Pediatric - Blueprint Exam 1

A nurse is caring for a child with an oral temperature of 103F. Which intervention should the nurse follow when providing a sponge bath to the client?

*Stop the sponge bath if the child shows signs of chilling.*

A nurse is documenting the vital signs of a preschool-age child. What should the nurse remember when obtaining the child's pulse?

*Take the radial pulse.*

A nurse in the pediatric unit of the healthcare facility may be required to assist in resuscitating a child. Which should the nurse know if required to assist in the procedure?

*The Broselow system of length may be substituted for weight.*

Which should the nurse do when applying the clove hitch restraint to a child?

*Tie a knot when applying the device*

A 4-year-old child at the healthcare facility is on intravenous (IV) therapy following diarrhea. Which method should the nurse use to determine the body temperature of this child?

*Tympanic temperature*

A nurse is preparing to administer an enema to an infant. Which should the nurse do when administering an enema?

*Use a rubber-tipped bulb syringe.*

A parent of a newborn asks the nurse, "when should I start introducing solid foods into my child's diet?" What is the best response by the nurse?

*When your child is about 4-6 months old*

The nurse is educating a nursing student about the diagnosis of whooping cough (pertussis) for an 8-year-old child. Which statements would the nurse include in the teaching plan? Select all that apply.

*Whooping cough is transmitted through direct contact and through droplets.* *Monitor the child closely for bronchopneumonia which is a serious complication* *The initial symptoms include bronchitis and temperature elevation and the cough worsens.*

A 3-year-old boy is diagnosed with otitis media. What further assessment question would the nurse ask the family?

*"Do you smoke in the home?"*

A preschool child requires hospitalization and states, "I want my mom and dad to stay with me!" What is the best response by the nurse?

*"You can have your parents stay with you if they are able to."*

A new mother is nervous because her infant's pulse is "really fast." The nurse explains that which range is typical for an infant heart rate?

*80 to 180 bpm*

A child is diagnosed with chicken pox. What medication should the nurse inform the parents to avoid when treating the fever?

*Aspirin*

A 10-year-old child has just been brought to the nursing unit after abdominal surgery Which of the following nursing interventions must the nurse perform for the child? Select all that apply.

*Assist the child to a side position.* *Check for return of peristalsis.* *Evaluate pain and discomfort.*

A nurse is caring for a 2-month-old child who has undergone surgery for pyloric stenosis. Which should the nurse do as part of the postoperative care?

*Bubble the baby as frequently as possible during feeding.*

A nurse has to apply a jacket device to a child at the healthcare facility. Which should the nurse do when applying the restraint to the child?

*Cross the straps in the front and tie at the back.*

*Separation Anxiety Stage* (page 1167)

*Denial*. The denial phase (detachment) may be interpreted as a sign that the child is protecting himself or herself from anxiety by rejecting family caregivers. In truth, the child's need for caregivers is more intense than ever.

A child has been admitted to the healthcare facility for surgery. The nurse observes that the child is inactive, miserable, and clutching her blanket. The nurse understands that the child is in which stage of anxiety?

*Despair*

The nurse is caring for a hospitalized child and observes the child's behavior as apathetic and sad. The child is most likely experiencing which of the following phases of separation anxiety?

*Despair*

*Separation Anxiety Stage* (page 1167)

*Despair*. In the despair stage, the child becomes inactive, apathetic and sad. Usual comfort measures, such as thumb-sucking and clutching a blanket, become prominent. He or she watches constantly for family caregivers, is quiet and withdrawn, and is uninterested in food or play.

A 10-year-old girl is admitted to a same-day surgery center to have a tonsillectomy and adenoidectomy. Which intervention would the nurse include in the post-operative care plan?

*Encourage the child to drink water*

Which should the nurse do when taking the blood pressure of a child?

*Ensure that the bladder of the cuff encircles the arm without overlapping.*

A 4-year-old girl is admitted to the hospital with symptoms that include inadequate physical growth, retarded motor development, inadequate social response, and delayed language development. The nurse recognizes these as symptoms of what condition?

*Failure to thrive*

A 10-month-old baby is brought to a healthcare facility. The parents report the child's abdominal pain and passage of stool mixed with clear mucus and blood. The healthcare provider diagnoses it as a case of intestinal intussusception. What complication would the nurse monitor the child for following this diagnosis?

*Gangrene leading to bowel rupture*

The nurse is reviewing feeding options for a pediatric client. The nurse knows which equipment is the preferred method for feedings in the pediatric population?

*Gavage button*

A nurse is evaluating the respiratory status of a child. Which of the following symptoms may indicate pediatric respiratory distress? Select all that apply.

*Head bobbing.* *Nasal flaring.* *Wheezing*

A nurse is caring for a child with celiac disease. What foods, if served on the meal tray, would alert the nurse to hold the food until verification could be done? Select all that apply.

*Honey oat cereal* *Processed vanilla ice cream* *Lunch meat sandwich with oat bran bread*

A child is found to be asymptomatic but tests positive as a carrier for diphtheria. What action does the nurse anticipate providing?

*Informing parents about the importance of adhering to prophylactic antibiotics*

When measuring the weight of a child, the nurse should document the weight using which unit?

*Kilograms*

The nurse is caring for a pediatric client. Which assessment finding would alert the nurse to assess further for respiratory concerns?

*Nasal flaring*

The nurse is obtaining data from a child who will be having a surgical procedure this morning. The nurse observes the child has a cough, runny nose, and temperature of 100F. What is the priority action by the nurse?

*Notify the surgeon of the findings*

A nurse is caring for an 8-year-old child with diarrhea. Which intervention should the nurse perform when caring for the child?

*Observe the child for skin excoriation*

A nurse is caring for a 3-year-old child. The child is known to have phenylketonuria, a hereditary metabolic disorder. The nurse knows that which food item can be safely included in the client's diet plan?

*Oranges*

The nurse is caring for a child preoperatively with Wilms tumor. When following the plan of care for this child, what intervention is essential?

*Place a clear warning sign over the bed*

A nurse is assessing a toddler during a well-child visit. What should the nurse document and assess? Select all that apply.

*Play patterns and activities* *Age of weaning* *Language development*

The nurse is caring for a child diagnosed with spina bifida. What would the nurse include in the plan of care?

