WEEK 1 FUNDAMENTALS OF PEDIATRIC NURSING DISCUSSION QUESTIONS (1A Slides)

DIRECTIONS: REVIEW the following ques ons prior to the rst class. You will be asked to discuss these during class.

A. A 3-week-old is being seen for rule out sepsis and a fever of 102. This is the mother’s rst child. She is tearful and
asking many ques ons.
1. What are the baby’s greatest needs at this me?
2. What are the baby’s needs that are similar to an adult with the same diagnosis?
3. How are this infant’s needs di erent from an adult? How is an infant more vulnerable than an older child?
4. What are the greatest psychosocial needs of an infant? Iden fy interven ons that address this baby’s
psychosocial / developmental needs.
5. What are the mother’s needs? How should the nurse address these needs?

B. A 2-year-old has a 2 day history of vomi ng and diarrhea. His 3 older siblings are also sick with acute
gastroenteri s. When approached by the nurse, the child cries and clings to his mother.
6. What are the child’s greatest needs at this me?
7. How are these needs similar to an adult with the same diagnosis? What needs are di erent from an adult?
8. What are the greatest psychosocial needs of a hospitalized toddler?
9. How can the nurse support the child’s psychosocial / developmental needs?Iden fy ways to communicate with the
toddler.
10. What are the mother’s needs? How can the nurse address her needs?

C. A 4-year-old is admi ed for an emergency appendectomy. He has a 3-day history of vomi ng with irritability and
abdominal pain. He is scheduled for surgery in 6 hrs. The child & parents are Spanish speaking only.
11. What are the child’s greatest needs at this me?
12. How are the child’s needs similar to an adult with the same diagnosis? What needs are di erent from an adult?
13. What are the psychosocial / developmental needs and fears of this child (discuss emergency surgery)?
14. What is the best way to prepare the child for the surgery?
15. What are the parent’s needs? How can the nurse address the family’s needs?

D. A 10-year-old girl with cys c brosis is admi ed with pneumonia. She will receive a 2 week course of IV an bio cs
and respiratory interven ons. This is her tenth hospitaliza on related to her CF, 4 have been in the past 2 years. She
has a 7-year-old sibling with CF who has only been hospitalized twice in his life.
16. What are the child’s greatest needs? How are the child’s needs similar to an adult with the same diagnosis?
17. What are the greatest psychosocial needs of a school aged child? How does this relate to this girl?
18. How are the child’s needs di erent from a child who does not have a chronic illness?
19. Iden fy ways to support this child’s psychosocial needs?
20. What are the family needs? How are they di erent with chronic illnesses? How can the nurse address these?

E. A 15-year-old is newly diagnosed with leukemia. She will be having a central line placed and induc on chemo
started. When approached by the nurse, she closes her eyes & states that she is red and wants to sleep.
21. What are this girl’s greatest needs at this me? How are these similar to an adult with the same diagnosis?
22. How are her needs di erent from an adult who has just been diagnosed with cancer?
23. What are the adolescent’s greatest psychosocial needs? How does this relate to this girl’s situa on?
24. How can the nurse best communicate with this girl and do teaching with her?
25. What are the needs of the family? How can the nurse best address these needs?

II. Fundamentals of Pediatric Nursing: Caring for Children & Families

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 A. Se ngs where Nurses Care for Children
1. Inpa ent hospital: med-surg, specialty (oncology, cardiac etc.), ICU
2. Outpa ent: procedure / surgical, diagnos c tes ng, MD o ce, clinics, urgent care, ED.
3. Long term care / rehab: usually chronic, o en brain injured
4. School: during school, a er school ac vi es
5. Ac vi es: camps, recrea onal venues (Disneyland, sports etc.)
6. Home health
7. ????

B. Key Concepts for Care of Children and Families

a. The FAMILY, not just the CHILD is the client. A Family-Centered Approach to nursing is cri cal to successful
care of children with acute and chronic illness

b. ANY illness / hospitaliza on (no ma er how seemingly minor) a STRESS for the en re family is (including the
siblings and those not present at the bedside).
1. Some families go into CRISIS mode when the child gets ill especially with hospitaliza on.
2. Many families have been dealing with the illness at home for days, weeks, months, even years – many are
EXHAUSTED!
3. Families are juggling work, other children, and chores (laundry, cooking, cleaning, homework etc), along
with the challenges of their child’s illness.
4. They are most likely dealing with EMOTIONS (worry, fear, grief) related to having an ill child, seeing their
child withstand painful procedures, dealing with change in parental role / control while in the hospital
(feeding, sleeping etc..), being separated from the rest of their family.
5. Communica on is Key: Ongoing and honest Communica on has been iden ed as the MOST important
need in many studies of parental needs.

