pediatric-- Chapter 1 eyaya 2021_250121083243.ppt

PEDIATRIC
By Eyayalem Melese
Assistant professor
(PHD Fellow)
2021
5/19/2023 1
Pediatrics for Bsc Anesthesia students

Chapter 1. Introduction to pediatrics
Pediatrics is a Greek word,
Pedia –Child
iatrike-Treatment
ics-Branch of medicine
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Chapter 1. Introduction to pediatrics
• Pediatrics definition: - the branch of medicine
dealing with children and their disease.
• It concern with prevention, promotion,
curative and rehabilitative of care
• Pediatrics is the practice of medicine which is
concerned with growth and development of
child from conception through childhood and
adolescences to maturity.
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Introduction to pediatrics
• This study of growth and development is
made through study of the normal child who
is healthy, happy, well adjusted and who is
interested in the life about him and meets it
eagerly with confidence and sense of security.
• Growth means increasing in size and
• Development refers to the function and
maturity.
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The life of the child may be divided into the
following periods:-
1. The prenatal period = before birth
2. Newborn = the 1st 24 hrs of life
3. Neonatal = first 4 weeks of birth
4. Infancy = first year of life
5. Toddler = 1-3 years of life
6. Preschool = 3 - 6 years of age (early childhood)
7. School age = 6-12 years of age (late childhood)
8. Puberty = starts 10-12 years of age in girls and one to two yrs.
later in boys
9. Adolescence of youth = 12 - 18 yrs.
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FACTORS AFFECTING CHILD HEALTH
• The health of the mothers greatly influences the health
development and well being of their children.
• The pattern of disease affecting children depends on the
genetics (inherited conditions) and the environment.
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a. Maternal Health Before Pregnancy
i. Pre-pregnancy Nutrition: The maternal nutrition
before pregnancy has a strong influence not only
on the growth of the fetus and birth weight of
newborn, but also on nutrition during infancy
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• A well nourished woman generally delivers
a well- nourished baby and she has an ample supply of
milk providing adequate calories and other nutrients to
the breast feed child.
• Those women who have chronic malnutrition of long standing
before pregnancy deliver
 low birth weight babies, severe chronic malnutrition in
women influences their ability to produce sufficient
breast milk.
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• Proper nutrition of girls during their childhood is extremely
important for the nutrition and health of their own children in
the future.
• In particular, emphasis should be placed on the need for
equal care of daughters & sons.
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ii. Infections prior to pregnancy:-
• Maternal antibodies passed to the fetus through the
placenta provide protection for some months after birth
against some of the common infections diseases.
• If mother does not treated earlier it may affect the growing
fetus and cause congenital deformities, or chronic infections
like tuberculosis.
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iii. Maternal Health During Pregnancy and Labour:-
 The mother's nutrition and infections during pregnancy greatly
affect fetal growth.
 Pregnant women who are well nourished, and gain about 10 - 12 kg.
Weight, deliver babies having good birth weights.
 By contrast, severally malnourished women and those who put on
very little weight during pregnancy deliver low birth weight infants.
 Improving the nutrition of severely malnourished pregnant women
increases the birth weight of their newborn infants
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iv. Infections During Pregnancy and the Child:-
 Acute infections such as rubella (German measles) and possibly other
viral diseases, can cause congenital deformities in the fetus or an
abortion.
 Many other infections can pass from the pregnant women to her
unborn child. In particular syphilis in the mother can lead to
congenital infection in the newborn baby.
 Infection in the mother's birth canal can cause infection of the
amniotic fluid surrounding the fetus in the uterus (amnionitis) or the
placenta (placentitis), which can lead to intrauterine fetal death or low
birth weight.
 The new born can swallow the infected amniotic fluid and suffer from
diarrhea, pneumonia or septicemia.
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v. Care mothers & children:-
 The mothers health can not be considered apart from that
of the child, the health care of women before pregnancy,
during pregnancy, labour and the lactation period should
always be an important part of primary health care, it is
obviously coupled with the health care of children.
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vi. CUSTOMS & CHILD HEALTH
– All over the world people have developed different ways
of living and behaving, and these customs are especially
important to the health of mothers and their children.
examples.
 Application of animal dung/butter on umbilical cord.
 Bathing a Newborn with cold water soon birth.
 Traditional cutting of Uvula
 Traditional removal/evacuation of the Gum
 Female genital mutilation…. etc.
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General Factors Affecting The Health Of
Children
• • Economic considerations
• • Educational, social and cultural considerations
• • Prevalence of infectious agents
• • Climate and geography
• • Agricultural resources and practices
• • Stage of industrialization and urbanization
• • Gene frequencies of disorders
• • Health and social welfare infrastructure
5/19/2023 Pediatrics for Bsc Anesthesia students 15

