132 terms

Peds ATI


Terms in this set (...)

Should med equipment be out when assessing a child?
Temperature for ages
3 mo-1 year
› Rectal (if exact measurement necessary)
-99.5 F

3year- 5 years
-oral if you can
99 F

98 F
Pulse Rate
◯ Newborn - 80 to 180/min (depending on activity)
◯ 1 week to 3 months - 80 to 220/min (depending on activity)
◯ 3 months to 2 years - 70 to 150/min (depending on activity)
◯ 2 to 10 years - 60 to 110/min (depending on activity)
◯ 10 years and older - 50 to 90/min (depending on activity)
◯ Newborn to 1 year - 30 to 35/min
◯ 1 to 2 years - 25 to 30/min
◯ 2 to 6 years - 21 to 25/min
◯ 6 to 12 years - 19 to 21/min
◯ 12 years and older - 16 to 19/min
Blood Pressure
◯ Infants - 65 to 80 mm Hg systolic and 40 to 50 mm Hg diastolic

Systolic (mm Hg) Diastolic (mm Hg) Systolic (mm Hg) Diastolic (mm Hg)
1 year 80/40 to 115/67
3 years 86/45 to 125/75
6 years 91/54 to 122/85
10 years 100/60 to 130/90
16 years 110/65 to 145/100
Spine assessment
■ Infants - Spines should be without dimples or tufts of hair. They should be midline with an
overall C-shaped lateral curve.
■ Toddlers appear squat with short legs and protuberant abdomens.
■ Preschoolers appear more erect than toddlers.
■ Children should develop the cervical, thoracic, and lumbar curvatures like that of adults.
■ Adolescents should remain midline (no scoliosis noted).
◯Gait of Toddlers and young children
A bowlegged or knock-knee appearance is a common finding.
Feet should face forward while walking
Sucking and rooting reflexes
Elicited by stroking an infant's cheek or the edge of
an infant's mouth

Birth to 4 months
Palmar grasp
Elicited by placing an object in an infant's palm
» The infant grasps the object.

Birth to 3 months
Plantar grasp
Elicited by touching the sole of an infant's foot
» The infant's toes curl downward.

Birth to 8 months
Moro reflex
Elicited by allowing the head and trunk of an infant
in a semi-sitting position to fall backward to an
angle of at least 30°
» The infant's arms and legs symmetrically extend,
then abduct while fingers spread to form C shape.

Birth to 4 months
Startle reflex
› Elicited by clapping hands or by a loud noise.
The newborn will abduct arms at the elbows, and
the hands will remain clenched.

Birth to 4 months
Tonic neck reflex
› Elicited by turning an infant's head to one side
» The infant extends the arm and leg on that side
and flexes the arm and leg on the opposite side

Birth to 3 to 4 months
Babinski reflex
Elicited by stroking the outer edge of the sole of an
infant's foot up toward the toes
» The infant's toes fan upward and out

Birth to 1 year
› Elicited by holding an infant upright with his feet
touching a flat surface
» The infant makes stepping movements

Birth to 4 weeks
Nerve tests
Olfactory › Difficult to test › Identifies smells through each nostril individually

II Optic › Looks at face and tracks with eyes › Has intact visual acuity, peripheral vision, and
color vision

III Oculomotor › Blinks in response to light
› Has pupils that are reactive to light
› Has no nystagmus and PERRLA is intact

IV Trochlear › Looks at face and tracks with eyes › Has the ability to look down and in with eyes

V Trigeminal › Has rooting and sucking reflexes › Is able to clench teeth together
› Detects touch on face with eyes closed

VI Abducens › Looks at face and tracks with eyes › Is able to see laterally with eyes

VII Facial › Has symmetric facial movements › Has the ability to differentiate between salty
and sweet on tongue
› Has symmetric facial movements

VIII Acoustic › Tracks a sound
› Blinks in response to a loud noise
› Does not experience vertigo
› Has intact hearing

› Has an intact gag reflex › Has an intact gag reflex
› Is able to taste sour sensations on back of tongue
X Vagus › Has no difficulties swallowing › Speech clear, no difficulties swallowing
› Uvula is midline

XI Spinal
› Moves shoulders symmetrically › Has equal strength of shoulder shrug against
examiner's hands

XII Hypoglossal › Has no difficulties swallowing
› Opens mouth when nares
are occluded
› Has a tongue that is midline
› Is able to move tongue in all directions with
equal strength against tongue blade resistance
◯ Deep tendon reflexes should demonstrate the following:
■ Partial flexion of the lower arm at the biceps tendon
■ Partial extension of the lower arm at the triceps tendon
■ Partial extension of the lower leg at the patellar tendon
■ Plantar flexion of the foot at the Achilles tendon
Cerebellar function (children and adolescents)
Finger to nose test - Rapid coordinated movements
■ Heel to shin test - Able to run the heel of one foot down the shin of the other leg while standing
■ Romberg test - Able to stand with slight swaying while eyes are closed
When does posterior fontanel close?
The infant's posterior fontanel closes by 6 to 8 weeks of age.
When does anterior fontanel close?
◯The infant's anterior fontanel closes by 12 to 18 months of age.
Infants - weight
Infants gain approximately 150 to 210 g (about 5 to 7 oz) per week the first 6 months
of life. Birth weight is at least doubled by the age of 6 months, and tripled by the age of
12 months
Infants - height
Infants grow approximately 2.5 cm (1 in) per month the first 6 months of life. Growth
occurs in spurts after the age of 6 months, and the birth length increases by 50% by the age of
12 months.
Infants - head circumference
The circumference of infants' heads increases approximately 1.5 cm (0.6 in)
per month for the first 6 months of life, and then approximately 0.5 cm (0.2 in) between 6 and
12 months of age.
Six to eight teeth should erupt in infants' mouths by the end of the first year of age.
The first teeth typically erupt between the ages of 6 and 10 months.

■ Teething pain can be eased using cold teething rings and over-the-counter teething gels.
Acetaminophen (Tylenol) and/or ibuprofen (Advil) are appropriate if irritability interferes with
sleeping and feeding, but should not be used for more than 3 days. Ibuprofen should be used
only in infants over the age of 6 months.
■ Clean infants' teeth using cool, wet washcloths.
■ Bottles should not be given to infants when they are falling asleep because prolonged exposure
to milk or juice can cause early childhood caries.
Gross & Fine Motor skills: Infants
1 month › Demonstrates head lag › Has a grasp reflex

2 months › Lifts head off mattress when prone › Holds hands in an open position

3 months › Raises head and shoulders off mattress
when prone
› Only slight head lag
› No longer has a grasp reflex
› Keeps hands loosely open

4 months › Rolls from back to side › Places objects in mouth

5 months › Rolls from front to back › Uses palmar grasp dominantly

6 months › Rolls from back to front › Holds bottle

7 months › Bears full weight on feet › Moves objects from hand to hand

8 months › Sits unsupported › Begins using pincer grasp

9 months › Pulls to a standing position
› Creeps on hands and knees instead
of crawling
› Has a crude pincer grasp

10 months › Changes from a prone to a sitting position › Grasps rattle by its handle

11 months › Walks while holding onto something › Places objects into a container
› Neat pincer grasp