c. Stressors / sources of anxiety: many are age related, some are universal
1. Fear of the unknown
2. Separa on anxiety from parents, family, peers
3. Fear of pain / bodily harm / body image change
4. Loss of control
5. Anger / frustra on
6. Guilt (o en experienced by parents, especially with delay in dx or seeking care)
7. Regression (common in young children)
8. Boredom (diversional ac vi es are needed for all ages)
9. Depression (especially with chronic illness and/or losses)
10. Surgery – similar list as above but OR, masks, equipment may be very frightening to young children. Preop
tours / prep and medical play can help with this.

d. Communica on & interac ng with the CHILD: (review “Considera ons for Choosing Language” document for
more info on wording “Do’s” and “Don’ts”)
1. With very fearful children, start by speaking with the parent / caregiver

2. Smile and speak slowly and at eye level with the child. Body language & your relaxa on level is a big
factor! Squat down, sit on bed, get on your knees etc.

3. Use “ice breakers” and li le games to develop a rapport (s ckers and small washable toys work
well!). With older children, try to get involved in their favorite game / ac vity before a emp ng to
start a discussion if they are reluctant to talk.

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 4. Speak at the developmentally appropriate level. Remember some children are delayed but may
understand more than they can speak. Many preschool or younger children living in families who
speak another language may not understand. Many with limited English understand more than speak.
Avoid medical jargon / words with double meaning.

5. Respect “safe zones” (beds, play rooms) as areas where they should not have anything painful occur.
Blood draws, IV starts and things that make children fearful should be in treatment rooms (or a place
away from where the child sleeps / plays).

6. Consent: minors cannot consent unless “emancipated” (married or living on own and nancially
independent). Assent is needed when possible.

7. Explain using language at a developmentally appropriate level. Avoid words with double meanings
(give you a shot, put you to sleep, s ck your arm etc.). Use non threatening words associa ng with
familiar experiences (arm “hug” for BP check, and IV is like a “ ny straw”, X Ray is a “big camera” etc.).
Avoid the word “test” for school aged children because of confusion with school tests. Younger
children need meframes that are meaningful – avoid clock me and other measures that they don’t
understand. Review “Considera ons for Choosing Language” for more info on wording “Do’s” and
“Don’ts”)

8. Do not threaten a painful procedure or medical interven ons as a means of obtaining compliance.
Teach a parent be er alterna ves to achieving coopera on and the poten al harm of doing this.

10. Each procedure should contain the following:

● Why the procedure is being performed (to nd out why your tummy hurts)
● Where the procedure will be done (treatment room, radiology etc) and how they will get there
(wheel chair, special bed with wheels etc).
● What to be expected during transport and procedure using the child's senses (you will go down a
long hallway and an elevator ride, you will feel a cool sensa on and a funny smell when wiped
with a li le white pad, the big camera will make a beep and a buzzing sound when it takes your
picture)
● Any pain / discomfort involved and how long it will last (e.g., “The needle will s ng, although I’ll
put some cream on rst to dull the feeling”) – do not lie or minimize, this a ects the child’s trust.
● Approximate length of me the procedure will take and when the child will return to his/her
room (using age appropriate me frames)
● Any special care a er the procedure (e.g., “lie quietly during one TV show”)

e. Support the FAMILY: Nurses have a powerful role in helping families adapt to the stress of illness and
hospitaliza on Develop a rapport and assist families with what they need when they need it.
1. Informa on: Ask what they want to know and LISTEN! Provide ongoing updates (be honest, follow up with
ques ons /concerns).
2. Respect and collaborate: Ask family what works best for their child (they are the expert), facilitate their
role whenever possible (feeds, cares, ADLs),
3. Parental involvement: Facilitate caregiver’s ability to be at the bedside with the child, providing comfort /
care as possible (holding, feeding, ADLs etc)
4. Support caregiver needs: provide breaks, supplies for showers, meals & drinks etc. Bringing a cup of co ee
can go a long way in showing kindness and empathy. Understand stressors of having a hospitalized child
along with managing home, work, nancial obliga on, siblings etc.
5. Privacy: children and families need privacy and space - especially with grieving / loss
6. Diversity: Respect and support diversity, cultural and/or spiritual needs, ask and observe behavior and
clues r/t these needs
7. Siblings:
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 ▪ Parental absence / rou ne disrup on: Recognize the family stress r/t parents juggling their care /
needs while being away from home to care for the child in the hospital. Acknowledge the parents
need to support children at home and di culty with managing it all. these children as well (can be
very stressful), encourage them to mobilize support system friends / family to help
▪ Sibling emo ons: consider impact of their emo ons related to the ill child and/or parent’s not
being available to them due to the sibling’s illness (fear, jealousy, guilt and other reac ons) of
siblings, facilitate siblings ability to discuss his/her feelings with family and/or professional
(psychologist etc)
▪ Connec on: facilitate visita on or other means of connec on (Face me, Skype etc),