CHILD MORTALITY
• India has the highest number of child births as
well as deaths.
• 27 million babies are born every year
• This accounts for a 20% of the global birth
cohort

DEFINITIONS
• Under 5 mortality rate
– Number of deaths under the age of
5 years per 1000 live births
– 51 per 1000 live births in
2019(Ethiopia)

CAUSES FOR UNDER 5 MORTALITY
–Pneumonia
–Complications of prematurity
–Diarrhea
–Birth asphyxia
–Neonatal sepsis
–Congenital anomalies
–Measles
–Injuries

DEFINITIONS
• Infant Mortality rate
– Number of deaths under the age of
1 year per 1000 live births
– 37 per 1000 live births in 2019

DEFINITIONS
• Neonatal Mortality Rate
– Number of deaths under the age
of 28days per 1000 live births
– 27.6 per 1000 live births in 2012

DEFINITIONS
• Early Neonatal Mortality Rate
– Number of deaths under the age of 7
days per 1000 live births
– 23 per 1000 live births in 2019

MODERN CONCEPT OF CHILD CARE
 Child care has a prime importance as the
mortality and morbidity rates are highest in
this group and most of the diseases are
preventable.
 The goal of Pediatric care is to foster the
growth and development of the child and
promote an optimum state of health
physically, mentally and socially, so that the
child may function at the peak of his capacity.
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The Role of health professionals in
Pediatrics
Areas to be considered:
Health promotion
Prevention of illness
Health maintenance
Health restoration
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Trends In Pediatric Care
The child is not treated as adult when planning and
providing health care any more.
The focus is on the child, its family and environment.
The reasons for the development of pediatrics as a
part of Medicine are,
1. High infant mortality
2. Low birth weight
3. Child mortality
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New Concepts On Pediatric Care
1. Child centered care.
2. Take care of the female child with
immunization to TT.
3. Health education on planned parenthood
and doing the maternal health assessment
before conception.
4. Early identification and family counseling
based on biochemical screening and
chromosomal studies.
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New Concepts On Pediatrics Nurse Role
5. Caring the health of the child from the day of
conception.
6. Participate in the prevention of illness and
health promotion activities.
7. Comprehensive care of the child in his home
through community health centers.
8. Flexibility in hospital setting.
9. Health oriented.
10.Warmth and love oriented.
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New Concepts On Pediatrics Nurse Role
11. Health promotion activities, services related
to fertility, sex education and counseling.
12. Safe guard and protect the childrens right by
health providing, cultural practice and laws
encouraging.
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Hospital Environment for sick Child
Purpose of Hospitalization:
• To allow necessary clinical assessment,
investigative and therapeutic procedures that
can not be done outside hospitals
• For care that would be difficult at home as in
severe physical or mental disorders.
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Indication for hospitalization
Patients may be admitted to hospital:
– For therapeutic or palliative medical or surgical
treatment
– For clinical evaluation
– To provide a break for regular home cares
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Implications for hospitalization
• Hospitalization is unsettling to the child and
the family, who will be anxious and fearful.
• Children are anxious about separation from
parents, siblings and playmates.
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Implications for hospitalization
• Hospitalization may be the first time the child is
separated from parents. It means a break in
family routines.
Will it hurt?
Will I get better; will I die?
Are there complications?
Shall my baby live (die)?
How long shall I be away from school (work)?
How much will it cost? Where will the money come from?
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General Principles of Hospitalization
• When admission has been decided and accepted,
rapport should be established between health care
personnel and his family to gain confidence and trust;
crucial aspects in clinical assessment, therapeutic and
palliative care
• The care giver should take full medical and social history
and record the essential information obtained. The
feelings of the family about the child’s illness should be
noted for immediate or future answering.
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General Principles of Hospitalization
• Children should be admitted in to a children’s
ward with “mother-child” accommodation, so
that mothers may continue caring for their
children (family-centered care).
– Breast feeding and emotional support
– Assisting in nursing procedures
– Learning therapeutic and nursing procedures to
facilitate home care (wound dressing, dosing,
insulin injection, etc) after discharge.
– Therapeutic play (recreational facilities)
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Chapter 2
Pediatric Assessment
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Essential Pediatric Care Skills
• Knowledge of Growth and Development
• Development of a Therapeutic Relationship
• Communication with children and their parents
• Understanding of family dynamics and parent-child
relationships: IDENTIFY KEY FAMILY MEMBERS
• Knowledge of Health Promotion & Disease Prevention
• Patient Education and Anticipatory Guidance
• Practice of Therapeutic and Atraumatic Care
• Patient and Family Advocacy
• Caring, Supportive & Culturally Sensitive Interactions
• Coordination and Collaboration
• CRITICAL THINKING
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Introduction
• Key elements.
• Times:
• Every month in the 1st year.
• Every 3 month of the 2nd and 3rd year.
• Each 6 month of 4th and 5th year.
• Yearly after the 6th year.
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Physical Exam
• Avoid touching painful areas until confidence
has been gained.
• Begin exam without instruments.
• Allow child to determine order of exam if
practical.
• Use the same format as adult physical exam.
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Infant Exam
• Examine on parent lap.
• Leave diaper on.
• Comfort measures such as pacifier or bottle.
• Talk softly.
• Start with heart and lung sounds.
• Ear and throat exam last.
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Toddler Exam
• Examine on parent lap if uncooperative.
• Use play therapy.
• Distract with stories.
• Let toddler play with equipment / BP.
• Call by name.
• Praise frequently.
• Quickly do exam.
5/19/2023 39