12 months › Sits down from a standing position
without assistance
› Tries to build a two-block tower
without success
Piaget - Sensorimotor stage (birth to 24 months)
Progress from reflexive to simple repetitive to imitative activities.
■ Separation, object permanence, and mental representation are the three important tasks
accomplished in this stage.
☐ Separation - Infants learn to separate themselves from other objects in the environment.
☐ Object permanence - The process by which infants know that an object still exists when it is
out of view. This occurs at approximately 9 months of age.
☐ Mental representation - The recognition of symbols.
Erikson - Trust vs. Mistrust (birth to 1 year)
Achieving this task is based on the quality of the caregiver-infant relationship and the
care received.
■ The infant begins to learn delayed gratification.
CHAPTER 3 Health Promotion of Infants (1 Month to 1 Year)
RN Nursing Care of Children 25
■ Trust is developed by meeting comfort, feeding, stimulation, and caring needs.
■ Mistrust develops if needs are inadequately or inconsistently met, or if needs are continuously
met before being vocalized by the infant.
Social Development
Social development is initially influenced by infants' reflexive behaviors and includes
attachment, separation, recognition/anxiety, and stranger fear.
■ Attachment is seen when infants begin to bond with their parents. This development is
seen within the first month, but it actually begins before birth. The process is enhanced
when infants and parents are in good health, have positive feeding experiences, and receive
adequate rest.
■ Separation-individuation occurs during the first year of life as infants first distinguish
themselves and their primary caregiver as separate individuals, and then develop
object permanence.
■ Separation anxiety begins around 4 to 8 months of age. Infants will protest when separated
from parents, which can cause considerable anxiety for parents.
■ Stranger fear becomes evident between 6 and 8 months of age, when infants are less likely to
accept strangers.
■ Reactive attachment disorder results from maladaptive or absent attachment between the
infant and primary caregiver, and continues through childhood and adulthood.
Age-Appropriate Activities for Infants
◯ Play should provide interpersonal contact and educational stimulation.
◯ Infants 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
the following.
■ Rattles
■ Teething toys
■ Nesting toys
■ Playing pat-a-cake
■ Playing with balls
■ Reading books
■ Mirrors
■ Brightly colored toys
■ Playing with blocks
Immunizations- Infants
■ 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, PCV
■ 6 months - DTaP, IPV (6 to 18 months), PCV, and Hep B (6 to 12 months); RV; Hib
■ 6 to 12 months - Seasonal influenza vaccination yearly (the trivalent inactivated influenza
vaccine (TIV) is available as an intramuscular injection)
◯ Feeding alternatives
Breastfeeding provides a complete diet for infants during the first 6 months.
■ Iron-fortified formula is an acceptable alternative to breast milk. Cow's milk is
not recommended.
■ It is recommended to begin vitamin D supplements within the first few days of life.
■ Iron supplements are recommended for infants who are being exclusively breastfed after the
age of 4 months.
■ Alternative sources of fluids, such as juice or water, are not needed during the first 4 months of life.
■ After the age of 6 months, 100% fruit juice should be limited to 4 to 6 oz per day
◯ Solids are introduced around 4 to 6 months of age.
Indicators for readiness include interest in solid foods, voluntary control of the head and trunk,
and disappearance of the extrusion reflex.
■ Iron-fortified cereal is typically introduced first due to its high iron content.
■ New foods should be introduced one at a time, over a 4- to 7-day period, to observe for signs of
allergy or intolerance, which may include fussiness, rash, vomiting, diarrhea, and constipation.
■ Vegetables or fruits are started first between 6 and 8 months of age. After both have been
introduced, meats may be added.
■ Citrus fruits, meat, and eggs are not started until after 6 months of age.
■ Breast milk/formula should be decreased as intake of solid foods increases, but should remain
the primary source of nutrition through the first year.
■ Table foods that are cooked, chopped, and unseasoned are appropriate by 9 months of age.
■ Appropriate finger foods include ripe bananas; toast strips; graham crackers; cheese cubes;
noodles; and peeled chunks of apples, pears, or peaches
◯ Weaning can be accomplished when infants show signs of readiness, and are able to drink from a
cup (sometime in the second 6 months).
■ One meal may be replaced with breast milk or formula in a cup with handles.
■ Bedtime feedings are the last to be stopped.
Sleep Patterns
◯ Nocturnal sleep pattern is established by 3 to 4 months of age.
◯ Infant sleeps 14 to 15 hr daily and 9 to 11 hr at night around the age of 4 months.
◯ Infant sleeps through the night and takes one to two naps during the day by the age of 12 months
How long should toddlers be in a car seat for?
Infants and toddlers remain in a rear-facing car seat until the age of 2 years or the height
recommended by the manufacturer.
Health Promotion of Toddlers (1 to 3 Years)
◯ Anterior fontanels close by 18 months of age.
◯ Weight - At 30 months of age, toddlers should weigh four times their birth weights.
◯ Height - Toddlers grow about 7.5 cm (3 in) per year.
◯ Head circumference and chest circumference are usually equal by 1 to 2 years of age
Gross & Fine Motor Skills - Toddler
15 months › Walks without help
› Creeps up stairs
› Uses a cup well
› Builds a tower of two blocks

18 months › Assumes a standing position
› Throws a ball overhand
› Jumps up and down with both feet
› Manages a spoon without rotation
› Turns pages in a book, two or three at
a time

2 years › Walks up and down stairs by placing
both feet on each step
› Builds a tower of six or seven blocks

2.5 years › Jumps across the floor using both feet
and off a chair or step
› Stands on one foot momentarily
› Draws circles
› Has good hand-finger coordination
Toddler: Piaget
Piaget - The sensorimotor stage transitions to the preoperational stage around the age of 19 to
24 months

■ The concept of object permanence becomes fully developed.
■ Toddlers have and demonstrate memories of events that relate to them.
■ Domestic mimicry (playing house) is evident.
■ Preoperational thought does not allow for toddlers to understand other viewpoints, but it does
allow them to symbolize objects and people to imitate previously seen activities.
Toddler: Age-Appropriate Activities
Solitary play evolves into parallel play, in which toddlers observe other children and then may
engage in activities nearby.
◯ Appropriate activities
■ Filling and emptying containers
■ Playing with blocks
■ Looking at books
■ Push-pull toys
■ Tossing balls
■ Finger paints
■ Large-piece puzzles
■ Thick crayons
● Immunizations: toddler
12 to 15 months - Inactivated poliovirus (IPV) (third dose between 6 to 18 months);
Haemophilus influenzae type B (Hib); pneumococcal vaccine (PCV); measles, mumps, and rubella
(MMR); and varicella
■ 12 to 23 months - Hepatitis A (Hep A), given in two doses at least 6 months apart
■ 15 to 18 months - Diphtheria and tetanus toxoids and pertussis (DTaP)
■ 12 to 36 months - Yearly seasonal trivalent inactivated influenza vaccine (TIV); live, attenuated
influenza vaccine (LAIV) by nasal spray (at 2 years of age)
Toddlers- Nutrition
Toddlers should consume 24 to 30 oz of milk per day, and may switch from drinking whole milk to
drinking low-fat milk after 2 years of age.
◯ Juice consumption should be limited to 4 to 6 oz per day.
◯ Trans fatty acids and saturated fats should be avoided.
◯ Diet should include 1 cup of fruit daily.
◯ Food serving size should be 1 tbsp for each year of age, or ¼ to 1/3 of an adult portion
Toddlers: Sleep & Rest
◯ Toddlers typically average 11 to 12 hr of sleep per day, including one nap.
◯ Naps often are eliminated in older toddlerhood.
◯ Resistance to bedtime and expression of fears are common in this age group.
Toddlers: Car
Motor-vehicle injuries
■ Infants and toddlers remain in a rear-facing car seat until the age of 2 years or the height
recommended by the manufacturer.
■ Toddlers over the age of 2 years, or who exceed the height recommendations for rear-facing car
seats, are moved to a forward-facing car seat.
Preschoolers: ● Physical Development
Weight - Preschoolers should gain about 2 to 3 kg (4.4 to 6.6 lb) per year.
◯ Height - Preschoolers should grow about 6.5 to 9 cm (2.6 to 3.5 in) per year.
◯ Preschoolers' bodies evolve away from the characteristically unsteady wide stances and protruding
abdomens of toddlers, into a more graceful, posturally erect, and sturdy physicality
Gross Motor Skills By Age- Preschoolers
› Rides a tricycle
› Jumps off bottom step
› Stands on one foot for a
few seconds