C. Learning Ac vity: Current Challenges for Families with Ill Children

Iden fy 1 - 2 possible causes and interven on strategies to address each of the challenges. Iden fy behaviors relevant to
current problems faced by families with children with acute and chronic illness. Use informa on from the textbook
Chapters 1, 2, and 3. Incorporate collabora ve care, cri cal thinking and therapeu c communica on strategies into nursing
interven ons. Content related to this exercise will be on the quizzes and exams.
o
Challenges Symptoms (behaviors) Causes / contribu ng factors interven ons
Poverty / Child missed 2 follow-up post ● Family doesn’t have a car ● Ask the family what happened
Knowledge op appointments. Wound is ● Only father drives & he works 2 ● Explain the importance of follow
de cit infected jobs up and treatment. Verify
● Mother didn’t understand the understanding by asking for a
importance of the apt return explana on. Use a
● Family forgot about the apt. translator if needed.
● Work with social service to obtain
bus vouchers
● Find a clinic within walking
distance that can do the wound
care / assessment.
● Set up a reminder call for families
the day prior to the scheduled visit.

Now it is your turn to iden fy causes and contribu ng factors along with possible interven ons for each of the challenges
below. Refer to the table below and textbook for ideas.
Challenges Symptoms (behaviors) Causes / contribu ng factors Nursing interven ons
6. Ethico legal Family hasn’t called or visited
issues in 3 days
7. Domes c Child has bruises and burns
Violence on his back / bu ocks
8. Divorce / Mother doesn’t want the
Custody step mother to visit
8. Family Family members are gh ng
Con icts at the bedside
9. Diversity Child refuses to eat hospital
needs food because it isn’t his
normal diet
9. Consent A 14 year old refuses
treatment
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 10. Complex Mother is reluctant to learn
homecare to suc on her baby’s new
needs trach

D. Challenging Situa ons / Behaviors (ideas for ac vity above):

Challenging Behaviors Contribu ng factors Selected Nursing Interven ons

● Lack of visi ng Many mes there may be Provide Informa on: encourage ques ons and journaling,
● Nonpar cipa on mul ple factors frequent updates, wri en instruc ons, validate
● Fearful or anxious ● Lack of Informa on understanding
● Crying, withdrawn ● Misinterpreta on Establish Trust: consistent caregivers; address issues
● Repe ous ques ons ● Lack of trust promptly, honesty & respect, give choices, LISTEN – really
● Blaming, fault nding ● Financial stress listen,
● “Overreac ng” ● Family needs Involve in Care: develop individualized plan based on child's
● Demanding, controlling ● Financial issues and family's unique needs – work to solve these rst, praise
● Over a en on to detail ● Role change e orts towards goal, support paren ng role with physical &
● Angry body language, ● Lack of control emo onal care of child
aggressive behavior ● Mourning loss of Provide Support to the child: collabora ve approach (child
● Passive aggressive behavior "normal" child life, social services, psychiatric, volunteers, spiritual care,
● Scapegoat ● Fa gue, exhaus on diversity support etc), developmental approach, hug/
● Noncompliance, lack of ● Lack of coping therapeu c touch, LISTEN!, address pain / comfort
follow up ● Guilt Feelings promptly,
● Refusal of care ● Anxiety & Fear Promote Family Support: encourage phone calls / video
● Ven ng frustra on ● Diversity / cultural chat, notes, photos etc when separated; promote family
● Doctor / hospital “hopping" norms presence during procedures, allow visits from siblings &
peers when possible, provide for parent / caregiver needs
Other behaviors: Other contribu ng factors: (food, hygiene, rest, “breaks” etc), support parental
involvement (ADLS, feeding etc as desired – may want a
break and have others do this for a while)
Other ideas