*Protect the child from lower extremity injury*

A 4-year-old boy, when approached by the nurse, slaps the hand away and clings to his mother. Which phase of separation anxiety is the boy experiencing?

*Protest*

*Separation Anxiety Stage* (page 1167)

*Protest*. In the protest phase, the child's need for family caregivers is conscious and sorrowful. The child cries and reacts aggressively, rejecting healthcare personnel. Fear of the unknown and anxiety cause the child to demand his or her own caregivers. Such a reaction is normal and denotes a healthy attachment to the caregivers.

Which intervention should the nurse perform with regard to an infant's bath?

*Provide daily shampoo to prevent cradle cap.*

Which of the following interventions should the nurse consider when administering medications to a child? Select all that apply.

*Reassure the child that crying is okay.* *Keep the time of administration to a minimum.* *Ensure accuracy in medication administration.*

The nurse is preparing to administer immunizations to an infant. The parent states, "won't those vaccines give my child autism?" What is the best response by the nurse?

*Recent research shows no connection between vaccines and autism*

The nurse is obtaining vital signs on an 18-month-old child. What data should the nurse obtain first?

*Respiratory rate*

The nurse assesses a child and notes a pimple-like red rash. The child is observed scratching the area. The nurse would expect the healthcare provider to further assess the child for what condition?

*Scabies*

The nurse is discussing typical behavior patterns with the parents of a toddler. Which issues should the nurse include in the discussion? Select all that apply.

*Separation anxiety* *Negativism* *Temper tantrums*

*Arm board and the IV* (page 1174)

Arm boards—Used to protect intravenous (IV) sites. • Pad the board with a washcloth or small towel and fasten with tape. Rationale: The cloth will absorb perspiration and provide comfort. Also, the nurse can change and wash it if it becomes soiled. • Secure the arm board to the client's extremity after the IV is in place and secure. Rationale: Ensure the security of the IV even if the board needs removal. • Check the child's circulation to the arm each hour. • Loosen or reapply tape, as needed. • Document your findings.

*Strep* (page 1195)

Group A beta-hemolytic streptococcal infections (GABHS) are fairly common among children older than 2 yrs. GABHS are disease causing strains of the genus Streptococcus, which are gram-positive bacteria normally found in the respiratory, alimentary, and female genital tracts. GABHS are spread by direct contact and large droplets. • Streptococcal (strep) throat is common in young children older than 2 y/o. • Treated with large doses of antibiotics, most often penicillin. It is started ASAP after a positive culture for strep. • A rapid strep screen or culture can differentiate strep throat from other types of throat problems • White patches on tonsils can be caused by strep • An elevated temp that doesn't fall after given an antipyretic( acetaminophen, ibuprofen) may also point to strep. • Lump in throat rather than a sore throat & feels sick all over, strep is likely the cause. • Most serious complication of strep throat are rheumatic fever, rheumatic heart disease, and nephritis.

*Adolescent Considerations* (page 1166)

Health supervision issues for adolescents: • Puberty • Smooth transition to young adulthood • Update of the diphtheria-tetanus immunization • Acne vulgaris • Menstrual dysfunction • Inadequate nutrition • Sexually transmitted diseases • Suicidal ideation • Chemical abuse • Adolescents feel more comfortable and are able to relate better with healthcare personnel in a setting customized for them.

*Pertussis* (page 1190-1192)

Pertussis or "whooping cough," is a highly contagious bacterial respiratory disease occurring most commonly in young children who have not been immunized. • Causative agent: Bordetella pertussis - a gram negative coccobacillus. • It is transmitted through direct contact and through droplets. • Pertussis can be prevented through the diphtheria, tetanus, acellular pertussis (DTaP) immunization. Booster immunizations for adolescents or adults are given via the combination vaccine Tdap. • The incubation period is 5 to 21 days. • Symptoms begin with bronchitis and a slight temperature elevation. The cough steadily worsens, leading to paroxysms (spasms) of coughing, characterized by a "whooping" sound. The person may cough so hard that he or she vomits or becomes dyspneic (labored breathing). • The first stage lasts about 1 week. • The severe coughing stage lasts 2 to 3 weeks. • It usually takes another 2 to 3 weeks for the cough to disappear, but whooping cough can last for several months. • The most serious complications are bronchopneumonia or death. • When treating individuals affected with whooping cough, maintain droplet Transmission-Based Precautions throughout the whooping period. • Give antibiotics and other medications as ordered. • Children need close supervision because respiratory difficulties and nutritional problems are likely to occur

*Separation Anxiety Stage* (page 1167)

Separation anxiety- is a developmental milestone, for children that can become more acute or problematic when experienced by a child being hospitalized.

*Red Measles* (page 1193)

Rubeola (Measles), Rubeola also known as the red measles, 10-day measles, or measles, is caused by the measles virus found in the nose, mouth, throat, eyes, and their discharges. • It is transmitted through direct contact with an affected individual and through airborne droplets. • Measles is highly communicable and difficult to recognize in its early stage, because the symptoms resemble those of the common cold, roseola infantum, and rubella (German measles, 3-day measles). • The incubation period is 10 to 20 days. • The disease begins with a slight temperature elevation, a runny nose, and watery eyes. • By day 2 or 3, diagnostic bluish-white pinpoint spots with a red rim, called Koplik spots, appear in the person's mouth. • Small, dark-red areas appear on the face and spread downward throughout the body. • These red areas grow large and group together, giving the skin a blotchy appearance. • Respiratory symptoms increase, and pneumonias are possible. • The child sneezes frequently, the eyes are sore, and the discharge becomes purulent; light hurts the eyes (photophobia). • The child also develops a sore throat and a hacking cough. • The rash, which may last for up to 10 days, is greatest at about the fourth day. • During the second week, the skin begins to flake off in tiny powder-like flakes (desquamation) for 5 to 10 days. • The child itches all over and soothing, antipruritic nursing measures are important to manage itching. • Measles is most hazardous to the very young child. • The infection may spread to the middle ear causing otitis media, pneumonia, and encephalitis. • Permanent brain damage, learning disabilities, or death can result from measles encephalitis. • All children should be immunized against measles because of the seriousness of the complications. Measles outbreaks occur periodically in populations in which a large group of individuals have not received necessary immunizations.

