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  • Phone numbersPediatric_ FM.indd iiPediatric_ FM.indd ii 11/27/2009 5:35:44 PM11/27/2009 5:35:44 PM
  • StaffPublisherChris BurghardtClinical DirectorJoan M. Robinson, RN, MSNArt DirectorElaine KasmerProduct ManagerDiane LabusEditorJaime Stockslager Buss, MSPH, ELSCopy EditorHeather DitchIllustratorBot RodaDesign AssistantKate ZulakAssociate Manufacturing ManagerBeth J. WelshEditorial AssistantsKaren J. Kirk, Jeri O’Shea,Linda K. RuhfThe clinical treatments described and recom-mended in this publication are based onresearch and consultation with nursing, medi-cal, and legal authorities. To the best of ourknowledge, these procedures reflect currentlyaccepted practice. Nevertheless, they can’t beconsidered absolute and universal recommen-dations. For individual applications, all recom-mendations must be considered in light of thepatient’s clinical condition and, before adminis-tration of new or infrequently used drugs, inlight of the latest package-insert information.The authors and publisher disclaim anyresponsibility for any adverse effects resultingfrom the suggested procedures, from anyundetected errors, or from the reader’s misun-derstanding of the text.© 2011 by Lippincott Williams & Wilkins. Allrights reserved. This book is protected bycopyright. No part of it may be reproduced,stored in a retrieval system, or transmitted, inany form or by any means—electronic,mechanical, photocopy, recording, or other-wise—without prior written permission of thepublisher, except for brief quotations embodiedin critical articles and reviews and testing andevaluation materials provided by publisher toinstructors whose schools have adopted itsaccompanying textbook. For information, writeLippincott Williams & Wilkins, 323 NorristownRoad, Suite 200, Ambler, PA 19002-2756.Printed in ChinaPEDMIQ2-010311ISBN-13: 978–1–60831–100–2ISBN-10: 1–60831–100–7Pediatric_ FM.indd ivPediatric_ FM.indd iv 11/27/2009 5:35:45 PM11/27/2009 5:35:45 PM
  • Pediatric_ FM.indd iiiPediatric_ FM.indd iii 11/27/2009 5:35:45 PM11/27/2009 5:35:45 PM
  • Theoriesofdevelopment,Growthrates,Heightandweighttables,Stagesofdevelopment,Sexualmaturity,PreparationforhospitalizationandsurgeryPreventivecare,Healthhistory,Vitalsigns,Lengthandheadcircumference,Physicalexamination,Dentition,Painassessment,Burns,Mentalhealth,AbuseChemistrytests,CBC,Antibioticlevels,Urine,Acid-basedisordersImmunizationschedules,Calculations,Conversions,BSA,Administrationmethodsandsites,Fluidneeds,,Bloodcompatibility,InsulinCPR,Choking,ACLSalgorithmsMedadministration,I.V.s,I.D.,Precautions,TracheostomycareSIDS,Choking,Toileting,Burns,Poison,Drowning,Falls,VehiclesafetyConversion,Nutrition,Sleep,CulturalconcernsAssessmentLaboratoryvaluesMeds/IVtherapyEmergencySkillsTeachingResourcesGrowth&DevelopmentPediatric_ FM.indd vPediatric_ FM.indd v 11/27/2009 5:35:45 PM11/27/2009 5:35:45 PM
  • ABG . . . . arterial blood gasAED. . . . . automated externaldefibrillatorALT . . . . . alanine aminotransferaseAST. . . . . aspartate aminotransferaseBP . . . . . . blood pressureBSA. . . . . body surface areaBUN . . . . blood urea nitrogenC . . . . . . . Celsiuscm. . . . . . centimeterCO2. . . . . carbon dioxideCPR. . . . . cardiopulmonaryresuscitationDTaP. . . . diphtheria and tetanustoxoids and acellularpertussisECG. . . . . electrocardiogramESR . . . . . erythrocyte sedimentationrateF. . . . . . . . FahrenheitFSH . . . . . follicle-stimulating hormoneg . . . . . . . gramG . . . . . . . gaugeGGT. . . . . gamma-glutamyl transferaseGI. . . . . . . gastrointestinalGU. . . . . . genitourinaryHBsAg . . hepatitis B surface antigenHBV. . . . . hepatitis B vaccineHCO3–. . . bicarbonateHDL. . . . . high-density lipoproteinHib . . . . . Haemophilus influenzaetype BHIV . . . . . human immunodeficiencyvirusHR . . . . . . heart rateI.M. . . . . . intramuscularIPV . . . . . inactivated poliovirusvaccineI.V. . . . . . intravenouskcal. . . . . kilocaloriekg . . . . . . kilogramL. . . . . . . . literlb. . . . . . . poundLDL . . . . . low-density lipoproteinLH . . . . . . luteinizing hormoneLOC . . . . . level of consciousnessmcg. . . . . microgrammEq. . . . . milliequivalentmg. . . . . . milligramml . . . . . . milliliterMMR. . . . measles, mumps, rubellaNaCl . . . . sodium chlorideNG. . . . . . nasogastricoz. . . . . . . ouncePALS. . . . pediatric advanced lifesupportPCV. . . . . pneumococcal conjugatevaccinePKU. . . . . phenylketonuriaP.O. . . . . . by mouthPPV. . . . . pneumococcalpolysaccharide vaccineRBC. . . . . red blood cellSIDS . . . . sudden infant deathsyndromeSTD. . . . . sexually transmitted diseasetbs. . . . . . tablespoonTd . . . . . . tetanus toxoidTSH. . . . . thyroid-stimulating hormonetsp. . . . . . teaspoonVZV . . . . . varicella zoster vaccineWBC . . . . white blood cellCommon abbreviationsPediatric_ FM.indd viPediatric_ FM.indd vi 11/27/2009 5:35:45 PM11/27/2009 5:35:45 PM
  • LWBK942-FM.qxd 6/25/11 8:45 AM Page x
  • 1G&DStages of childhood development• Infancy: Birth to age 1• Toddler stage: Ages 1 to 3• Preschool stage: Ages 3 to 6• School-age: Ages 6 to 12• Adolescence: Ages 12 to 19Patterns of developmentThis chart shows the patterns of development and their progres-sion and gives examples of each.Pattern Path of progression ExamplesCephalocaudal From head to toe Head control precedesability to walk.Proximodistal From the trunk to the tipsof the extremitiesThe young infant canmove his arms andlegs but can’t pick upobjects with hisfingers.General to specific From simple tasks to morecomplex tasks (masteringsimple tasks beforeadvancing to those thatare more complex)The child progressesfrom crawling to walk-ing to skipping.Pediatric_G&D Chap01.indd 1Pediatric_G&D Chap01.indd 1 11/27/2009 5:47:12 PM11/27/2009 5:47:12 PM
  • 2G&DTheoriesofdevelopmentThechilddevelopmenttheoriesdiscussedinthischartshouldn’tbecompareddirectlybecausetheymeasuredifferentaspectsofdevelopment.ErikErikson’spsychosocial-basedtheoryisthemostcommonlyacceptedmodelforchilddevelopment,althoughitcan’tbeempiricallytested.Age-groupPsychosocialtheoryCognitivetheoryPsychosexualtheoryMoraldevelopmenttheoryInfancy(birthtoage1)TrustversusmistrustSensorimotor(birthtoage2)OralNotapplicableToddlerhood(ages1to3)AutonomyversusshameanddoubtSensorimotortopreoperationalAnalPreconventionalPreschoolage(ages3to6)InitiativeversusguiltPreoperational(ages2to7)PhallicPreconventionalSchoolage(ages6to12)IndustryversusinferiorityConcreteoperational(ages7to11)LatencyConventionalAdolescence(ages12to19)IdentityversusroleconfusionFormaloperationalthought(ages11to15)GenitaliaPostconventionalPediatric_G&D Chap01.indd 2Pediatric_G&D Chap01.indd 2 11/27/2009 5:47:12 PM11/27/2009 5:47:12 PM
  • 3G&DA closer look at theories of developmentPsychosocial theory(Erik Erikson)Trust versus mistrust:•Develops trust as the primarycaregiver meets his needs.Autonomy versus shame•and doubt: Learns to controlbody functions; becomesincreasingly independent.Initiative versus guilt: Learns•about the world through play;develops a conscience.Industry versus inferiority:•Enjoys working with others;tends to follow rules; formingsocial relationships takes ongreater importance.Identity versus role confu-•sion: Is preoccupied with howhe looks and how others viewhim; tries to establish his ownidentity while meeting theexpectations of his peers.Cognitive theory (JeanPiaget)Sensorimotor stage:•Progresses from reflex activ-ity, through simple repetitivebehaviors, to imitativebehaviors; concepts to bemastered include objectpermanence, causality, andspatial relationships.Preoperational stage: Is ego-•centric and employs magicalthinking; concepts to be mas-tered include representationallanguage and symbols andtransductive reasoning.Concrete operational stage:•Thought processes becomemore logical and coherent;can’t think abstractly; conceptsto be mastered include sorting,ordering, and classifying factsto use in problem solving.Formal operational thought•stage: Is adaptable and flexi-ble; concepts to be masteredinclude abstract ideas andconcepts, possibilities, induc-tive reasoning, and complexdeductive reasoning.Psychosexual theory(Sigmund Freud)Involves the• id (primitiveinstincts; requires immediategratification), ego (conscious,rational part of the personal-ity), and superego (a person’sconscience and ideals).Oral stage: Seeks pleasure•through sucking, biting, andother oral activities.Anal stage: Goes through•toilet training, learning how tocontrol his excreta.(continued)Pediatric_G&D Chap01.indd 3Pediatric_G&D Chap01.indd 3 11/27/2009 5:47:12 PM11/27/2009 5:47:12 PM
  • 4G&DA closer look at theories of development(continued)Phallic stage: Interested in his•genitalia; discovers the differ-ence between boys and girls.Latency period: Concentrates•on playing and learning (notfocused on a particular bodyarea).Genitalia stage: At matura-•tion of the reproductivesystem, develops the capacityfor object love and maturity.Moral development theory(Lawrence Kohlberg)Preconventional level of•morality: Attempts to followrules set by authority figures;adjusts behavior according togood and bad, right andwrong.Conventional level of•morality: Seeks conformityand loyalty; follows fixedrules; attempts to maintainsocial order.Postconventional autono-•mous level of morality:Strives to construct a valuesystem independent ofauthority figures and peers.Pediatric_G&D Chap01.indd 4Pediatric_G&D Chap01.indd 4 11/27/2009 5:47:12 PM11/27/2009 5:47:12 PM
  • 5G&DExpectedgrowthratesAge-groupWeightHeightorlengthHeadcircumferenceInfancy(birthtoage1)Birthweightdoublesbyage•5monthsBirthweighttriplesbyage1•Gains1½lb(680g)/monthfor•first5monthsGains•¾lb(340g)/monthduringsecond6monthsBirthlengthincreasesby•50%byage1,withmostgrowthoccurringinthetrunkratherthanthelegsGrows1•Љ(2.5cm)/monthduringfirst6monthsGrows•½Љ(1.3cm)/monthduringsecond6monthsIncreasesbyalmost•33%byage1Increases•¾Љ(2cm)/monthduringthefirst3monthsIncreases•¹/³Љ(1cm)/monthfromages4to6monthsIncreases•¼Љ(0.5cm)/monthduringsecond6monthsToddlerhood(ages1to3)Birthweightquadruplesby•age2½Gains8oz(227g)/month•fromages1to2Gains3to5lb(1.5to2.5kg)•fromages2to3Growthoccursmostlyin•legsratherthantrunkGrows3•½Љto5Љ(9to12.5cm)fromages1to2Grows2•Љto2½Љ(5to6.5cm)fromages2to3Increases1•Љfromages1to2Increaseslessthan•½Љ(1.3cm)/yearfromages2to3Preschoolage(ages3to6)Gains3to5lb•(1.5to2.5kg)/yearGrowthoccursmostlyin•legsratherthantrunkGrows2•½Љto3Љ(6.5to7.5cm)/yearIncreaseslessthan•½Љ/yearfromages3to5Schoolage(ages6to12)Gains6lb(2.5kg)/year•Grows2•Љ(5cm)/yearNotapplicable•Adolescence(ages12to19)Girls:Gain15to55lb•(7to25kg)Boys:Gain15to65lb•(7to30kg)Girls:Grow3•Љto6Љ(7.5to15cm)/yearuntilage16Boys:Grow3•Љto6Љ/yearuntilage18Notapplicable•Pediatric_G&D Chap01.indd 5Pediatric_G&D Chap01.indd 5 11/27/2009 5:47:12 PM11/27/2009 5:47:12 PM
  • 6G&DHeight measurements for boys, ages 2through 19 yearsAge Height by percentile10% 50% 90%cm inches cm inches cm inches2 years 86.9 34.2 91.9 36.2 96.8 38.13 years 92.6 36.5 98.2 38.7 105.2 41.44 years 99.9 39.3 106.8 42.1 113.9 44.85 years 107.0 42.1 114.6 45.1 120.8 47.66 years 114.0 44.9 120.8 47.6 127.0 50.07 years 113.5 44.7 125.2 49.3 133.1 52.48 years 123.6 48.7 130.3 51.3 139.1 54.89 years 129.2 50.9 137.1 54.0 143.9 56.610 years 133.0 52.4 141.5 55.7 151.3 59.611 years 140.6 55.4 149.4 58.8 161.1 63.412 years 145.2 57.2 153.9 60.6 164.8 64.913 years 149.7 58.9 162.2 63.9 173.5 68.314 years 158.4 62.3 169.0 66.5 179.0 70.515 years 163.5 64.4 174.8 68.8 182.0 71.716 years 166.9 65.7 176.0 69.3 186.9 73.617 years 167.5 65.9 176.8 69.6 185.2 72.918 years 167.1 65.8 176.4 69.4 186.3 73.319 years 165.3 65.1 177.4 69.8 186.6 73.5Adapted from McDowell, M.A., et al. Anthropometric Reference Data for Childrenand Adults: United States, 2003-2006. U.S. Department of Health and HumanServices, Centers for Disease Control and Prevention, National Center for HealthStatistics, 2008.Pediatric_G&D Chap01.indd 6Pediatric_G&D Chap01.indd 6 11/27/2009 5:47:12 PM11/27/2009 5:47:12 PM
  • 7G&DWeight measurements for boys, birththrough 19 yearsAge Weight by percentile10% 50% 90%kg lb kg lb kg lbBirth to 2 months * * 5.2 11.5 * *3 to 5 months 6.2 13.6 7.2 15.9 8.2 18.16 to 8 months 6.8 15.0 8.4 18.5 9.9 21.89 to 11 months * * 9.7 21.4 * *1 year 9.2 20.3 11.5 25.3 13.8 30.52 years 12.0 26.5 13.9 30.7 16.4 36.13 years 13.4 29.5 15.3 33.8 18.7 41.24 years 15.2 33.4 18.1 39.8 22.7 50.15 years 17.4 38.4 21.0 46.3 26.9 59.36 years 19.5 43.0 23.7 52.2 29.5 65.17 years 19.6 43.3 25.6 56.4 33.9 74.68 years 23.4 51.7 29.0 64.0 41.9 92.39 years 25.8 56.9 32.3 71.2 44.1 97.210 years 28.4 62.6 37.3 82.2 56.8 125.311 years 33.2 73.2 44.2 97.4 67.0 147.812 years 35.9 79.2 46.9 103.3 72.8 160.513 years 39.4 86.9 55.6 122.5 81.0 178.614 years 43.9 96.9 59.8 131.8 84.3 185.815 years 52.4 115.4 66.3 146.1 89.9 198.116 years 55.3 121.8 70.7 155.8 101.9 224.717 years 56.7 125.0 70.6 155.6 101.3 223.418 years 57.2 126.2 72.7 160.3 105.8 233.219 years 58.1 128.1 76.5 168.7 107.3 236.5* = figure doesn’t meet standards of reliability or precisionAdapted from McDowell, M.A., et al. Anthropometric Reference Data for Children andAdults: United States, 2003-2006. U.S. Department of Health and Human Services,Centers for Disease Control and Prevention, National Center for Health Statistics, 2008.Pediatric_G&D Chap01.indd 7Pediatric_G&D Chap01.indd 7 11/27/2009 5:47:12 PM11/27/2009 5:47:12 PM
  • 8G&DHeight measurements for girls, ages 2through 19 yearsAge Height by percentile10% 50% 90%cm inches cm inches cm inches2 years 84.0 33.1 90.2 35.5 95.6 37.63 years 91.9 36.2 98.1 38.6 104.1 41.04 years 99.2 39.1 105.2 41.4 111.9 44.15 years 105.2 41.4 111.7 44.0 119.6 47.16 years 112.7 44.4 118.2 46.6 127.6 50.27 years 118.0 46.5 125.6 49.5 133.1 52.48 years 123.3 48.5 130.5 51.4 138.7 54.69 years 130.2 51.2 138.3 54.5 147.1 57.910 years 135.0 53.2 143.7 56.6 152.8 60.111 years 141.1 55.6 151.4 59.6 161.3 63.512 years 148.3 58.4 156.7 61.7 166.6 65.613 years 150.0 59.1 157.7 62.1 167.9 66.114 years 150.7 59.3 161.0 63.4 169.3 66.715 years 154.3 60.7 162.0 63.8 170.1 67.016 years 153.6 60.5 162.8 64.1 172.4 67.917 years 155.6 61.3 162.2 63.8 169.2 66.618 years 154.7 60.9 162.8 64.1 171.1 67.319 years 153.1 60.3 163.3 64.3 172.4 67.9Adapted from McDowell, M.A., et al. Anthropometric Reference Data for Childrenand Adults: United States, 2003-2006. U.S. Department of Health and HumanServices, Centers for Disease Control and Prevention, National Center for HealthStatistics, 2008.Pediatric_G&D Chap01.indd 8Pediatric_G&D Chap01.indd 8 11/27/2009 5:47:12 PM11/27/2009 5:47:12 PM
  • 9G&DWeight measurements for girls, birththrough 19 yearsAge Weight by percentile10% 50% 90%kg lb kg lb kg lbBirth to 2 months * * 4.9 10.8 * *3 to 5 months * * 6.6 14.5 * *6 to 8 months * * 8.0 17.7 * *9 to 11 months * 17.5 9.0 19.9 * *1 year 8.8 19.3 10.9 24.1 13.0 28.62 years 10.7 23.7 13.1 29.0 16.1 35.43 years 12.8 28.2 15.5 34.2 18.5 40.84 years 14.8 32.6 17.5 38.6 20.8 45.85 years 15.9 35.1 19.6 43.3 25.5 56.16 years 18.4 40.6 22.1 48.8 29.7 65.57 years 21.1 46.5 25.7 56.6 35.5 78.38 years 22.3 49.3 28.2 62.1 42.1 92.89 years 26.2 57.9 34.0 75.0 50.7 111.810 years 29.1 64.1 40.5 89.2 58.5 129.111 years 33.3 73.3 47.3 104.3 68.2 150.312 years 36.4 80.2 49.5 109.1 76.2 168.013 years 41.2 90.9 54.4 119.9 76.0 167.614 years 44.0 97.1 54.4 120.0 81.0 178.615 years 46.5 102.4 57.6 126.9 81.0 178.516 years 47.2 104.2 58.8 129.7 79.6 175.517 years 49.1 108.1 60.6 133.6 87.3 192.518 years 47.8 105.3 63.0 138.8 92.1 203.019 years 50.9 112.2 63.0 138.9 92.7 204.3* = figure doesn’t meet standards of reliability or precisionAdapted from McDowell, M.A., et al. Anthropometric Reference Data for Children andAdults: United States, 2003-2006. U.S. Department of Health and Human Services,Centers for Disease Control and Prevention, National Center for Health Statistics, 2008.Pediatric_G&D Chap01.indd 9Pediatric_G&D Chap01.indd 9 11/27/2009 5:47:12 PM11/27/2009 5:47:12 PM
  • 10G&DAge Gross motor skills Fine motor skills1 month Can hold head parallel momentarily•but still has marked head lagBack is rounded in sitting•position, with no head controlStrong grasp reflex•Hands remain mostly•closed in a fist2 months In prone position, can lift head 45•degrees off tableIn sitting position, back is still•rounded but with more head controlDiminishing grasp•reflexHands open more•often3 months Displays only slight head lag•when pulled to a seated positionIn prone position, can use fore-•arms to lift head and shoulders 45 to90 degrees off tableCan bear slight amount of weight on•legs in standing positionGrasp reflex now•absentHands remain open•Can hold a rattle and•clutch own hand4 months No head lag•Holds head erect in sitting•position, back less roundedIn prone position, can lift head and•chest 90 degrees off tableCan roll from back to side•Regards own hand•Can grasp objects•with both handsMay try to reach for•an object without suc-cessCan move objects•toward mouth5 months No head lag•Holds head erect and steady when•sittingBack is straight•Can put feet to mouth when supine•Can roll from stomach to back•Can voluntarily grasp•objectsCan move objects•directly to mouth6 months • Can lift chest and upper abdomenoff table, bearing weight on hands• Can roll from back to stomach• Can bear almost all of weight onfeet when held in standing position• Sits with support• Can hold bottle• Can voluntarily graspand release objectsINFANTInfant gross and fine motor developmentPediatric_G&D Chap01.indd 10Pediatric_G&D Chap01.indd 10 11/27/2009 5:47:12 PM11/27/2009 5:47:12 PM
  • 11G&DInfant gross and fine motor development(continued)Age Gross motor skills Fine motor skills7 months • Can sit, leaning forward on handsfor support• When in standing position, canbear full weight on legs andbounce• Transfers objects fromhand to hand• Rakes at objects• Can bang objects ontable8 months • Can sit alone without assistance• Can move from sitting to kneelingposition• Has beginning pincer grasp• Reaches for objects outof reach9 months • Creeps on hands and knees withbelly off floor• Pulls to standing position• Can stand, holding on to furniture• Refining pincer grasp• Use of dominant handevident10 months • Can move from prone to sittingposition• Stands with support; may lift afoot as if to take a step• Refining pincer grasp11 months • Can cruise (take side steps whileholding on to furniture) or walkwith both hands held• Can move objects intocontainers• Deliberately drops objectto have it picked up• Neat pincer grasp12 months • Cruises well, may walk with onehand held• May try to stand alone• May attempt to builda two-block tower• Can crudely turn pagesof a book• Feeds self with cup andspoonPediatric_G&D Chap01.indd 11Pediatric_G&D Chap01.indd 11 11/27/2009 5:47:12 PM11/27/2009 5:47:12 PM
  • 12G&DInfant language and social developmentAge Behaviors0 to 2 months Listens to voices; quiets to soft music, singing,•or talkingDistinguishes mother’s voice after 1 week, father’s•by 2 weeksPrefers human voices to other sounds•Produces vowel sounds “ah,” “eh,” and “oh”•3 to 4 months Coos and gurgles•Babbles in response to someone talking to him•Babbles for own pleasure with giggles, shrieks, and•laughsSays “da,” “ba,” “ma,” “pa,” and “ga”•Vocalizes more to a real person than to a picture•Responds to caregiver with social smile by 3 months•5 to 6 months Notices how his speech influences actions•of othersMakes “raspberries” and smacks lips•Begins learning to take turns in conversation•Talks to toys and self in mirror•Recognizes names and familiar sounds•7 to 9 months Tries to imitate more sounds; makes several sounds•in one breathBegins learning the meaning of “no” by tone of•voice and actionsExperiences early literacy; enjoys listening to•simple books being readEnjoys pat-a-cake•Recognizes and responds to his name and names•of familiar objects10 to 12 months May have a few word approximations, such as•“bye-bye” and “hi”Follows one-step instructions such as “go to daddy”•Recognizes words as symbols for objects•Says “ma-ma-ma” and “da-da-da”•Pediatric_G&D Chap01.indd 12Pediatric_G&D Chap01.indd 12 11/27/2009 5:47:12 PM11/27/2009 5:47:12 PM
  • 13G&DInfant cognitive developmentand playThis chart shows the infant’s development of two cognitiveskills, object permanence and causality. It includes play, anintegral part of infant development.Age ObjectpermanenceCausality Play0 to 4months• Objects out of sightare out of mind• Continues to look athand after object isdropped out of it• Creates bodily sen-sations by actions(for example, thumb-sucking)• Grasps and movesobjects such as arattle• Looks at contrastingcolors4 to 8months• Can locate a partiallyhidden object• Visually tracksobjects when dropped• Uses causal be-haviors to re-createaccidentally discov-ered interesting ef-fects (for example,kicking the bed afterthe chance discov-ery that this will setin motion a mobileabove the bed)• Reaches and graspsan object and thenwill mouth, shake,bang, and drop theobject (in this order)9 to 12months• Object permanencedevelops• Can find an objectwhen hidden but can’tretrieve an object that’smoved in plain viewfrom one hiding place toanother• Knows parent still ex-ists when out of viewbut can’t imaginewhere they might be(separationanxiety may arise)• Understanding ofcause and effectleads to intentionalbehavior aimed atgetting specificresults• Manipulates objectsto inspect with eyesand hands• Has ability to pro-cess informationsimultaneously in-stead of sequentially• Ability to play peek-a-boo demonstratesobject permanencePediatric_G&D Chap01.indd 13Pediatric_G&D Chap01.indd 13 11/27/2009 5:47:12 PM11/27/2009 5:47:12 PM
  • 14G&DAge Gross motor skills Fine motor skills1 year Walks alone using a wide stance•Begins to run but falls easily•Grasps a very small•object (but can’t release ituntil about 15 months)2 years Runs without falling most of the•timeThrows a ball overhand without•losing his balanceJumps with both feet•Walks up and down stairs•Uses push and pull toys•Builds a tower of four•blocksScribbles on paper•Drops a small pellet into•a small, narrow containerUses a spoon well and•drinks well from acovered cupUndresses himself•TODDLERToddler gross and fine motordevelopmentPediatric_G&D Chap01.indd 14Pediatric_G&D Chap01.indd 14 11/27/2009 5:47:12 PM11/27/2009 5:47:12 PM
  • 15G&DToddler language developmentDuring toddlerhood, the ability to understand speech is muchmore developed than the ability to speak.This chart highlightslanguage development during the toddler years.Age Language skills1 year The toddler uses one-word sentences or holophrases (real•words that are meant to represent entire phrases or ideas).The toddler has learned about four words.•About 25% of a 1-year-old’s vocalization is understandable.•2 years The number of words learned has increased from about 4 (at•age 1) to approximately 300.The toddler uses multiword (two- to three-word) sentences.•About 65% of speech is understandable.•Frequent, repetitive naming of objects helps•toddlers learn appropriate words for objects.Toddler socializationToddlers develop social skills that determine the way theyinteract with others. As the toddler develops psychologically,he can:differentiate himself from others•tolerate being separated from a parent•withstand delayed gratification•control his bodily functions•acquire socially acceptable behaviors•communicate verbally•become less egocentric.•Pediatric_G&D Chap01.indd 15Pediatric_G&D Chap01.indd 15 11/27/2009 5:47:12 PM11/27/2009 5:47:12 PM