II. Developmental Approach to Caring for Children: (1B Slides)

Ac vity: Complete/review growth and development prep materials. This content will be on the quizzes and exams.
A. Infant Birth to 1 year
1. Developmental Stages
a. Social / Erikson: Trust vs Mistrust
b. Cogni ve / Piaget: Sensorimotor
c. Language Communica on
d. Physical Development, Gross Motor & Fine Motor Development
e. Health Promo on / Nutri on / Safety / Play

2. Administering Oral Meds to infants / young children

a. Syringe to back of the cheek – hold face upright, watch for swallowing Mixing in bo le not recommended
(di cult to be sure child nishes med)
b. Pills - crushed & mixed with chaser (applesauce, pudding etc). Needs to be able to feed well with a spoon
(usually > 9 mo), some pills dissolve in liquid (water etc.)

3. Developmental approach: Infant

a. Support sucking, comfor ng, holding and cuddling needs (volunteers if needed)
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 b. Maintain home rou nes / naps and feeds, familiar and comfort objects as possible
c. Provide age appropriate infant toys and developmental s mula on / distrac on
d. Parental support (support parental presence when possible)
e. Provide con nuity of care

B. Toddler Age 1-3

1. Developmental Stages:
a. Social / Erikson: Autonomy vs Shame & Doubt
b. Cogni ve / Piaget: Sensorimotor
c. Language Communica on
a. Physical Development, Gross Motor & Fine Motor Development
b. Health Promo on / Nutri on / Safety / Play

2. Developmental approach: Toddler

a. An cipate stranger and separa on anxiety - approach slowly, talk with parent rst
b. Support parental / caretaker presence, support parental comfort / visita on needs
c. Make interac ons fun and nonthreatening (make them “fun” when possible)
d. Use developmentally appropriate language. Keep it short and simple. Be honest.
e. Give choices, control when possible
f. An cipate regression, provide comfort – avoid painful procedures, when possible
g. Maintain home rou nes and home foods when possible, support security objects
h. Support play needs: bring in “fresh” toys, simple medical play, solitary / parallel play, play rooms, child life
and other support programs.

C. Early Childhood “Preschool Age” Age 3-6

1. Developmental Stages:
a. Social / Erikson: Ini a ve vs Guilt
b. Cogni ve / Piaget: Preopera onal
c. Language / Communica on
d. Physical Development, Gross Motor & Fine Motor Development
e. Health Promo on / Nutri on / Safety / Play

2. Developmental approach: Preschool Aged Child

a. Smile, relax: put your “inner Disney” on!
b. An cipate fears/fantasy – may be afraid of dark, needles, noises etc. (ask the child and parent about fears)
c. Use developmentally appropriate language. Answer ques ons honestly with brief answers. Prepare child for
experience with focus on sensory experiences and outcomes.
d. Support parental / caretaker presence
e. Maintain home rou nes, home food choices when possible
f. Give choices and control when possible. For example:
● Se ng us a s cker chart for a child who has to take several medica ons
● Asking a child if he wants juice or water as a “chaser” to drink when taking meds
● Have child hold the co on ball on his arm a er having his blood drawn
f. An cipate regression, help the child deal with the emo ons related to regression (bedwe ng, being in a crib
etc.), Support security objects and need for comfort
g. Support play needs: age appropriate toys, medical play, stories, drawings, drama c play, associa ve play,
coopera ve play begins (late), child life, playrooms / programs.

D. Middle Childhood “School Age” Age 6 - 12

1. Developmental Stages: Complete / review school age content on self-study table & terms list
a. Social / Erikson: Industry vs Inferiority
b. Cogni ve / Piaget: Concrete Opera ons

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 c. Language Communica on
d. Physical Development, Gross Motor & Fine Motor Development
e. Health Promo on / Nutri on / Safety / Play

2. Developmental approach: School Aged Child

a. Allow the child to “warm up” to you. Use games or other distrac ng ac vi es to “break the ice”
b. Be honest. Use age appropriate wording, no “baby talk”. Be careful not to “over explain”.
c. O er choices / control whenever possible. “Mastery” is the developmental stage.
d. Encourage the child to bring in favorite foods & toys (CAREFUL not to lose them!)
e. Protect body integrity / modesty (pull drapes, keep covered etc)
f. Encourage play (medical, imagina ve, crea ve) express feelings, distrac on, recrea on,
g. Facilitate siblings to visit when possible, encourage connec on with friends & school
h. Work with school / family to bring in schoolwork
i. For children with long-term hospitaliza on, “make a wish” (or other organiza ons), pet therapy visits, ac vity
rooms / carts, & other programs.