*Preschooler Screening (DDST)* (page 1164)

The Denver-II Developmental Screening Test (DDST) is a tool used to identify developmental delays in infants, toddlers, and preschoolers.

*Growth & Development Issues /Toddlers* (page 1164-1165)

Toddler: • Dental care: dental visits • Weaning from the bottle • Diet and solid food • Behavior patterns: separation anxiety, negativism and temper tantrums • Discipline and limit setting • Poison prevention • Toilet training Toddler care: • As growth progresses independence & autonomy become important. • Well child checkup will include: • Age of weaning from breast or bottle to cup (achieved by age 12 months) • Ages at which toilet training was started and completed • Language development • Play patterns & activities • Sleep patterns • Talk about behavior patterns & type of discipline used at home. Encourage dental checkup for toddlers as early as 12 months of age. • Teaching requires a strong focus on safety. Toddlers are very mobile but lack the judgement to protect themselves. Observe caregiver-toddler interaction.

*Child's Development Level* (page 1164)

Well-child visit information includes: • The nurse should obtain specific information related to the child's age. • vital signs • height and weight o Plot the child's height and weight on a growth chart that allows comparison with other children of the same age. o At each visit, the child's growth should be compared with what is considered "normal limits." Early detection of abnormal trends can lead to preventive treatments. • occipital-frontal circumference (OFC) of the head (to 3 years of age) • abdominal girth • limb measurements You can view comprehensive facts about child development on the Centers for Disease Control and Prevention Website. Tools for a more detailed preliminary assessment of child development are available. *The Hawaii Early Learning Profile (HELP) charts are designed to help determine a child's developmental level.* • The charts are available in sets that cover six primary domains, including: cognitive, language, gross motor, ne motor, social-emotional, and self-help. • If a delay is identified or suspected, a more detailed evaluation of the child may be performed. Basic principles of safety and child care apply for both well and ill children.

*Influenza* (page 1193)

• "The flu" is a general term for a variety of seasonal viruses or a specific endemic virus. Typically, in fall a virus develops and spreads through vulnerable populations, such as infants, the immunocompromised or the elderly. • S/S- vary from mild to severe, usually involving respiratory difficulties, fatigue and malaise. Different from common cold, generally it takes longer for a client to recuperate. • Treatment- For the flu is symptomatic for fever and vomiting. Antiviral medications or antibiotic medications are used for some individuals • Vaccines for immunization against a specific flu are typically developed annually as needed, generally requiring several months to develop

*Average Ranges/VSs/Infant/Toddler* (page 1169)

• *Infant*: o Pulse (beats/min): 80-180 o Respiration (breaths/min): 20-40 o Systolic BP (mm Hg): 74-100 o Diastolic BP (mm Hg): 50-70 • *Toddler*: o Pulse: 80-140 o Respiration: 20-30 o Systolic BP: 80-112 o Diastolic BP: 50-80 • *Preschooler*: o P: 70-117 o R: 20-25 o Systolic BP: 82-110 o Diastolic BP: 50-78 • *School-age*: o P: 65-110 o R: 17-22 o Systolic BP: 84-120 o Diastolic BP: 54-80 • *Adolescent*: o P: 60-90 o R: 15-20 o Systolic BP: 94-140 o Diastolic BP: 62-88

*Separation Anxiety Stage* (page 1167)

• A frequent initiating factor of anxiety is a child's separation from a familiar person and environment and the initiation of an unfamiliar, and therefore stressful, new lifestyle. • When separated from the primary caregiver/ surroundings the children experience: o Feel threatened and unsafe o Crying o Resisting attention or treatment o Screaming o Loss of Control -the child's inability to maintain newly learned concepts associated with autonomy, such as walking, being potty trained or feeding oneself. o Fussy o Scream o Have tantrums o Cling to their caregiver o Feel threatened and unsafe o Concept of time and ability to remember is lacking • Separation anxiety begins at about 7 to 9 months and resolving by 24 months. • If separation anxiety is severe and last longer than the child's second birthday, a healthcare professional should be consulted. Separation anxiety is not uncommon in toddlers, as discussed later in the chapter.

*Gastroenteritis* (page 1205)

• A physiological problem, such as cystic fibrosis, celiac disease, gastroenteritis, parasites, or congenital heart disease, may cause FTT (failure to thrive) • Rotavirus (RV) is a virus that causes a severe form of gastroenteritis in infants and young children. Epidemics are not uncommon during the winter seasons, generally November To April. Adults can be infected, but their symptoms are less severe than those in children. It is spread via the fecal-oral route, contaminated food or water, contact with contaminated surfaces or, occasionally, via respiratory tract secretions. The incubation period is about 2 days. o Symptoms include vomiting, watery diarrhea, fever, and abdominal pain for 3 to 8 days. Diagnosis may be made via rapid antigen detection of RV in stool specimens. Generally, a self-limiting infection, RV treatment is symptomatic, with emphasis on rehydration of the client. Hospitalization may be required to treat dehydration via intravenous (IV) fluids.

*Bronchiolitis Interventions* (page 1225)

• A viral respiratory infection resulting in inflammation of the bronchioles. • It is seen most often in children younger than 2 years and tends to be a seasonal illness, occurring in winter and early spring. Illness begins with symptoms of a cold, which gradually worsen. • Chest x-ray studies reveal air trapping in the lungs. • The illness usually resolves within 10 days. • A severe case of bronchiolitis may require hospitalization and treatment with IV fluids and oxygen administered by mist tent. • RSV is believed to cause more than half the cases of bronchiolitis.

*Lice* (page 1197)

• Also known as Pediculosis as tiny parasites, most common in children attach to the children's head (hair follicle) • All have same three stages egg (nit), the nymph (young adult), and adult • Nits take 1-2 wks. to hatch into a nymph, smaller louse takes 9-12 days to grow, adult lice are tan and gray about the size of the sesame seed, Nymph and adult Lice feed on blood. • Bedding and clothing generally become infested when used by infected by people, direct physical contact with the infested person, clothing, bed, bed linens, or towels can spread the parasite. • Regular bathing and clean clothing can prevent infestations. Children are more vulnerable, DX: is based on viewing the lice or their eggs o Treatment- Apply over the counter pediculicides, such as Lindane or Pyrethrins (Pyrinyl, RID) to the affected area & thoroughly cleaning all clothing, and personal articles, if infestation occurs entire family needs to be treated.