History
Bio-graphic Demographic
 Name, Date of Birth, Age
 Parents & siblings info
 Cultural practices
 Religious practices
 Parents’ occupations
 Adolescent – work info
Past Medical History
•Allergies
•Past illness
•Trauma / hospitalizations
•Surgeries
•Birth history
•Developmental
•Family Medical/Genetics
Current Health Status
•Immunization Status
•Chronic illnesses or conditions
•What concerns do you have today?
Personal Hx., Life styles, Health Hx. (past and current), and Family Hx.
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Equipment
What’s in Your setting?
• Stethoscope &
Sphygmomanometer
• Pen Light
• Otoscope /
Opthalmoscope
• Scale
5/19/2023 41

Review of Systems
• Ask questions about each system
• Measurements: weight, height, head
circumference, growth chart, BMI
• Nutrition: breastfed, formula, favorite foods,
beverages, eating habits
• Growth and Development: Milestones for
each age group
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Physical Exam Technique
• Inspection- eye only.
• Palpation- tip of finger.
• Percussion- use. . .
• Dullness (solid organ), resonance (over solid
organ or filled air), tympanic (hollow organ).
• Auscultation- stethoscope.
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History: Review of Systems
• Skin
• HEENT
• Neck
• Chest & Lungs /
Respiratory
• Heart &
Cardiovascular
• GI
• GU & GYN
• Musculoskeletal
& Extremities
• Neuro
• Endocrine
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• Sleep & Activity
• Appetite
• Bowel & Bladder
– In a time crunch, these three questions should
give you enough insight into the child’s general
functioning –
– Can get more detailed if any (+) responses
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Physical Assessment
• The approach is:
– Orderly
– Systematic
– Head-to-toe
• But FLEXIBILIY is essential
• And be kind and gentle
• but firm, direct and honest
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Physical Assessment
– Facial expression
– Posture / movement
– Hygiene
– Behavior
– Developmental Status
General Appearance & Behavior
5/19/2023 47

Vital Signs
• Temperature: rectal only when absolutely
necessary
• Pulse: apical on all children under 1 year
• Respirations: infant use abdominal muscles
• Blood pressure: admission base line
• And the “Fifth” Vital Sign is ____ ?
5/19/2023 48

Pediatric Vital Signs – Normal Ranges
Parameter Infants Toddler School age Adolescent
Heart Rate 80-150 70-110 60-110 60-100
Respiratory
Rate
24-38 22-30 14-22 12-22
Systolic blood
pressure
65-100 90-105 90-120 110-125
Diastolic
blood
pressure
45 - 65 55-70 60-75 65-85
5/19/2023 49