  • 16G&DToddler psychosocial developmentAccording to Erikson, the developmental task of toddlerhood isautonomy versus doubt and shame.Toddlers:are in the final stages of developing a sense of trust (the task•from infancy) and start asserting control, independence, andautonomydisplay negativism in their quest for autonomy•need to maintain sameness and reliability for comfort; employ•ritualismview “paternal” person in their life as a significant other•develop an ego, which creates conflict between the impulses•of the id (which requires immediate gratification) and sociallyacceptable actionsbegin to develop a superego, or conscience, which starts to•incorporate the morals of society.Toddler cognitive developmentAccording to Piaget, a child moves from the sensorimotor stageof infancy and early toddlerhood (birth to age 2) to the longer,preoperational stage (ages 2 to 7). In these stages, toddlers:employ tertiary circular reactions (use of active experimenta-•tion; also called trial and error [in the 13- to 18-month old])may be aware of the relationship between two events (cause•and effect) but may be unable to transfer that knowledge to anew situationlook for new ways to accomplish tasks through mental calcu-•lations (ages 18 to 24 months)advance in understanding object permanence and gain aware-•ness of the existence of objects or people that are out of sightengage in imitative play, which indicates a deeper understand-•ing of their role in the familybegin to use preoperational thought with increasing use of•words as symbols, problem solving, and creative thinking.Pediatric_G&D Chap01.indd 16Pediatric_G&D Chap01.indd 16 11/27/2009 5:47:13 PM11/27/2009 5:47:13 PM
  • 17G&DToddler playPlay changes considerably as the toddler’s motor skills•develop; he uses his physical skills to push and pull objects; toclimb up, down, in, and out; and to run or ride on toys.A short attention span requires frequent changes in toys and•play media.Toddlers increase their cognitive abilities by manipulating•objects and learning about their qualities, which makes tactileplay (with water, sand, finger paints, clay) important.Many play activities involve imitating behaviors the child sees•at home, which helps them learn new actions and skills.Toddlers engage in parallel play—playing with others without•actually interacting. In this type of play, children play side-by-side, commonly with similar objects. Interaction is limited tothe occasional comment or trading of toys.Safe toddler toysPlay dough and modeling clay•Building blocks•Plastic, pretend housekeeping toys, such as pots,•pans, and play foodStackable rings and blocks of varying sizes•Toy telephones•Wooden puzzles with big pieces•Textured or cloth books•Plastic musical instruments and noise-makers•Toys that roll, such as cars and trains•Tricycle or riding car•Fat crayons and coloring books•Stuffed animals with painted faces (button eyes•are a choking hazard)Pediatric_G&D Chap01.indd 17Pediatric_G&D Chap01.indd 17 11/27/2009 5:47:13 PM11/27/2009 5:47:13 PM
  • 18G&DPRESCHOOLERPreschool gross and fine motordevelopmentAge Gross motor skills Fine motor skills3 years Stands on one foot for a few•secondsClimbs stairs with alternating•feetJumps in place•Performs a broad jump•Dances but with somewhat•poor balanceKicks a ball•Rides a tricycle•Builds a tower of 9 to•10 blocks and a 3-blockbridgeCopies a circle and imi-•tates a cross and verticaland horizontal linesDraws a circle as a•head, but not a completestick figureUses a fork well•4 years Hops, jumps, and skips on•one footThrows a ball overhand•Rides a tricycle or bicycle•with training wheelsCopies a square and•traces a crossDraws recognizable•familiar objects or humanfigures5 years Skips, using alternate feet•Jumps rope•Balances on each foot for•4 to 5 secondsCopies a triangle and a•diamondDraws a stick figure•with several body parts,including facial featuresPediatric_G&D Chap01.indd 18Pediatric_G&D Chap01.indd 18 11/27/2009 5:47:13 PM11/27/2009 5:47:13 PM
  • 19G&DPreschool psychosocial developmentAccording to Erikson, childrenages 3 to 5 have mastered asense of autonomy and face thetask of initiative versus guilt.During this time, the child’s:significant other is the family•conscience begins to•develop, introducing theconcept of right and wrongsense of guilt arises when he•feels that his imagination andactivities are unacceptable orclash with his parents’ expec-tationssimple reasoning develops•and longer periods of delayedgratification are tolerated.Preschool playIn the preschool stage, theparallel play of toddlerhood isreplaced by more interactive,cooperative play, including:more associative play, in•which children play togetherbetter understanding of the•concept of sharingenjoyment of large motor•activities, such as swinging,riding tricycles or bicycles,and throwing ballsmore dramatic play, in which•the child lives out the dramasof human life (in preschoolyears) and may have imagi-nary playmates.By the time a child reachespreschool age:his vocabulary increases to•about 900 words by age 3 and2,100 words by age 5he may talk incessantly and•ask many “why” questionshe usually talks in three- to•four-word sentences by age 3;by age 5, he speaks in longersentences that contain allparts of speech.Socialization continues todevelop as the preschooler’sworld expands beyond him-self and his family (althoughparents remain central). Regu-lar interaction with same-agechildren is necessary to furtherdevelop social skills.Preschool language developmentand socializationPediatric_G&D Chap01.indd 19Pediatric_G&D Chap01.indd 19 11/27/2009 5:47:13 PM11/27/2009 5:47:13 PM
  • 20G&DPreschool cognitive developmentPreschool moral and spiritual developmentPiaget’s theory divides thepreoperational phase of thepreschool years into two stages.Preconceptual phaseDuring the preconceptualphase (from ages 2 to 4), thechild can:form beginning concepts•that aren’t as complete orlogical as an adult’smake simple classifications•rationalize specific concepts•but not the idea as a wholeexhibit egocentric thinking•(evaluating each situationbased on his feelings orexperiences, rather than thoseof others).Intuitive thought phaseDuring the intuitive thoughtphase (from ages 4 to 7), thechild:can classify, quantify, and•relate objects (but can’t yetunderstand the principlesbehind these operations)uses intuitive thought•processes (but can’t fully seethe viewpoints of others)uses many words appropri-•ately (but without true under-standing of their meaning).Kohlberg’s preconventionalphase spans the preschoolyears and more, extending fromages 4 to 10. During this phase:conscience emerges and•emphasis is on controlthe preschooler’s moral stan-•dards are those of others, andhe understands that thesestandards must be followed toavoid punishment for inappro-priate behavior or gainrewards for good or desiredbehaviorthe preschooler behaves•according to what freedom isgiven or what restriction isplaced on his actions.Preschoolers can under-stand the basic plot of simplereligious stories but typicallydon’t grasp the underlyingmeanings. Religious principlesare best learned from concreteimages in picture books andsmall statues such as thoseseen at a place of worship.During this stage, childrenmay view an illness or hos-pitalization as a punishmentfrom a higher being for somereal or perceived bad behavior.Pediatric_G&D Chap01.indd 20Pediatric_G&D Chap01.indd 20 11/27/2009 5:47:13 PM11/27/2009 5:47:13 PM
  • 21G&DSCHOOL-AGE CHILDSchool-age fine motor developmentDevelopment of small-•muscle and eye-handcoordination increases duringthe school-age years, leadingto the skilled handling oftools, such as pencils andpapers for drawing andwriting.During the remainder of this•period, the child refines physi-cal and motor skills andcoordination.Pubertal changesThe pubertal growth spurt•begins in girls at about age 10and in boys at about age 12.The feet are the first part of•the body to experience agrowth spurt.Increased foot size is followed•by a rapid increase in leglength and then trunk growth.In addition to bones, gonadal•hormone levels increase andcause the sexual organs tomature.Preparation for mensesThe first menstruation (called•menarche) can occur as earlyas age 9 or as late as age 17and still be considered normal.The menstrual cycle may be•irregular at first.Secondary sexual character-•istics may start to develop(breasts, hips, and pubic hair),and the girl may experience asudden increase in height.School-age language developmentand socializationThe school-age child has an•efficient vocabulary andbegins to correct previousmistakes in usage.Peers become increasingly•significant; his need to findhis place within a group isimportant.The child may be overly con-•cerned with peer rules;however, parental guidancecontinues to play an impor-tant role in his life.The school-age child typically•has two to three best friends(although choice of friendsmay change frequently).Pediatric_G&D Chap01.indd 21Pediatric_G&D Chap01.indd 21 11/27/2009 5:47:13 PM11/27/2009 5:47:13 PM
  • 22G&DSchool-age psychosocial developmentThe school-age child entersErikson’s stage of industry ver-sus inferiority. In this stage:the child wants to work and•produce, accomplishing andachieving tasksthe child may display nega-•tive attributes of inadequacyand inferiority if too much isexpected of him or if he feelsunable to measure up to setstandards.School-age cognitive developmentThe school-age child is inPiaget’s concrete-operationalperiod. In this period:magical thinking diminishes,•and the child has a much bet-ter understanding of causeand effectthe child begins to accept•rules but may not necessarilyunderstand themthe child is ready for basic•reading, writing, andarithmeticabstract thinking begins to•develop during the middleelementary school yearsparents remain very impor-•tant and adult reassurance ofthe child’s competence andbasic self-worth is essential.School-age moral and spiritualdevelopmentThe school-age child is inKohlberg’s conventional level.During this time, the childbehaves according to sociallyacceptable norms because anauthority figure tells him to doso. As the child approachesadolescence, school andparental authority is ques-tioned, and even challengedor opposed.The importance ofthe peer group intensifies, andit eventually becomes thesource of behavior standardsand models.Spiritual lessons should betaught in concrete terms duringthis time. Children have a hardtime understanding supernatu-ral religious symbols.Pediatric_G&D Chap01.indd 22Pediatric_G&D Chap01.indd 22 11/27/2009 5:47:13 PM11/27/2009 5:47:13 PM
  • 23G&DADOLESCENTAdolescent psychosocial developmentAccording to Erikson, adolescents enter the stage of identityversus role confusion. During this stage, they:experience rapid changes in their bodies•have a preoccupation with looks and others’ perceptions of them•feel pressure to meet expectations of peers and conform to•peer standards (diminishes by late adolescence as young adultsbecome more aware of who they are)try to establish their own identities.•Adolescent cognitive developmentTeenagers move from the concrete thinking of childhood into Piaget’sstage of formal operational thought, which is characterized by:logical reasoning about abstract concepts•derivation of conclusions from hypothetical premises•forethought of future events instead of focus on the present•(as in childhood).Adolescent moral and spiritualdevelopmentKohlberg’s conventional level of moral development continuesinto early adolescence. At this level, adolescents do what is rightbecause it’s the socially acceptable action.As adolescence ends, teenagers enter the postconventional, orprincipled, level of moral development. During this time, adolescents:form moral decisions independent of their peer group•choose values for themselves instead of letting values be•dictated by peersdevelop solidified worldviews•formulate questions about the larger world as they consider•religion, philosophy, and the values held by parents, friends,and otherssort through and adopt religious beliefs that are consistent•with their own moral character.Pediatric_G&D Chap01.indd 23Pediatric_G&D Chap01.indd 23 11/27/2009 5:47:13 PM11/27/2009 5:47:13 PM
  • 24G&DDevelopment of secondary sexcharacteristicsThe pituitary gland is stimulated at puberty to produce andro-gen steroids responsible for secondary sex characteristics.Thehypothalamus produces gonadotropin-releasing hormone,which triggers the anterior pituitary gland to produce follicle-stimulating hormone (FSH) and luteinizing hormone (LH). FSHand LH promote testicular maturation and sperm production inboys and initiate the ovulation cycle in girls.Male secondary sexual developmentMale secondary sexual development consists of genital•growth and the appearance of pubic and body hair.Most boys achieve active spermatogenesis at ages 12 to 15.•Female secondary sexual developmentFemale secondary sexual development involves increases in•the size of the ovaries, uterus, vagina, labia, and breasts.The first visible sign of sexual maturity is the appearance of•breast buds.Body hair appears in the pubic area and under the arms, and•menarche occurs.The ovaries, present at birth, remain inactive until puberty.•Pediatric_G&D Chap01.indd 24Pediatric_G&D Chap01.indd 24 11/27/2009 5:47:13 PM11/27/2009 5:47:13 PM
  • 25G&DSexual maturity in boysGenital development and pubic hair growth are the first signs ofsexual maturity in boys.The illustrations below show the devel-opment of the male genitalia and pubic hair in puberty.Stage 1No pubic hair is present.Stage 2Downy hair develops laterally andlater becomes dark; the scrotumbecomes more textured, and thepenis and testes may become larger.Stage 3Pubic hair extends across the pubis;the scrotum and testes are larger;the penis elongates.Stage 4Pubic hair becomes more abundantand curls, and the genitalia resemblethose of adults; the glans penis hasbecome larger and broader, and thescrotum becomes darker.Stage 5Pubic hair resembles an adult’s in qual-ity and pattern and the hair extendsto the inner borders of the thighs; thetestes and scrotum are adult in size.Pediatric_G&D Chap01.indd 25Pediatric_G&D Chap01.indd 25 11/27/2009 5:47:13 PM11/27/2009 5:47:13 PM
  • 26G&DSexual maturity in girlsBreast development and pubic hair growth are the first signs ofsexual maturity in girls.These illustrations show the develop-ment of the female breast and pubic hair in puberty.Breast developmentStage 1Only the papilla (nipple)elevates (not shown).Stage 2Breast buds appear; the areolais slightly widened and appears asa small mound.Stage 3The entire breast enlarges; thenipple doesn’t protrude.Stage 4The breast enlarges; thenipple and the papillaprotrude and appear as asecondary mound.Stage 5The adult breast has developed; thenipple protrudes and the areola nolonger appears separate from thebreast.Pediatric_G&D Chap01.indd 26Pediatric_G&D Chap01.indd 26 11/27/2009 5:47:14 PM11/27/2009 5:47:14 PM
  • 27G&DSexual maturity in girls (continued)Pubic hair developmentStage 1No pubic hair is present.Stage 2Straight hair begins to appear on thelabia and extends between stages2 and 3.Stage 3Pubic hair increases in quantity; itappears darker, curled, and more denseand begins to form the typical (butsmaller in quantity) female triangle.Stage 4Pubic hair is more dense and curled;it’s more adult in distribution, butless abundant than in an adult.Stage 5Pubic hair is abundant, appears in anadult female pattern, and may extendonto the medial part of the thighs.Pediatric_G&D Chap01.indd 27Pediatric_G&D Chap01.indd 27 11/27/2009 5:47:16 PM11/27/2009 5:47:16 PM
  • 28G&DMinimizing the trauma ofhospitalizationPrepare a child for hospitaliza-•tion and procedures to help thechild cope more effectively andmake it easier for him to trustthe health care professionalsresponsible for his care.Consider the child’s age,•developmental stage, person-ality, and the length of theprocedure or treatment whenpreparing him.Utilize child life specialists,•who can explain proceduresstep by step and can also staywith the child during thoseprocedures.Help the child and his family•cope with fears associatedwith hospitalization by:explaining procedures–answering questions–openly and honestlyminimizing separation from–the parentsstructuring the environ-–ment to allow the child toretain as much control aspossible.Foster family-centered care,•which permits the family toremain as involved as possi-ble and helps give the childand his family a sense ofcontrol in a difficult andunfamiliar situation.Use developmentally appro-•priate activities to help thechild cope with the stress ofhospitalization.The importance of playPlay is an excellent stress•reducer and tension reliever.It allows the child freedomof expression to act out hisfears, concerns, andanxieties.Play provides a source of•diversion, alleviating separa-tion anxiety.Play provides the child with•a sense of safety and securitybecause, while he’s engagingin play, he knows that nopainful procedures will occur.Developmentally appropriate•play fosters the child’s normalgrowth and development,especially for a child who’srepeatedly hospitalized for achronic condition.Play puts the child in the•driver’s seat, allowing him tomake choices and giving hima sense of control.Pediatric_G&D Chap01.indd 28Pediatric_G&D Chap01.indd 28 11/27/2009 5:47:19 PM11/27/2009 5:47:19 PM
  • 29G&DConcepts of death in childhoodDevelopmentalstageConcept ofdeathNursingconsiderationsInfancy None• Be aware that the older•infant will experienceseparation anxiety.Help the family cope•with death so they canbe available to the infant.EarlychildhoodKnows the words•“dead” and “death”Reactions are influ-•enced by the atti-tudes of his parentsHelp the family mem-•bers (including siblings)cope with their feelings.Allow the child to•express his own feelingsin an open and honestmanner.MiddlechildhoodUnderstands univer-•sality and irreversibil-ity of deathMay have a fear of•parents dyingUse play to facilitate•the child’s understandingof death.Allow siblings to•express their feelings.LatechildhoodBegins to incorpo-•rate family and cultur-al beliefs about deathExplores views of an•afterlifeFaces the reality of•own mortalityProvide opportunities•for the child to verbalizehis fears.Help the child discuss•his concerns with hisfamily.Adolescence Has adult perception•of death, but stillfocuses on the “hereand now”Use opportunities to•open discussion aboutdeath.Allow expression of•feelings of guilt, confu-sion, and anxiety.Support and maintain•the child’s self-esteem.Pediatric_G&D Chap01.indd 29Pediatric_G&D Chap01.indd 29 11/27/2009 5:47:19 PM11/27/2009 5:47:19 PM
  • 30G&DPreparing children for surgeryWhat a child imagines aboutsurgery is likely much morefrightening than the reality.A child who knows what toexpect ahead of time will beless fearful and more coopera-tive and will learn to trust hiscaregivers.Before surgeryBegin by asking the child to•tell you what he thinks isgoing to happen during hissurgery.Ask the child about worries•or fears. Chances are, he’ll beworried about something thatisn’t going to happen.Provide honest, age-•appropriate explanations.Involve the parents (unless•the adolescent would ratherbe prepared alone).Focus on what the child will•see, hear, and feel; where hisparents will be waiting forhim; and when they’ll bereunited.Encourage the child to ask•questions.Reassure the child that he•won’t wake up during the sur-gery but that the doctorknows how and when to wakehim up afterward.Show the child an induction•mask (if it will be used) andallow him to “practice” byplacing it on his face (oryours).Prepare the child for equip-•ment (monitors, drains, andI.V. lines) he’ll wake up with.Tell the child about the sights•and sounds of the operatingroom.Tell the child that his doctor•and nurse will be in the oper-ating room with him.Reassure him that they’ll talkto him and tell him what’shappening.If possible, show the child•where he’ll be waking up inthe recovery room and wherehis parents will be waiting forhim.If the child will initially be•cared for in an intensive caresetting, allow him to visit thearea ahead of time and tomeet some of the nurses whowill be caring for him.Tell the child it’s perfectly•fine to be afraid and to cry.After the surgery, encourage•the child to talk about theexperience; he may alsoexpress his feelings throughart or play.Pediatric_G&D Chap01.indd 30Pediatric_G&D Chap01.indd 30 11/27/2009 5:47:19 PM11/27/2009 5:47:19 PM
  • 31G&DPreparing children for surgery (continued)Many of the concerns that children have about hospitalizationand surgery relate to their particular stage of development.Age ConsiderationsInfants, toddlers,and preschoolersInfants and toddlers are most concerned about•separation from their parents, making separationduring surgery especially difficult.Because toddlers think concretely, showing is as•important as telling when preparing toddlers forsurgery.Preschoolers may view medical procedures,•including surgeries, as punishments for perceivedbad behavior.Preschoolers are also likely to have many miscon-•ceptions about what will happen during surgery.School-agechildrenSchool-age children have concerns about fitting in•with peers and may view surgery as something thatsets them apart from their friends.A desire to appear “grown up” may make the•school-age child reluctant to express his fears.Despite a reluctance to express fear, school-age•children are especially curious and interested inlearning, are very receptive to preoperative teaching,and will likely ask many important questions (althoughthey may need to be given “permission” to do so).Adolescents Adolescents struggle with the conflict between•wanting to assert their independence and needingtheir parents (and other adults) to take care of themduring illness and treatment.Adolescents may want to discuss their illness and•treatment without a parent present.In addition, adolescents may have a hard time•admitting that they’re afraid or experiencing pain ordiscomfort.Pediatric_G&D Chap01.indd 31Pediatric_G&D Chap01.indd 31 11/27/2009 5:47:19 PM11/27/2009 5:47:19 PM