*Strategy/Adolescent* (page 1166-1167)

• As a rule, older children are able to understand the need for hospitalization, although they often hide many fears. • Younger school-aged children may experience fear of separation when they are ill. Peer relationships are important to children, especially adolescents. Most healthcare facilities allow friends to visit, but activities should be regulated to prevent sick teens from becoming overtired. • A telephone should be available for the child client; however, rules for its use should be clearly established. • A smile is a universal language.

*Poison Treatment* (page 1199)

• In the event of poisoning, family caregivers should call their local poison control center of the American Association of Poison Control Centers at 1-800-222-1222 immediately. • Special personnel can determine the best treatment for the particular poison. The person calling should take the container of the substance to the telephone in order to give info as quickly as possible. The PCC's number should be placed on all phones used. In the U.S and Canada dialing 911 provides immediate access to emergency assistance. • When a poisoned child arrives in the ED, specific procedures are performed. Sometimes the stomach is washed out (gastric lavage), usually with normal saline, in an effort to remove as much poison as possible. This procedure must be done quickly to prevent as much absorption of the harmful substance into the bloodstream as possible.

*Burns* (page 1199)

• Chief nursing concerns are combating shock, alleviating pain, and restoring fluid and electrolyte balance. Secondary interventions include the prevention of infection and contractures, and the reconstruction or repair of damage. Severe burns cared in specialized units. • Treatments for burns is long term. • Pressure garments are used to prevent contractures & scarring. • Children may need to wear pressure garments continuously for 12 to 18 months; these garments require replacement to accommodate growth • Children under 5 have difficulty recovering from burns because their thin skin receives deep burns, they have incomplete immune systems, & they become dehydrated easily. Special considerations: • Even a superficial burn is critical if it covers ⅔ or more of an infant's body. • An infant's head is large in proportion to the body. • The newborn: The head is 17% of the entire body surface; each arm, 8%; each leg,13%; the front or back, 20% and genitals,1% • The 3 yr. old: Head 15%, each arm 8%; each leg 14%, the front or back 20%; and genitals 1% • The 6 yr. old: Head 11%, each arm 8%, each leg 16%, front or back 20%, and genitals 1% • Over 12 yrs. old: the rule of nines applies, the head is 9%, each arm, 9%; each leg, 18%; front or back, 18%; and genitals,1%.

*Measuring the Child* (page 1170-1171)

• Children on an infant or child scale, always keeping a hand near them for safety. Older children are weighed standing up. • Measure the weight in kilograms. Often, you will need to convert this weight to pounds for the benefit of family caregivers (2.2 lb. = 1 kg). Documenting weight in kilograms allows accurate dosage calculation for medication administration, particularly for intravenous (IV) fluids. • To maintain medical asepsis, place a clean paper on the infant scale before weighing a child, and disinfect the scale after the procedure. After weighing is finished, discard the paper and document the weight. Wash your hands before and after weighing. Use Standard Precautions throughout the procedure. • You should report any deviations in weight immediately. Observe and document any signs of edema, dehydration, and the child's nutritional state. • Use the following guidelines when weighing an infant: o Weigh the infant at the same time each day, before feeding o Balance the scale carefully before obtaining the infant's weight o Weigh the infant without clothes and a diaper o Note additional equipment being weighed (IV, arm board, brace, cast)

*Pt. Teaching Injury Prevention* (page 1198-1200)

• Constant vigilance is the key component to safety • Keep small buckets of any fluid away from young children, never let kids swim alone, drownings can occur in any body of water • Children should not use pillows until they are able to turn themselves over freely. No plastic bags on mattresses • Keep sharp objects out of reach of children • Never allow kids to pet an unfamiliar dog or go near a dog that's eating. • Cleanse all animal scratches carefully and apply an antibiotic ointment • Cut food into small pieces and teach children to eat slowly and to not laugh and talk with food in their mouth. • Avoid serving nuts, popcorn, chewing gum, hard candy, raisins, carrot sticks, and hot dogs to children younger than 4 years of age. • Store small household items away and monitor children when such items are being used. • Post local poison control number on all phones • Label poisonous materials and lock cabinets • Keep meds and poisonous materials in original containers • Use childproof caps when possible • Keep edibles separate from inedible • Don't purchase meds resembling candy, animals, people, or cartoon characters. • Read labels carefully • Dispose of poisonous materials and meds carefully do not throw them in the trash or flush down toilet • Never smoke around children • Watch children when visiting relatives and friends • Remain calm in an emergency, give all info and follow directions • If poisoning occurs, take containers to the ED with you if you're unsure list all possible substances.

*Safe Mealtime/Pt. Teaching* (page 1198)

• Cut children's food into small pieces. • Teach children to eat slowly. • Teach children not to laugh and talk when they have food in their mouth. • Serve foods appropriate to a child's age. Avoid serving nuts, popcorn, chewing gum, hard candy, raisins, carrot sticks, and hot dogs to children younger than 4 years of age. • Keep small objects, such as coins, marbles, beads, and small toy pieces, away from children younger than 4 years of age. • Store small household items, such as pins, buttons, toothpicks, nails, screws, and thumbtacks, away from children's reach. Monitor children when they are in an area where such items are being used.