Physical Assessment
• General
• Skin, hair, nails
• Head, neck,
lymph nodes
• Eyes, ears, nose,
throat
• Chest,Tanner Scale
• Heart
• Abdomen
• Genitalia,Tanner Scale,
• Rectal
• Musculoskeletal: feet,
legs, back, gait
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Palpation
Use of your fingers
and palms to
determine:
Temperature
Hydration
Texture
Shape
Movement
Areas of Tenderness
 Warm hands and short
nails
 Palpate areas of tenderness
/ pain last
 Talk with the child during
palpation to help him
relax
 Be observant of reactions
to palpation
 Move firmly without
hesitation
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H E E N T
Head
Eyes
Ears
Nose
Neck
Throat
5/19/2023 52

HEENT: Head & Neck, Eyes, Ears,
Nose, Face, Mouth & Throat
• Head: Symmetry of skull and face
• Neck: Structure, movement, trachea, thyroid,
vessels and lymph nodes
• Eyes: Vision, placement, external and internal
fundoscopic exam
• Ears: Hearing, external, ear canal and otoscopic
exam of tympanic membrane
• Nose: Structure, exudate, sinuses
• Mouth: Structures of mouth, teeth and pharynx
5/19/2023 53

Head
Shape:
“NormoCephalic –
ATraumatic”
Lesions
? Edema
5/19/2023 54

Head: Key Points
• Head Circumference (HC
• Fontannels/sutures: Anterior closes at 10-18 months,
posterior by 2 months
• Symmetry & shape: Face & skull
• Bruits: Temporal bruits may be significant after 5 yrs
• Hair: Patterns, loss, hygiene, pediculosis in school aged
child
• Sinuses: Palpate for tenderness in older children
• Facial expression: Sadness, signs of abuse, allergy,
fatigue
• Abnormal facies: “Diagnostic facies” of common
syndromes or illnesses
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5/19/2023 57

Neuro Assessment
• LOC / Glasgow coma scale
• Pupil size
• Vital Signs
• Pain
• Seizure Activity
• Focal Deficits
5/19/2023 58

Bacterial Meningitis
Clinical Manifestations in an Older Child
High fever
Headache
LOC Changes / GCS
Nuchal rigidity / stiff neck
+ Kernigs = inability to extend legs
+ Brudzinski sign = flexion of hips when neck is
flexed
Purple rash (check for blanching)
“Looks Sick”
5/19/2023 59

Eyes
• PERRR (Pupils are equal,round
and react to light)
• Red Reflex
• Corneal Light Reflex
• Strabismus:
– Alignment of eye important due to
correlation with brain development
– May need to corrected surgically
• Preschoolers should have vision
screening
– Refer to ophthalmologist is there
are concerns
o
5/19/2023 60

Red Reflex

Eyes: Key Points
 Vision: Red reflex & blink in neonate
 Examine external structure of the:
 1- Conjunctiva- glassy
 2- Sclera- clear
 3- Cornea- cover the iris and pupil
 4- pupils- compare for size, shape, test for reaction.
 5- Iris- color, size and clarity. 6-12 M.
 Snellen chart for older children
 Irritations & infections
 PERRL
 Amblyopia (lazy eye): Corneal light reflex, binocular vision,
cover-uncover test
5/19/2023 62

Ears: Key Points
Ask about hearing concerns
Inquire about infant’s response to
Observe an older infant’s/toddlers speech pattern
Inspect the ears
•Assess the shape of the ears
Determine if both ears are well formed
•Assess
External shape and size.
Pinna: line, low set ear (retardation).
Internal structure.
5/19/2023 63

Ear Exam
Pinna is pulled down and back to straighten ear canal in
children under 3 years.
5/19/2023 64

Common Ear Infections
Otitis Media
Most common reason
children come to the
pediatrician or
emergency room
Fever or tugging at ear
Often increases at night
when they are sleeping
History of cold or
congestion
 Infection can lead to
rupture of ear drum.
 Chronic effusion can lead
to hearing loss.
 OM is often a contributing
factor in more serious
infections: mastoiditis,
cellulitis, meningitis,
bacteremia.
 Chronic ear effusion in the
early years may lead to
decreased hearing and
speech problems.
5/19/2023 65

Nose & Throat / Mouth
Exudate
Pharynx
Tonsils
Signs & Symptoms of Allerg
Assess for symmetry,
deformity, skin lesion.
Palpate for septal deviation.
Smooth and moist, with
pinkish color.
ic Rhinitis
Palate
Gums
Swallow
Oral Hygiene
Condition of teeth
Missing teeth
Orthodontic
Appliances
5/19/2023 66