› Skips and hops on one foot
› Throws ball overhead

› Jumps rope
› Walks backward with heel to toe
› Throws and catches a ball with ease
Piaget- Preschoolers
◯ Piaget - The preconceptual phase transitions to the phase of intuitive thought around the age of
4 years. The phase of intuitive thought lasts until the age of 7 years.
Preschooler thinking
Magical thinking - Thoughts can cause events to occur.
☐ Animism - Inanimate objects are alive.
☐ Centration - Focus on one aspect instead of considering the whole
Erikson- Preschooler thinking
Erikson - initiative vs. guilt
■ Preschoolers become energetic learners, despite not having all of the physical abilities necessary
to be successful at everything.
■ Guilt may occur when preschoolers believe they have misbehaved or when they are unable to
accomplish a task.
■ Guiding preschoolers to attempt activities within their capabilities while setting limits
is appropriate.
■ By the age of 5 years, preschoolers begin comparing themselves with peers.
Pre school: ● Age-Appropriate Activities
Parallel play shifts to associative play during the preschool years. Play is not highly organized, but
cooperation does exist between children. Appropriate activities include:
■ Playing ball
■ Putting puzzles together
■ Riding tricycles
■ Playing pretend and dress-up activities
■ Role playing
■ Painting
■ Simple sewing
CHAPTER 5 Health Promotion of Preschoolers (3 to 6 Years)
44 RN Nursing Care of Children
■ Reading books
■ Wading pools
■ Skating
■ Computer programs
■ Electronic games
Preschool: ● Immunizations
■ 4 to 6 years - diphtheria and tetanus toxoids and pertussis (DTaP); measles, mumps, and
rubella (MMR); varicella; and inactivated poliovirus (IPV)
■ 3 to 6 years - yearly seasonal influenza vaccine; trivalent inactivated influenza vaccine (TIV); or
live, attenuated influenza vaccine (LAIV) by nasal spray
Preschool: ● Nutrition
◯ Preschoolers consume about half the amount of energy that adults do (1,800 kcal).
◯ Picky eating may remain a behavior in preschoolers, but often by 5 years of age they become more
willing to sample different foods.
◯ Preschoolers need 13 to 19 g/day of protein in addition to adequate calcium, iron, folate, and
vitamins A and C.
◯ Saturated fats should be less than 10% of preschoolers' total caloric intake, and total fat over
several days should be 20% to 30% of total caloric intake.
Cars: Preschool
When the forward-facing car seat is outgrown, the preschooler transitions to a booster seat.
■ It is recommended that children use an approved car restraint system until they achieve a
height of 145 cm (4 feet, 9 in).
School age: Physical Development
◯ Weight - School-age children will gain about 2 to 3 kg (4.4 to 6.6 lb) per year.
◯ Height - School-age children will grow about 5 cm (2 inches) per year.
■ Masters the concept of conservation
☐ Conservation of mass is understood first, followed by weight, and then volume
Learns to tell time
■ Classifies more complex information
■ Able to see the perspective of others
◯ Erikson-
industry vs. inferiority