*FTT - Failure to Thrive* (page 1206)

• FTT- inadequate physical growth. Psychosocial rather than a congenital physical cause. o May involve only weight or weight and height. o Characteristic developmental symptoms include retarded motor development, inadequate social response, and delayed language development. o Children are withdrawn and apathetic, do not relate to their environment and do not cry. o Flat affect - little or no emotional expression in response to external stimulation o Can be caused by physiologic problems such as cystic fibrosis, celiac disease, gastroenteritis, parasites, or congenital heart disease. • Familial Causes o Early separation of mother from infant, which leads to inadequate bonding o Major depression or mental illness of a prominent caregiver early in the child's life o Major family crisis that disrupts normal family interaction o Serious illness of the infant, which leads to an inability to form strong familial bonding o Family caregivers who isolate themselves or who have marital problems o Very young caregivers or caregivers with minimal parenting skills o Serious illness or death of caregiver or sibling • Infant-Related Causes o Prematurity, illness, congenital malformation, malabsorption disorders o Reduced responsiveness and interaction with others in environment o Dislike of cuddling, slow social development (e.g., does not smile), difficulty in feeding o Disorders, such as severe autism or mental retardation

*Infection Control Measures* (page 1174-1189)

• Healthcare personnel and family members of children younger than 2 years are usually required to wear isolation protection when handling children with contagious diseases to prevent the spread of infection. • Most healthcare facilities use disposable gowns • Change your gown at least once each shift and more often if needed, and discard after use • Scrub before putting on the gown and scrub thoroughly after removing it • Wear gloves if you will come in contact with any body fluids or substances, including stool, emesis, urine or blood. Transmission-based precautions: used when suspecting or caring for individuals with specific infectious diseases. • Transmission Based precautions include isolation procedures, which require the use of PPE such as N95 quality oropharyngeal filtering masks, gowns or eye protection. • Types of isolation precautions: o For direct contact with the infectious agent, use Contact precautions o For moisture droplets that connect with humans through close respiratory or mucous membrane contact, use Droplet Precautions o For respiratory routes that transmit infectious microorganisms through longer distances suspended in the air (infectious aerosolization), use Airborne Precautions

*Restraint Application* (page 1172-1174)

• Healthcare provider's order is usually required before application of any restraint device. • Release and reapply every 1 to 2 hours • Check child's skin and circulation each hour • Sometimes, enforcing bed rest by applying a child safety device called a restraint is necessary. Small children should be restrained whenever they are in a high chair, wheelchair, or other device. Types of restraints: o Bubble top- clear plastic attached to the top of the crib Be sure it's firmly attached Use for any child who may be able to climb or jump over the sides • Jacket- used in cribs, high chairs, beds, or wheelchairs o Apply over clothing o Straps come out on each side and usually cross in front and tie in back o Tie straps to back of chair or frame of bed. On a moveable part. Not on side rails o Check circulation ever 1 to 2 hours o Document and report any evidence of skin irritation • Clove hitch or commercial wrist device- Kerlix bandage or stockinette applied in a figure 8 knot or manufactured device, can be used to restrain one or more extremities. o Apply padding under restraints o Tie knot so it doesn't get too tight o Check extremity every hour o Remove restraints every 2 hours to allow exercise of the extremity • Arm boards - protect intravenous sites o Pad the board with a washcloth and fasten with tape o Secure the arm board to the client's extremity after IV is in place o Check the child's circulation each hour o Loosen and reapply tape as needed o Document findings • Quick-Release Knot- If the child pulls on the strap from his or her end, the knot will tighten. However, when you pull on the free end, it will release easily. The free end must be out of the child's reach. This knot is safer than a traditional knot because it can be released quickly in an emergency. • Hold-Fast Bow-To tie a bow that will not come untied spontaneously, wrap the second end all the way around before pulling through the loop to make the second half of the bow. The knot will come untied when you pull on the free end, just like any other bowknot, but will not easily come untied. The knot is handy for shoelaces and for restraints that are tied to each other. It must be kept out of the child's reach

*Hep. B* (page 1190)

• Hepatitis B (HepB) is one of a large group of disorders that involves some form of inflammation of the liver. • HepB is a serious disease and is typically the first immunization received by a newborn. • It is spread by contact with the hepatitis B virus (HBV) found in infectious blood, semen, sexually related body fluids, contaminated needles, and transmission from infected mother to a newborn. It can be an acute mild case, but commonly results in serious chronic illness, liver disease, and liver cancer. • Treatment is symptomatic. Prevention via vaccination is recommended for all infants and unvaccinated children, adolescents, and adults. • Healthcare workers are commonly provided with HepB immunization as a part of employment protocols

*Adolescent Considerations* (page 1166)

• Illness or injury threatening self-image. o Many young people worry about damage to their bodies or about death, whether the threat is real or not. o Acutely aware of their emerging sexuality; therefore. Their modesty should be respected. o Include adolescents in planning and performing care as much as possible to encourage their emerging independence. • Adolescents may be too embarrassed to ask questions, particularly about their health. A bulletin board or brochure rack well stocked with informational pamphlets about common concerns can aid communication. • Adolescents are capable of expressing individual concerns; therefore, you will benefit from talking separately with caregivers and with adolescents. • Adolescents need unbiased and accurate information regarding their rapidly changing bodies and the issues they may encounter during this transition to young adulthood. Health education should include information concerning sexually transmitted diseases and prevention, including HIV/AIDS, sexual identity, pregnancy, birth control, substance use and abuse, depression, and suicide.

*Toddler/Otitis Media* (page 1213)

• Infection behind the eardrum in the middle ear is a frequent complication of a cold especially in children • Eustachian tube is wider and more horizontal in children, allowing bacteria from the nasopharynx to readily enter the middle ear. • One primary cause of Otitis Media is passive smoke inhalation. Infants and young children who live in homes w/ smokers have a higher incidence of Otitis Media. • Breast-fed babies have a lower incidence of otitis media, perhaps because they receive immunoglobulin, propping a baby's bottle may allow fluid to flow through the eustachian tube, causing otitis media. • S/S: Pain may be present, young child may show sign by pulling at ear. Signs of infection, High temp 104, swollen glands, loss of appetite. • Most serious complication include mastoiditis and occasionally encephalitis, meningitis • Medical Treatment- o Antihistamines & decongestants may be administered for otitis media, warm moist packs may provide comfort. Some children experience more comfort with an ice pack because it reduces fever. Acetaminophen for fever. o Surgical Treatment-An outpatient procedure may be performed called a myringotomy (surgical opening into eardrum an inserting a polyethylene ventilating tube as a temporary or permanent accessory eustachian tube.) Tympanoplasty-is reconstruction of the middle ear, either with the placement of a homograft transplant of the structure. Myringoplasty- Is reconstruction of the eardrum, usually with a graft of temporalis fascia.