Nose: Key Points
• Exam nose & mouth after ears
• Observe shape & structural deviations
• Nares: (check patency, mucous membranes,
discharge, turbinates, bleeding)
• Septum: (check for deviation)
• Infants are obligate nose breathers
• Nasal flaring is associated with respiratory
distress
5/19/2023 67

Nose and Throat
Sinusitis:
Fever
Purulent rhinorrhea
Facial Pain – cheeks, forehead
Breath odor
Chronic cough – could be day and night
(+) Post-nasal drip
5/19/2023 68

Mouth & Pharynx: Key Points
• Lips: color, symmetry, moisture, swelling, sores, fissures
• Buccal mucosa, gingivae, tongue & palate for moisture,
color, intactness, bleeding, lesions.
• Tongue & frenulum - movement, size & texture
• Teeth - caries, malocclusion and loose teeth.
• Uvula: symmetrical movement or bifid uvula
• Voice quality, Speech
• Breath - halitosis
5/19/2023 69

Ears, Nose and Throat
Sore Throats
Is it strept or is it viral
or could it be mono?
Lymph nodes
& ROM
5/19/2023 70

Neck: Key Points
• √ position, lymph nodes, masses, fistulas, clefts
• Range of Motion (ROM)
• Check clavicle in newborn
• Head control in infant
• Trachea & thyroid in midline
• Carotid arteries (bruits)
• Meningeal irritation
5/19/2023 71

• All 4 quadrants
• Front and back
• Take the time to listen
• Be sure about “lungs CTAB”
(clear to auscultation bilaterally)
Chest Assessment
•How does the child look?
•Color
•Work of Breathing: Effort
used to breathe
Auscultation
5/19/2023 72

Chest
• Anatomy.
• Inspection: symmetry, movement of chest
wall.
• Breathing pattern- abdominal breathing.
• Palpation:
• 1- light palpation: in light circular motion to
detect lesion and masses
• 2- deep palpation: palpate for internal organ
like liver and spleen.
5/19/2023 73

Lungs & Respiratory: Key Points
• Clubbing
• Snoring (expiratory): upper airway obstruction, allergy,
• Dullness to percussion: fluid or mass
Increased or Decreased Respirations
Stridor
Wheezing
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5/19/2023 75

Chest Assessment
Auscultation
Wheezing
Retractions
Subcostal
Intercostal
Sub-sternal
Supra-clavicular
Red Flags:
grunting
nasal flaring
stridor
5/19/2023 76

All that Wheezes
isn’t always Asthma…
Think:
• Infection
• Foreign body aspiration
• Anaphylaxis
– Insect bites/stings,
medications, food allergies
5/19/2023 77

And all Asthma
doesn’t always Wheeze!
• Cough
• Fatigue
• Reduced exercise
tolerance
5/19/2023 78

Cough - Characteristics
• Dry, non-productive
• Mucousy – productive
• Croupy
• Acute – less than 2-3 weeks
• Chronic – more than 2-3 weeks
• Associating Symptoms
5/19/2023 79

•Auscultating Heart Sounds
Pillitter
Circulatory
The Auscultation Assistant – Hear Heart Murmurs, Heart Sounds,
and Breath Sounds. http://www.wilkes.med.ucla.edu/inex.htm
•Perfusion – capillary refill
•“Warm to touch”
5/19/2023 80

Abdominal Assessment
Pillitteri
Gastro-Intestinal
5/19/2023 81

Abdomen
• Use supine position with pillow under the
head and knee flexed.
• Divide abd. to 4 Quadrant, and examine from
button to top.
• Examination of the abdomen involve the
inspection, auscultation, palpation and
percussion.
5/19/2023 82

Abdomen: Key Points
• Contour
• Bowel Sounds & Peristalsis
• Skin: color, veins
• Umbilicus
• Assess for Tenderness, Ridigity, Tympany, Dullness
• Hernias: umbilical, inguinal, femoral
• Masses - size, shape, dullness, position, mobility
• Liver, Spleen, Kidneys, Bladder
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5/19/2023 85

Abdominal Girth
Abdominal girth should be measured over the umbilicus
Whenever possible.
5/19/2023 86

Bowel Sounds
• Normal: every 10 to 30 seconds.
• Listen in each quadrant long enough to hear at
least one bowel sound.
– Absent
– Hypoactive; peritonitis, paralytic illeus
– Normoactive
– Hyperactive, GE, Intestestinal obs.
5/19/2023 87