A sense of industry is achieved through the development of skills and knowledge that allows
the child to provide meaningful contributions to society.
■ A sense of accomplishment is gained through the ability to cooperate and compete with others.
■ Children should be challenged with tasks that need to be accomplished, and be allowed to
work through individual differences in order to complete the tasks.
Unit 1 foundations of nursing care of children
Section: Perspectives of Nursing Care of Children
Chapter 6 Health Promotion of School-Age Children (6 to 12 Years)
CHAPTER 6 Health Promotion of School-Age Children (6 to 12 Years)
RN Nursing Care of Children 51
■ Creating systems that reward successful mastery of skills and tasks can create a sense of
inferiority in children unable to complete the tasks or acquire the skills
■ Children should be taught that not everyone will master every skill.
■ Later school-age years: behavior
☐ Able to judge the intentions of an act rather than just its consequences.
☐ Understand different points of view instead of just whether or not an act is right or wrong.
☐ Conceptualizes treating others as they like to be treated.
● Age-Appropriate Activities
◯ Children from 6 to 9 years of age
Play simple board and number games.
■ Play hopscotch.
CHAPTER 6 Health Promotion of School-Age Children (6 to 12 Years)
52 RN Nursing Care of Children
■ Jump rope.
■ Collect rocks, stamps, cards, coins, or stuffed animals.
■ Ride bicycles.
■ Build simple models.
■ Join organized sports (for skill building).
● Age-Appropriate Activities
◯ Children from 9 to 12 years of age
Make crafts.
■ Build models.
■ Collect things/engage in hobbies.
■ Solve jigsaw puzzles.
■ Play board and card games.
■ Join organized competitive sports.
● Immunizations
If not given between 4 and 5 years of age, children should receive the following vaccines by
6 years of age - diphtheria and tetanus toxoids and pertussis (DTaP); inactivated poliovirus (IPV);
measles, mumps, and rubella (MMR); and varicella
■ Both: Yearly seasonal influenza vaccine - trivalent inactivated influenza vaccine (TIV) or live,
attenuated influenza vaccine (LAIV) by nasal spray
■ 11 to 12 years - tetanus and diphtheria toxoids and pertussis vaccine (Tdap); human
papillomavirus vaccine - HPV2 or HPV4 in three doses for females, HPV4 for males; and
meningococcal (MCV4).
● Nutrition
By the end of the school-age years, children should eat adult portions of food. They need quality
nutritious snacks.
◯ Obesity is an increasing concern of this age group that predisposes children to low self-esteem,
diabetes, heart disease, and high blood pressure. Advise parents to:
■ Avoid using food as a reward.
■ Emphasize physical activity.
Chapter 7 Health Promotion of Adolescents (12 to 20 Years): Physical
the final 20% to 25% of height is achieved during puberty.
◯ Acne may appear during adolescence.
◯ Girls stop growing at about 2 to 2.5 years after the onset of menarche. They grow 5 to 20 cm (2 to 8 in)
and gain 7 to 25 kg (15.5 to 55 lb).
◯ Boys stop growing at around 18 to 20 years of age. They grow 10 to 30 cm (4 to 12 inches) and gain
7 to 30 kg (15.5 to 66 lb).
adolescent: ◯ Piaget - formal operations
Able to think through more than two categories of variables concurrently
■ Capable of evaluating the quality of their own thinking
■ Able to maintain attention for longer periods of time
■ Highly imaginative and idealistic
■ Increasingly capable of using formal logic to make decisions
■ Think beyond current circumstances
■ Able to understand how the actions of an individual influence others
Erikson - identity vs. role confusion
Adolescents develop a sense of personal identity, and come to view themselves as unique individuals.
☐ Group identity - Adolescents become part of a peer group that greatly influences behavior.
Adolescence: ● Age-Appropriate Activities
Nonviolent video games
◯ Nonviolent music
◯ Sports
◯ Caring for a pet
◯ Career-training programs
◯ Reading
◯ Social events (going to movies, school dances)
Adolescence: ● Immunizations
■ Yearly seasonal influenza vaccine - Trivalent inactivated influenza vaccine (TIV) or live, attenuated
influenza vaccine (LAIV) by nasal spray.
■ 16 to 18 years - Meningococcal (MCV4) booster is recommended if first dose was received
between the ages of 13 and 15 years. A booster dose is not needed if the first dose is received at
age 16 or older.
● Oral Medication
◯ Avoid measuring liquid medication in a teaspoon or tablespoon.
◯ Avoid mixing medication with formula or putting it in a bottle of formula because the infant may
not take the entire feeding, and the medication may alter the taste of the formula.
◯ Hold the infant in a semireclining position similar to a feeding position.
◯ Administer the medication in the side of the mouth in small amounts. This allows the infant or
child to swallow.
◯ Only use the droppers that come with the medication for measurement.
◯ Stroke the infant under the chin to promote swallowing while holding cheeks together.
atraumatic care
Mix the medication in a small amount of sweet fluid.
■ Offer juice, a soft drink, or snack after administration.
■ Have the child pinch her nose before, during, and shortly after administration.
■ Add flavoring to medications.
■ Use a nipple to allow the infant to suck the medication
● Optic Medication
◯ Place the child in a supine or sitting position.
Pull the lower eye lid downward and apply medication in the pocket.
◯ Administer ointments before nap or bedtime.
■ Apply light pressure to the lacrimal punctum for 1 minute to prevent unpleasant taste.
● Nasal Medication
◯ Position the child with the head extended.
◯ Use a football hold for infants.
◯ Provide atraumatic care.
■ Insert the tip into the naris vertically, then angle it prior to administration.
■ Play games with younger children.
● Intradermal
◯ Administer on the inside surface of the forearm.
◯ Use a TB syringe with a 26- to 30-gauge needle with an intradermal bevel.
◯ Insert needle at a 15° angle.
◯ Do not aspirate.
● Subcutaneous (SQ)
◯ Give anywhere there is SQ tissue. Common sites are the lateral aspect of the upper arm, abdomen,
and anterior thigh.
◯ Inject volumes of less than 0.5 mL.
◯ Use a 1 mL syringe with a 26- to 30-gauge needle.
◯ Insert at a 90° angle. Use a 45° angle for children who are thin.
◯ Check policy for aspiration practices.
● Intramuscular (IM)
Use a 22- to 25-gauge, ½- to 1-inch needle.
◯ Vastus lateralis is the recommended site in infants and small children.
■ Position the child supine, side lying, or sitting.
■ Inject up to 0.5 mL for infants.
■ Inject up to 2 mL in children.

◯ Ventrogluteal
■ Position the child supine, side lying, or prone.
■ Inject 0.5 to 1.0 mL depending on muscle size of infant.
■ Inject up to 2 mL in children.

◯ Deltoid
■ Position the child sitting or standing.
■ Inject up to 1 mL.

◯ Provide atraumatic care
■ Apply eutectic mixture of lidocaine and prilocaine (EMLA) to the site for 60 min prior
to injection.
■ Change needle after puncturing a rubber stopper.
■ Use the smallest gauge of needle possible.
■ Secure the child firmly to decrease movement of the needle while injecting.
■ Use distraction.
■ Use play therapy.
■ Offer sucrose pacifiers to infants.
● Intravenous (IV) Medications
◯ Peripheral venous access devices
■ Use a 24- to 20-gauge catheter.
■ Use for continuous and intermittent IV medication administration.
■ A child who requires short-term IV therapy may complete it at home with the assistance of a
home health nurse.
◯ Central venous access devices
■ Short term: nontunneled catheter or peripherally inserted central catheters (PICC)
■ Long term: tunneled catheter or implanted infusion ports
◯ Provide atraumatic care
■ Decide to insert a PICC before multiple peripheral attempts.
■ Use a transilluminator to assist in vein location.
■ Avoid terminology such as a "bee sting" or "stick."
■ Attach an extension tubing to decrease movement of the catheter.
■ Use play therapy.
■ Apply EMLA to the site for 60 minutes prior to attempt.
■ Keep equipment out of site until procedure begins.
■ Perform procedure in a treatment room.
■ Use nonpharmacologic therapies.
■ Allow parents to stay if they prefer.
■ Use therapeutic holding.
■ Avoid using the dominant or sucking hand.
■ Cover site with a colorful wrap.
■ Swaddle infants.
■ Offer nonnutritive sucking to infants before, during, and after the procedure.
Young infant
☐ Loud cry
☐ Rigid body or thrashing
☐ Local reflex withdrawal from pain stimulus
☐ Expressions of pain (eyes tightly closed, mouth open in a squarish shape, eyebrows lowered
and drawn together)
☐ Lack of association between stimulus and pain
■ Older infant
☐ Loud cry
☐ Deliberate withdrawal from pain
☐ Facial expression of pain
■ Toddler
☐ Loud cry or screaming
☐ Verbal expressions of pain
☐ Thrashing of extremities
☐ Attempt to push away or avoid stimulus
☐ Noncooperation
☐ Clinging to significant person
☐ Behaviors occur in anticipation of painful stimulus
■ School-age child
☐ Stalling behavior
☐ Muscular rigidity
☐ Any behaviors of the toddler, but less intense in the anticipatory phase and more intense
with painful stimulus
■ Adolescent
☐ More verbal expressions of pain with less protest
☐ Muscle tension with body control
Pain assessment tool for Evaluation by age
FLACC (2 months to 7 years)
-face, legs, arms, cry, Consolability

FACES (3 years and older)

Oucher (3 to 13 years)
› Pain rated on a scale of 0 to 5 using six photographs.

Numeric scale (5 years and older)
› Pain rated on a scale of 0 to 10.

Non-communicating children's pain checklist (3 to 18 years)
› Behaviors are observed for 10 min.
› Six subcategories are scored on a scale 0 to 3.
Pain tips
Combining a nonopioid and an opioid medication treats pain peripherally and centrally. This
offers greater analgesia with less adverse effects (respiratory depression, constipation, nausea).