*B/P Assessment* (page 1170)

• It is necessary to use a smaller blood pressure cuff for children. When choosing a cuff, measure the width of the cuff against the width of the child's arm. The cuff should cover approximately two thirds of the upper arm. The bladder of the cuff should be long enough to encircle the arm without overlapping. Be sure to use the same size of cuff each time. Cuff size will vary with a child's age and size. The most important aspect is the trend of the blood pressure or temperature: You should determine whether each is going up or down. • If taking blood pressure at an infant's thigh, record it as "thigh pressure." In children older than 1 year, thigh pressure is approximately 20 mm Hg higher than arm pressure. If you must use the radial artery (wrist), radial blood pressure is 10 mm Hg lower than that of the brachial artery. Note use of the radial artery on the record.

*Impetigo* (page 1239,1240,1285)

• Most common bacterial infection of children 2-5 years • Most commonly caused by streptococcal or staphylococcal bacteria • Contagious among infants and young children • Treated with systemic antibiotics and topical antibiotics • Begins in superficial layers of epidermis as a red inflamed vesicle near the nose, mouth, face, neck, hands, or diaper region (first stage) • Characteristic vesicles ooze a clear exudate, which develops a golden-yellow crust that causes local discomfort and pruritus (second stage) • Avoid touching exudate and crust to prevent spread of infection • Last stage is a red mark which heals without leaving a scar • Sores may be itchy but not painful • Nursing considerations: o Frequent handwashing o Encourage child not to scratch o Keep child's clothes, linens, and washcloths away from others o Clip child's fingernails o Cotton mask over the nose may help limit scratching and might make the child feel more like a pirate than a client o Contact precautions

*Mumps* (page 1193-1194)

• Mumps, also called epidemic parotitis, is a viral disease that affects the salivary glands, especially the parotids. • It is transmitted through direct and indirect contact and through salivary secretions. Children younger than 2 years and adults seldom contract mumps. However, adults who contract mumps may suffer serious after effects, including sterility in men. Close contact is required for mumps to be transmitted. The incubation period is 2 to 3 weeks. • The first sign is usually a swelling of the parotid gland, on one side or both. Sometimes, the individual has a low-grade fever, headache, and general malaise before the swelling appears. The swollen gland is painful, and opening the mouth and eating are uncomfortable. The swelling begins to disappear by the second or third day and is usually gone by day 10. The disease is considered communicable until the swelling disappears. • Treatment of the symptoms is the typical nursing measure.

*Head to Chest Ratio* (page 1171)

• Normally, the newborn's head is larger than the chest. • Chest and head measurements are approx. equal for children aged 1 to 2 years, after which the chest begins to become larger than the head. • By age 5, a child's chest is about 2 to 3 in (5 to 7.6 cm) larger than the head. • Measure the chest at the child's nipple line, using a paper tape.

*Pediculosis/Treatment/Pt. Teaching/Definition* (page 1197)

• Pediculus pubis (lice, pubic lice, "crabs") are tiny parasites that attach themselves to pubic hair follicles and cause intense itching. o Can spread through sexual contact, infested bed linens and clothing, or close physical contact • The most common lice infestation (pediculosis) in children occurs on the head (pediculosis capitis) o Direct physical contact with the infested person, clothing, bed, bed linens, or towels can spread the parasite o Regular bathing and clean clothes are necessary to prevent infestations • Treatment: consists of applying OTC pediculicides, such as lindane (Kwell) or pyrethrins (Pyrinyl, RID), to the affected area and thoroughly cleaning all clothing and personal articles • Kwell is contraindicated during pregnancy, alternate medications must be ordered if the woman is or suspects she is pregnant • Generally, scalps or bodies need at least two separate treatments to ensure the death of any nits that hatch after the first treatment. • If an infestation occurs, the entire family needs to be treated. • The lice die within 24 hours after being separated from the body, but the nits can live for approximately 2 weeks • A repeated treatment is needed at that time • Sexual partners and household members must be treated simultaneously • Contact precautions are necessary to prevent the spread of lice and scabies.

*Prioritizing Toddler VSs* - Be alert for signs of pediatric respiratory distress (page 1177)

• Restlessness, apprehension, panic • Tachycardia • Tachypnea • Nasal flaring • Wheezing • Stridor • Change in color (e.g., pallor, circumoral cyanosis- a darkening of skin color, particularly around the nose, eyes, and mouth that is a significant sign of poor oxygenation) • Expiratory grunt- a significant indicator of impending respiratory arrest • Retractions: substernal, subcostal, intercostal, suprasternal, supraclavicular. • Gasping & shallow, labored breaths • Head bobbing Signs of respiratory distress include (page 1170) • Xiphoid retraction • Nares dilation • Expiratory grunt Respiration (page 1169) • Take respirations before taking other VS, because you will be unable to obtain accurate respiratory rate if a child is crying. Count for a full minute. • If unable to obtain RR observe for signs of respiratory distress by checking skin color, pallor, and the presence of breath sounds Data collection on admission (page 1169) • Observe for signs of rash, abrasion, discharge or alteration in consciousness level Pulse (page 1170) : younger than 2 yrs. old take apical pulse & older than 2 yrs. take radial pulse Temperature (page 1170)- oral or tympanic if older than 6; younger than 6 tympanic, axillary, or rectal or are disoriented, unconscious, or severe respiratory distress. • Do not take a rectal temperature if a child had had any immune or hematologic disorder, rectal surgery, or diarrhea • Do not take a tympanic temp if a child has had ear surgery or has ventilating tubes or infection . Blood pressure (page 1170) • Measure the width of the cuff with the width of the child's arm, the cuff should cover approximately ⅔ of the upper arm. The bladder of the cuff should be long enough to encircle the arm without overlapping • If taking blood pressure at an infant's thigh, record it as "thigh pressure." In children older than 1 year, thigh pressure is approximately 20 mmHg higher than arm pressure. If you must use that radial artery (wrist), radial blood pressure is 10 mmHg lower than that of the brachial artery. Note use of the radial artery n the record. Weight and height • Weigh small children on an infant or child scale, always keeping a hand near them for safety. Older children weighed standing up. Weight in kilograms. (2.2lb= 1kg) • To maintain medical asepsis, place clean paper on infant scale before weighing a child & disinfect the scale after. Discard paper & document weight. Wash hands before and after. Report any deviations in weight immediately. o Observe & document signs of edema, dehydration, and the child's nutritional state. • Use following guidelines when weighing an infant: • Weight at same time each day before feeding • Balance the scale before weighing • Weigh infant without clothes or diaper • Note additional equipment being weighed (e.g., IV, arm board, brace, cast) • Child's length can be measured from head to toe on bed and then measure between the marks instead of trying to measure a moving child. • Use a disposable paper tape measure when obtaining measurements. Rationale: A cloth tape measure may stretch and alter measurement findings. Disposable tape measures also prevent cross-contamination. Key concept: (Page 1171) • The OFC (occipital- frontal circumference) reflects intracranial volume pressure, which is a significant finding. Factors that affect head circumference include brain development, intracranial pressure, hydrocephalus, brain tumor, and some congenital defects, such as microcephaly & hydrocephalus. Chest circumference: (page 1171) • Measure & compare the child's chest circumference with the OFC. Normally the NB head is larger than the chest. Chest & head are equal children aged 1 to 2 years, chest becomes larger than the head after. • At age 5 chest is 2 to 3in (5 to 7.6cm) larger than the head. • Measure chest at the child's nipple line, using a paper tape. Other measurements (page 1171) • Other important measurements include abdominal circumference, extremity length, & extremity circumference. Measure the abdomen at the child's umbilicus.