E. Adolescent Age 13 - 18
1. Developmental Stages:
a. Social / Erikson: Iden ty vs Role Confusion
b. Cogni ve / Piaget: Formal Opera ons
c. Language Communica on
c. Physical Development, Gross Motor & Fine Motor Development
d. Health Promo on / Nutri on / Safety

2. Developmental approach: Adolescent

a. Protect body integrity / privacy – this is REALLY important. (pull drapes, keep covered etc). Allow the
adolescent to wear home clothing if it doesn’t interfere with treatment.
b. Allow the adolescent “warm up” to you. Some mes just giving the teen some space and a chance to talk
will allow them me to open up. Some mes a game or other distrac ng ac vity works as will. For some, it
just may not happen in a single day.
c. Be honest. Use age appropriate wording. Don’t try to act / talk like a teenager. Don’t “over explain” but
give complete answers. Watch for teen’s cues to tell the di erence.
d. O er choices / control whenever possible. Be honest and provide updates to both the adolescent and his /
her family whenever possible.
e. Facilitate reading, journaling / blog, watching movies, video games and other distrac ons and recrea on.
Facilitate family and friends to visit when possible. Encourage friends / family to bring in mementos and
cards, friends to post on walls (as desired by adolescents).
f. Work with school / family to bring in schoolwork
g. For teens with long-term hospitaliza on, work with child life for “make a wish” (or other organiza ons),
“pet therapy visits, ac vity rooms / carts, & other programs.

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 III. Pediatric Approach and Pediatric Assessment Overview (1C Slides)

A. Pediatric Physical Assessment “Pearls”

1. Maximize accuracy, minimize stress
2. Use a systema c but exible approach. Start with least invasive (respira ons, respiratory e ort, color, ac vity
level etc) progress to most invasive. This will change with the age of the child. For example: Assessment of
genitalia / groin is much more invasive for older children than for infants / toddlers who have rou ne diaper
changes. Taking a blood pressure is a challenge in a young child (they do not like their arm restrained and react
to the pressure of the in ated cu ).
3. Use knowledge of normal G&D to determine what is normal (vital signs, behaviors etc)
4. Keep parents involved, use distrac ons and any “tricks” you can learn from the experts, watch parents, nurses
and others who are experienced with children

B. Pediatric Vital Sign Measurement: Refer to normal VS Table in back of Mc Kinney book. Use medical play to assist
with vital signs coopera on with toddlers and preschool aged children.

1. Temperature: consider pros and cons of each type, learn equipment available
Hints: Tuck the thermometer under the arm closest to the parent’s body and hold the child in a swaddled posi on
while distrac ng him. Give choices for which arm for Axillary measurement.
● Axillary: ensure good skin contact under arm, least invasive, most common for infants
● Oral: must hold under tongue, not appropriate for young children
● Tympanic: ensure a good seal, measurement issues with poor technique
● Rectal (rarely done): lubricate, < 1 inch, hold legs, most invasive, contraindicated for onc pts.
● Alternate methods may be used in various se ngs such as forehead readers, paci er readers etc. Be sure to
use validated, research-based methods devices

2. Blood Pressure: This can be the biggest challenge in infants and young children! Try these tricks if you are having
di culty: A ach BP cu and tuck the infant’s arm in a blanket. Take the measurement when the baby has se led.
It may help to have the baby suck on a bo le or breas eed. Use noninvasive terms "arm hug" etc. when describing
to a toddler or preschool aged child. Allow the child to assist with cu placement / press bu ons. Allow the child
to choose the arm when possible. You may need to distract to get it done!
● Readings can be done on arms or legs. Be sure to use the appropriate cu size (too small - false high reading;
too large - false low reading).
● Rou ne BP measurements are o en not as frequent as adults, may be acceptable to delay morning
measurement if having di culty and if the BP is stable (verify with RN)

3. Pulse: take apical pulse (use stethoscope) x 1 minute (or as long as possible!!)
Hints: Listen from the back in infants, let the child listen to your heart or doll /bear before you listen to the child’s.
Distrac ng with toys, electronics, talking etc. , Infant: heart more horizontal; Le of LMCL; 3-4 ICS (above rib),
Child: LMCL; 5th ICS

4. Respira ons: observe x 1 minute Note: - color, rate and e ort (retrac ons, nasal aring, color, shoulder shrug,
grun ng) before child reacts to you.