Stomachaches and Abdominal Pain
• Excessive gas
• Chronic constipation
• Lactose intolerance
• Viral gastroenteritis
• Irritable bowel
syndrome
• Heartburn or
indigestion
• GERD (Gastroesophageal
reflux disease)
• Food allergy
• Parasite infections
(Giardia)
What are we most concerned about?
5/19/2023 88

• Appendicitis
• Bowel obstruction --
Cholecystitis with or without
gallstones
• Food poisoning
(salmonella, shigella)
• Inflammatory Bowel
Disease –
– Ulcerative colitis
• Hernia
• Intussusception
• Kidney stones
• Pancreatitis
• Sickle cell crisis
• Ulcers
• Urinary tract
infections
Stomachaches and Abdominal Pain
5/19/2023 89

Signs and Symptoms
• Appearance –color, facial, ROM, gait, position
• Pain – get your pain scales out
• Nausea
• Vomiting
• Diarrhea
• Bloating
• Vomiting
• Inability to pass gas or stool
5/19/2023 90

Musculo-Skeletal
• FROM, MAE - neck, shoulder, elbow, wrist, hip, knee,
ankle, foot, digits
• Alignment, contour, strength, weakness & symmetry
• Limb, joint mobility: stiffness, contractures
• Gait – observe child walking without shoes
• Spinal alignment - Scoliosis
• Muscle Strength & Tone
• Hips – O & B
• Reflexes
5/19/2023 91

• Bone, joints-cartilages, ligaments and muscles.
• Inspect the joint for flexion and extension,
abduction, adduction, rotation.
• Inspect the symmetry and observe the edema.
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5/19/2023 93

Scoliosis
Lateral curvature of spine
Medline.com
Key Points:
•Barefoot
•Feet Together
•Bend Over –”Diving Of a Diving Board”
•Check Hips
5/19/2023 94

Assessment
• The Five P’s:
– Pain
– Paresthesia
– Passive stretch
– Pressure
– Pulse-less-ness
5/19/2023 95

Skin, Nails & Hair
• Rashes
• Lesions
• Lacerations
• Lumps
• Bumps
• Bruises
• Bites
• Infections
5/19/2023 96

Common Skin Lesions
Macule
Papule
Vesicle, bulla
Pustule
Cyst
Patch
Plaque
Wheal
Striae
Scale
Crust
Keloid
Fissure
Ulcer
Petechiae
Purpura
Ecchymosis
Capillary bleeding: Petichiae and purpura
usually indicate serious conditions
5/19/2023 97

Skin Infections
• Bacterial infections
• Abscess formation
• Severity varies with skin integrity, immune and
cellular defenses
• Examples:
– impetigo
– cellulitis
5/19/2023 98

The School-Age Child
• Privacy and modesty.
• Explain procedures
and equipment.
• Interact with child
during exam.
5/19/2023 99

Adolescent
• Privacy issues – first
consideration
• HEADS: home life,
education, alcohol,
drugs, sexual activity /
suicide
• GAPS Guidelines for
Adolescent Preventive
Services
• Bright Futures
5/19/2023 100

Psychosocial Assessment
HEADS
Home life
Emotions /
Depression or
Education
Activities
Drugs / Alcohol /
Substance
Abuse
Sexuality
activity or
Suicide
SHADESS
•School
•Home
•Activities
•Drugs / Substance
Abuse
•Emotions /
Depression
•Sexuality
•Safety
5/19/2023 101

Common School Health
Focused Assessments
The “I don’t feel good”
– where do I begin?
Behavioral / Mental
Health Concerns
Chronic Conditions &
Special Needs
What Else?
5/19/2023 102

The “I don’t feel good”
5/19/2023 103

The Frequent Fliers
Headaches
Stomachaches
Nosebleeds
Chest Pain
Coughs
& Fevers
5/19/2023 104

5/19/2023 105

The Power of Nursing
Never doubt how vitally important you are;
never doubt how important your work is –
and never expect anyone to acknowledge it
before you do.
Every moment, in everything you do,
you are making a difference.
In fact, you are in the business of making a
difference in other people’s lives.
In that difference lies their healing and
your power.
Never forget it.
Leah L. Curtin, RN, MS, MA, DSC, FAAN
5/19/2023 106

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