  • 32Birth history and earlydevelopmentDid the child’s mother have a•disease or another problem dur-ing the pregnancy?Was there birth trauma or a•difficult delivery?Did the child arrive at develop-•mental milestones—such assitting up, walking, andtalking—at the usual ages?Ask about childhood diseases•and injuries and the presence ofknown congenital abnormalities.More specific questions will•depend on which body system isbeing assessed.Eyes and earsLook for clues to familial eye•disorders, such as refractiveerrors and retinoblastoma(such as a family history ofglaucoma).Does the child hold reading•materials too close to his facewhile reading?Ask about behavior problems•or poor performance in school.Ask about the child’s birth his-•tory for risk of congenitalhearing loss. (Maternal infection,maternal or infant use of oto-toxic drugs, hypoxia, and traumaare all risk factors.)Ask the parents about behav-•iors that indicate possiblehearing loss such as delayedspeech development.Respiratory systemAsk the parents how often the•child has upper respiratory tractinfections.Find out if the child has had•other respiratory signs andsymptoms, such as a cough,dyspnea, wheezing, rhinorrhea,and a stuffy nose. Ask if thesesymptoms appear to be relatedto the child’s activities or to sea-sonal changes.Cardiovascular systemAsk the parents if the child has•difficulty keeping up physicallywith other children his age.Ask if the child experiences•cyanosis on exertion, dyspnea,or orthopnea.Find out if the child assumes a•squatting position or sleeps in theknee-chest position (either signmay indicate tetralogy of Fallot oranother congenital heart defect).GI systemIf the child has abdominal pain,•ask him questions to help deter-mine the pain’s nature andseverity.Determine the frequency and•consistency of bowel move-ments and if the child suffersfrom constipation or diarrhea.Pediatric health historyAssessPediatric_Assess Chap02.indd 32Pediatric_Assess Chap02.indd 32 11/27/2009 5:37:33 PM11/27/2009 5:37:33 PM
  • Assess33Pediatric health history (continued)Determine the characteristics of•nausea and vomiting, especiallyprojectile vomiting.Urinary systemAsk about a history of urinary•tract malformations.Explore a history of discomfort•with voiding and persistentenuresis after age 5.Nervous systemFind out if the child has experi-•enced head or neck injuries,headaches, tremors, seizures,dizziness, fainting spells, or mus-cle weakness.Ask the parents if the child is•overly active.Musculoskeletal systemDetermine the ages at which•the child reached major motordevelopment milestones:For an infant, these mile-–stones include the age at whichhe held up his head, rolled over,sat unassisted, and walkedalone.For an older child, these–milestones include the age atwhich the child first ran, jumped,walked up stairs, and pedaled atricycle.Ask about a history of repeated•fractures, muscle strains orsprains, painful joints, clumsi-ness, lack of coordination,abnormal gait, or restrictedmovement.Hematologic and immunesystemsCheck for anemia:•Ask the parents if the child–has exhibited the common signsand symptoms of pallor, fatigue,failure to gain weight, malaise,and lethargy.Ask the mother who’s bottle-–feeding if she uses an iron-fortifiedinfant formula.Ask about the patient’s history•of infections. For an infant, 5 to 6viral infections per year are nor-mal; 8 to 12 are average forschool-age children.Obtain a thorough history of•allergic conditions.Ask about the family’s history•of infections and allergic or auto-immune disorders.Endocrine systemObtain a thorough family his-•tory from one or both parents.Many endocrine disorders, suchas diabetes mellitus and thyroidproblems, can be hereditary.Others, such as delayed or pre-cocious puberty, sometimesshow a familial tendency.Ask about a history of poor•weight gain, feeding problems,constipation, jaundice, hypo-thermia, or somnolence.Pediatric_Assess Chap02.indd 33Pediatric_Assess Chap02.indd 33 11/27/2009 5:37:33 PM11/27/2009 5:37:33 PM
  • 34AssessAge-specific interview and assessmenttipsInfantBefore performing a proce-•dure, talk to and touch theinfant.Use a gentle touch.•Speak softly.•Allow the infant to hold a fav-•orite toy during theassessment.Let an older infant hold a•small block in each hand.Remember that an older•infant may be wary ofstrangers.Be alert to infant cues, such•as crying, kicking, or wavingarms.Perform traumatic proce-•dures last when the infant iscrying.Use distractions, such as•bright objects, rattles, andtalking.Enlist the parent’s aid when•examining the ears andmouth.Avoid abrupt, jerky move-•ments.When the child is quiet, aus-•cultate the heart, lungs, andabdomen.ToddlerEncourage the parents to be•with you during the interview.Allow the toddler to be close•to his parents.Provide simple explanations•and use simple language.Use play as a communica-•tion tool.Tell the toddler that it’s okay•to cry.Watch for separation anxiety.•Use the toddler’s favorite toy•as a tool during the interview.Encourage the toddler to usethe toy for communication.Use play (count fingers or•tickle toes) to assess body parts.Use parent assistance during•the examination. For example,ask the parents to remove thetoddler’s outer clothing andhelp restrain the child duringeye and ear examination.Use encouraging words dur-•ing the examination.Preschool childAsk simple questions.•Allow the child to ask•questions.Provide simple explanations.•Avoid using words that•sound threatening or havedouble meanings.Avoid slang words.•Validate the child’s perception.•Use toys for expression.•Use simple visual aids.•Pediatric_Assess Chap02.indd 34Pediatric_Assess Chap02.indd 34 11/27/2009 5:37:33 PM11/27/2009 5:37:33 PM
  • Assess35Age-specific interview and assessmenttips (continued)Enlist the child’s help during•the examination, such as byallowing him to give you thestethoscope.Allow the child to touch and•operate the diagnosticequipment.Explain what the child is•going to feel before ithappens. For example, explainthat the stethoscope will becold before using it on thechild.Utilize the child’s imagination•through puppets and play.Give the child choices when•possible.School-age childProvide explanations for pro-•cedures.Explain the purpose of•equipment, such as anophthalmoscope to see insidethe eye.Avoid abstract explanations.•Help the child vocalize his•needs.Allow the child to engage in•the conversation.Perform demonstration.•Allow the child to undress•himself.Respect the child’s need for•privacy.AdolescentGive the adolescent control•whenever possible.Facilitate trust and stress•confidentiality.Encourage honest and open•communication.Be nonjudgmental.•Use clear explanations.•Ask open-ended questions.•Anticipate that the adoles-•cent may be angry or upset.Ask if you can speak to the•adolescent without the parentpresent.Ask the adolescent about•parental involvement beforeinitiating it.Give your undivided atten-•tion to the adolescent.Respect the adolescent’s•views, feeling, and differences.Allow the adolescent to•undress in private, andprovide the child with a gown.Expose only the area to be•examined.Explain findings during the•examination.Emphasize the normalcy of•adolescent’s development.Examine genitalia last but•examine them as you wouldexamine any other body partPediatric_Assess Chap02.indd 35Pediatric_Assess Chap02.indd 35 11/27/2009 5:37:33 PM11/27/2009 5:37:33 PM
  • 36AssessVITAL SIGNSNormal heart rates in childrenAge Awake(beats/minute)Asleep(beats/minute)Exercise orfever (beats/minute)Neonate 100 to 160 80 to 140 < 2201 week to3 months100 to 220 80 to 200 < 2203 monthsto 2 years80 to 150 70 to 120 < 2002 to 10years70 to 110 60 to 90 < 200> 10 years 55 to 100 50 to 90 < 200Age Weight (kg) Systolic BP(mm Hg)Diastolic BP(mm Hg)Neonate 1 40 to 60 20 to 36Neonate 2 to 3 50 to 70 30 to 451 month 4 64 to 96 30 to 626 months 7 60 to 118 50 to 701 year 10 66 to 126 41 to 912 to 3 years 12 to 14 74 to 124 39 to 894 to 5 years 16 to 18 79 to 119 45 to 856 to 9 years 20 to 26 80 to 124 45 to 8510 to 13 years 32 to 42 85 to 135 55 to 88>14 years > 50 90 to 140 60 to 90Normal blood pressure in childrenPediatric_Assess Chap02.indd 36Pediatric_Assess Chap02.indd 36 11/27/2009 5:37:33 PM11/27/2009 5:37:33 PM
  • Assess37Normal respiratory rates in childrenNormal temperature ranges in childrenAge Breaths per minuteBirth to 6 months 30 to 606 months to 2 years 20 to 303 to 10 years 20 to 2810 to 18 years 12 to 20Age TemperatureºF ºCNeonate 98.6 to 99.8 37 to 37.73 years 98.5 to 99.5 36.9 to 37.510 years 97.5 to 98.6 36.4 to 3716 years 97.6 to 98.8 36.4 to 37.1Pediatric_Assess Chap02.indd 37Pediatric_Assess Chap02.indd 37 11/27/2009 5:37:33 PM11/27/2009 5:37:33 PM
  • 38AssessMeasuring lengthBecause of an infant’s tendency to be flexed and curled up, usethese tips to help make assessing an infant’s length easy andaccurate:Place the infant’s head in the midline position at the top of the•measurement board.Hold one knee down with your hand and gently press it down•toward the table until it’s fully extended.Take the length measurement from the tip of the infant’s head•to his heel.Pediatric_Assess Chap02.indd 38Pediatric_Assess Chap02.indd 38 11/27/2009 5:37:33 PM11/27/2009 5:37:33 PM
  • Assess39Measuring head circumferenceTo obtain an accurate head circumference measurement:Use a paper measuring tape to avoid stretching (as can hap-•pen with a cloth tape).Use landmarks—typically, place the tape just above the•infant’s eyebrows and around the occipital prominence at theback of the head to measure the largest diameter of the head.Take into consideration the shape of the infant’s head and•make adjustments as needed to measure the largest diameter.Pediatric_Assess Chap02.indd 39Pediatric_Assess Chap02.indd 39 11/27/2009 5:37:33 PM11/27/2009 5:37:33 PM
  • 40AssessCARDIOVASCULAR SYSTEMCardiovascular assessmentNormal findings for a cardiovascular assessment are describedbelow. Abnormal findings appear in color.InspectionSkin is pink, warm, and dry.•Chest is symmetrical.•Pulsations may be visible in children with thin chest walls.The point•of maximal impulse is commonly visible.Capillary refill is no more than 2 seconds.•Cyanosis may be an early sign of a cardiac condition in an infant or•a child.Dependent edema is a late sign of heart failure in children.•PalpationPulses should be regular in rhythm and strength:•4– ϩ ϭ bounding3– ϩ ϭ increased2– ϩ ϭ normal1– ϩ ϭ weak0– ϭ absentNo thrills or rubs are evident.•AuscultationHeart sounds are regular in rhythm, clear, and distinct (not weak or•pounding, muffled, or distant).First heart sound (S• 1) is heard best with stethoscope diaphragmover the mitral and tricuspid areas.Second heart sound (S• 2) is heard best with stethoscope diaphragmover pulmonic and aortic areas.Third heart sound (S• 3) is heard best with stethoscope bell over themitral area.This sound is considered normal in some children andyoung adults but is abnormal when heard in older adults.S• 4, if present, indicates the need for further cardiac evaluationbecause it’s rarely heard as a normal heart sound.Murmurs in children may be innocent, functional, or organic. If a•murmur is heard, note its location, timing within the cardiac cycle,intensity in relation to the child’s position, and loudness.Pediatric_Assess Chap02.indd 40Pediatric_Assess Chap02.indd 40 11/27/2009 5:37:34 PM11/27/2009 5:37:34 PM
  • Assess41Heart sound sitesGrading murmursGrade I• is a barely audible murmur.Grade II• is audible but quiet and soft.Grade III• is moderately loud, without a thrust or thrill.Grade IV• is loud, with a thrill.Grade V• is very loud, with a palpable thrill.Grade VI• is loud enough to be heard before the stethoscopecomes into contact with the chest.When recording your findings, use Roman numerals as partof a fraction, always with VI as the denominator. For instance, agrade III murmur would be recorded as grade III/VI.AorticPulmonicTricuspidMitralPediatric_Assess Chap02.indd 41Pediatric_Assess Chap02.indd 41 11/27/2009 5:37:34 PM11/27/2009 5:37:34 PM
  • 42AssessRESPIRATORY SYSTEMRespiratory assessmentNormal findings for a respira-tory assessment are describedbelow. Abnormal findingsappear in color.InspectionRespirations are regular and•effortless.No nasal flaring, grunting, or•retractions are present.The presence of nasal flar-•ing, expiratory grunting, andretractions are signs of respi-ratory distress in children.PalpationChest wall expands symmet-•rically on inspiration.Tactile fremitus is palpable.•No rubs or vibrations are•present.PercussionResonance is heard over•most lung tissue.Dullness is normal over the•heart area.AuscultationBreath sounds normally•sound louder and harsherthan in adults due tothe closeness of the stetho-scope to the origins of thesound.Breath sounds are clear and•equal; adventitious breathsounds are absent.Absent or diminished breath•sounds are always abnormaland require further evaluation.Looking for retractionsClavicularSuprasternalIntercostalSubsternalSubcostalPediatric_Assess Chap02.indd 42Pediatric_Assess Chap02.indd 42 11/27/2009 5:37:34 PM11/27/2009 5:37:34 PM
  • Assess43Qualities of normal breath soundsAbnormal breath soundsBreath sound Quality LocationTracheal Harsh, high-pitched Over tracheaBronchial Loud, high-pitched Next to tracheaBronchovesicular Medium loudness and pitch Next to sternumVesicular Soft, low-pitched Remainder of lungsSound DescriptionCrackles Light crackling, popping, intermittent nonmusicalsounds — like hairs being rubbed together — heard oninspiration or expirationPleuralfrictionrubLow-pitched, continual, superficial, squeaking or gratingsound — like pieces of sandpaper being rubbedtogether — heard on inspiration and expirationRhonchi Low-pitched, monophonic snoring sounds heard primarilyon expiration but also throughout the respiratory cycleStridor High-pitched, monophonic crowing sound heard on inspi-ration; louder in the neck than in the chest wallWheezes High-pitched, continual musical or whistling sound heardprimarily on expiration but sometimes also on inspirationPediatric_Assess Chap02.indd 43Pediatric_Assess Chap02.indd 43 11/27/2009 5:37:35 PM11/27/2009 5:37:35 PM
  • 44AssessTest Patient’s reaction ScoreBest eye opening response Open spontaneously 4Open to verbal command 3Open to pain 2No response 1Best motor response Obeys verbal command 6Localizes painful stimuli 5Flexion-withdrawal 4Flexion-abnormal (decorticate rigidity) 3Extension (decerebrate rigidity) 2No response 1Best response toauditory and/orvisual stimulusFor a child older than age 2Oriented 5Confused 4Inappropriate words 3Incomprehensible sounds 2No response 1orFor a child younger than age 2Smiles, listens, follows 5Cries, consolable 4Inappropriate persistent cry 3Agitated, restless 2No response 1NEUROLOGIC SYSTEMPediatric coma scaleTo quickly assess a patient’s LOC and to uncover baselinechanges, use the pediatric coma scale.This assessment toolgrades consciousness in relation to eye opening and motorresponse and responses to auditory or visual stimuli. Adecreased reaction score in one or more categories warns ofan impending neurologic crisis. A patient scoring 7 or lower iscomatose and probably has severe neurologic damage.Total possible score: 3 to 15Pediatric_Assess Chap02.indd 44Pediatric_Assess Chap02.indd 44 11/27/2009 5:37:35 PM11/27/2009 5:37:35 PM
  • Assess45Infant reflexesReflex How to elicit Age atdisappearanceTrunkincurvatureWhen a finger is run laterally down theneonate’s spine, the trunk flexes and thepelvis swings toward the stimulated side.2 monthsTonic neck(fencingposition)When the neonate’s head is turnedwhile he’s lying supine, the extremitieson the same side extend outward whilethose on the opposite side flex.2 to 3 monthsGrasping When a finger is placed in each of theneonate’s hands, his fingers grasp tightlyenough to be pulled to a sitting position.3 to 4 monthsRooting When the cheek is stroked, the neonateturns his head in the direction of thestroke.3 to 4 monthsMoro(startlereflex)When lifted above the crib and suddenlylowered (or in response to a loud noise),the arms and legs symmetrically extendand then abduct while the fingers spreadto form a “C.”4 to 6 monthsSucking Sucking motion begins when a nipple isplaced in the neonate’s mouth.6 monthsBabinski’s When the sole on the side of the smalltoe is stroked, the neonate’s toes fanupward.2 yearsStepping When held upright with the feet touch-ing a flat surface, the neonate exhibitsdancing or stepping movements.VariablePediatric_Assess Chap02.indd 45Pediatric_Assess Chap02.indd 45 11/27/2009 5:37:35 PM11/27/2009 5:37:35 PM
  • 46AssessLocating the fontanelsThe locations of the anterior and posterior fontanels aredepicted in this illustration of the top of a neonatal skull.Theanterior fontanel typically closes by age 18 months, the poste-rior fontanel by age 2 months.Frontal sutureFrontal boneAnteriorfontanelCoronal sutureSagittal sutureLambdoid sutureParietal bonePosteriorfontanelOccipital bonePediatric_Assess Chap02.indd 46Pediatric_Assess Chap02.indd 46 11/27/2009 5:37:35 PM11/27/2009 5:37:35 PM
  • Assess47GI AND GU SYSTEMSGI and GU assessmentNormal findings for a GI and GUassessment are described below.Abnormal findings appear in color.InspectionGI: Abdomen symmetrical and•fairly prominent when sitting orstanding (flat when supine); noumbilical herniationGU: Urethra free from discharge•or inflammation; no inguinal her-niation; both testes descendedVisible peristaltic waves may be•a normal finding in infants andthin children; however, they mayalso indicate obstructive disor-ders such as pyloric stenosis.AuscultationGI: Normal bowel sounds; pos-•sible borborygmiGU: No bruits over renal arteries•Absent or hyperactive bowel•sounds warrant further investiga-tion because each usuallyindicates a GI disorder.PercussionGI:Tympany over empty stom-•ach or bowels; dullness over liver,full stomach, or stool in bowelsGU: No tenderness or pain•over kidneysPalpationGI: No tenderness, masses, or•pain; strong and equal femoralpulsesGU: No tenderness or pain•over kidneysTips for pediatric abdominal assessmentWarm your hands before beginning the assessment.•Note guarding of the abdomen and the child’s ability to move•around on the examination table.Flex the child’s knees to decrease abdominal muscle tightening.•Have the child use deep breathing or distraction during the exam-•ination; a parent can help divert the child’s attention.Have the child “help” with the examination.•Place your hand over the child’s hand on the abdomen and•extend your fingers beyond the child’s fingers to decrease ticklish-ness when palpating the abdomen.Auscultate the abdomen before palpation (palpation can produce•erratic bowel sounds); lightly palpate tender areas last.Pediatric_Assess Chap02.indd 47Pediatric_Assess Chap02.indd 47 11/27/2009 5:37:37 PM11/27/2009 5:37:37 PM
  • 48AssessAbdominal quadrantsRight upper quadrant• Right lobe of the liver• Gallbladder• Pylorus• Duodenum• Head of the pancreas• Hepatic flexure of the colon• Portions of the transverse andascending colonLeft upper quadrant• Left lobe of the liver• Stomach• Body of the pancreas• Splenic flexure of the colon• Portions of the transverseand descending colonRight lower quadrant• Cecum and appendix• Portion of the ascending colonLeft lower quadrant• Sigmoid colon• Portion of the descendingcolonPediatric_Assess Chap02.indd 48Pediatric_Assess Chap02.indd 48 11/27/2009 5:37:37 PM11/27/2009 5:37:37 PM
  • Assess49MUSCULOSKELETAL SYSTEMMusculoskeletal assessmentNormal findings for a musculo-skeletal assessment are describedbelow. Abnormal findings appearin color.InspectionExtremities are symmetrical in•length and size.No gross deformities are present.•Good body alignment is•evident.The child’s gait is smooth with•no involuntary movements.The child can perform active•range of motion with no pain inall muscles and joints.No swelling or inflammation is•present in joints or muscles.A lateral curvature of the spine•indicates scoliosis.PalpationMuscle mass shape is normal,•with no swelling or tenderness.Muscles are equal in tone,•texture, and shape bilaterally.No involuntary contractions or•twitching is evident.Bilateral pulses are equally•strong.The 5 Ps of musculoskeletal injuryPainAsk the child whether he feelspain. If he does, assess its loca-tion, severity, and quality.ParesthesiaAssess the child for loss of sen-sation by touching the injuredarea with the tip of an opensafety pin. Abnormal sensationor loss of sensation indicatesneurovascular involvement.ParalysisAssess whether the patient canmove the affected area.If he can’t, he might have nerveor tendon damage.PallorPaleness, discoloration, andcoolness on the injured sidemay indicate neurovascularcompromise.PulseCheck all pulses distal tothe injury site. If a pulse isdecreased or absent, blood sup-ply to the area is reduced.Pediatric_Assess Chap02.indd 49Pediatric_Assess Chap02.indd 49 11/27/2009 5:37:39 PM11/27/2009 5:37:39 PM
  • 50AssessDENTITIONSequence of tooth eruptionA child’s primary and secondary teeth will erupt in a predictableorder, as shown in these illustrations.Primary tooth eruptionMaxilla(upper teeth)Mandible(lower teeth)Teeth Age of eruptionCentral incisors 8 to 12 monthsLateral incisors 9 to 13 monthsCanines 16 to 22 monthsFirst molars Boys: 13 to 19 monthsGirls: 14 to 18 monthsSecond molars 25 to 33 monthsSecond molars Boys: 23 to 31 monthsGirls: 24 to 30 monthsFirst molars 14 to 18 monthsCanines 17 to 23 monthsLateral incisors 10 to 16 monthsCentral incisors 6 to 10 monthsPediatric_Assess Chap02.indd 50Pediatric_Assess Chap02.indd 50 11/27/2009 5:37:39 PM11/27/2009 5:37:39 PM
  • Assess51Sequence of tooth eruption (continued)Secondary (or permanent) tooth eruptionTeeth Age of eruptionCentral incisors 7 to 8 yearsLateral incisors 8 to 9 yearsCuspids 11 to 12 yearsFirst bicuspids 10 to 11 yearsSecond bicuspids 10 to 12 yearsFirst molars 6 to 7 yearsSecond molars 12 to 13 yearsThird molars VariableThird molars 17 to 21 yearsSecond molars 11 to 13 yearsFirst molars 6 to 7 yearsSecond bicuspids 11 to 12 yearsFirst bicuspids 10 to 12 yearsCuspids 9 to 10 yearsLateral incisors 7 to 8 yearsCentral incisors 6 to 7 yearsMaxilla (upper teeth)Mandible (lower teeth)Pediatric_Assess Chap02.indd 51Pediatric_Assess Chap02.indd 51 11/27/2009 5:37:39 PM11/27/2009 5:37:39 PM
  • 52AssessPAINPain assessmentAssessing pain in infants and young children requires the coopera-tion of the parents and the use of age-specific assessment tools. Ifthe child can communicate verbally, he can also aid in the process.History questionsTo help you better understand the child’s pain, ask the parentsthese questions:What kinds of pain has your child had in the past?•How does your child usually respond to pain?•How do you know your child is in pain?•What do you do when he’s hurting?•What does your child do when he’s hurting?•What works best to relieve your child’s pain?•Is there anything special you would like me to know about•your child and pain?Behavioral responses to painBehavior is the language infants and children rely on to conveyinformation about their pain. In an infant, facial expression isthe most common and consistent behavioral response to allstimuli, painful or pleasurable, and may be the single best indi-cator of pain for the provider and the parent. Facial expressionsthat tend to indicate that the infant is in pain include:mouth stretched open•eyes tightly shut•brows and forehead knitted (as they are in a grimace)•cheeks raised high enough to form a wrinkle on the nose.•In young children, facial expression is joined by other behav-iors to convey pain. In these patients, look for such signs as:narrowing of the eyes•grimace or fearful appearance•frequent and longer-lasting bouts of crying, with a tone that’s•higher and louder than normalless receptiveness to comforting by parents or other caregivers•holding or protecting the painful area.•Pediatric_Assess Chap02.indd 52Pediatric_Assess Chap02.indd 52 11/27/2009 5:37:41 PM11/27/2009 5:37:41 PM
