Fallot (most common cyanotic — VSD, overriding aorta, pulmonary stenosis, RV hypertrophy), Transposition of Great Arteries (TGA), Truncus Arteriosus, Tricuspid Atresia, Total Anomalous Pulmonary Venous Return. Symptoms: cyanosis (especially with crying/feeding), clubbing (chronic), tet spells (TOF — knee-chest position), polycythemia. Nursing: monitor SpO2, strict I&O, calorie-dense feedings (small frequent), cluster care to minimize O2 demand, pre/post-op cardiac surgery care, family education.

Narrowing of the aorta — usually near the ductus arteriosus (juxtaductal). Assessment: hypertension in upper extremities with hypotension/weak pulses in lower extremities (BP difference >20 mmHg between upper and lower extremities is classic), bounding radial pulses with weak/absent femoral pulses, cool lower extremities, epistaxis, headaches, dizziness, late signs of HF in neonates if severe. Often associated with bicuspid aortic valve, Turner syndrome. Diagnosis: 4-extremity BP (arms vs legs), echo, CXR (rib notching in older children), CT/MRI. Treatment: surgical repair or balloon angioplasty/stenting. Post-op: monitor for rebound hypertension, assess femoral pulses and lower extremity perfusion, monitor for abdominal pain (mesenteric arteritis), BP in all 4 extremities. Long-term: monitor for re-coarctation, lifelong cardiology follow-up.