*Rheumatic Fever*(page 1195)

• Rheumatic fever, an autoimmune reaction to GABHS, belongs to a group of diseases called collagen diseases(diseases of connective tissues). It is believed to result from continued streptococcal infections (e.g., scarlet fever, streptococcal sore throat), in which the child becomes sensitive to streptococci or develops an autoimmune response. Prompt And complete treatment of streptococcal infections greatly reduces the child's risk of contracting rheumatic fever. Rheumatic heart disease is the most common complication of rheumatic fever. The incidences of rheumatic fever and rheumatic heart disease have decreased in countries with access to healthcare resources, although they continue to be a problem in many countries where healthcare is limited. • Signs and Symptoms. Symptoms of rheumatic fever vary in degree from mild to severe. Loss of weight and appetite, fatigue, irritability, aches, joint pain, and tenderness in the extremities may be signs. Fever may begin suddenly, especially after a cold or sore throat, and becomes highest in the evening. The most significant symptom of rheumatic fever is polyarthritis, in which the child's shoulders, elbows, wrists, or knees swell and become excruciatingly painful. Pain travels or migrates from one joint to another and may affect several joints at the same time. It usually lasts for a few days to a week in each joint, then subsides gradually. Fortunately, the polyarthritis does not cause joint deformities, and the joints usually return to normal after the attack. • Diagnostic tests with the following results may indicate rheumatic fever (not all findings need be present) o Elevated white blood cell count (WBC) o Elevated erythrocyte sedimentation rate (ESR), commonly known as "sed rate" o Positive C-reactive protein (CRP) o Elevated antistreptolysin-O titer (ASO) Signs to watch for include jerky, uncontrolled movements of the face, neck, arm, and leg muscles, which are known as Sydenham chorea; small nodules under the skin over the elbows, ankles, legs, knuckles, and at the back of the head; and frequent nosebleeds. A common and serious complication of rheumatic fever is rheumatic carditis or rheumatic heart disease, in which valvular lesions impair mitral valve efficiency. The consequence of valvular insufficiency can eventually lead to severe cardiac failure. • Medical Treatment. o Most children recover from rheumatic fever and lead normal lives. When severe instances of carditis or heart failure (HF) occur, hospitalization is necessary; however, most cases of rheumatic fever are treated in the home. The disease's course depends primarily on the degree of heart damage. The degree of carditis directly affects recovery time. Recovery may be complete, but carditis can also be fatal. Rheumatic fever's active phase usually lasts 1 to 4 months, but other outbreaks are likely to follow. The key to treating rheumatic fever is to prevent permanent heart damage. Complete bed rest is maintained until the child is afebrile. Keeping the child inactive is fairly easy during the acute phase because he or she is very sick; however, aggressive family teaching is important during convalescence, when regulating the child's activity may be difficult. Drugs, such as acetaminophen, are given for pain relief and fever reduction. Aspirin may be used for its anti-inflammatory properties (as opposed to aspirin's effects as an antipyretic). Cortisone reduces inflammation but is prescribed only if absolutely necessary because of associated adverse reactions. Antibiotics are administered. Because recurrence is probable, prophylactic antibiotic medication may be prescribed for up to 5 years. For example, if the child needs dental work, has an infection, or is having an invasive procedure antibiotic are typically given as prophylactic treatment. Some children continue on prophylactic antibiotics for many years. Surgical replacement of a cardiac valve, particularly the mitral valve, may be necessary. If any sign of a strep throat exists, family caregivers should consult a healthcare provider immediately.

*SID VS SUID* (page 1200)

• Sudden unexpected infant death (SUID) is the term used when an infant dies suddenly and unexpectedly. The causative agents for SUIDS are not immediately known before investigation. o Causes of SUIDS may include metabolic disorders, poisonings, hypothermia, hyperthermia, neglect, abuse, and accidental suffocation, or can remain unknown. • Sudden infant death syndrome (SIDS) is the sudden, unexplained death of a seemingly healthy infant. Half of all defined SUIDS cases are owing to SIDS. SIDS occurs while the infant is asleep and is the primary cause of death in infants 1 month to 1 year of age. This diagnosis can be made only following a thorough autopsy, forensic evaluation of the scene of death, and a review of the child's clinical history. o Although the etiology of SIDS is unknown, one theory suggests that an abnormality in brain-stem functioning results in faulty respirations. Sleeping in a prone position has a strong connection to SIDS. Additional causes may include incomplete bubbling after feeding, secondhand smoke, and the use of a pillow. o Small-for-gestational-age (SGA) infants are at a greater risk. Prolonged infantile apnea (PIA) is defined as cessation of breathing for at least 20 seconds or for a shorter time with accompanying bradycardia, cyanosis (bluish skin), and/or pallor. When this condition is discovered (via a "near miss"), an apnea monitor can be used to prevent SIDS. Some infants at high risk are placed on an apnea monitor until about 1 year of age. The apnea monitor functions through electrodes placed on the infant that are attached to a small bedside monitor. The machine sounds an alarm when there is a breach of preset respiratory parameters (e.g., no respirations for more than 15 seconds). In addition to experiencing profound shock and grief, families of children who die suddenly often feel overwhelming guilt. When this tragedy occurs, be particularly sensitive and offer support and compassion. Provide families with information regarding support groups which are available locally.