  • Assess53FLACC ScaleThe Face, Legs, Activity, Cry, Consolability (FLACC) Scale usesthe characteristics listed below to measure pain in infants.The FLACC is a behavioral pain assessment scale for use innonverbal patients unable to provide reports of pain. Here’s howto use it: 1. Rate patient in each of the five measurement catego-ries; 2. Add scores together; 3. Document total pain score.Category Score0 1 2Face No particularexpression orsmileOccasionalgrimace or frown,withdrawn,disinterestedFrequent to con-stant frown,clenched jaw, andquivering chinLegs Normal positionor relaxedUneasy, restless,tenseKicking or legsdrawn upActivity Lying quietly,normal position,moves easilySquirming, shiftingback/forth, tenseArched, rigid, orjerkingCry No cry (awakeor asleep)Moans or whim-pers, occasionalcomplaintCrying steadily,screams or sobs,frequent com-plaintsConsolability Content, relaxed Reassured byoccasional touch-ing, hugging, or“talking to,”distractibleDifficult to con-sole or comfortAdapted with permission from “The FLACC: A behavioral scale for scoringpostoperative pain in young children,” by S. Merkel, et al. Pediatric Nursing,23(3), 293-97, 1997. © 2002,The Regents of the University of Michigan.Pediatric_Assess Chap02.indd 53Pediatric_Assess Chap02.indd 53 11/27/2009 5:37:41 PM11/27/2009 5:37:41 PM
  • 54AssessMeasuring pain in young childrenFor children who are old enough to speak and understand suffi-ciently, three useful tools can help them communicate informa-tion for measuring their pain. Here’s how to use each one.The child age 3 and older canuse the faces scale to rate hispain. When using this tool,make sure he can see andpoint to each face and thendescribe the amount of paineach face is experiencing. Ifhe’s able, the child can readthe text under the picture;otherwise, you or his parentcan read it to him.Avoid saying anything thatmight prompt the child tochoose a certain face.Then askthe child to choose the facethat shows how he’s feelingright now. Record his responsein your assessment notes.Wong-Baker FACES Pain Rating ScaleFrom Hockenberry, M.J., andWilson, D. Wongs Essentials of Pediatric Nursing,8th ed. St. Louis: Mosby, 2009. Used with permission. Copyright Mosby.A visual analog pain scaleis simply a straight line withthe phrase “no pain” at oneend and the phrase “the mostpain possible” at the other.Children who understand theconcept of a continuum canmark the spot on the line thatcorresponds to the level ofpain they feel.Visual analog scaleNopainThe mostpain possible0No hurt0Alternatecoding:1Hurtslittle bit22Hurts littlemore43Hurts evenmore64Hurtswhole lot85Hurtsworst10Pediatric_Assess Chap02.indd 54Pediatric_Assess Chap02.indd 54 11/27/2009 5:37:41 PM11/27/2009 5:37:41 PM
  • Assess55Chip toolThe chip tool uses four identi-cal chips to signify levels ofpain and can be used for thechild who understands thebasic concept of adding onething to another to get more.If available, you can use pokerchips. If not, simply cut fouruniform circles from a sheet ofpaper. Here’s how to presentthe chips:First say, “I want to talk with•you about the hurt you mightbe having right now.”Next, align the chips horizon-•tally on the bedside table, aclipboard, or other firm sur-face where the child can easilysee and reach them.Point to the chip at the child’s•far left and say, “This chip isjust a little bit of hurt.”Point to the second chip and•say, “This next chip is a littlemore hurt.”Point to the third chip and•say, “This next chip is a lot ofhurt.”Point to the last chip and say,•“This last chip is the mosthurt you can have.”Ask the child, “How many•pieces of hurt do you haveright now?” (You won’t needto offer the option of “no hurtat all” because the child willtell you if he doesn’t hurt.)Record the number of chips.•If the child’s answer isn’t clear,talk to him about his answer,and then record your findings.Measuring pain in young children (continued)Pediatric_Assess Chap02.indd 55Pediatric_Assess Chap02.indd 55 11/27/2009 5:37:42 PM11/27/2009 5:37:42 PM
  • 56AssessCommon pediatric pain medicationsDrug ConsiderationsOpioidsMorphine Give single I.V. doses slowly over at least 5 minutes.•Use only preservative-free preparations in neonates.•Monitor the patient for respiratory depression after•administration.Fentanyl Infuse I.V. doses slowly, over at least 5 minutes.•Instruct the child to suck on lozenges, not chew•them.Monitor the patient for respiratory depression after•administration.Hydromorphone Monitor the patient for respiratory depression after•administration.Assess for pain relief 30 minutes after administration.•NonopioidsAcetaminophen Watch for signs and symptoms of hepatotoxicity after•administration, even with moderate doses.Don’t administer more than 5 doses in 24 hours.•Ibuprofen Instruct the patient (or his parents) that the drug•should be taken with meals or milk to reduce the riskof GI upset.Tablets may be crushed if the child can’t swallow•them; other alternatives include using suspension ordrops.Naproxen Use suspension if the child can’t swallow tablets.•Give the drug with food to reduce the risk of GI upset.•Pediatric_Assess Chap02.indd 56Pediatric_Assess Chap02.indd 56 11/27/2009 5:37:42 PM11/27/2009 5:37:42 PM
  • Assess57INTEGUMENTARY SYSTEMCauses of burnsClassifying burnsBurns are classified according to the depth of the injury, asfollows:First-degree burns• are limited to the epidermis. Sunburn is atypical first-degree burn.These burns are painful but self-limiting.They don’t lead to scarring and require only localwound care.Second-degree burns• extend into the dermis but leave someresidual dermis viable.These burns are painful and the skin willappear swollen and red with blister formation.Third-degree,• or full-thickness, burns involve the destructionof the entire dermis, leaving only subcutaneous tissue exposed.These burns look dry and leathery and are painless because thenerve endings are destroyed.Fourth-degree burns• are a rare type of burn usually associatedwith lethal injury.They extend beyond the subcutaneous tissue,involving the muscle, fasciae, and bone. Occasionally termedtransmural burns, these injuries are commonly associated withcomplete transection of an extremity.Type CausesThermal Flames, radiation, or excessive heat from fire, steam,or hot liquids or objectsChemical Various acids, bases, and causticsElectrical Electrical current and lightningLight Intense light sources or ultraviolet light, includingsunlightRadiation Nuclear radiation and ultraviolet lightPediatric_Assess Chap02.indd 57Pediatric_Assess Chap02.indd 57 11/27/2009 5:37:42 PM11/27/2009 5:37:42 PM
  • 58Assess1%2%13%1½%1½%2%1%1%Relative percentages of areas affected by ageAt birth 0 to 1 yr 1 to 4 yr 5 to 9 yr 10 to 15 yr 16+ yrA: Half of head9½% 8½% 6½% 5½% 4½% 3½%B: Half of thigh2½% 3½% 4% 4½% 4½% 4½%C: Half of leg2½% 2½% 2½% 3% 3½% 3½%Estimating the extent of burnsLund-Browder chartUse to estimate the extent ofan infant’s or a child’s (up toage 7) burns.Rule of NinesUse to estimate the extent ofan older child’s or a teenager’sburns.4½%4½%4½% 4½% 4½% 4½%18%1%18%9% 9%9% 9%AABBC CBBC CPediatric_Assess Chap02.indd 58Pediatric_Assess Chap02.indd 58 11/27/2009 5:37:42 PM11/27/2009 5:37:42 PM
  • Assess59MENTAL HEALTHRecognizing child abuse and neglectIf you suspect a child is being harmed, contact your local childprotective services or the police. Contact the Childhelp USANational Child Abuse Hotline (1-800-4-A-CHILD) to find outwhere and how to file a report.The following signs may indicate child abuse or neglect.ChildrenShow sudden changes in behavior or school performance•Haven’t received help for physical or medical problems•brought to the parent’s attentionAre always watchful, as if preparing for something bad to•happenLack adult supervision•Are overly compliant, passive, or withdrawn•Come to school or activities early, stay late, and don’t want to•go homeParentsShow little concern for the child•Deny or blame the child for the child’s problems in school or at•homeRequest that teachers or caregivers use harsh physical disci-•pline if the child misbehavesSee the child as entirely bad, worthless, or burdensome•Demand a level of physical or academic performance the child•can’t achieveLook primarily to the child for care, attention, and satisfaction•of emotional needsParents and childrenRarely look at each other•Consider their relationship to be entirely negative•State that they don’t like each other•Pediatric_Assess Chap02.indd 59Pediatric_Assess Chap02.indd 59 11/27/2009 5:37:43 PM11/27/2009 5:37:43 PM
  • 60AssessSigns of child abuseHere are some signs associated with specific types of childabuse and neglect.These types of abuse are typically found incombination rather than alone.Physical abuseHas unexplained burns, bites, bruises, broken bones, black•eyesHas fading bruises or marks after absence from school•Cries when it’s time to go home•Shows fear at approach of adults•Reports injury by parent or caregiver•NeglectIs frequently absent from school•Begs or steals food or money•Lacks needed medical or dental care, immunizations, or•glassesIs consistently dirty and has severe body odor•Lacks sufficient clothing for the weather•Sexual abuseHas difficulty walking or sitting•Suddenly refuses to change for gym or join in physical activities•Reports nightmares or bedwetting•Demonstrates bizarre, sophisticated, or unusual sexual•knowledge or behaviorBecomes pregnant or contracts a venereal disease when•younger than age 14Emotional maltreatmentShows extremes in behavior, such as overly compliant or•demanding behavior, extreme passivity, or aggressionIs inappropriately adult (parenting other children) or•inappropriately infantile (frequent rocking or head banging)Shows delayed physical or emotional development•Reports a lack of attachment to the parent•Has attempted suicide•Pediatric_Assess Chap02.indd 60Pediatric_Assess Chap02.indd 60 11/27/2009 5:37:43 PM11/27/2009 5:37:43 PM
  • Assess61Suicide warning signsWatch for these warning signs of impending suicide:withdrawal or social isolation•signs of depression, which may include crying, fatigue, help-•lessness, hopelessness, poor concentration, reduced interest indaily activities, sadness, constipation, and weight lossfarewells to friends and family•putting affairs in order•giving away prized possessions•expression of covert suicide messages and death wishes•obvious suicide messages such as, “I would be better off dead.”•Answering a threatIf a patient shows signs of impending suicide, assess the seri-ousness of the intent and the immediacy of the risk. Considera patient with a chosen method who plans to commit suicidein the next 48 to 72 hours a high risk.Tell the patient that you’re concerned. Urge him to avoidself-destructive behavior until the staff has an opportunity tohelp him. Consult with the treatment team about psychiatrichospitalization.Initiate the following safety precautions for those at highrisk for suicide:Provide a safe environment.•Remove dangerous objects, such as belts, razors, suspend-•ers, electric cords, glass, knives, nail files, and clippers.Make the patient’s specific restrictions clear to staff mem-•bers, and plan for observation of the patient.Stay alert when the patient is shaving, taking medication, or•using the bathroom.Encourage continuity of care and consistency of primary•nurses.Pediatric_Assess Chap02.indd 61Pediatric_Assess Chap02.indd 61 11/27/2009 5:37:43 PM11/27/2009 5:37:43 PM
  • 62Comprehensive metabolic panelThyroid panelTest Conventional units SI unitsAlbumin 3.5 to 5 g/dl 35 to 50 g/LAlkalinephosphatase2 to 10 yr: 100 to 300 units/L11 to 18 yr:Male: 50 to 375 units/L;Female: 30 to 300 units/L2 to 10 yr: 100 to 300 units/L11 to 18 yr:Male: 50 to 375 units/L;Female: 30 to 300 units/LALT < 1 yr: 5 to 28 units/L> 1 yr: 820 units/L< 1 yr: 5 to 28 units/L> 1 yr: 820 units/LAST < 1 yr: 15 to 60 units/L> 1 yr: < 20 units/L< 1 yr: 15 to 60 units/L> 1 yr: < 20 units/LBilirubin, total < 10 mg/dl < 171 µmol/LBUN 5 to 20 mg/dl 2 to 7 mmol/LCalcium, ionized 4.48 to 4.92 mg/dl 1.12 to 1.23 mmol/LCalcium, total 8 to 10.5mg/dl 2 to 2.6 mmol/LCarbon dioxide 22 to 26 mEq/L 22 to 26 mmol/LChloride 94 to 106 mEq/L 94 to 106 mmol/LCreatinine 0.3 to 0.7 mg/dl 27 to 62 µmol/LGlucose 60 to 105 mg/dl 3.3 to 5.8 mmol/LPotassium 3.5 to 5 mEq/L 3.5 to 5 mmol/LProtein, total 6.5 to 8.6 g/dl 65 to 86 g/LSodium 135 to 145 mEq/L 135 to 145 mmol/LLabsTest Conventional units SI unitsTriiodothyronine(T3)1 to 5 yr: 105 to 269 ng/dl5 to 10 yr: 94 to 241 ng/dl10 to 15 yr: 83 to 215 ng/dl1 to 5 yr: 1.62 to 4.14 nmol/L5 to 10 yr: 1.45 to 3.71 nmol/L10 to 15 yr: 1.28 to 3.31 nmol/LThyroxine (T4),free0.7 to 1.7 ng/dl 9 to 22 pmol/LT4, total 1 to 5 yr: 7.3 to 15 mcg/dl5 to 10 yr: 6.4 to 13.3 mcg/dl10 to 15 yr: 5.6 to 11.7 mcg/dl1 to 5 yr: 94 to 194 nmol/L5 to 10 yr: 83 to 172 nmol/L10 to 15 yr: 72 to 151 nmol/LTSH 0.4 to 4.2 µunits/L 0 to 5.5 mIU/mlPediatric_Labs Chap03.indd 62Pediatric_Labs Chap03.indd 62 11/27/2009 5:48:13 PM11/27/2009 5:48:13 PM
  • 6363LabsOther chemistry testsTest ConventionalunitsSI unitsAmmonia 13 to 48 mcg/dl 9 to 34 µmol/LAmylase > 1 yr: 26 to 102 units/L > 1 yr: 26 to 102 units/LAnion gap 7 to 14 mEq/L 7 to 14 mmol/LBilirubin, direct < 0.5 mg/dl < 6.8 µmol/LCalcium, ionized 4.48 to 4.92 mg/dl 1.12 to 1.23 mmol/LCortisol a.m.: 8 to 18 mcg/dlp.m.: 16 to 36 mcg/dl225 to 505 nmol/L450 to 1010 nmol/LC-reactive protein < 0.8 mg/dl < 8 mg/LFerritin 7 to 144 ng/ml 7 to 144 mcg/LFolate 1.8 to 9.0 ng/ml 4 to 20 nmol/LGGT 0 to 23 units/L 0 to 23 units/LGlycosylatedhemoglobin(HbA1c )3.9% to 7.7% 0.039 to 0.077Iron 53 to 119 mcg/dl 9.5 to 27 µmol/LIron-bindingcapacity250 to 400 mcg/dl 45 to 72 µmol/LMagnesium 1.5 to 2.0 mEq/l 0.75 to 1 mmol/LOsmolality 285 to 295 mOsm/kg 285 to 295 mOsm/kgPhosphate 1 yr: 3.8 to 6.2 mg/dl2 to 5 yr: 3.5 to 6.8 mg/dl1 yr: 1.23 to 2 mmol/L2 to 5 yr: 1.03 to 2.2mmol/LUric acid 2 to 7 mg/dl 120 to 420 µmol/LPediatric_Labs Chap03.indd 63Pediatric_Labs Chap03.indd 63 11/27/2009 5:48:13 PM11/27/2009 5:48:13 PM
  • 64LabsComplete blood count with differentialTest Conventional units SI unitsHemoglobin 2 to 6 mo: 10.7 to 17.3 g/dl1 to 12 yr: 9.5 to 14.1 g/dl6 to 16 yr: 10.3 to 14.9 g/dl2 to 6 mo: 107 to 173 mmol/L1 to 12 yr: 95 to 141 mmol/L6 to 16 yr: 103 to 149 mmol/LHematocrit 2 to 6 mo: 35% to 49%6 mo to 1 yr: 29% to 43%1 to 6 yr: 30% to 40%6 to 16 yr: 32% to 42%2 to 6 mo: 0.35 to 0.496 mo to 1 yr: 0.29 to 0.431 to 6 yr: 0.30 to 0.406 to 16 yr: 0.32 to 0.42RBC 6 mo to 1 yr: 3.8 to 5.2 ϫ106/mm36 to 16 yr: 4 to 5.2 ϫ 106/mm36 mo. to 1 yr: 3.8 to5.2 ϫ 1012/L6 to 16 yr: 4 to 5.2 ϫ 1012/LMCH 2 to 6 yr: 24 to 30 pg/cell6 to 12 yr: 25 to 33 pg/cell12 to 18 yr: 25 to 35 pg/cell2 to 6 yr: 0.37 to 0.47 fmol/cell6 to 12 yr: 0.39 to 0.51 fmol/cell12 to 18 yr: 0.39 to 0.53fmol/cellMCHC 34 g/dl 340 g/LMCV 2 to 6 yr: 82 mm36 to 12 yr: 86 mm312 to 18 yr: 88 mm32 to 6 yr: 82 fL6 to 12 yr: 86 fL12 to 18 yr: 88 fLWBC 2 mo to 6 yr: 5,000 to19,000 cells/mm36 to 18 yr: 4,800 to10,800 cells/mm32 mo to 6 yr: 5 to 19 ϫ 1096 to 18 yr: 4.8 to 10.8 ϫ 109Bands 5% to 11% 0.05 to 0.11Basophils 0% 0Eosinophils 0% to 3% 0 to 0.03Lymphocytes 25% to 76% 0.25 to 0.76Monocytes 0% to 5% 0 to 0.05Neutrophils 54% to 62% 0.54 to 0.62Platelets 150,000 to 450,000/mm3150 to 450 ϫ 109/LPediatric_Labs Chap03.indd 64Pediatric_Labs Chap03.indd 64 11/27/2009 5:48:13 PM11/27/2009 5:48:13 PM
  • 65Labs65Antibiotic peaks and troughsTest Conventional units SI unitsAmikacin PeakTrough20 to 30 mcg/ml1 to 4 mcg/ml34 to 52 µmol/L2 to 7 µmol/LChloramphenicol PeakTrough15 to 25 mcg/ml5 to 15 mcg/ml46.4 to 77 µmol/L15.5 to 46.4 µmol/LGentamicin PeakTrough4 to 8 mcg/ml1 to 2 mcg/ml4 to 16.7 µmol/L2.1 to 4.2 µmol/LTobramycin PeakTrough4 to 8 mcg/ml1 to 2 mcg/ml4 to 16.7 µmol/L2.1 to 4.2 µmol/LVancomycin PeakTrough25 to 40 mcg/ml5 to 10 mcg/ml17 to 27 µmol/L3.4 to 6.8 µmol/LUrine testsTest Conventional units SI unitsUrinalysisAppearance Clear to slightly hazy —Color Straw to dark yellow —pH 4.5 to 8 —Specific gravity 1.005 to 1.035 —Glucose None —Protein None —RBCs None or rare —WBCs None or rare —Osmolality 50 to 1,200 mOsm/kg —Lipid panel (children ages 2 to 19)Test Conventional units SI unitsTotal cholesterol Acceptable: < 170 mg/dl; Borderline:170 to 199 mg/dl; High: > 200 mg/dl—LDL Acceptable: < 110 mg/dl; Borderline:110 to 129 mg/dl; High: > 130 mg/dl—HDL > 35 mg/dl —Triglycerides < 150 mg/dl —Pediatric_Labs Chap03.indd 65Pediatric_Labs Chap03.indd 65 11/27/2009 5:48:13 PM11/27/2009 5:48:13 PM
  • 66LabsDisorder ABG findings Possible causesRespiratoryacidosis(excess CO2retention)pH < 7.35•HCO• 3–> 26 mEq/L(if compensating)Pa• CO2> 45 mm HgCentral nervous system depres-•sion from drugs, injury, or diseaseHypoventilation from respiratory,•cardiac, musculoskeletal, or neu-romuscular diseaseRespiratoryalkalosis(excess CO2loss)pH > 7.45•HCO• 3–< 22 mEq/L(if compensating)Pa• CO2< 35 mm HgHyperventilation due to anxiety,•pain, or improper ventilatorsettingsRespiratory stimulation from•drugs, disease, hypoxia, fever,or high room temperatureGram-negative bacteremia•Metabolicacidosis(HCO3–loss oracid retention)pH < 7.35•HCO• 3–< 22 mEq/LPa• CO2< 35 mm Hg(if compensating)Depletion of HCO• 3–from renaldisease, diarrhea, or small-bowelfistulasExcessive production of organic•acids from hepatic disease,endocrine disorders such asdiabetes mellitus, hypoxia,shock, or drug toxicityInadequate excretion of acids•due to renal diseaseMetabolicalkalosis(HCO3–retentionor acid loss)pH > 7.45•HCO• 3–> 26 mEq/LPa• CO2> 45 mm Hg(if compensating)Loss of hydrochloric acid from•prolonged vomiting or gastricsuctioningLoss of potassium from•increased renal excretion (as indiuretic therapy) or corticosteroidoverdoseExcessive alkali ingestion•Recognizing acid-base disordersPediatric_Labs Chap03.indd 66Pediatric_Labs Chap03.indd 66 11/27/2009 5:48:13 PM11/27/2009 5:48:13 PM
  • 6767Meds/IV67ChildhoodimmunizationscheduleRecommendedimmunizationscheduleforpersonsaged0–6years—UnitedStates,2009AgeVaccineBirth1mo2mo4mo6mo12mo15mo18mo19–23mo2–3yr4–6yrHepatitisBHepBHepBHepBRotavirusRVRVRVDiphtheria,tetanus,pertussisDTaPDTaPDTaPDTaPDTaPHaemophilusinfluenzaetypebHibHibHibHibPneumococcalPCVPCVPCVPCVPPSVInactivatedpoliovirusIPVIPVIPVIPVInfluenzaInfluenza(yearly)Measles,mumps,rubellaMMRMMRVaricellaVaricellaVaricellaHepatitisAHepA(2doses)HepAseriesMeningococcalMCVKey:RangeofrecommendedagesCertainhigh-riskgroupsFormoredetailedinformation,seeCentersforDiseaseControlandPrevention.Recommendedimmunizationschedulesforpersonsages0–6years—UnitedStates,2008.(continued)Pediatric_Meds Chap04.indd 67Pediatric_Meds Chap04.indd 67 11/27/2009 5:49:27 PM11/27/2009 5:49:27 PM
  • 68Meds/IVChildhoodimmunizationschedule(continued)Recommendedimmunizationscheduleforpersonsaged7–18years—UnitedStates,2009AgeVaccine7–10years11–12years13–18yearsTetanus,diphtheria,pertussisSeefullscheduleTdapTdapHumanpapillomavirusSeefullscheduleHPV(3doses)HPVseriesMeningococcalMCVMCVMCVPneumococcalPPSVInfluenzaInfluenza(yearly)HepatitisAHepAseriesHepatitisBHepBseriesInactivatedpoliovirusIPVseriesMeasles,mumps,rubellaMMRseriesVaricellaVaricellaseriesKey:RangeofrecommendedagesCatch-upimmunizationCertainhigh-riskgroupsFormoredetailedinformation,seeCentersforDiseaseControlandPrevention.Recommendedimmunizationschedulesforpersonsages7–18years—UnitedStates,2008.Pediatric_Meds Chap04.indd 68Pediatric_Meds Chap04.indd 68 11/27/2009 5:49:28 PM11/27/2009 5:49:28 PM
  • 6969Meds/IV69Catch-up immunizationsProtection from certain serious communicable diseases can beobtained through immunization with a variety of vaccines. With-out proper immunization, these diseases can cause chronic ill-ness, disability, cancer, or death. Most immunizations are givenin a series during infancy and childhood and provide lifelongprotection if the series is completed. Some vaccines, such astetanus, require booster shots to maintain immunity.If a child hasn’t had access to medical care, has been seri-ously ill, or is an immigrant, he might not have received therecommended immunizations. Catch-up immunizations shouldbe administered to protect that child and to protect others fromexposure in such facilities as daycares and schools.Complete information about catch-up immunizations can befound at Chap04.indd 69Pediatric_Meds Chap04.indd 69 11/27/2009 5:49:28 PM11/27/2009 5:49:28 PM
  • 70Meds/IVDosage calculation formulas andcommon conversionsCommon calculationschild’s dose in mg = child’s BSA in m2× pediatric dose in mgm2/daychild’s BSA in m2child’s dose in mg =average adult BSA (1.73 m2)× average adult dosemcg/ml = mg/ml × 1,000ml/minute =ml/hour60mg/minute =mg in bag× flow rate Ϭ 60ml in bagmcg/minute =mg in bagϬ 0.06 × flow rateml in bagmcg/kg/minute = mcg/ml × ml/minuteweight in kgCommon conversions1 kg ϭ 1,000 g 1 L ϭ 1,000 ml 8 oz ϭ 240 ml1 g ϭ 1,000 mg 1 ml ϭ 1,000 microliters 1 oz ϭ 30 g1 mg ϭ 1,000 mcg 1 tsp ϭ 5 ml 1 lb ϭ 454 g1 tbs ϭ 15 ml 2.2 lb ϭ 1 kg1Љ ϭ 2.54 cm 2 tbs ϭ 30 mlPediatric_Meds Chap04.indd 70Pediatric_Meds Chap04.indd 70 11/27/2009 5:49:28 PM11/27/2009 5:49:28 PM
  • 7171Meds/IV71Estimating BSA in childrenAdapted with permission from Behrman, R.E., et al. NelsonTextbook of Pediatrics,16th ed. Philadelphia: W.B. Saunders Co., 2000.Pediatric_Meds Chap04.indd 71Pediatric_Meds Chap04.indd 71 11/27/2009 5:49:28 PM11/27/2009 5:49:28 PM
  • 72Meds/IVI.M.injectionsitesinchildrenWhenselectingthebestsiteforachild’sI.M.injection,considerthechild’sage,weight,andmuscledevelopment;theamountofsubcutaneousfatovertheinjectionsite;thetypeofdrugyou’readmin-istering;andthedrug’sabsorptionrate.Theseguidelinesmayassistyouinmakingaselection.VentroglutealAppropriateage•Infants•Toddlers•Preschoolandolderchildren•AdolescentsNeedlesizeandlength•23to25gauge,5/8Љneedleforinfantslessthan4months•22to25gauge,1Љneedleforallotherage-groupsRecommendedmaximumamount•Give1mlorlesstoinfants.•Give2mlorlesstotoddlers.•Give3mlorlesstopre-schoolandolderchildren.•Give5mlorlesstoadolescents.Specialconsiderations•Thissiteislesspainfulthanthevastuslateralis.•Thissiteisalsorelativelyfreefrommajornervesandbloodvessels.VastuslateralisAppropriateage•Infants•ToddlersNeedlesizeandlength•Infantsunder4months:23to25gauge,5/8Љ•Infantsover4monthsandtoddlers:22to25gauge,1ЉRecommendedmaximumamount•Give1mlorlesstoinfants.•Give2mlorlesstotoddlers.Specialconsiderations•Thevastuslateralisisalarge,well-developedmusclewithfewmajorbloodvesselsornerves.•Therectusfemorismuscleshouldbeavoidedwhenusingthisinjectionsite.GreatertrochanterRectusfemorismuscleInjectionsiteFemoralarteryIliaccrestInjectionsiteAnteriorsuperioriliacspinePediatric_Meds Chap04.indd 72Pediatric_Meds Chap04.indd 72 11/27/2009 5:49:28 PM11/27/2009 5:49:28 PM