◯ IM injections are not recommended for pain control in children.
◯ Intranasal medications are not recommended for children younger than 18 years.
◯ Rectal medications have variable absorption rates, and children dislike them.
◯ Intradermal medications are used for skin anesthesia prior to procedures.
Oral pain meds
› Take 1 to 2 hr to reach peak analgesic effects. Oral medications are not suited for
children experiencing pain that requires rapid relief or pain that is fluctuating in nature
› Eutectic mixture of local anesthetics (EMLA) contains equal quantities of lidocaine and
prilocaine in the form of a cream or disk.
» Used for any procedure in which the skin will be punctured (IV insertion, biopsy) 60 min
prior to a superficial puncture and 2.5 hr prior to a deep puncture.
» Place an occlusive dressing over the cream after application.
» Prior to procedure, remove the dressing or disk and clean the skin. Indication of an
adequate response is reddened or blanched skin.
» Demonstrate to the child that the skin is not sensitive by tapping or scratching lightly.
» Instruct parents to apply EMLA at home prior to coming to a health care facility for
the procedure.
› Fentanyl
» Use for children older than 12 years of age.
» Use to provide continuous pain control. Onset of 12 to 24 hr and a duration of 72 hr.
» Use an immediate-release opioid for breakthrough pain.
» Treat respiratory depression with naloxone (Narcan).
» Rapid pain control in approximately 5 min
» Use for medications such as morphine, hydromorphone
› Continuous - provides steady blood levels
› Patient-controlled analgesia (PCA)
» Self-administration of pain medication
» Can be basal, bolus, or combination
» Has lockouts to prevent overdosing
› Family-controlled analgesia
» Same concept as PCA
» Parent or caregiver manages the child's pain
● Separation anxiety during hospitalization manifests in three behavioral responses.
◯ Protest (screaming, clinging to parents, verbal and physical aggression toward strangers)
◯ Despair (withdrawl from others, depression, decreased communication, developmental regression)
◯ Detachment (interacts with strangers, forms new relationships, appears happy)
Infant: Impact of
› Experiences stranger anxiety between 6 to 18 months of age
› Displays physical behaviors as expressions of discomfort due to inability to verbalize
› May experience sleep deprivation due to strange noises, monitoring devices,
and procedures

› Place infants whose parents are not in attendance close to nurses' stations so that their
needs may be quickly met.
› Provide consistency in assigning caregivers.
Toddler:Impact of
› Experiences separation anxiety
› May exhibit an intense reaction to any type of procedure due to the intrusion of boundaries
› Behavior may regress

› Encourage parents to provide routine care for the child, such as changing diapers
and feeding.
› Encourage the child's autonomy by offering appropriate choices.
› Provide consistency in assigning caregivers.
Preschooler: Impact of
› Fears related to magical thinking
May experience separation anxiety
› May harbor fears of bodily harm
› May believe illness and hospitalization are a punishment

› Explain procedures using simple, clear language. Avoid medical jargon and terms that
can be misinterpreted.
› Encourage independence by letting the child provide self-care.
› Encourage the child to express feelings.
› Validate the child's fears and concerns.
› Provide toys that allow for emotional expression, such as a pounding board to release
feelings of protest.
› Provide consistency in assigning caregivers.
› Give choices when possible, such as, "Do you want your medicine in a cup or a spoon?"
› Allow younger children to handle equipment if it is safe.
School-age: impact of hospitalization
› Fears loss of control
› Seeks information as a way to maintain a sense of control
› May sense when not being told the truth
› May experience stress related to separation from peers and regular routine

› Provide factual information.
› Encourage the child to express feelings.
› Try to maintain a normal routine for long hospitalizations, including time for school work.
› Encourage contact with peer group.
Adolescent: interventions
› Provide factual information.
› Include the adolescent in the planning of care to relieve feelings of powerlessness and
lack of control.
› Encourage contact with peer group.
Content of Play
● Social affective - taking pleasure in relationships
● Sense-pleasure - objects in the environment catching the child's attention
● Skill - demonstrating new abilities
● Unoccupied behavior - focusing attention on something of interest
● Dramatic - pretending and fantasizing
● Games - imitative, formal, or competitive
Social Character of Play
Onlooker - the child observing others
● Solitary - the child playing alone
● Parallel - children playing independently but among other children, which is characteristic of toddlers
● Associative - children playing together without organization, which is characteristic of preschoolers
● Cooperative play - organized playing in groups, which is characteristic of school-age children
Play Activities Related to Age
◯ Birth to 3 months - colorful moving mobiles, music/sound boxes
◯ 3 to 6 months - noise-making objects and soft toys
◯ 6 to 9 months - teething toys and social interaction
◯ 9 to 12 months - large blocks, toys that pop apart, and push-and-pull toys

● Toddlers
◯ Cloth books, puzzles with large pieces
◯ Large crayons and paper
◯ Push-and-pull toys, balls
◯ Tricycles
◯ Educational television
◯ Videos for children

● Preschoolers
◯ Imitative and imaginative play
◯ Drawing, painting, riding a tricycle, swimming, jumping, and running
◯ Educational television and videos

● School-age children
◯ Games that can be played alone or with another person
◯ Team sports
◯ Musical instruments
◯ Arts and crafts
◯ Collections

● Adolescents
◯ Team sports
◯ School activities
◯ Reading and listening to music
◯ Peer interactions
● Physical manifestations of death
◯ Sensation of heat when the body feels cool
◯ Decreased sensation and movement in the lower extremities
◯ Loss of senses (hearing is the last to be lost)
◯ Confusion or loss of consciousness (LOC)
◯ Decreased appetite and thirst
◯ Swallowing difficulties
◯ Loss of bowel and bladder control
◯ Bradycardia, hypotension
◯ Cheyne-Stokes respirations
● Viral (or aseptic) meningitis usually requires only supportive care for recovery.
● Bacterial (or septic) meningitis is a contagious infection. The prognosis depends on how quickly care
is initiated.
Incidence of bacterial meningitis has decreased in all age groups except infants under the age
of 2 months since the introduction of the Hib and pneumococcal conjugate vaccines (PCV).

Subjective Data
◯ Photophobia
◯ Nausea
◯ Irritability
◯ Headache

■ CSF analysis indicative of meningitis. via lumbar puncture
☐ Bacterial
X Cloudy color
X Elevated WBC count
X Elevated protein content
X Decreased glucose content
X Positive Gram stain**
☐ Viral
X Clear color
X Slightly elevated WBC count
X Normal or slightly elevated protein content
X Normal glucose content
X Negative Gram stain**


-put npo immediately after diagnosis
-Maintain NPO status if the client has a decreased level of consciousness. As the client's condition
improves, advance to clear liquids and then to a diet that the client can tolerate
◯ Correct fluid volume deficits and then restrict fluids until no evidence of increased ICP and serum
sodium levels within the expected range.

◯ Corticosteroids - dexamethasone (Decadron)
-bacterial only

■ Acetaminophen (Tylenol) with codeine may be used to relieve discomfort.

Encourage parents to maintain appropriate immunizations for the client. Children should
receive the Hib and PCV vaccines at 2, 4, and 6 months of age, then again between 12 and
15 months of age.