*Gaining Child's Cooperation* (page 1169)

• The equipment for the physical examination of a child is the same as that for an adult, except that some pieces are smaller. • The child's cooperation is of utmost importance. A little extra time helping children become comfortable often works wonders. • Show the child the equipment and let him or her handle it to promote a sense of control. If the child is too young, ill, or frightened to understand how to cooperate, you may need to restrain him or her for parts of the examination. Use restraint only as a last resort because it makes children feel more threatened and frightened.

*Autism Spectrum Disorder* (page 1190)

• The persistent myth that autism is associated with immunizations, such as measles, mumps, and rubella (MMR) has been disproven by numerous scientific studies. • Autism Spectrum Disorder (ASD) is a lifelong, complex developmental disorder characterized by intellectual, social, and communication deficits. It is an umbrella term that covers a spectrum of neurodevelopmental disorders that impair a Child's ability to communicate and interact with others. • ASD can greatly diminish the individual's ability to function and perform social, occupational, and behavioral interactions. • Autism is not actually a disease, but a syndrome of behaviors that vary widely. • Asperger syndrome is a term formerly used to indicate autism that is at the mild end of the autism spectrum. • ASD can show signs in early infancy. o Some children develop normally for many months or years but suddenly become withdrawn, aggressive, or lose language skills that they have acquired. o Each pattern of symptomatic behaviors is unique, and abilities range from low- to high-functioning. • Risk factors for ASD: o The cause or causes of ASD are not well understood, but o are possibly both genetic and environmental. o Gender; boys are more likely to develop problems than girls. o A family who has one child with ASD is more likely to have another child with the disorder. o Also, if one child is diagnosed with ASD, another child may have noticeable problems related to behavioral, communication, and social interactions. o Extremely preterm infants (i.e., infants of 26 weeks or less gestation) o Some children may have other medical disorders that have behaviors similar to those of ASD, for example: FXS or TS. Risk factors also include extremely • Sign/Symptoms: o S/Ss develop suddenly without warning. o Some children succeed in reaching their developmental milestones for many months or years, but for an unexplained reason, these abilities are lost. o Initially becomes withdrawn, aggressive and may lose previously acquired language skills. o Demonstrate a profound lack of social interaction and communication o Do not respond to verbal stimuli o Do not like to be cuddle or to be touched

*Toddler Activities* (page 1165)

• Toddlers are very mobile, but lack the judgement to protect themselves • As their growth progresses independence and autonomy become important • Dental care and visits • Weaning from the bottle • Diet and solid food • Behavior patterns: separation anxiety, negativism, and temper tantrums • Discipline and limit setting • Poison prevention • Toilet training

*Chicken Pox* (page 1194)

• Varicella- originates with the varicella zoster virus, which is the same virus that cause herpes zoster (shingles) found in adults who had chicken pox in earlier years • Following of concurrent with a rash, a fever develops. • The itchy rash develops first into papules then vesicles and finally pustules that turn into crust-like lesions that fall off in 1 to 3 weeks. • A highly infectious disease, the chickenpox virus is found in the nose, throat, blisters and crusts • The blisters generally concentrate on the face, scalp, and trunk • Severe complications, more common in adolescents and adults than in infants and children include: o Bacterial meningitis o Encephalitis o Pneumonia • Immunized persons may get milder forms of the disease that non-immunized individuals • Transmission is by highly infectious droplets from coughing and sneezing or by direct contact • TX: includes droplet and contact precautions as well as symptomatic treatment for the fever and rash. • The most common complication is infection caused by scratching the blisters, which can leave scars or "pock marks" • Caregivers should keep the child's fingernails short to prevent scratching • Antihistamines (diphenhydramine [Benadryl]) and anti-itching measures, such as antipruritic medications in a bath, may relieve intense itching • The administration of antiviral medications, such as acyclovir (Zovirax), may be helpful in reducing symptoms

*Pediatric Safety* (page 1172)

• Wash your hands before and after giving care. Follow standard and transmission based precautions, as necessary. • Make sure side rails on beds & cribs are up at all times. Beds should always be in the lowest position unless you are performing specific procedures. (Prevent injuries from falls) • Adequately support children when you carry or transfer them. Always support their heads and necks and watch the position of their extremities carefully. • Use safety restraints when transporting a child. Never leave the child unattended. Always use the provided safety devices when a child is in a high chair. • When taking a child's temp consider his or her ability to cooperate • Never prop bottles (prevents choking and ear infections) • Never leave a young child unattended during eating. Cut food into small bites. Avoid giving foods that are slippery or hard to chew. • Teach family caregivers good safety practices, and make sure they understand the reason behind them. • Be alert for any broken equipment, furniture, or glass items.

*Priority Action Prior Surgery* (page 1183)

• When the child arrives on the morning of surgery, observe and document any signs of upper respiratory infection (URI), such as fever, cough, or runny nose. URI makes respiratory complications more likely and will probably cause surgery to be delayed until the infection clears. • A child is more likely than an adult to have a URI • Be sure to chart the presence of any open wounds, rashes, or other unusual conditions. • Notify the surgeon of the findings

*Child Abuse/S/S's* (page 1201)

• Widespread social problem and as a consequence has serious implications • Actions that are seen as threats, situations that are potential for harm (unsafe environments) having a child earn money (exploitation) leaving a child to care for younger siblings, or having the child cook for family injury or death • The term "child" usually indicates someone younger than 18 • Child abuse takes several forms including physical abuse , emotional abuse, physical abuse. • As a nurse you are considered a mandatory reporter for child abuse • S/S-Confused with the activities of normal growth & development o Physical Abuse-Unexplained bruises, various stages of healing, cigarette burns, scars, and numerous unexplained fractures that have healed are common indicators, o Emotional Abuse- may notice frequent verbal comments that result in loss or destruction of a child's self-esteem. Rejecting and threatening the child may also be observed, o Sexual abuse- sudden behavioral changes, Abdominal pain, gastric distress, or headaches, emotional disturbances, avoidance of touching or physical contact, vaginal or rectal bleeding, or lesions