  • 7373Meds/IV73Appropriateage•Childrenolderthanage2yearsNeedlesizeandlength•20to25gauge,1/2Љto11/2ЉneedleRecommendedmaximumamount•Give1.5mlorlesstochil-drenages2to6.•Give2mlorlesstochil-drenoverage6.Specialconsiderations•Thissiteisn’trecom-mendedforchildrenwhohaven’tbeenwalkingforatleastayear.•Injurytothesciaticnerveispossiblewhenusingthissite.Appropriateage•Toddlers•Preschoolandolderchil-dren•AdolescentsNeedlesizeandlength•22to25gauge,5/8Љto1Љneedleinallage-groupsRecommendedmaximumamount•Give1mlorlessintod-dlersandpreschoolandolderchildren.•Give1to11/2mlinadolescents.Specialconsiderations•Thissiteisassociatedwithlesspainthanthevastuslateralissite.•Becausebloodflowsfasterinthedeltoidmusclethaninothermusclesites,drugabsorptionisfaster.•Injurytotheradialnerveispossiblewhenusingthissite.I.M.injectionsitesinchildren(continued)DorsoglutealDeltoidPosteriorsuperioriliaccrestGreatertrochanterInjectionsiteSciaticnerveBrachialarteryRadialnerveInjectionsitePediatric_Meds Chap04.indd 73Pediatric_Meds Chap04.indd 73 11/27/2009 5:49:29 PM11/27/2009 5:49:29 PM
  • 74Meds/IVTips for pediatric injectionsWhen giving a child an injection, the major goal should be tominimize trauma and discomfort while providing safe, efficientadministration of a necessary medicine or vaccination.To most toddlers and preschoolers—and to many olderchildren—the prospect of an injection is the most frighteningpart of a doctor’s visit or even a hospitalization. Many strate-gies, including those outlined here, can be used to minimize thetrauma of receiving an injection, while establishing trust betweenthe child and the health care team and making future injectionseasier for the child (and for the nurse who’s giving the injection).Medicine to keep you healthyGive the child a simple, age-appropriate explanation for why•the injection is being given. When a child is being vaccinated,that explanation might be, “This shot will give you medicine tokeep you from getting sick.” (Young children may think an injec-tion is being given as a punishment and may not even realizethat medication is being given.)Allow the child to give a “shot” to a doll or stuffed animal to•give him a sense of control, to let him see that the injection hasa beginning and an end, and to give him a clear understandingof what will happen.The best policyBe honest; tell the child that it will hurt for a moment but that•it will be over quickly. (Honesty promotes trust; if a nurse ishonest about the potential for pain, the child will believe herwhen she tells him something won’t hurt.)Coping and comfortGive the child a coping strategy, such as squeezing his mother’s•hand, counting to five, singing a song, and looking away.Have a parent hold and comfort the child while the injection is•being given. A parent’s presence reassures the child that nothingtruly bad will happen. (The child may actually cry more when a par-ent is present, but this is because he feels safe enough to do so.)Pediatric_Meds Chap04.indd 74Pediatric_Meds Chap04.indd 74 11/27/2009 5:49:29 PM11/27/2009 5:49:29 PM
  • 7575Meds/IV75Tips for pediatric injections (continued)Praise and coverWhen the injection has been given, tell the child that “the•hurting part” is over, and praise him for what a good job he did(regardless of how he reacted). Never tell a child to “be brave,”to “be a big boy,” or not to cry, as these requests will set thechild up for failure.Give the child a bandage. (A young child may not believe the•“hurting part” is over until a bandage has been applied.)Always give injections in a designated treatment area. Avoid•performing painful procedures in a playroom or, if possible, inthe child’s hospital room, because he needs to know there areplaces where he can feel completely safe.Giving the injectionApply firm pressure at the site for 10 to 15 seconds immedi-•ately before giving the injection to decrease discomfort(a numbing patch may be used).When two or more injections are needed, give them simulta-•neously in different extremities; have two or more nurses assist(and provide manual restraint, if needed) during the proce-dures. (The child has only one painful experience when multipleinjections are given simultaneously; this is believed to be lesstraumatic than receiving painful injections one after the other.)Apply bandages to each site, and immediately comfort and•console the child following the injections.Always keep resuscitation equipment and epinephrine readily•available in case of an anaphylactic response to an immunization.Pediatric_Meds Chap04.indd 75Pediatric_Meds Chap04.indd 75 11/27/2009 5:49:29 PM11/27/2009 5:49:29 PM
  • 76Meds/IVPerforming intraosseous administrationIn an emergency, intraosseousdrug administration may beused for a critically ill childyounger than age 6. Insert abone marrow needle (or spinalneedle with stylette, trephine,or standard 16G to 18Ghypodermic needle) into theanteromedial surface of theproximal tibia 3/8Љ to 11/4Љ(1 to 3 cm) below the tibialtuberosity.To avoid the epi-physeal plate, direct theneedle at a perpendicular orslightly inferior angle.After penetrating the bonycortex and inserting theneedle into the marrow cav-ity, you’ll feel no resistance,you’ll be able to aspiratebone marrow, the needle willremain upright without sup-port, and the infusion will flowfreely without subcutaneousinfiltration. If bone or marrowobstructs the needle, replacethe needle by passing a sec-ond one through the cannula.When the needle is properlyinserted, stabilize and secure itwith gauze dressing and tape.Discontinue the intraosseousneedle and line when a secureI.V. line is established.Anteromedialsurface of tibiaTibial tuberosityNeedleperpendicularto surfacePediatric_Meds Chap04.indd 76Pediatric_Meds Chap04.indd 76 11/27/2009 5:49:29 PM11/27/2009 5:49:29 PM
  • 7777Meds/IV77Calculating pediatric fluid needsDetermining and meeting the fluid needs of children areimportant nursing responsibilities. Keep in mind that fluidreplacement can also be affected by clinical conditions thatcause fluid retention or loss. Children with these conditionsshould receive fluids based on their individual needs.Fluid needs based on weightChildren weighing under 10 kg require 100 ml of fluid per kilo-•gram of body weight per day:weight in kg ϫ 100 ml/kg/day ϭ fluid needs in ml/dayChildren weighing 10 to 20 kg require 1,000 ml of fluid per day•for the first 10 kg plus 50 ml for every kilogram over 10:(total kg Ϫ 10 kg) ϫ 50 ml/kg/day ϭ additional fluid need in ml/day1,000 ml/day ϩ additional fluid need ϭ fluid needs in ml/dayChildren weighing more than 20 kg require 1,500 ml of fluid•for the first 20 kg plus 20 ml for each additional kilogram:(total kg Ϫ 20 kg) ϫ 20 ml/kg/day ϭ additional fluid need in ml/day1,500 ml/day ϩ additional fluid need ϭ fluid needs in ml/dayFluid needs based on caloriesA child should receive 120 ml of fluid for every 100 kilocaloriesof metabolism (calorie requirements can be found in a table ofrecommended dietary allowances for children, or calculated bya dietitian):fluid requirements in ml/day ϭcalorie requirementsϫ 120 ml100 kcalFluid needs based on BSAMultiply the child’s BSA by 1,500 to calculate the daily fluidneeds of a child who isn’t dehydrated:fluid maintenance needs in ml/day ϭ BSA in m2ϫ 1,500 ml/day/m2Pediatric_Meds Chap04.indd 77Pediatric_Meds Chap04.indd 77 11/27/2009 5:49:30 PM11/27/2009 5:49:30 PM
  • 78Meds/IVI.V. insertion sites in infantsThis illustration shows the preferred sites for inserting venousaccess devices in infants. If a scalp vein is used, hair may beshaved around the area to enable better visualization of the veinand monitoring of the site after insertion. (Be sure to preparethe parents for this possibility and save the hair for them.)Frontal veinMediancubital veinBasilic veinCephalic veinMedian veinGreatsaphenousveinDorsal venousarchSuperficialtemporal veinPosteriorauricular veinCephalic veinBasilic veinDorsal venousnetwork withtributariesMedianmarginal veinPediatric_Meds Chap04.indd 78Pediatric_Meds Chap04.indd 78 11/27/2009 5:49:30 PM11/27/2009 5:49:30 PM
  • 7979Meds/IV79I.V. solutionsIsotonicIsotonic solutionsexpand the intravas-cular compartment.When administeringan isotonic solution,monitor for fluidoverload. Isotonicsolutions include:D• 5W0.9% NaCl•Ringer’s solution•lactated Ringer’s•solution.HypertonicHypertonic solutionsgreatly expand theintravascular com-partment and drawfluid from intravas-cular areas. Whenadministering ahypertonic solution,monitor for fluidoverload. Hypertonicsolutions include:D• 10W3% NaCl•5% NaCl•D• 5LRD• 50.45% NaClD• 50.9% NaCl.HypotonicHypotonic solutionscause a fluid shiftfrom the intravas-cular compartmentinto the cells. Whenadministering ahypotonic solution,monitor for cardio-vascular collapse.Hypotonic solutionsinclude:D• 2.5W0.45% NaCl•0.33% NaCl.•Determining compatibility for bloodtransfusionsCompatible donors(universal donor) O– O+ B– B+ A– A+ AB– AB+Patient’sABOgroup(universal recipient) AB+ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔AB– ✔ ✔ ✔ ✔A+ ✔ ✔ ✔ ✔A– ✔ ✔B+ ✔ ✔ ✔ ✔B– ✔ ✔O+ ✔ ✔O– ✔Pediatric_Meds Chap04.indd 79Pediatric_Meds Chap04.indd 79 11/27/2009 5:49:30 PM11/27/2009 5:49:30 PM
  • 80Meds/IVInsulin overviewInsulintypeOnset Peak UsualeffectivedurationUsualmaximumdurationAnimalRegular 0.5 to 2 hr 3 to 4 hr 4 to 6 hr 6 to 8 hrNPH 4 to 6 hr 8 to 14 hr 16 to 20 hr 20 to 24 hrHumanInsulin aspart 5 to 10 min 1 to 3 hr 3 to 5 hr 4 to 6 hrInsulin lispro < 15 min 0.5 to 1.5 hr 2 to 4 hr 4 to 6 hrRegular 0.5 to 1 hr 2 to 3 hr 3 to 6 hr 6 to 10 hrNPH 2 to 4 hr 4 to 10 hr 10 to 16 hr 14 to 18 hrLente 3 to 4 hr 4 to 12 hr 12 to 18 hr 16 to 20 hrUltralente 6 to 10 hr — 18 to 20 hr 20 to 24 hrInsulin glargine 1.1 hr — 24 hr 24 hrPediatric_Meds Chap04.indd 80Pediatric_Meds Chap04.indd 80 11/27/2009 5:49:30 PM11/27/2009 5:49:30 PM
  • 8181Meds/IV81Insulin injection sites in childrenUse these illustrations to instruct the child and his parents aboutthe injection sites for insulin administration that are recom-mended by the American Diabetes Association.Pediatric_Meds Chap04.indd 81Pediatric_Meds Chap04.indd 81 11/27/2009 5:49:30 PM11/27/2009 5:49:30 PM
  • 82Meds/IVSafe drug administration guidelinesWhen administering a drug, besure to adhere to best practices toavoid potential problems.You canhelp prevent drug mistakes byfollowing these guidelines as wellas your facility’s policies.Drug ordersDon’t rely on the pharmacy•computer system to detect allunsafe orders. Before you give adrug, understand the correctdosage, indications, and adverseeffects. If necessary, check a cur-rent drug reference guide.Be aware of the drugs your•patient takes regularly, andquestion any deviation from hisregular routine. As with anydrug, take your time and readthe label carefully.Ask all prescribers to spell out•drug names and any error-proneabbreviations.Before you give drugs that are•ordered in units, such as insulinand heparin, always check theprescriber’s written order againstthe provided dose. Never abbre-viate the word “units.”• If you must accept a verbalorder, have another nurse listenin; then transcribe that orderdirectly onto an order form andrepeat it to the prescriber toensure that you’ve transcribed itcorrectly.To prevent an acetaminophen•overdose from combined anal-gesics, note the amount ofacetaminophen in each drug.Beware of substitutions by thepharmacy because the amountof acetaminophen may vary.Keep in mind that lipid-based•products have different dosagesthan their conventional counter-parts. Check the doctor’s ordersand labels carefully to avoidconfusion.Drug preparationIf a familiar drug has an•unfamiliar appearance, find outwhy. If the pharmacist cites amanufacturing change, ask himto double-check whether he hasreceived verification from themanufacturer. Document theappearance discrepancy, youractions, and the pharmacist’sresponse in the patient record.Obtain a new allergy history•with each admission. If thepatient’s history must be faxed,name the drugs, note howmany are included, and followyour facility’s faxing safe-guards. If the pharmacy alsoadheres to strict guidelines, thecomputer-generated medicationadministration record should beaccurate.Pediatric_Meds Chap04.indd 82Pediatric_Meds Chap04.indd 82 11/27/2009 5:49:31 PM11/27/2009 5:49:31 PM
  • 8383Meds/IV83Safe drug administration guidelines(continued)Giving drugsUse two patient identifiers,•such as the patient’s name andassigned medical record num-ber, to identify the patient beforeadministering any drug or treat-ment.Teach the patient or hisparents to offer the identificationbracelet for inspection whenanyone arrives with drugs and toinsist on having it replaced if it’sremoved.Ask the patient or his parents•about the use of alternative ther-apies, including herbs, andrecord your findings in his medi-cal record. Monitor the patientcarefully and report unusualevents. Ask the patient or hisparents to keep a diary of alltherapies used and to take thediary for review to each visitwith a health care professional.Calculation errorsWriting the mg/kg or mg/m• 2dose and the calculated doseprovides a safeguard againstcalculation errors. Whenever aprescriber provides the calcula-tion, double-check it anddocument that the dose wasverified.Don’t assume that liquid drugs•are less likely to cause harmthan other forms, includingparenteral ones. Pediatric andgeriatric patients commonlyreceive liquid drugs and may beespecially sensitive to the effectsof an inaccurate dose. If a unit-dose form isn’t available,calculate carefully and double-check your math and the druglabel.Read the label on every drug•you prepare and never adminis-ter any drug that isn’t labeled.Dosage equationsAfter you calculate a drug dos-•age, always have another nursecalculate it independently todouble-check your results. Ifdoubts or questions remain orif the calculations don’t match,ask a pharmacist to calculatethe dose before you give thedrug.Incorrect administrationrouteWhen a patient has multiple•I.V. lines, label the distal end ofeach line.Using a parenteral syringe to•prepare oral liquid drugsincreases the chance for errorbecause the syringe tip fits easilyinto I.V. ports.To safely give anoral drug through a feeding tube,use a dose prepared by thepharmacy and a syringe with theappropriate tip.Pediatric_Meds Chap04.indd 83Pediatric_Meds Chap04.indd 83 11/27/2009 5:49:31 PM11/27/2009 5:49:31 PM
  • 84Meds/IVPreventing medication errorsMedication errors can happen to patients of any age, but theconsequences can be far more devastating if the patient is achild. Here are some pediatric-specific strategies for reducingmedication errors:Record the patient’s weight in kilograms because this mea-•surement becomes the standardized weight used forprescriptions, medical records, and staff communication.Don’t administer drugs that are classified as “high risk” until•the child has been weighed, except in emergency situations.Ask each prescriber to write out the calculations used to•derive dosages, as dose per weight, so that you can double-check the calculations.Use pediatric-specific medication formulations and concentra-•tions whenever possible.Use clear, highly visible warning labels on all adult formula-•tions that have been repackaged for use in pediatricpopulations.Provide verbal and written instructions to the child and care-•givers, including information on adverse reactions.Ask another nurse to double-check all calculations.•Confirm the patient’s identity before giving each dose.•Verify the drug order and dosage before administering a•medication.If a child or caregiver questions whether a drug should be•administered, listen, ask questions, and double-check the order.Pediatric_Meds Chap04.indd 84Pediatric_Meds Chap04.indd 84 11/27/2009 5:49:31 PM11/27/2009 5:49:31 PM
  • 8585Meds/IV85Medication safety tips for parentsProvide these instructions to parents and other caregivers:On admittance to the hospital, provide an up-to-date list of all•medicines (prescription and over-the-counter) and dietary sup-plements your child is taking.Make sure that all of your child’s health care providers are•aware of any allergies your child has. For life-threatening aller-gies, be sure your child wears a MedicAlert bracelet at all times.Be aware that medications administered to children are based•on a child’s weight in kilograms. For purposes of preparingappropriate dosages of medicines, your child’s weight inpounds must be divided by 2.2 in order to convert it into kilo-grams. Be aware of this calculation and your child’s weight inkilograms, and reconfirm the correct dosage if you haveconcerns.Be sure that you’re given verbal and written information about•your child’s medications, their common side effects, and sideeffects that should be reported to a health care provider.Pay close attention to how your child is feeling while in the•hospital. Notify a nurse or doctor immediately if you notice anynegative side effects from administered medications, such assudden difficulty swallowing or breathing.If your child is given a liquid medication to take after release•from the hospital, be sure you’re given an appropriate measur-ing device and instructions to ensure proper medication doses.In case of an emergency, be sure that your child’s school has a•list of any medical conditions and allergies your child has.Pediatric_Meds Chap04.indd 85Pediatric_Meds Chap04.indd 85 11/27/2009 5:49:31 PM11/27/2009 5:49:31 PM
  • 86CPRInfant (0 to 1 year)Check forunresponsivenessGently shake and flick bottom of foot and callout name.Call for help/call 911 Call after 2 minutes of CPR; call immediatelyfor witnessed collapse.Position patient Place patient in a supine position on a hard,flat surface.Open airway Use head-tilt, chin-lift maneuver unless con-traindicated by trauma. Don’t hyperextend theinfant’s neck.If you suspect trauma Open airway using jaw-thrust method if traumais suspected.Check breathing Look, listen, and feel for 10 seconds.Perform ventilations Do two breaths at 1 second/breath initially;then one every 3 to 5 seconds.If chest doesn’t rise Reposition and reattempt ventilation. Severalattempts may be necessary.Check pulse Palpate brachial or femoral pulse for no morethan 10 seconds.Start compressionsPlacement Place two fingers 1 fingerwidth below nipples.Depth 1/3 to 1/2 depth of the chestRate 100/minuteComp:Vent ratio 30:2 (If intubated, continuous chest compres-sion at a rate of 100/min. without pauses forventilation; ventilation at 8 to 10 breaths/min.)Check pulse Check after 2 minutes of CPR and as appropri-ate thereafter. Minimize interruptions in chestcompressions.EmergPediatric_Emerg Chap05.indd 86Pediatric_Emerg Chap05.indd 86 11/27/2009 5:44:26 PM11/27/2009 5:44:26 PM
  • Emerg87CPRChild (1 year to onset of adolescence or puberty)Check forunresponsivenessGently shake and shout, “Are you okay?”Call for help/call 911Call after 2 min of CPR. Call immediately forwitnessed collapse.Position patient Place patient in a supine position on a hard, flatsurface.Open airway Use head-tilt, chin-lift maneuver unless contrain-dicated by trauma.If you suspecttraumaOpen airway using jaw-thrust method if trauma issuspected.Check breathing Look, listen, and feel for 10 sec.PerformventilationsDo two breaths initially that make the chest riseat 1 sec/breath; then one every 3 to 5 sec.If chest doesn’triseReposition and reattempt ventilation. Severalattempts may be necessary.Check pulse Palpate the carotid or femoral for no more than 10 sec.Start compressionsPlacement Place heel of one hand or place both hands, oneatop the other, with elbows locked, on lower halfof sternum between the nipples.Depth 1/3 to 1/2 depth of the chestRate 100/minComp:Vent ratio 30:2 (if intubated, continuous chest compressionsat a rate of 100/min without pauses for ventila-tion; ventilation at 8 to 10 breaths/min)Check pulse Check after 2 min of CPR and as appropriate there-after. Minimize interruptions in chest compressions.AED Use as soon as available and follow prompts. Usechild pads and child system for child age 1 to8 years. Provide 2 min of CPR after first shock isdelivered before activating AED to reanalyzerhythm and attempt another shock.Pediatric_Emerg Chap05.indd 87Pediatric_Emerg Chap05.indd 87 11/27/2009 5:44:27 PM11/27/2009 5:44:27 PM
  • 88EmergCPRBefore beginning basic life support, CPR, or rescue breathing,activate the appropriate code team.Adolescent or adultCheck for unresponsiveness Gently shake and shout, “Are you okay?”Call for help/call 911 Immediately call 911 for help. If a second rescueris available, send him to get help or an AED andinitiate CPR if indicated. If asphyxial arrest is likely,perform 5 cycles (about 2 min) of CPR beforeactivating EMS.Position patient Place patient in supine position on hard, flatsurface.Open airway Use head-tilt, chin-lift maneuver unlesscontraindicated by trauma.If you suspect trauma Open airway using jaw-thrust method if trauma issuspected.Check for adequate breathing Look, listen, and feel for 10 sec.Perform ventilations Do two breaths initially that make the chest riseat 1 second/breath; then one every 5 to 6 sec.If chest doesn’t rise Reposition and reattempt ventilation. Severalattempts may be necessary.Check pulse Palpate the carotid for no more than 10 sec.Start compressionsPlacement Place both hands, one atop the other, on lowerhalf of sternum between the nipples, with elbowslocked; use straight up-and-down motion withoutlosing contact with chest.Depth One-third depth of chest or 1½” to 2”Rate 100/minComp-to-vent ratio 30:2 (if intubated, continuous chest compressionsat a rate of 100/min without pauses for ventilation;ventilation at 8 to 10 breaths/min)Check pulse Check after 2 min of CPR and as appropriate there-after. Minimize interruptions in chest compressions.Use AED Apply as soon as available and follow prompts.Provide 2 min of CPR after first shock is deliveredbefore activating AED to reanalyze rhythm andattempt another shock.Pediatric_Emerg Chap05.indd 88Pediatric_Emerg Chap05.indd 88 11/27/2009 5:44:27 PM11/27/2009 5:44:27 PM