-monitor for signs of ICP increase
Lumbar puncture info
This is the definitive diagnostic test for meningitis.
☐ Insertion of a spinal needle into the subarachnoid space between L3 and L4 or L4 and L5
vertebral spaces.
☐ Measures spinal fluid pressure and collects CSF for analysis.
☐ Nursing Actions
X Have the child empty his bladder.
X Assist the provider with the procedure.
X A topical anesthetic (EMLA cream) may be applied over the biopsy area 45 min to 1 hr
prior to the procedure.
X Place the child in the side-lying position with the head flexed and knees drawn up toward
the chest, and assist in maintaining the position. Distraction may need to be used.
X The child may be sedated with fentanyl (Sublimaze) and midazolam (Versed).
X The provider will clean the skin and inject a local anesthetic.
X The provider will take pressure readings and collect three to five test tubes of CSF.
X Pressure and an elastic bandage will be applied to the puncture site after the needle
is removed.
X Label specimens appropriately, and deliver them to the laboratory.
X Monitor the site for bleeding, hematoma, or infection.
☐ Client Education
X Instruct the client to remain in bed for 4 to 8 hr in a flat position to prevent leakage and a
resulting spinal headache. This may not be possible for an infant, toddler, or preschooler.
■ CT scan or MRI
☐ These may be performed to identify increased ICP and/or an abscess.
☐ Nursing Actions
X Assist with positioning.
X Administer sedatives as prescribed.
Meningitis Physical Assessments
◯ Physical Assessment Findings
■ Manifestations of viral and bacterial meningitis are similar.
■ Newborns
☐ No illness is present at birth, but it progresses within a few days.
☐ Clinical manifestations are vague and difficult to diagnose.
X Poor muscle tone, weak cry, poor suck, refuses feeding, and vomiting or diarrhea
X Possible fever or hypothermia
☐ Neck is supple without nuchal rigidity.
☐ Bulging fontanels are a late sign.
■ 3 months to 2 years
☐ Seizures with a high-pitched cry
☐ Fever and irritability
☐ Bulging fontanels
☐ Possible nuchal rigidity
☐ Poor feeding
☐ Vomiting
☐ Brudzinski's and Kernig's signs not reliable for diagnosis
■ 2 years through adolescence
☐ Seizures (often initial sign)
☐ Nuchal rigidity
☐ Positive Brudzinski's sign (flexion of extremities occurring with deliberate flexion of the
child's neck)
☐ Positive Kernig's sign (resistance to extension of the child's leg from a flexed position)
View Images
› Brudzinski's Sign › Kernig's Sign
☐ Fever and chills
☐ Headache
☐ Vomiting
☐ Irritability and restlessness that may progress to drowsiness, delirium, stupor, and coma
☐ Petechia or purpuric type rash (seen with meningococcal infection)
☐ Involvement of joints (seen with meningococcal and Hib)
☐ Chronic draining ear (seen with pneumococcal infection)
Reye Syndrome (brain problems but liver as well)
Reye syndrome primarily affects the liver and brain, causing:
◯ Liver dysfunction
◯ Cerebral edema
● The cause of Reye syndrome is not understood.
● Peak incidence of Reye syndrome occurs when influenza is most common, typically January, February,
and March.
● Reye syndrome can be mistaken for other disorders, including encephalitis, meningitis, poisoning,
sudden infant death syndrome (SIDS), diabetes mellitus, and psychiatric illness.
● The prognosis for the client who has Reye syndrome is best with early recognition and treatment.

***◯ Recent viral illness or use of aspirin (Bayer Children's).

-◯ There is a potential association between using aspirin (salicylate) products for treating fevers
caused by viral infections and the development of Reye syndrome

Reye syndrome presents in clinical stages based on the severity of liver and neurologic findings.
☐ Lethargy
☐ Irritability
☐ Combativeness
☐ Confusion
☐ Delirium
☐ Profuse vomiting
☐ Convulsions
☐ Loss of consciousness

-■ Liver biopsy
■ CSF analysis
☐ A lumbar puncture should be performed to collect CSF and rule out meningitis
◯ Maintain hydration while preventing cerebral edema.
◯ Monitor coagulation and prevent hemorrhage.

◯ Vitamin K
■ Improves synthesis of blood clotting factors in the liver
◯Osmotic diuretic - mannitol (Osmitrol)
■ To decrease cerebral swelling, administer as prescribed.
■ Nursing Considerations
☐ Monitor the client for increased ICP.
tonic-clonic seixure
Tonic-clonic seizure (previously referred to as grand mal)
☐ Onset without warning

☐ Tonic phase (10 to 20 seconds)
X Eyes roll upward
X Loss of consciousness
X Tonic contraction of entire body, with arms flexed and legs, head and neck extended
X Possible piercing cry
X Increased salivation
X Loss of swallowing reflex
X Apnea leading to cyanosis

☐ Clonic phase (time varies)
X Violent jerking movements of the body
X May having foaming in the mouth
X May be incontinent
X Gradual slowing of movements until cessation

☐ Postictal state
-out of it, sleepy
-nothing working, can vomit
-sleep several hours
-no recollection

■ Absence seizure (previously referred to petit mal)
Onset between age 4 to 12 years and ceases by puberty
☐ Loss of consciousness lasting 5 to 10 seconds
☐ Minimal or no change in behavior
☐ Resembles daydreaming or inattentiveness
☐ May drop items being held
☐ Lip smacking, twitching of eyelids or face, or slight hand movements
☐ Unable to recall episodes

Myoclonic seizure
☐ Variety of seizure episodes
☐ Symmetric or asymmetric involvement
☐ Brief contractions of muscle or groups of muscle
☐ No postictal state
☐ May or may not lose consciousness

■ Atonic or akinetic seizure
☐ Muscle tone is lost for a few seconds.
☐ A period of confusion follows.
☐ Loss of muscle tone frequently results in falling
more seizures...
Infantile Spasms
■ Most common during first 8 months of life
■ Sudden, brief, symmetric muscle contractions
■ Flexed head, extended arms with legs drawn up
■ Possible eyes rolling upward and inward
■ Possible loss of consciousness
■ Possible flushing, pallor or cyanosis
■ Possible cry or giggle before or after

◯ Partial (focal/local)
Simple partial seizures with motor signs
☐ Aversive seizure: eyes and head turn away from the side of focus, with or without loss of
☐ Rolandic seizure: tonic-clonic movements involving the face and most common
during sleep
■ Simple partial seizure with sensory signs
☐ Tingling, numbness or pain in one area of the body then spreading to other parts, with
visual sensations.
■ Complex partial seizures
☐ Altered behavior
☐ Inability to respond to the environment
☐ Impaired consciousness
☐ Confusion and unable to recall event
☐ Complex sensory aura: strange feeling in stomach that rises to the throat, auditory or visual
hallucinations, feelings of fear, distorted sense of time and self
EEGs & other tests

NO Caffeine before the eeg

■ Magnetic resonance imaging (MRI) is used to detect malformations, cortical dysplasia, or tumors.
■ Lumbar puncture (LP) detects infection.
■ Computed tomography (CT) scan detects hemorrhage, infarction or malformations
Protect from injury (move furniture away, hold head in lap if on the floor).
■ Maintain a position to provide a patent airway.
■ Be prepared to suction oral secretions.
■ Turn client to the side (decreases risk of aspiration).
■ Loosen restrictive clothing.
■ Do not attempt to restrain the child.
■ Do not attempt to open the jaw or insert an airway during seizure activity (this may damage
teeth, lips, or tongue). Do not use padded tongue blades.
■ Remove glasses.
■ Administer oxygen.
■ Remain with the child.
■ Note onset, time, and characteristics of seizure.
■ Allow the seizure to end spontaneously.
Antiepileptic drugs (AEDs)
diazepam (Valium), phenytoin (Dilantin), carbamazepine (Tegretol),
valproic acid (Depakene), and fosphenytoin sodium (Cerebyx)
Status epilepticus
is prolonged seizure activity that lasts longer than 30 min or continuous seizure
activity in which the client does not enter a postictal phase. This acute condition requires immediate
treatment to prevent loss of brain function, which may become permanent.