  • Emerg89ChokingInfant (younger than 1 year)SymptomsInability to cry or make significant sound•Weak, ineffective coughing•Soft or high-pitched sounds while inhaling•Bluish skin color•Interventions1. Assess that airway is obstructed. Don’t perform the next twosteps if infant is coughing forcefully or has a strong cry.2. Lay infant face down along your forearm. Hold infant’s chestin your hand and his jaw with your fingers. Point the infant’shead downward, lower than the body. Use your thigh or lap forsupport.3. Give five quick, forceful blows between the infant’s shoulderblades using the heel of your free hand.After five blows1. Turn the infant face up.2. Place two fingers on the middle of infant’s sternum justbelow the nipples.3. Give five quick thrusts down, compressing the chest at 1/3 to1/2 the depth of the chest or 1/2” to 1” (2 to 2.5 cm).4. Continue five back blows and five chest thrusts until theobject is dislodged or the infant loses consciousness. If thelatter occurs, perform CPR. Each time you open the airway todeliver rescue breaths, look in the mouth and remove anyobject you see. Never perform a blind finger-sweep.Pediatric_Emerg Chap05.indd 89Pediatric_Emerg Chap05.indd 89 11/27/2009 5:44:27 PM11/27/2009 5:44:27 PM
  • 90EmergChokingChild (older than 1 year) or adultSymptomsGrabbing the throat with the hand•Inability to speak•Weak, ineffective coughing•High-pitched sounds while inhaling•Interventions1. Shout, “Are you choking? Can you speak?” Assess for airwayobstruction. Don’t intervene if the person is coughing forcefullyand able to speak; a strong cough can dislodge the object.2. Stand behind the person and wrap your arms around theperson’s waist (if pregnant or obese, wrap arms around chest).3. Make a fist with one hand; place the thumbside of your fistjust above the person’s navel and well below the sternum.4. Grasp your fist with your other hand.5. Use quick, upward and inward thrusts with your fist (performchest thrusts for pregnant or obese victims).6. Continue thrusts until the object is dislodged or the victimloses consciousness. If the latter occurs, activate the emergencyresponse number and provide CPR. Each time you open the air-way to deliver rescue breaths, look in the mouth and removeany object you see. Never perform a blind finger-sweep.Pediatric_Emerg Chap05.indd 90Pediatric_Emerg Chap05.indd 90 11/27/2009 5:44:27 PM11/27/2009 5:44:27 PM
  • Emerg91Pediatric BLS algorithmNo movement or responseOpen airway and check breathing.If not breathing, give 2 breaths that make chest rise.One rescuer: Give cycles of 30 compressions and 2 breaths.Push hard and fast (100/min) and release completely.Minimize interruptions in compressions.Two rescuers: Give cycles of 15 compressions and 2 breaths.If not already done, phone 911; for child, get AED/defibrillator.Infant (< 1 year): Continue CPR until ALS responders take over or victim starts to move.Child (> 1 year): Continue CPR; use AED/defibrillator after 5 cyclesof CPR (use AED as soon as it is available for sudden, witnessed collapse).Send someone to phone 911; getAED.If no response, check pulse:Definite pulse within 10 seconds?Lone rescuer: For sudden collapse,phone 911 and get AED.• Give 1 breath every 3 seconds.• Recheck pulse every 2 minutes.Give 1shock.Resume CPRimmediatelyfor 5 cycles.Child > 1year: Checkrhythm.Shockablerhythm?Resume CPRimmediately for5 cycles. Checkrhythm every5 cycles; continueuntil ALS providerstake over or victimstarts to move.Reprinted with permission: “2005 American Heart Association Guidelines forCardiopulmonary Resuscitation and Emergency Cardiovascular Care,” Circulation 112(suppl. IV), 2005. © 2005, American Heart Association, Inc.DefinitepulseShockableNotShockableNo pulsePediatric_Emerg Chap05.indd 91Pediatric_Emerg Chap05.indd 91 11/27/2009 5:44:27 PM11/27/2009 5:44:27 PM
  • 92EmergPediatric pulseless arrest algorithmPulseless arrest• BLS algorithm: Continue CPR.• Give oxygen when available.• Attach monitor/defibrillator when available.1Continue CPR whiledefibrillator is charging.Give 1 shock.• Manual: 4 J/kg• AED: > 1 year of ageResume CPR immediately.Give epinephrine.• I.V./I.O.: 0.01 mg/kg(1:10000: 0.1 mL/kg)• Endotracheal tube:0.1 mg/kg (1:1000: 0.1 mL/kg)Repeat every 3 to 5minutes.Check rhythm.Shockable rhythm?2VF/VT3 Asystole/PEA9Give 1 shock.• Manual: 2 J/kg• AED: > 1 year of ageUse pediatric system if availablefor 1 to 8 years of age.Resume CPR immediately.4 Resume CPR immediately.Give epinephrine.• I.V./I.O.: 0.01 mg/kg (1:10000: 0.1 mL/kg)• Endotracheal tube: 0.1 mg/kg(1:1000: 0.1 mL/kg)Repeat every 3 to 5 min.10Check rhythm.Shockable rhythm?5• If asystole, go tobox 10.• If electricalactivity, checkpulse. If nopulse, go tobox 10.• If pulse present,begin postresus-citation care.12Checkrhythm.Shockablerhythm?11Check rhythm.Shockable rhythm?7Go to box 4.13ShockableShockableShockableShockableNotshockableNotshockableNotshockableNotshockableGive 5 cycles of CPR.* Give 5 cycles of CPR.*Give 5 cycles of CPR.*6Pediatric_Emerg Chap05.indd 92Pediatric_Emerg Chap05.indd 92 11/27/2009 5:44:27 PM11/27/2009 5:44:27 PM
  • Emerg93ShockableDuring CPR• Push hard and fast (100/min).• Ensure full chest recoil.• Minimize interruptions in chestcompressions.• One cycle of CPR: 15 compressions, then2 breaths; 5 cycles Ϸ 1 to 2 min.• Avoid hyperventilation.• Secure airway and confirm placement.• Rotate compressors every 2 minutes withrhythm checks.• Search for and treat possible contributingfactors:HypovolemiaHypoxiaHydrogen ion (acidosis)Hypokalemia or hyperkalemiaHypoglycemiaHypothermiaToxinsTamponade, cardiacTension pneumothoraxThrombosis (coronary or pulmonary)Trauma* After an advanced airway is placed,rescuers no longer deliver “cycles” of CPR.Give continuous chest compressions withoutpauses for breaths. Give 8 to 10 breaths/minute. Check rhythm every 2 minutes.Continue CPR whiledefibrillator is charging.Give 1 shock.• Manual: 4 J/kg• AED: > 1 year of ageResume CPR immediately.Consider antiarrhythmics(such as amiodarone5 mg/kg I.V./I.O. or lidocaine1 mg/kg I.V./I.O.).Consider magnesium 25 to50 mg/kg I.V./I.O., max 2 gfor torsades de pointes.After 5 cycles of CPR*go to box 5 above.8Reprinted with permission: “2005 American Heart Association Guidelines forCardiopulmonary Resuscitation and Emergency Cardiovascular Care,” Circulation 112(suppl. IV), 2005. © 2005, American Heart Association, Inc.Pediatric_Emerg Chap05.indd 93Pediatric_Emerg Chap05.indd 93 11/27/2009 5:44:27 PM11/27/2009 5:44:27 PM
  • 94EmergPediatric tachycardia with pulsesand poor perfusion algorithmSearch for andtreat cause.Consider vagalmaneuvers (no delays)Symptoms persistNarrow QRS (£0.08 sec)Probable sinustachycardia• Compatible historyconsistent withknown cause• P waves present/normal• Variable RR;constant PR• Infants: rate usually<220 bpm• Children: rate usually<180 bpmProbablesupraventriculartachycardia• Compatible history(vague, nonspecific)• P waves absent/abnormal• HR not variable• History of abrupt ratechanges• Infants: rate usually≥220 bpm• Children: rate usually≥180 bpm• Synchronizedcardioversion:0.5 to 1 J/kg; if noteffective, increaseto 2 J/kgSedate if possiblebut don’t delaycardioversion.• May attemptadenosine if itdoesn’t delayelectricalcardioversion.Wide QRS (>0.08 sec)Possible ventriculartachycardiaEvaluate rhythm with 12-lead ECG or monitor.Evaluate QRS duration.Tachycardiawith pulses and poor perfusion• Assess and support ABCs as needed.• Give oxygen.• Attach monitor/defibrillator.Pediatric_Emerg Chap05.indd 94Pediatric_Emerg Chap05.indd 94 11/27/2009 5:44:27 PM11/27/2009 5:44:27 PM
  • Emerg95• If I.V. access isreadily available:Give adenosine0.1 mg/kg (maximumfirst dose 6 mg) byrapid bolus.May double firstdose and give once(maximum seconddose 12 mg).OR• Synchronizedcardioversion: 0.5 to1 J/kg; if not effective,increase to 2 J/kg.Sedate if possiblebut don’t delaycardioversion.During Evaluation• Secure and verify airway and vascular access whenpossible.• Consider expert consultation.• Prepare for cardioversion.Treat possible contributing factors:HypovolemiaHypoxiaHydrogen ion (acidosis)Hypokalemia or hyperkalemiaHypoglycemiaHypothermiaToxinsTamponade, cardiacTension pneumothoraxThrombosis (coronary or pulmonary)Trauma (hypovolemia)Expert consultationadvised• Amiodarone5 mg/kg I.V. over20 to 60 minutesOR• Procainamide15 mg/kg I.V. over30 to 60 minutes(Don’t routinelyadministeramiodarone andprocainamidetogether.)Reprinted with permission: ”2005 American Heart Association Guidelines forCardiopulmonary Resuscitaion and Emergency Cardiovascular Care,” Circulation 112(suppl.IV), 2005. © 2005, American Heart Association, Inc.Pediatric_Emerg Chap05.indd 95Pediatric_Emerg Chap05.indd 95 11/27/2009 5:44:27 PM11/27/2009 5:44:27 PM
  • 96EmergPediatric tachycardia with adequateperfusion algorithm• BLS Algorithm: Assess and support ABCs(assess signs of circulation and pulse;provide oxygen and ventilation as needed).• Provide oxygen.• Attach monitor/defibrillator.• Evaluate 12-lead ECG if practical.What is the QRS duration?Evaluate rhythm.Consider vagalmaneuvers.Probable ventricular tachycardiaProbable sinustachycardia• Historycompatible• P wavespresent/normal• HR often varieswith activity• Variable RRwith constantPR• Infants: rateusually < 220bpm• Children: rateusually < 180bpmProbablesupraventriculartachycardia (ST)• Historyincompatiblewith ST• P wavesabsent/abnormal• HR not variablewith activity• Abrupt ratechanges• Infants: rateusually ³220bpm• Children: rateusually ³180bpmConsideralternativemedications.• Amiodarone5 mg/kg I.V.over 30 to 60minutesOR• Procainamide15 mg/kg I.V.over 30 to60 minutes(Don’t routinelyadminister ami-odarone andprocainamidetogether.)OR• Lidocaine1 mg/kg I.V.bolusQRS wide (> 0.08 sec)QRS normal (£0.08 sec)Pediatric_Emerg Chap05.indd 96Pediatric_Emerg Chap05.indd 96 11/27/2009 5:44:27 PM11/27/2009 5:44:27 PM
  • Emerg97• Establishvascularaccess.• Consideradenosine0.1 mg/kg I.V.(maximum firstdose: 6 mg).• May double andrepeat doseonce (maximumsecond dose:12 mg).• Use rapid bolustechnique.During evaluation• Provide oxygen andventilation as needed.• Support ABCs.• Confirm continuous monitor/pacer attached.• Consider expert consultation.• Prepare for cardioversion 0.5to 1 J/kg (consider sedation).Identify and treat possiblecauses• Hypovolemia• Hypoxia• Hyperthermia• Hyperkalemia orhypokalemia and metabolicdisorders• Tamponade, cardiac• Tension pneumothorax• Toxins• Thrombosis (coronary orpulmonary)• Pain• Consult pediatric cardiologist.• Attempt cardioversion with 0.5 to 1 J/kg (may increaseto 2 J/kg if initial dose is ineffective).• Sedate prior to cardioversion.• Obtain 12-lead ECG.Reprinted with permission: ”2005 American Heart Association Guidelines forCardiopulmonary Resuscitaion and Emergency Cardiovascular Care,” Circulation 112(suppl.IV), 2005. © 2005, American Heart Association, Inc.Pediatric_Emerg Chap05.indd 97Pediatric_Emerg Chap05.indd 97 11/27/2009 5:44:27 PM11/27/2009 5:44:27 PM
  • 98EmergYesNoBradycardia with a pulsecausing cardiorespiratory compromise• Support ABCs as needed.• Give oxygen.• Attach monitor/defibrillator.Bradycardia still causing cardiorespiratory compromise?• Support ABCs; giveoxygen if needed.• Observe.• Consider expertconsultation.Perform CPR if, despite oxygenation andventilation, HR < 60/min with poorperfusion.Persistent symptomatic bradycardia?• Give epinephrine.I.V./I.O.: 0.01 mg/kg (1:10000:0.1 mL/kg)Endotracheal tube: 0.1 mg/kg(1:1000: 0.1 mL/kg)Repeat every 3 to 5 minutes.• If increased vagal tone or primaryAV block:Give atropine, first dose: 0.02 mg/kg,may repeat. (Minimum dose: 0.1 mg;maximum total dose for child: 1 mg)• Consider cardiac pacing.If pulseless arrest develops, go to Pulseless Arrest Algorithm.Pediatric bradycardia with pulsealgorithmNoYesReprinted with permission: ”2005 American Heart Association Guidelines forCardiopulmonary Resuscitaion and Emergency Cardiovascular Care,” Circulation 112(suppl.IV), 2005. © 2005, American Heart Association, Inc.Pediatric_Emerg Chap05.indd 98Pediatric_Emerg Chap05.indd 98 11/27/2009 5:44:27 PM11/27/2009 5:44:27 PM
  • Skills99Breast milk handlingPlace freshly pumped milk in•clean containers.Label each container with the•infants name and identifica-tion number and the date andtime the milk was pumped.Refrigerate or freeze freshly•pumped milk as soon as pos-sible unless it will be usedwithin 4 hours.In hospital settings, freeze•freshly pumped milk if it won’tbe used within 72 hours.Immediately freeze freshly•pumped milk if volumes aregreater than anticipated feed-ing needs for 24 hours.Store freshly pumped milk in•the freezer for no more than3 months.Don’t add fresh milk to•already frozen milk within astorage container.Assess the state of milk thats•brought from home—whetherits fresh, cold, or frozen—andstore it appropriately.Thawing frozen breast milkThaw frozen human milk by•moving the container to therefrigerator for several hoursor by sitting the containerinside a clean glove and sub-mersing the glove in warmwater. Keep water fromdirectly touching the containeror lid, which may expose milkto water contaminants.When milk is liquid but still•chilled, label the containerwith the date and time themilk was thawed and returnthe container to the refrigera-tor.Thawed milk must be usedwithin 24 hours or discarded.Dont refreeze breast milk.Immediately before feeding,•warm the milk by placing thecontainer inside a glove andsubmersing the glove in warmwater or by holding the con-tainer under running warm tapwater to bring milk to physio-logic temperature. Keep the liddry to avoid contamination.Never microwave human•milk. Resultant "hot spots"within the milk place the infantat risk for burns. Additionally,immunoglobulin A and otheranti-infective properties arereduced when milk is heatedin the microwave.Before feeding, verify with•another member of the healthcare team or a parent that theinformation on the labeledmilk container and the infantsidentification are correct.Don’t save milk from a used•bottle for use at another feeding.Pediatric_Skill Chap06.indd 99Pediatric_Skill Chap06.indd 99 11/27/2009 5:56:06 PM11/27/2009 5:56:06 PM
  • 100SkillsEardrop instillationWash your hands.•Confirm the patients identity•using two patient identifiersaccording to your facilityspolicy.Explain the procedure to the•child in terms he can under-stand.Have the child lie on the side•opposite the affected ear.Reinforce the need to keep•the head still.Make sure the drops are at•room temperature. If neces-sary, warm them by rollingthe container between thepalms of your hands.Straighten the patients ear•canal:Gently pull the pinna–down and back in a childyounger than age 3 (asshown below).Gently pull the pinna up–and back in children age 3 andolder (as shown at top right).Instill the medication using a•dropper:To avoid damaging the ear–canal with the dropper, gentlysupport the hand holding thedropper against the patientshead.To avoid patient discom-–fort, aim the dropper so thatthe drops fall against thesides of the ear canal, not onthe eardrum.Hold the ear canal in posi-•tion until you see themedication disappear downthe canal; then release the ear.Massage the tragus (the•fleshy part in front of the earcanal) with your finger.Instruct the child to remain•on his side for several minutesto allow the medication to rundown into the ear canal.If necessary, loosely tuck a•piece of cotton into the openingof the ear canal to prevent themedication from leaking out.Clean and dry the outer ear.•Pediatric_Skill Chap06.indd 100Pediatric_Skill Chap06.indd 100 11/27/2009 5:56:06 PM11/27/2009 5:56:06 PM
  • Skills101Confirm the childs identity•using two patient identifiersaccording to your facilityspolicy.Assess the childs previous•experiences with ophthalmicmedications.Assess the familys under-•standing of the need for themedication.Put on gloves.•Clean the eye with a cotton•ball or gauze soaked withnormal saline solution, ifneeded:Clean from the inner to the–outer canthus.To prevent contamination,–use a new cotton ball or pieceof gauze each time you sweepthe eye.Position the child in a supine•position in bed or on a flatsurface with the head lowerthan the body.Rest your dominant hand•against the childs forehead.Tell the child to open his eyes.•With your nondominant hand,•pull down the lower eyelid toexpose the conjunctival sac.Ask the child to look up, if•possible.For eye drops, instill the cor-•rect number of drops into theconjunctival sac, being carefulnot to touch the dropper tothe eye.For ointment, place a thin•ribbon of ointment or the pre-scribed amount along theentire conjunctival sac, mov-ing from the inner canthus tothe outer canthus.Have the child keep his eyes•gently closed for 1 minuteafter administration.Wipe off excess medication•with a cotton ball or tissue.Eye medication instillationPediatric_Skill Chap06.indd 101Pediatric_Skill Chap06.indd 101 11/27/2009 5:56:09 PM11/27/2009 5:56:09 PM
  • 102SkillsI.V. Catheter insertion and removalInsertionGather all equipment.•Verify the childs identity•using two patient identifiersaccording to your facilityspolicy and by comparing theinformation on the solutioncontainer with the patientswristband.Wash your hands thoroughly.•Explain the procedure to the•child and family.Tell him thatthe venipuncture will hurt butonly for a short time.Ensure adequate pain relief•using pharmacologic and non-pharmacologic methods priorto insertion.Place the child in a comfort-•able, reclining position.Select the puncture site. If•the child’s veins are difficult tolocate, use a device to transil-luminate them.If appropriate, apply a•tourniquet.Lightly palpate the vein with•the index and middle fingersof your nondominant hand.Stretch the skin to anchor thevein.Clean the site with chlorhexi-•dine using a back-and-forthscrubbing motion, and thenallow it to dry.Insert and advance the•device.Attach the infusion tubing•and regulate the flow of theinfusion.Clean the skin completely.•Dispose of sharps in a•sharps container.Use a transparent semiperme-•able dressing to dress the site.Pediatric_Skill Chap06.indd 102Pediatric_Skill Chap06.indd 102 11/27/2009 5:56:10 PM11/27/2009 5:56:10 PM
  • Skills103Apply a catheter securement•device to secure the catheter.If a catheter securementdevice isnt available, usesterile hypoallergenic tape orsterile surgical strips to securethe device.Loop the I.V. tubing on the•patients limb, and secure thetubing with tape.Check the site frequently.•Monitor the fluid infusion•and the child’s urine output.RemovalRemove the catheter secure-•ment deviceLoosen the tape and trans-•parent dressing.Turn off the infusion.•Put on gloves.•Gently side the I.V. device•out of the vein.Apply pressure with a dry•gauze dressing.Apply a small adhesive•bandage.I.V. Catheter insertion and removal(continued)Pediatric_Skill Chap06.indd 103Pediatric_Skill Chap06.indd 103 11/27/2009 5:56:10 PM11/27/2009 5:56:10 PM
  • 104SkillsNasal medication administrationWash your hands and then•put on gloves.Bring the medication to•room temperature by gentlyrotating the bottle in yourhands.Confirm the childs identity•using two patient identifiersaccording to your facilityspolicy.Have the child blow her•nose. If the child isnt oldenough or able to cooperate,use a bulb syringe.Nose dropsPosition the child in a supine•position with the head hyper-extended or with a rolledtowel or pillow placed underthe neck and shoulders (asshown below).Aim the tip of the dropper•toward the nasal passage andinstill the ordered number ofdrops into the specified nos-tril, being careful not to touchthe sides of the nostril.Have the child remain in that•position for several minutes ifpossible to allow time formedication absorption.Nose sprayHave the child stand or sit in•semi-Fowler’s position withthe head slightly tilted back.Hold or have the child hold•one nostril closed.While holding the one nostril•closed, instill the spray in thealternate nostril. Direct thespray to the side away fromthe septum and toward thetop of the ear on that side.Instruct the child to take a•deep breath through the nos-tril while the medication isbeing given.Pediatric_Skill Chap06.indd 104Pediatric_Skill Chap06.indd 104 11/27/2009 5:56:11 PM11/27/2009 5:56:11 PM
  • Skills105Wash your hands and then•put on gloves.Place the infant supine on a•hard surface or hold the infanton your lap with the headtilted slightly back.If needed, instill several•drops of saline solution intothe infant’s nostril (as shownbelow).Compress the sides of the•rubber-tipped bulb syringecompletely and then place thetip in the infant’s nostril (asshown below).Release the pressure on the•bulb.Remove the bulb syringe.•Squeeze the bulb syringe•over a tissue to empty secre-tions (as shown below).Repeat the procedure as•necessary on the other nostril.Clean the bulb syringe with•warm water after each useand allow it to dry.Nasal suction with a bulb syringePediatric_Skill Chap06.indd 105Pediatric_Skill Chap06.indd 105 11/27/2009 5:56:11 PM11/27/2009 5:56:11 PM
  • 106SkillsNasogastric tube insertionConfirm the doctors order,•including the type and size of theordered tube.Confirm the childs identity•using two patient identifiersaccording to your facilitys pol-icy.Assess the child for signs and•symptoms of gastric distention orirritation, the presence of orth-odontic appliances (if the tube isto be inserted through themouth), and the potential foraspiration secondary to accumu-lated gastric secretions and fluidsor impaired gag reflex. If the childhas an orthodontic appliance, tellhim to remove it to prevent dis-lodgement during the procedure,which could lead to aspiration.Explain the procedure to the•parents or guardians and thechild, as appropriate.Provide privacy.•Position the child:•An infant or toddler may need–to be restrained in a supine posi-tion with a swaddle-type restraintor a second person may need tosecurely hold the child to keep thechilds hands away from the tube.An older child may be placed–in a sitting position with hishead slightly extended if he cancooperate or if a second careprovider can effectively supporthim and keep him calm duringthe procedure.Put on gloves.•If you anticipate that the child•will cough or splash secretions,put on proper eye protection anda mask to provide further protec-tion.Determine the length of the•tube to be inserted by measur-ing from the tip of the childsnose to the earlobe and from theearlobe to the tip of the xiphoidprocess (as shown below).Mark this distance on the tube•with a piece of tape.Dip the distal tip of a water-•activated–lubricant-impregnatedtube in water to activate thelubricant.Lubricate the distal tip of the•tube liberally with water-solublelubricant if the tube isnt prelu-bricated.Pediatric_Skill Chap06.indd 106Pediatric_Skill Chap06.indd 106 11/27/2009 5:56:12 PM11/27/2009 5:56:12 PM
  • Skills107If a stylet is present, check that•it moves freely to preventtrauma to the area. Never rein-sert a stylet into a tube after thestylet has been removed.Gently insert the tube into the•nostril or mouth, aiming downand back to help the tube followthe normal nasopharyngealanatomy.When the tube reaches the•pharynx, expect to feel slightresistance and expect the childto gag. Unless contraindicated,offer the child a cup of waterwith a straw and direct him tosip and swallow as you slowlyadvance the tube. (If you arentusing water, ask the child toswallow or stimulate swallowingin an infant by using a pacifier.)Lower the childs head slightly•to close the trachea and openthe esophagus.Then rotate thetube 180 degrees toward theopposite nostril to redirect itaway from the childs mouth.Watch for respiratory distress•as you advance the tube.Continue to pass the tube until•the measured segment of thetube reaches the opening of thechilds nostril.Temporarily secure the tube to•avoid accidental dislodgementand minimize trauma until place-ment is verified.Attach a catheter-tip or bulb•syringe and aspirate the stom-ach contents.Place several drops of aspirate•on a piece of pH paper. Gastricplacement is likely if the aspiratehas a typical gastric fluid appear-ance (brown or grassy green,clear, and colorless with mucusshreds) and a pH less than orequal to 5.If you dont obtain stomach•contents, position the child onhis left side to move the con-tents into the stomachs greatercurvature; then aspirate again.If you still cant aspirate the•stomach contents, advance thetube 1" to 2" (2.5 to 5 cm) andtry again.Finally, confirm that the external•length of the tube is at the base-line measurement. Mark the tubeat insertion, and assess this markevery time you use the tube.When proper tube placement is•confirmed, anchor the tube tothe childs face with tape or atransparent dressing, makingsure to avoid interfering with thechilds visual field, causing pres-sure, and irritating the nasalmucosa.Nasogastric tube insertion (continued)Pediatric_Skill Chap06.indd 107Pediatric_Skill Chap06.indd 107 11/27/2009 5:56:13 PM11/27/2009 5:56:13 PM
  • 108SkillsNeonate identification and footprintingApply identification (ID)•bands to the neonates ankleand wrist before the neonateleaves the delivery room.When the neonate is stable,•gather the footprinting sup-plies.Press the neonates foot•firmly on the ink pad.Position the neonates foot•on the footprint ID form andapply firm, gentle pressure toensure the footprint transfersonto the form. A second set offootprints may be obtained togive to the parents.Apply a security device to•the neonates ankle per facilitypolicy, and explain the pur-pose of the device to theparents. (The security devicemust stay on the neonatesankle at all times until thetime of discharge.The devicetracks the neonates locationin case of abduction.)Always check the mothers•or father’s ID band against theneonate’s ID bands before giv-ing the neonate to the motheror father.Document ID band applica-•tion in the mothers andneonates medical records.Document the neonatesname and ID number on thefootprint sheet and placeit in the neonates medicalrecord.If the neonate must remain•hospitalized after maternaldischarge, ask the parents tocontinue to wear their IDbands to ensure proper IDwhen they visit.Teach parents to verify their•neonates ID number beforeaccepting the neonate.Pediatric_Skill Chap06.indd 108Pediatric_Skill Chap06.indd 108 11/27/2009 5:56:13 PM11/27/2009 5:56:13 PM
  • Skills109Pulse oximetry monitoringWash your hands.•Confirm the childs identity•using two patient identifiersaccording to your facilityspolicy.Explain the procedure to the•child and family.Attach the probe to the child,•with the light source on oneside of the tissue pad and thesensor on the other side.Preferred sites for probeattachment include:for a neonate:– foot, hand,or foreheadfor an infant:– great toe, ballof the foot below the toes,forehead, palm, earlobe, orwristfor an older child:– indexfinger, forehead, or earlobe.Turn the oximeter on and•observe the readout.If continuously monitoring•oxygen saturation, set thealarm parameters accordingto the manufacturers guide-lines, the doctors orders, andthe childs age, underlyinghealth problem, and medicalhistory.If an alarm goes off, assess•the child for respiratory dis-tress, bradycardia,hypothermia, hypotension,and vasoconstriction. Alsoassess the pulse oximeter forpossible malfunction.Frequently check the condi-•tion of the skin and rotate thesensor position every fewhours.Pediatric_Skill Chap06.indd 109Pediatric_Skill Chap06.indd 109 11/27/2009 5:56:13 PM11/27/2009 5:56:13 PM
  • 110SkillsStandard precautionsThese guidelines were devel-oped by the Centers for DiseaseControl and Prevention (CDC)to provide the widest possibleprotection against the transmis-sion of infection. CDC officialsrecommend that health careworkers handle all blood, bodyfluids, tissues, and contact withmucous membranes and brokenskin as if they contained infec-tious agents, regardless of thepatient’s diagnosis.ImplementationWash your hands before and•after patient care, after removinggloves, or immediately after con-tamination with blood, bodyfluid, excretions, secretions, ordrainage.Wear gloves if you will or could•come in contact with blood,specimens, tissue, body fluids,secretions, excretions, mucousmembranes, broken skin, or con-taminated objects or surfaces.Change gloves and wash your•hands between patients or if youtouch anything with a high con-centration of microorganismswhen caring for the samepatient.Wear a fluid-resistant gown,•eye protection, and mask duringprocedures that are likely togenerate droplets of blood orbody fluids.Carefully handle used patient•care equipment that’s soiled withblood or body fluids. Followfacility guidelines for cleaningand disinfecting equipment andenvironmental surfaces.Keep contaminated linens away•from your body and place inproperly labeled containers.Handle needles and sharp in-•struments carefully andimmediately discard in an imper-vious disposal box after use. Useneedles with safety featureswhenever possible.Immediately notify your super-•visor of a needle stick or sharpinstrument injury, mucosalsplash, or contamination of non-intact skin with blood or bodyfluids so appropriate investiga-tion of the incident and care canbegin immediately.Use mouthpieces, resuscitation•bags, or ventilation devices inplace of mouth-to-mouth resus-citation.Place the patient who can’t•maintain hygiene measures orwho may contaminate theenvironment in a private room.If occupational exposure to•blood is likely, get the hepatitis Bvirus vaccine series.Become familiar with your•facility’s infection control policiesand procedures.Pediatric_Skill Chap06.indd 110Pediatric_Skill Chap06.indd 110 11/27/2009 5:56:13 PM11/27/2009 5:56:13 PM
  • Skills111Transmission-based precautionsFollow transmission-based precautions and standard precautionswhen a patient is known or suspected to be infected with a highlycontagious or epidemiologically important pathogen that’s transmit-ted by air, droplet, or contact with dry skin or other contaminatedsurfaces.Airborne precautionsFollow these precautions, inaddition to standard precautions:Place the patient in a private•room that has monitored nega-tive air pressure in relation tosurrounding areas. Keep thedoor closed.Respiratory protection must be•worn by all persons entering theroom. Such protection isprovided by a disposable respi-rator (N-95 respirator orhigh-efficiency particulate airrespirator) or a reusable respira-tor (powered air-purifyingrespirator).Limit patient transport and•movement out of the room. Ifthe patient must leave the room,he must wear a surgical mask.Droplet precautionsFollow these precautions, inaddition to standard precautions:Place the patient in a private•room.Wear a mask when working•within 3 ft of the infected patient.For a patient with known tuber-culosis, wear a disposable orreusable respirator.Instruct visitors to wear a mask•if within 3 ft of the patient.Limit patient transport and•movement out of the room. Ifthe patient must leave the room,he must wear a surgical mask.Contact precautionsFollow these precautions, inaddition to standard precautions:Place the patient in a private•room.Wear gloves whenever you•enter the patient’s room. Alwayschange gloves after contact withinfected material. Remove thembefore leaving the room. Washyour hands with an antimicrobialsoap or use a waterless antisep-tic immediately after removinggloves and avoid touching con-taminated surfaces.Wear a fluid-resistant gown•when entering the patient’sroom if you think your clothingwill become contaminated bycontact, blood, or body fluids.Remove the gown before leavingthe room.Limit patient transport and•movement out of the room. Ifthe patient must leave the room,he must wear a surgical mask.Pediatric_Skill Chap06.indd 111Pediatric_Skill Chap06.indd 111 11/27/2009 5:56:13 PM11/27/2009 5:56:13 PM
  • 112SkillsTracheostomy careConfirm the childs identity•using two patient identifiersaccording to your facilityspolicy.Perform hand hygiene.•Put on personal protective•equipment if needed. Use aface shield if the child is infec-tious or has copioussecretions.Explain the procedure to the•family and the child, as appro-priate, using developmentallyappropriate language.Assist the child into a supine•position with the neck slightlyextended.Place a rolled towel under•the childs shoulders.Suction the tracheostomy.•Perform hand hygiene.•Put on nonsterile gloves.•Clean around the tracheos-•tomy site with the prescribedsolution using cotton-tippedapplicators and working fromjust around the tracheostomytube outward.Rinse with sterile water•using cotton-tipped applica-tors in a similar fashion.Place precut sterile gauze•under the tracheostomy tube.If an assistant is helping you,•have the assistant hold thetracheostomy tube in placewhile you remove the old tra-cheostomy ties by cutting thetwill tape or opening theVelcro tabs.If using twill ties:•Thread one Velcro tab–through the flange and thensecure that tab to the body ofthe tracheostomy tie.Thread the tapered ends–into the tracheostomy tubeflanges, passing one tiebehind the neck to the oppo-site side. Alternate the sideon which you tie the knotwith each tracheostomy tiechange to minimize skinirritation.Pull the excess twill tape–through the flange until onefinger can be inserted underthe tape at the back of theneck (as shown on the nextpage). Be aware that fasteningthe tie too tightly can causeskin breakdown and vascularobstruction; fastening it tooloosely can lead todecannulation.Pediatric_Skill Chap06.indd 112Pediatric_Skill Chap06.indd 112 11/27/2009 5:56:13 PM11/27/2009 5:56:13 PM
  • Skills113Tie the twill tape on the–side of the neck using asquare, double, or triple knot,according to facility policy.Cut off the excess twill–tape, leaving about 2″ (5 cm)on each end.If using Velcro ties:•Thread one Velcro tab–through the flange and thensecure that tab to the body ofthe tracheostomy tie.Bring the loose end of the–tie around the back of the neck.Thread the remaining–Velcro tab through the otherflange and secure it to thebody of the tracheostomy tie.Adjust the right and left–Velcro tabs as needed toensure that only one fingercan slide under the tie at theback of the neck. Be awarethat fastening the tie too tight-ly can cause skin breakdownand vascular obstruction; fas-tening it too loosely can leadto decannulation.Tracheostomy care (continued)Pediatric_Skill Chap06.indd 113Pediatric_Skill Chap06.indd 113 11/27/2009 5:56:13 PM11/27/2009 5:56:13 PM
  • 114SkillsUrine bag specimen collectionConfirm the childs identity•using two patient identifiersaccording to your facilityspolicy.Wash your hands.•Place the child on a linen-•saver pad.Clean the perineal area with•soap and water.Thoroughly rinse the area•with clear water and then dryit with a towel.Dont use powders, lotions,•or creams because these sub-stances counteract theadhesive.Place the child in a frog posi-•tion, with the legs separatedand knees flexed.Remove the protective cov-•erings from the collectionbags adhesive flaps.Attach the bag as described•below:For girlsApply the narrow portion of–the bag to the perineal spacebetween the anal and vulvarareas first (as shown below).Then, working upward–toward the pubis, attach therest of the adhesive rim (asshown below).For boysEnsure that the bag is–applied over the penis andscrotum, and then press theadhesive rim to the skin.After the bag is attached,•tuck the bag downward insidethe diaper.Check the bag frequently for•urine.Pediatric_Skill Chap06.indd 114Pediatric_Skill Chap06.indd 114 11/27/2009 5:56:14 PM11/27/2009 5:56:14 PM
  • 115TeachSIDS preventionSudden infant death syndrome (SIDS) is the sudden death ofa previously healthy infant when the cause of death isn’t con-firmed by a postmortem examination. It’s the most commoncause of death between ages 1 month and 1 year, and the thirdleading cause of death in all infants from birth to age 1 year.Even so, the incidence of SIDS has declined dramatically bymore than 40% since 1992, which is mostly attributed to the1992 initiative to put babies on their backs for sleeping, calledthe “Back to Sleep” campaign.Preventive strategiesParents should be informed of simple mea-sures that they can take to prevent SIDS,including:putting the infant on his back to sleep•not smoking anywhere near the infant•removing from the infant’s crib or sleep-•ing environment all pillows, quilts, stuffedtoys, and other soft surfaces that may trapexhaled airusing a firm mattress with a snug-fitting•sheetmaking sure the infant’s head remains•uncovered while sleepingkeeping the infant warm while sleeping•but not overheated.Pediatric_Teach Chap07.indd 115Pediatric_Teach Chap07.indd 115 11/27/2009 5:57:56 PM11/27/2009 5:57:56 PM
  • 116TeachHandling temper tantrumsAs they assert their independence, toddlers demonstrate“temper tantrums,” or violent objections to rules or demands.These tantrums include such behaviors as lying on the floor andkicking feet, screaming, or holding breath.How to handle themDealing with a child’s temper tantrums can be a challenge forparents who may be frustrated, embarrassed, or exhausted bytheir child’s behavior. Reassure the parents that temper tan-trums are a normal occurrence in toddlers, and that the childwill outgrow them as he learns to express himself in moreproductive ways.This type of reassurance should be accompa-nied by some concrete suggestions for dealing effectively withtemper tantrums:Provide a safe, childproof environment.•Hold the child to keep him safe if his behavior is out of control.•Give the toddler frequent opportunities to make developmen-•tally appropriate choices.Give the child advance warning of a request to help prevent•tantrums.Remain calm and be supportive of a child having a tantrum.•Ignore tantrums when the toddler is seeking attention or•trying to get something he wants.Help the toddler find acceptable ways to vent his anger and•frustration.When to get helpParents should be advised to seek help from a health careprovider when problematic tantrums:persist beyond age 5•occur more than five times per day•occur with a persistent negative mood•cause property destruction•cause harm to the child or others.•Pediatric_Teach Chap07.indd 116Pediatric_Teach Chap07.indd 116 11/27/2009 5:57:56 PM11/27/2009 5:57:56 PM
  • 117TeachChoking hazardsChoking can easily occur in toddlers because they’re still explor-ing their environments with their mouths.Toddlers may ingestsmall objects, while the small size of their oral cavities increasesthe risk of choking while eating. Foods that are round and lessthan 1Љ (2.5 cm) in diameter can obstruct the airway of a childwhen swallowed whole.Common items that may cause choking include:foods, such as popcorn, peanuts, whole grapes, cherry or•grape tomatoes, chunks of hot dogs, raw carrots, hard candy,bubble gum, long noodles, dried beans, and marshmallowssmall toys, such as broken latex balloons, button eyes, beaded•necklaces, and small wheelscommon household items, such as broken zippers, pills, bottle•caps, and nails and screws.Preventive strategiesProvide parents with these preventive strate-gies to reduce the risk of choking:Cut food into small pieces to prevent•obstruction of the airway. Slicing hot dogsinto short, lengthwise pieces is a safe option.Avoid fruits with pits, fish with bones, hard•candy, chewing gum, nuts, popcorn, wholegrapes, and marshmallows.Encourage the child to sit whenever eating.•Keep easily aspirated objects out of a tod-•dler’s environment.Be especially cautious about what toys the•child plays with (choose sturdy toys withoutsmall, removable parts).Learn how to relieve airway obstruction in•infants and children as part of a CPR course.Pediatric_Teach Chap07.indd 117Pediatric_Teach Chap07.indd 117 11/27/2009 5:57:56 PM11/27/2009 5:57:56 PM
  • 118TeachToilet trainingPhysical readiness for toilet training occurs between ages 18and 24 months; however, many children aren’t cognitively readyto begin toilet training until they’re between ages 36 and42 months.Signs of readinessWhen physically and cognitively ready, the child can start toilettraining.The process can take 2 weeks to 2 months to completesuccessfully. It’s important to remember that there’s consider-able variation from one child to another. Other signs of readi-ness include:periods of dryness for 2 hours or more, indicating bladder•controlchild’s ability to walk well and remove clothing•cognitive ability to understand the task•facial expression or words suggesting that the child knows•when he’s about to defecate.Step-by-stepSteps to toilet training include:teaching words for voiding and defecating•teaching the purpose of the toilet or potty chair•changing the toddler’s diapers frequently to give him the•experience of feeling dry and cleanhelping the toddler make the connection between dry pants•and the toilet or potty chairplacing the child on the potty chair or toilet for a few moments•at regular intervals, and rewarding successeshelping the toddler understand the physiologic signals by•pointing out behaviors he displays when he needs to void ordefecaterewarding successes but not punishing failures.•Pediatric_Teach Chap07.indd 118Pediatric_Teach Chap07.indd 118 11/27/2009 5:57:56 PM11/27/2009 5:57:56 PM
  • 119TeachPreventing burnsBurns can easily occur inyoung children becausethey’re tall enough to reachthe stovetop and can walk toa fireplace or a wood stove totouch. Preventive measuresto teach parents include:setting the hot water heater•thermostat at a temperatureless than 120º F (49º C)checking bath water temper-•ature before a child entersthe tubkeeping pot handles turned•inward and using the backburners on the stovetopkeeping electrical appliances•toward the backs of countersplacing burning candles,•incense, hot foods, and ciga-rettes out of reachavoiding the use of table-•cloths so the curious childdoesn’t pull it to see what’s onthe table (possibly spilling hotfoods or liquids on himself)teaching the child what “hot”•means and stressing the dan-ger of open flamesstoring matches and ciga-•rette lighters in lockedcabinets, out of reachburning fires in fireplaces or•wood stoves with close super-vision and using a fire screenwhen doing sosecuring safety plugs in all•unused electrical outlets andkeeping electrical cordstucked out of reachteaching preschoolers who•can understand the hazards offire to “stop, drop, and roll”if their clothes are on firepracticing escapes from•home and school with pre-schoolersvisiting a fire station to rein-•force learningteaching preschoolers how•to call 911 (for emergency useonly).Pediatric_Teach Chap07.indd 119Pediatric_Teach Chap07.indd 119 11/27/2009 5:57:56 PM11/27/2009 5:57:56 PM
  • 120TeachPreventing poisoningAs a young child’s gross motor skills improve and he becomesmore curious, he’s able to climb onto chairs and reach cabinetswhere medicines, cosmetics, cleaning products, and other poi-sonous substances are stored. Preventive measures to teachparents include:keeping medicines and other toxic materials locked away in•high cupboards, boxes, or drawersusing child-resistant containers and cupboard safety latches•avoiding storage of a large supply of toxic agents•teaching the child that medication isn’t candy or a treat (even•though it might taste good)teaching the child that plants inside or outside aren’t edible,•and keeping houseplants out of reachpromptly discarding empty poison containers and never reus-•ing them to store a food item or other poisonalways keeping original labels on containers of toxic substances•having the poison control center number (1-800-222-1222)•prominently displayed on every telephone. (The AmericanAcademy of Pediatrics no longer recommends keeping syrup ofipecac in the home; instead, parents should keep the poisoncontrol center number clearly posted.)Pediatric_Teach Chap07.indd 120Pediatric_Teach Chap07.indd 120 11/27/2009 5:57:56 PM11/27/2009 5:57:56 PM
  • 121TeachPreventing drowningToddlers and preschoolers are quite susceptible to drowningbecause they can walk onto docks or pool decks and stand or climbon seats in a boat. Drowning can also occur in mere inches ofwater, resulting from falls into buckets, bathtubs, hot tubs, toilets,and even fish tanks. Preventive strategies to teach parents include:instituting close adult supervision of any child near water•teaching children never to go into water without an adult and•never to horseplay near the water’s edgeusing child-resistant pool covers and fences with self-closing•gates around backyard poolsemptying buckets when not in use and storing them upside-down•using U.S. Coast Guard–approved child life jackets near water•and on boatsproviding the child with swimming lessons.•Preventing fallsFalls can easily occur in youngchildren as gross motor skillsimprove and they’re able tomove chairs to climb ontocounters, climb ladders, andopen windows. Preventivestrategies to teach parentsinclude:providing close supervision•at all times during playkeeping crib rails up and the•mattress at the lowest positionplacing gates across the tops•and bottoms of stairwaysinstalling window locks on•all windows to keep themfrom opening more than3Љ (7.5 cm) without adultsupervisionkeeping doors locked or•using child-proof doorknobcovers at entries to stairs,high porches or decks, andlaundry chutesremoving unsecured scatter•rugsusing a nonskid bath mat or•decals in the bathtub orshoweravoiding the use of walkers,•especially near stairsalways restraining children•in shopping carts and neverleaving them unattendedproviding safe climbing toys•and choosing play areas withsoft ground cover and safeequipment.Pediatric_Teach Chap07.indd 121Pediatric_Teach Chap07.indd 121 11/27/2009 5:57:56 PM11/27/2009 5:57:56 PM