■ Maintain airway, administer oxygen, establish IV access, perform ECG monitoring, and monitor
pulse oximetry and ABG results.
■ As prescribed, administer a loading dose of diazepam (Valium) or lorazepam (Ativan). If seizures
continue after the loading dose is given, fosphenytoin followed by phenobarbital should
be administered.
☐ Increased intracranial pressure (ICP)
Infants: bulging fontanel, separation of cranial sutures, irritability, increased sleeping,
high-pitched cry, poor feeding, setting-sun sign
X Children: nausea, headache, vomiting, blurred vision, increased sleeping, inability to
follow simple commands, seizures
X Late Signs: alterations in pupillary response, posturing (decorticate and decerebrate),
bradycardia, decreased motor response, decreased sensory response, Cheyne-Stokes
respirations, coma
Z 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.
Z Decerebrate (dysfunction at the midbrain) - Demonstrates a backward arching of the
head and arms with legs rigidly extended and toes pointing downward
Head injury care & meds
◯ Administer oxygen as indicated to maintain an oxygen saturation level greater than 95%.
◯ Use padded restraints for clients who have agitation to prevent injury.
◯ Assess for clear fluid drainage from ears or nose (cerebral spinal fluid) and report to the provider.

◯ Corticosteroids - dexamethasone (Decadron) and methylprednisolone (Solu-Medrol) - used to
decrease cerebral edema
◯ Mannitol (Osmitrol) - osmotic diuretic used to treat cerebral edema
◯ Antiepileptics - used to prevent or treat seizures that may occur
◯ Antibiotics - in cases of CSF leakage, lacerations, or penetrating injuries
◯ Analgesics - acetaminophen (Tylenol) - used for headache/pain management
◯ Implement actions that will decrease ICP.
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 client's body in alignment, avoiding hip flexion/extension.
■ Minimize endotracheal or oral suctioning.
■ Instruct the client to avoid coughing and blowing her nose, because these activities
increase ICP.
◯ Administer stool softener to prevent straining (Valsalva maneuver).
Provide adequate fluids to maintain cerebral perfusion. When a large amount of IV fluids is
ordered, monitor the client for excess fluid volume, which may increase ICP.
Visual Impairments
Risk Factors
◯ Prenatal or postnatal conditions such as retinopathy of prematurity, trauma, and postnatal infections.
◯ Perinatal infections such as herpes, rubella, syphilis, chlamydia, and toxoplasmosis.
◯ Chronic illness such as sickle cell disease, rheumatoid arthritis, retinoblastoma, and Tay-Sachs disease.

■ Partial visual impairment is classified as visual acuity of 20/70 to 20/200.
■ Legal blindness is classified as visual acuity of 20/200 or worse.
› Sees close objects clearly, but not objects in
the distance
› Headaches and vertigo
› Eye rubbing
› Difficulty reading
› Clumsiness (frequently walking into objects)
› Poor school performance
Hyperopia (farsightedness)
› Sees distant objects clearly, but not objects that
are close
› Because of accommodation, not usually detected
until age 7
Strabismus - Esotropia (inward deviation of eye);

Exotropia (outward deviation of eye)
› Abnormal corneal light reflex or cover test
› Misaligned eyes
› Frowning or squinting
› Difficulty seeing print clearly

› One eye closed to enable better vision
› Head tilted to one side
› Headache, dizziness, diplopia, photophobia, and
crossed eyes

› Decreased ability to see clearly
› Possible loss of peripheral vision
› Nystagmus
› Strabismus
› Gray opacity of the lens
› Absence of red reflex
Loss of peripheral vision
› Perception of halos around objects
› Red eye
› Excessive tearing (epiphora)
› Photophobia
› Spasmodic winking (blepharospasm)
› Corneal haziness
› Enlargement of the eyeball (buphthalmos)
› Possible pain
Common Respiratory Illnesses
Infants between 3 and 6 months of age are at an increased risk due to the decrease of maternal
antibodies acquired at birth and the lack of antibody protection.
■ Viral infections are more common in toddlers and preschoolers. The incidence of these
infections decreases by age
Nasopharyngitis (common cold)
» Self-limiting virus that persists for
7 to 10 days
› Nasal inflammation, rhinorrhea, cough, dry throat, sneezing,
and nasal qualities in voice
› Fever, decreased appetite, and irritability
› Bacterial tracheitis
» Infection of the lining of the trachea
Thick, purulent drainage from the trachea that can obstruct
the airway and cause respiratory distress
› Fever, croupy cough, stridor
› Bronchitis (tracheobronchitis)
» Associated with an upper
respiratory infection (URI) and
inflammation of large airways
» Self-limiting and requires
symptomatic relief
Persistent cough as a result of inflammation
› Resolves in 5 to 10 days
› Bronchiolitis
» Mostly caused by RSV******
» Primarily affects the bronchi
and bronchioles
» Occurs at the bronchiolar level
Rhinorrhea - intermittent fever, cough, and wheezing
› Coughing that progresses toward wheezing, increased
respiratory rate, nasal flaring, retractions, and cyanosis
› Possible posttussive vomiting due to coughing
› Allergic rhinitis
» Caused by seasonal reaction
to allergens most often in the
autumn or spring
Watery rhinorrhea; nasal congestion; itchiness of the nose, eyes,
and pharynx; itchy, watery eyes; nasal quality of the voice; dry,
scratchy throat; snoring; poor sleep leading to poor performance
in school; and fatigue
Pneumonia (RSV, Streptococcus
pneumoniae, Haemophilus
influenzae, Mycoplasma pneumoniae
High fever
› Cough that may be unproductive or productive of white sputum
› Retractions and nasal flaring
› Rapid, shallow respirations
› Report of chest pain
› Adventitious breath sounds (rhonchi, crackles)
› Pale color that progresses to cyanosis
› Irritability, anxiety, agitation, and fatigue
› Abdominal pain, diarrhea, lack of appetite, and vomiting
› Sudden onset, usually following a viral infection
(bacterial pneumonia)
Bacterial epiglottitis
(acute supraglottitis)
» Medical emergency
» Caused by Haemophilus
Predictive signs - absence of cough, drooling, and agitation
› Sitting with chin pointing out, mouth opened, and tongue
› Dysphonia (hoarseness or difficulty speaking)
› Dysphagia (difficulty swallowing)
› Inspiratory stridor (noisy inspirations)
› Sore throat, high fever, and restlessness
Acute laryngotracheobronchitis
» Causative agents include
RSV, influenza A and B, and
Mycoplasma pneumoniae
Low-grade fever, restlessness, hoarseness, barky cough,
dyspnea, inspiratory stridor, and retractions
› Acute spasmodic laryngitis
» Self-limiting illness that may result
from allergens
› Barky cough, restlessness, difficulty breathing, hoarseness, and
nighttime episodes of laryngeal obstruction
› Influenza A and B
» Mild, moderate, or severe
› Sudden onset of fever and chills
› Dry throat and nasal mucosa
› Dry cough
› Flushed face
› Photophobia
› Myalgia
› Fatigue
Lab tests for respiratory illness?
■ Blood samples
☐ Elevated serum antistreptolysin-O (ASO) titer
☐ Elevated C-reactive protein (CRP) or sedimentation rate in response to an inflammatory reaction
☐ CBC to assess for anemia and infection