  • 122TeachMotor vehicle and bicycle safetyMotor vehicle and bicycle injuries can easily occur in childrenbecause they may be able to unbuckle seat belts, resist riding ina car seat, or refuse to wear a bicycle helmet. Preventive mea-sures to teach parents include:learning about the proper fit and use of bicycle helmets, and•requiring the child to wear a helmet every time he rides a bicycleteaching the preschool-age child never to go into a road with-•out an adultnot allowing the child to play on a curb or behind a parked car•checking the area behind vehicles before backing out of the•driveway (small children may not be visible in rear-view mirrorsbecause of blind spots, especially in larger vehicles)providing a safe, preferably enclosed, area for outdoor play•for younger children (and keeping fences, gates, and doorslocked)learning how to use child safety seats for all motor vehicle•trips, and ensuring proper use by having the seats inspected(many local fire departments offer free inspections)encouraging older children to wear brightly colored clothing•whenever riding bicycles. (Discourage the child from riding hisbicycle during dusk hours or after dark; if he must ride duringthese hours, affix reflective tape to his clothing to make him eas-ily visible and make sure his bicycle has a light and reflectors.)Pediatric_Teach Chap07.indd 122Pediatric_Teach Chap07.indd 122 11/27/2009 5:57:56 PM11/27/2009 5:57:56 PM
  • 123TeachCar safety seat guidelinesProper installation and use of a car safety seat are critical.TheAmerican Academy of Pediatrics recommends that all infantsride rear-facing from birth until the child reaches the maximumweight or height allowed by the car seat manufacturer. At aminimum, children should ride rear-facing until they are at leastage 1 year and weigh at least 20 lb (9 kg).Types of car safety seatsInfant-only seats• are small and have carrying handles.Theyusually come with a base and can be used for infants weighingup to 32 lb (14.5 kg), depending on the model.Convertible seats• can be used rear-facing for infants and thenswitched to forward-facing for toddlers and older children.They’re usually bulkier than infant seats and don’t come withcarrying handles or a separate base.Booster seats• are used for older children who have outgrowntheir forward-facing car safety seats. Children should usebooster seats until adult belts fit correctly, usually when a childreaches about 4’ 9” in height and is between ages 8 and 12.Children who have outgrown their booster seats should ride ina lap and shoulder belt in the back seat until age 13.Pediatric_Teach Chap07.indd 123Pediatric_Teach Chap07.indd 123 11/27/2009 5:57:56 PM11/27/2009 5:57:56 PM
  • 124ResourceNeonateandinfantweightconversionUsethistabletoconvertfrompoundsandouncestogramswhenweighingneonatesorinfants.PoundsOunces01234567891011121314150—2857851131421701982272552833123403693974251454484510539567595624652680709737765794822850879290793696499210211049107711061134116211911219124712761304133231361138914171446147415031531155915881616164416731701172917581786418141843187118991928195619842013204120702098212621552183221122405226822962325235323812410243824662495252325512580260826372665269362722275027782807283528632892292029482977300530333062309031183147731753203323232603289331733453374340234303459348735153544357236008362936573685371437423770379938273856388439123941396939974026405494082411141394167419642244252428143094337436643944423445144794508104536456445934621464946784706473447634791481948484876490449334961114990501850465075510351315160518852165245527353015330535853865415125443547155005528555755855613564256705698572757555783581258405868135897592559535982601060386067609561236152618062096237626562946322146350637964076435646464926520654965776605663466626690671967476776156804683268606889691769456973700270307059708771157144717272017228Pediatric_Resource Chap08.indd 124Pediatric_Resource Chap08.indd 124 11/27/2009 5:51:45 PM11/27/2009 5:51:45 PM
  • 125ResourceWeight conversionTo convert a patient’s weight in pounds to kilograms, divide thenumber of pounds by 2.2 kg; to convert a patient’s weight inkilograms to pounds, multiply the number of kilograms by 2.2 lb.Pounds Kilograms10 4.520 930 13.640 18.150 22.760 27.270 31.880 36.390 40.9100 45.4110 49.9120 54.4130 59140 63.5150 68160 72.6170 77.1180 81.6190 86.2200 90.8210 95.5220 100230 104.5240 109.1250 113.6260 118.2270 122.7280 127.3290 131.8300 136.4Pediatric_Resource Chap08.indd 125Pediatric_Resource Chap08.indd 125 11/27/2009 5:51:45 PM11/27/2009 5:51:45 PM
  • 126ResourceTemperature conversionTo convert Fahrenheit to Celsius, subtract 32 from the tempera-ture in Fahrenheit and then divide by 1.8; to convert Celsius toFahrenheit, multiply the temperature in Celsius by 1.8 and thenadd 32.(F Ϫ 32) Ϭ 1.8 ϭ degrees Celsius(C ϫ 1.8) ϩ 32 ϭ degrees FahrenheitDegreesFahrenheit(°F)DegreesCelsius (°C)DegreesFahrenheit(°F)DegreesCelsius(°C)89.6 32 100.8 38.291.4 33 101 38.393.2 34 101.2 38.494.3 34.6 101.4 38.695 35 101.8 38.895.4 35.2 102 38.996.2 35.7 102.2 3996.8 36 102.6 39.297.2 36.2 102.8 39.397.6 36.4 103 39.498 36.7 103.2 39.698.6 37 103.4 39.799 37.2 103.6 39.899.3 37.4 104 4099.7 37.6 104.4 40.2100 37.8 104.6 40.3100.4 38 104.8 40.4105 40.6Pediatric_Resource Chap08.indd 126Pediatric_Resource Chap08.indd 126 11/27/2009 5:51:45 PM11/27/2009 5:51:45 PM
  • 127ResourceNutritional guidelines for infantsand toddlersBreast-feeding is recom-•mended exclusively for the first6 months of life, and then shouldbe continued in combinationwith infant foods until age 1year.If breast-feeding isn’t possible•or desired, bottle-feeding withiron-fortified infant formula is anacceptable alternative for thefirst 12 months of life.After age 1, whole cow’s milk•can be used in place of breastmilk or formula.New foods should be intro-•duced to the infant’s diet one ata time, waiting 5 to 7 daysbetween them. If the infantrejects a food initially, theparents should offer it againlater.Unpasteurized products, such•as honey or corn syrup, shouldbe avoided.Toddlers should be offered a•variety of foods, including plentyof fruits, vegetables, and wholegrains.Serving size should be approxi-•mately 1 tablespoon of solidfood per year of age (or one-fourth to one-third the adultportion size) so as not to over-whelm the child with largerportions.Solid foods and infant ageAge Type of food Rationale4 mo Rice cereal mixed with breastmilk or formulaAre less likely than wheat tocause an allergic reaction5 to 6 mo Strained vegetables (offeredfirst) and fruitsOffer first because they may bemore readily accepted than ifintroduced after sweet fruits7 to 8 mo Strained meats, cheese, yogurt,rice, noodles, puddingProvide an important source ofiron and add variety to the diet8 to 9 mo Finger foods (bananas, crackers) Promote self-feeding10 mo Mashed egg yolk (no whitesuntil age 1); bite-size cookedfood (no foods that may causechoking)Decrease risk of choking (avoid-ing foods that can cause chok-ing is the safest option, eventhough the infant chews well)12 mo Foods from the adult table(chopped or mashed accordingto the infant’s ability to chewfoods)Provide a nutritious and varieddiet that should meet theinfant’s nutritional needsPediatric_Resource Chap08.indd 127Pediatric_Resource Chap08.indd 127 11/27/2009 5:51:45 PM11/27/2009 5:51:45 PM
  • 128ResourceNutritional guidelines for children olderthan age 2 yearsKey recommendations for chil-dren and adolescents from theDietary Guidelines for Americans(2005) issued by the U.S. Depart-ment of Health and HumanServices and the U.S. Departmentof Agriculture are listed here. Allchildren should be encouraged toeat a variety of fruits, vegetables,and whole grains.Weight managementFor overweight children and ado-•lescents, reduce body weight gainwhile achieving normal growthand development. Consult with ahealth care practitioner beforeplacing a child on a weight-reduction diet.For overweight children with•chronic diseases or those on med-ication, consult with a health carepractitioner before starting aweight-reduction program toensure management of otherhealth conditions.Physical activityChildren and adolescents•should engage in at least60 minutes of physical activityon most, preferably all, days.Food groups to encourageAt least one-half of grains con-•sumed should be whole grains.Children ages 2 to 8 years•should consume 2 cups of fat-free or low-fat milk (or equivalentmilk product) per day.Children ages 9 years and older•should consume 3 cups of fat-free or low-fat milk (or equivalentmilk product) per day.FatsFor children ages 2 to 3 years,•fat intake should be 30% to 35%of total daily calories consumed.For children ages 4 to 18 years,•fat intake should be 25% to 35%of total daily calories consumed.Most fats should come from•sources of polyunsaturated andmonounsaturated fatty acids,such as fish, nuts, and vegetableoils.Food safetyInfants and young children•shouldn’t eat or drink raw(unpasteurized) milk or productsmade from unpasteurized milk,raw or partially cooked eggs orfoods containing raw eggs, rawor undercooked meat or poultry,raw or uncooked fish or shell-fish, unpasteurized juices, or rawsprouts.Pediatric_Resource Chap08.indd 128Pediatric_Resource Chap08.indd 128 11/27/2009 5:51:45 PM11/27/2009 5:51:45 PM
  • 129ResourcePreventing obesityHealthy snacks for childrenEncourage parents of your pediatric patients to begin goodeating habits early by offering healthy snacks to their chil-dren. Here are some suggestions:peanut butter spread on apple slices or rice cakes•frozen yogurt topped with berries or fruit slices•raw or dried fruit served with a dip such as low-fat yogurt•or puddingraw red and green peppers, carrots, and celery sticks served•with low-fat salad dressing as a dipfruit smoothies made with blended low-fat milk or yogurt•and fresh or frozen fruitapplesauce.•Obesity and being overweightare serious health problems.An estimated 16% of childrenand adolescents are nowoverweight. Over the last twodecades, this rate has skyrock-eted in young Americans; therate has doubled in children andtripled in adolescents. Excessbody fat is problematic becauseit increases a person’s risk fordeveloping such serious healthproblems as type 2 diabetes,hypertension, dyslipidemia,certain types of cancers, andmore. Additionally, overweightchildren have a high probabilityof becoming obese adults.What to doWeight-loss diets may not bethe answer for children andadolescents because growthand development increasenutritional needs. However,some dietary changes canhave significant results. Sug-gestions include:avoiding fast-food•eating low-fat after-school•snacksswitching from whole milk to•skim milkexchanging fresh vegetables•for fried snack foodseating a variety of fresh and•dried fruits.Additionally, children whoare overweight or even of nor-mal weight should be encour-aged to participate in sometype of daily vigorous, aerobicactivity to help reduce orprevent childhood obesity andpromote a habit of daily exer-cise that will last a lifetime.Pediatric_Resource Chap08.indd 129Pediatric_Resource Chap08.indd 129 11/27/2009 5:51:45 PM11/27/2009 5:51:45 PM
  • 130ResourceThe Food Guide PyramidAdapted from U.S. Department of Agriculture, Center for Nutrition Policy andPromotion, April 2005. Available at*Grains• An ounceequivalent is:– 1 piece ofbread– 1/2 cup ofcooked cereallike oatmeal– 1/2 cup ofrice or pasta– 1 cup coldcereal.• 4- to 8-year-olds need 4- to5-ounce equiv-alents/day.• 9- to 13-year-old girls need5-ounce equiv-alents/day.• 9- to 13-year-old boys need6-ounce equiv-alents/day.Vegetables• 4- to 8-year-olds need 11/2cups/day.• 9- to 13-year-old girls need 2cups/day.• 9- to 13-year-old boys need21/2 cups/day.Fruits• 4- to 8-year-olds need 1 to11/2 cups/day.• 9- to 13-year-olds need11/2 cups/day.*Fats• 2- to 3-year-olds need 30%to 35% of totaldaily calories tocome from fat.• 4- to 18-year-olds need 25%to 35% of totaldaily calories tocome from fat.• Most fatshould comefrom fish, nuts,and vegetableoils.Milk(or othercalcium-richfoods such asyogurt, cheese,or calcium-fortified orangejuice for exam-ple)• 4- to 8-year-olds need 1 to 2cups/day (orother calcium-rich foods).• 9- to 13-year-olds need 3cups/day (orother calcium-rich foods).Meatand Beans• An ounceequivalent is:– 1 oz of meat,poultry, or fish– 1/4 cup drybeans cooked– 1 egg– 1 tablespoonof peanut butter– small handfulof nuts or seeds.• 4- to 13-year-olds need51/2-ounce equiv-alents/day.Pediatric_Resource Chap08.indd 130Pediatric_Resource Chap08.indd 130 11/27/2009 5:51:45 PM11/27/2009 5:51:45 PM
  • 131ResourceSleep guidelinesAge-group Hrs ofsleepneededper daySpecial considerationsInfantBirth to 6 mo6 mo to 12 mo15 to 161/2133/4 to141/2To help prevent sudden infant death syndrome, all•infants should be placed on their backs to sleep.At ages 4 to 6 months, infants are physiologically•capable of sleeping (without feeding) for 6 to 8 hours atnight.From birth to age 3 months, infants may take many•naps per day; from ages 4 to 9 months, two naps perday; and by 9 to 12 months, only one nap per day.Toddler1 to 2 yr2 to 3 yr10 to 1510 to 12Most toddlers sleep through the night without•awakening.A consistent routine (set bedtime, reading, and a secu-•rity object) helps toddlers prepare for sleep.Up to age 3, toddlers take one nap per day; after age 3,•many toddlers don’t need a nap.Preschool-age 10 to 12 If the preschooler no longer naps, a “quiet” or rest•period may be useful.Dreams or nightmares become more real as magical•thinking increases and a vivid imagination develops.Problems falling asleep may occur due to over-•stimulation, separation anxiety, or fear of the dark ormonsters.School-age 9 to 10 Compliance at bedtime becomes easier.•Nightmares are usually related to a real event in the•child’s life and can usually be eradicated by resolving anyunderlying fears the child might have.Sleepwalking and sleeptalking may begin.•Adolescent At least 8 Sleep requirements increase because of physical•growth spurts and high activity levels.The hours needed for sleep can’t be made up or stored•(“catch-up” sleep on the weekends isn’t effective inreplenishing a teen’s sleep store).Pediatric_Resource Chap08.indd 131Pediatric_Resource Chap08.indd 131 11/27/2009 5:51:46 PM11/27/2009 5:51:46 PM
  • 132ResourceCultural considerations in patient careHealth care professionals interact with a diverse, multiculturalpatient population. Culture and language differences can resultin misunderstandings, lack of compliance, or other factors thatcan negatively influence patient outcomes.You must rememberthat your patients’ cultural behaviors and beliefs may differfrom your own. By learning about diverse population groupsand continually enhancing your awareness, knowledge, andskills related to cultural differences, you can ensure the deliveryof effective, understandable, and respectful care to all patients.Cultural competenceCultural competence refers to a person’s sensitivity to issuesrelated to diverse cultures. Culturally competent health careworkers are willing and have a desire to learn about and interactwith patients and families from different cultures, social groups,and races. In order to provide culturally competent care, con-sider these points:Identify your own values and beliefs.•Realize that you may stereotype people from countries you•aren’t familiar with and people who speak English as a secondlanguage.Identify your possible biases and prejudices.•Seek and obtain information about different cultures and eth-•nic groups, including:nonverbal and verbal communication practices–activities of daily living–food practices–symptom management–birth rituals and child care–death rituals–family relationships–spiritual and religious beliefs–illness beliefs–health practices.–Pediatric_Resource Chap08.indd 132Pediatric_Resource Chap08.indd 132 11/27/2009 5:51:46 PM11/27/2009 5:51:46 PM
  • 133ResourceCultural considerations in patient care(continued)Look for opportunities to interact with patients from various•cultures.Perform a cultural needs assessment at admission, including•the patient and his family or caregivers:Find out about the patient’s native language, ability to speak–and read English, and ability to read lips as well as whether herequires an interpreter.Ask the patient how he wants to be addressed.–Observe the patient’s nonverbal communication style for eye–contact and expressiveness.Determine whether the patient understands common signs–and gestures.Determine the patient’s social orientation, including culture,–race, ethnicity, family role, function, work, and religion.Establish the patient’s comfort level, particularly in light of–his conversation, proximity to others, body movement, andspace perception.Ask about food preferences, family health history, religious–and cultural health practices, and definitions of health andillness.Identify the patient’s major support people.–Determine whether the patient is past-, present-, or future-–oriented.Using an interpreterLanguage assistance services should be readily available topatients with limited English proficiency at all points of contactduring all hours of facility operation.These services may includeinterpreter services at no cost to the patient. Whenever pos-sible, use a trained interpreter rather than a family member orfriend, who may have role conflicts, lack the medical vocabularynecessary to adequately assist, change the message based onpersonal perception of the situation, or withhold potentiallyembarrassing but vital information.(continued)Pediatric_Resource Chap08.indd 133Pediatric_Resource Chap08.indd 133 11/27/2009 5:51:46 PM11/27/2009 5:51:46 PM
  • 134ResourceCultural considerations in patient care(continued)Consider these tips when using an interpreter:Before beginning, meet with the interpreter to explain the pur-•pose of the session.If appropriate, have the interpreter speak briefly with the•patient beforehand to learn his educational level and needs.Instruct the interpreter to interpret exactly what the patient•says and not to edit or summarize any information.Expect the session to move slower than a usual interchange•because careful interpretation requires time.Speak in short sentences and avoid using complex medical•terms, slang, and jargon.Speak clearly and somewhat slowly but not more loudly.•During the interaction, look at and speak directly to the•patient, not to the interpreter, and look at and listen to thepatient as he speaks.Avoid body language and gestures that could be offensive or•be misinterpreted.Periodically check the patient’s understanding of what you•have been talking about by asking him to repeat it back to you.Avoid asking “Do you understand?”Pediatric_Resource Chap08.indd 134Pediatric_Resource Chap08.indd 134 11/27/2009 5:51:46 PM11/27/2009 5:51:46 PM
  • 135ResourceBasic English-to-Spanish translationsbothersomemolestothrobbingpulsanteintenseintensopain dolormildleveMy name is . Mi nombre es .I am your nurse. Soy su enfermero(a).Come in, please. Entre, por favor.What is your name? ¿Cómo se llama?How are you feeling? ¿Cómo se siente?How old are you? ¿Cuántos años tiene?Do you take any medications? ¿Toma medicamentos?Are you allergic to any medications? ¿Es usted alérgico(a) a algún medicamento?Who is your doctor? ¿Quién es su médico?Are you comfortable? ¿Está cómodo(a)?Do you follow a special diet? ¿Tiene Ud. una dieta especial?I would like to give you: Quisiera darle a Ud. un(a):an injection.• inyección.•an I.V. medication.• medicamento por vía intravenosa.•a liquid medication.• medicamento en forma líquida.•a medicated cream or powder.• medicamento en pomada o polvo.•a medication through your epidural•catheter.medicamento por el catéter epidural.•a medication through your rectum.• medicamento por el recto.•a medication through your• tube. medicamento por su• tubo.a medication under your tongue.• medicamento debajo de la lengua.•some pill(s).• píldoras.•a suppository.• supositorio.•Pediatric_Resource Chap08.indd 135Pediatric_Resource Chap08.indd 135 11/27/2009 5:51:46 PM11/27/2009 5:51:46 PM
  • 136Selected references“2005 American Heart Association Guidelines for CardiopulmonaryResuscitation and Emergency Cardiovascular Care: Pediatric BasicLife Support,” Circulation 112(Suppl 24):IV-156-IV-166, December2005.Bickley, L.S., and Szilagyi, P.G., eds. Bates’ Guide to Physical Examina-tion and HistoryTaking, 10th ed. Philadelphia: Lippincott Williams &Wilkins, 2008.Bowden, V.R., and Greenberg, C.S. Pediatric Nursing Procedures,2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2008.Centers for Disease Control and Prevention. “Guidelines for thePrevention of Intravascular Catheter-Related Infections,” MMWRRecommendations and Reports 51(RR10):1-26, August 2002.Hockenberry, M.J., and Wilson, D. Wong’s Essentials of PediatricNursing, 8th ed. St. Louis: Mosby, 2009.Kyle,T. Essentials of Pediatric Nursing. Philadelphia: LippincottWilliams & Wilkins, 2008.Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearingand Childrearing Family, 6th ed. Philadelphia: Lippincott Williams &Wilkins, 2010.Pediatric_ BM.indd 136Pediatric_ BM.indd 136 11/27/2009 5:35:57 PM11/27/2009 5:35:57 PM
  • 137Abuse, 59-60Acid-base disorders, 66ACLS algorithms, 91-98Adolescent development,23-27Anthropometric data, 6-9Assessment, 32-61Bike safety, 122Blood compatibility, 79Body surface area, 71fluid needs and, 77Breast development, 26Breast milk, 99Breath sounds, 43Burns, 57-58prevention, 119Calculations,dosage, 70fluid needs, 77temperature, 126weight, 124, 125Cardiovascularassessment, 40-41Car seat guidelines, 123Choking,guidelines, 89-90hazards, 117prevention, 117Coma scale, 44CPR, 86-88Cultural considerations,132-135Death, concepts of, 29Dentition, 50-51Development, 1-31cognitive,13,16,20,22,23language, 12, 15, 19, 21moral, 20, 22, 23motor skills, 10-11, 14,18, 21play, 13, 17, 19, 28psychosocial, 16, 19,22, 23sexual, 21, 24-27social, 12, 15, 19, 21spiritual, 20, 22, 23theories of, 2, 3-4Drug administrationeardrops, 100eye medication, 101nasal medication, 104safety, 82-85Fontanels, 46Food Guide Pyramid, 130GI/GU assessment, 47-48Growth rates, 5, 6-9Head circumference, 39Health history, 32-35Height data, 6, 8Hospitalization, 28, 30-31Immunization schedules,67-69Infant development, 10-13Injection/insertion sites,insulin, in children, 81I.M., in children, 72-73I.V., for infants, 78Injection tips, 74-75Insulin, 80, 81Intraosseous administra-tion, 76I.V. catheters, 102-103I.V. solutions, 79Laboratory values, 62-66Language development,12, 15Length, measuring, 38Medications/I.V. therapy,67-85Mental health, 59-61Murmurs, 41Musculoskeletalassessment, 49Nasal suctioning, 105Nasogastric tubes, 106-107Neonate identification, 108Neurologic assessment,44-46Nutrition, 127-130Obesity prevention, 129Painassessment, 52-55medications, 56Play, 13, 17, 19, 28Preschooler development,18-20Puberty, 21, 24, 25-27Pulse oximetry monitoring,109Reflexes, 45Respiratoryassessment, 42-43Safety precautions, 82-83,117, 119-123School-age child develop-ment, 21-22Sexual maturity, 21, 24-27SIDS prevention, 115Skills, 99-114Sleep guidelines, 131Social development,12, 15Solid food guidelines, 127Stages of development, 1Suicide, 61Surgery, 30-31Temperaturenormal ranges, 37Temper tantrums, 116Theories of development,2, 3-4Toddler development,14-17Toilet training, 118Tracheostomy care,112-113Urine specimen, 114Vaccinations, 67-68, 69Vehicle safety, 122, 123Vital signs, 36-37Weightdata, 7, 9IndexPediatric_ BM.indd 137Pediatric_ BM.indd 137 11/27/2009 5:35:57 PM11/27/2009 5:35:57 PM