■ Sputum culture and sensitivity to detect infection
◯ Diagnostic Procedures

■ Collection of direct aspiration of nasal secretions
☐ The secretions are collected for immunofluorescence analysis to detect RSV. Instill 1 to 3 mL of
0.9% sodium chloride into one of the child's nostrils. The fluid is then aspirated for evaluation.
☐ Nursing Actions
X Place the child in a supine position.
X Use a sterile syringe without a needle.
☐ Client Education - Caregivers should be educated about the potential need for isolation,
dependent on the results of laboratory tests.

■ Chest x-ray
☐ Identifies infiltration in pneumonia
☐ Nursing Actions - Ensure the child is positioned correctly to avoid the need for a repeat x-ray.
☐ Client Education - Inform adolescents of childbearing age of the need for confirmation of
nonpregnant status.
Bronchiolitis treatment
◯ Provide humidified oxygen as prescribed.
◯ Monitor continuous oximetry.
◯ Encourage fluid intake if tolerated.
◯ Administer IV fluids if oral intake not tolerated.
◯ Suction nasopharynx as needed.
◯ Administer nebulized bronchodilator.
◯ Corticosteroids and antihistamines are not recommended.
◯ Antibiotics are not recommended for RSV.
◯ Chest percussion and postural drainage is not recommended.
◯ Ribavirin administration is controversial
● Bacterial epiglottitis treatment
◯ Protect airway.
■ Avoid throat culture or using a tongue blade.
◯ Prepare for intubation.
◯ Provide humidified oxygen.
◯ Monitor continuous oximetry.
◯ Administer racemic epinephrine, corticosteroids, and IV fluids as prescribed.
◯ Administer antibiotic therapy (ceftriaxone sodium or cephalosporin), starting with IV, then
transition to oral to complete a 10-day course, as prescribed
Influenza meds
Amantadine (Symmetrel) - for type A
☐ Shortens the length of the illness.
☐ Administer within 24 to 48 hr of onset of symptoms.
■ Rimantadine (Flumadine) - for type A
☐ Treats manifestations.
☐ Give orally two times per day for 7 days for children older than 1 year.
■ Zanamivir (Relenza) - for type A and B
☐ Treatment of influenza for children 7 and older or for prophylaxis for children 5 and older.
☐ Start within 48 hr of manifestations.
☐ Inhaled two times per day for 5 days.
CHAPTER 17 Acute and Infectious Respiratory Illnesses
170 RN Nursing Care of Children
■ Oseltamivir (Tamiflu) - for type A and B
☐ Decreases manifestations.
☐ Give orally for 5 days for children older than 1 year.
☐ Start within 48 hr of manifestations.
■ Influenza vaccine - prevention
☐ Recommended for children 6 months and older.
☐ Live vaccination should not be used in children who are immunocompromised, have
respiratory conditions, are pregnant, or have a history of Guillain-Barre syndrome.
■ Antipyretic (pain or fever)
Pneumothorax complications
● Pneumothorax - accumulation of air in the pleural space
◯ Clinical Manifestations - dyspnea, chest pain, back pain, labored respirations, decreased oxygen
saturations, and tachycardia
◯ Nursing Interventions
■ Prepare client for an emergent needle aspiration with insertion of chest tube to closed drainage.
■ Provide for chest tube management.
■ Assess respiratory status.
■ Administer oxygen as prescribed
Pleural effusion complications
- accumulation of fluid in the pleural space
◯ Clinical manifestations - dyspnea, chest pain, back pain, labored respirations, decreased oxygen
saturations, and tachycardia
◯ Nursing Interventions
■ Prepare the client for an emergent needle aspiration with insertion of chest tube to closed drainage.
■ Provide for chest tube management.
■ Assess respiratory status.
■ Administer oxygen as prescribed.
asthma types
◯ Intermittent - Symptoms occur two or fewer times per week, nighttime symptoms two or fewer
per month, no interference with normal activity, uses short-acting ß-agonist less than two
times per week.
◯ Mild persistent - Symptoms occur more than twice a week, but not daily. Nighttime symptoms
one to two times per month for 0- to 4-year-old and three to four times per month for
5- to 11-year-old. Minor limitations with activity, use of short-acting ß-agonist more than two
days per week but not daily.
◯ Moderate persistent - Daily symptoms. Nighttime symptoms three to four times a month for 0- to
4-year-old and more than one time per week, but not daily for 5- to 11-year-old. Some limitation
in activity. Uses short-acting ß-agonist daily.
◯ Severe persistent - Symptoms occur continually, nighttime symptoms more than one time per
week for 0- to 4-year-old and nightly for 5- to 11-year-old. Limited activity. Use short-acting
ß-agonist several times per day
Asthma meds
● Medications
◯ Bronchodilators (inhalers)
■ Short-acting beta2 agonists (albuterol [Proventil], levalbuterol [Xopenex], terbutaline [Brethine])
☐ Used for acute exacerbations
☐ Prevention of exercised-induced asthma
■ Cholinergic antagonists (anticholinergic medications), such as ipratropium (Atrovent), block
the parasympathetic nervous system, providing relief of acute bronchospasms.
■ Nursing Considerations
☐ Instruct the child and family in the proper use of MDI, DPI, or nebulizer.
☐ Watch the child for tremors and tachycardia when taking albuterol.
☐ Observe the child for dry mouth when taking ipratropium.

☐ Encourage older children who are taking ipratropium to suck on hard candies to help with
☐ Teach children to administer prior to exercise or activity.
● Status asthmaticus
A life-threatening episode of airway obstruction that is often unresponsive to common treatment
◯ Manifestations include wheezing, labored breathing, nasal flaring, lack of air movement in lungs,
use of accessory muscles, distended neck veins, and risk for cardiac and/or respiratory arrest.
◯ Nursing Actions
■ Monitor oxygen saturations continuously.
■ Place on continuous cardiorespiratory monitoring.
■ Position the child sitting upright, standing, or leaning slightly forward.
■ Administer humidified oxygen.
■ Administer three nebulizer treatments of a beta2-agonist, 20 to 30 min apart or continuously.
Ipratropium bromide may be added to the nebulizer to increase bronchodilation.
■ Obtain IV access.
■ Monitor ABGs and serum electrolytes.
■ Administer corticosteroid.
■ Prepare for emergency intubation
When is albuterol taken?
prior to exercise
Peak flow meter
-stand up while doing it
-three attempts, record best
-zero it each attempt
Special test for cystic fibrosis?
salty sweat