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 C. Pediatric System Assessment Overview: This is a brief overview; refer to Pediatric Assessment Videos for more
details – addi onal info r/t assessment will be covered each week.
1. Respiratory
● Color, oxygen satura on level if measured
● Respiratory rate, breath sounds (listen for crackles, rales, wheezes)
● Chest shape and movement
● Respiratory quality / e ort (retrac ons, nasal aring, head bobbing, grun ng, stridor)
● Hints: Use O2 and treatment technique best handled by the child (ex: teddy bear cuddling nebulizer
treatment), games for breathing exercises (bubbles, pinwheel, blow with a straw)

2. Circulatory
● Ausculta on: Rate, rhythm, murmurs, clicks, rubs
● Peripheral Perfusion
o Pulses: central and peripheral
o Cap re ll: < 2 sec normal
o Temperature of extremi es
o Color: central and peripheral

3. Neurological
● Fontanels: Anterior - diamond shape closes 12-18 mo, posterior – triangle closes 2-3 mo
● Cerebral func on tests / LOC – pediatric Glasgow Coma Scale, careful of “sleepy” baby / child – could be
lethargy, agita on could be a sign of decreased LOC and/or air hunger.
● Pain and comfort level
● Developmental level – assess for delays, loss or failure to achieve milestones

4. Skin / Protec ve
● Turgor
● Altera ons: Rashes, insect bites, cuts, bruises, scars, incisions, pressure sores, ta oos, other wounds,
cultural considera ons. Young infants normal ndings: Mongolian spots, infant acne, milia & small
hemangiomas “stork bites”.
● Assess hair pa erns and condi on. Preterm infants: ne hair (lanugo) is a normal nding
● Assess for infec ons / infesta ons (impe go, candidiasis, pediculosis, mites etc)

5. Elimina on:
● Assess history bowel / bladder habits (# wet &/or “poopy” diapers / day), older child - parent may not
know urina on / stool pa ern, child may be reluctant to discuss it
● Abdominal Assessment - Observa on / Palpa on ( at, round, distended, so , tender, etc.) – round belly is
normal in young children – check distension and/or rmness. May be considered invasive, especially if the
child has abdominal pain
● Urine output measurement – accurate I&O is important
o Weigh diapers to measure output – zero scale with same size dry diaper
o Older children – male use “urinal”, female use “hat” in toilet
● Stool pa erns
o Infant: Breast fed - gold, liquid, may be infrequent; Formula fed - rmer
o > 2yrs: adult like

6. Gastrointes nal / Nutri onal

a. Nutri onal needs: promo ng adequate intake is a common challenge ue in pediatric pts

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 1. Infants / children need more nutrients (calories, protein, minerals, and vitamins) / kg than adults
because of higher metabolic rates and for growth.
2. Inadequate intake (Failure to Thrive) is a common problem with infants/children with chronic illness
3. Daily Caloric needs in kcal/kg/day: (compared to adults 30-35 kcal/kg; day).
a. Infant: 90 - 120,
b. 1-7 yrs: 75-90,
c. 7-12 yrs: 60-75,
d. 12-18 yrs: 30-60

b. Liquid Feeding (infant and those who cannot swallow):

1. Diet type (breast / formula). Formula brand, type, kcal / oz. Breast fed or expressed breast milk. Human
milk or other for ers (MCT oil, polycose, avocado etc) used or concentrated formulas used to increase
kcal/oz. “Standard” formula is 18-20 kcal/oz.
2. Assess appe te, feeding pa erns (how much, how o en), note usual amount taken or minimum
requirement, schedule.
3. Assess suck / swallow / breathe (coordina on may be an issue with premature and acutely ill infants) –
desatura on, color change, choking, vomi ng or other signs of intolerance
4. Assess feeding behaviors – eager suck, sleepy, nipple preferences, posi on preferences

c. Solid food (older infant – older child)

1. Assess for mouth pain, loose teeth and other oral patho
2. Food preferences, picky eaters, “food jags” (typical toddler but can be any age)
3. Assistance required (i.e. cut up in small pieces to avoid choking, spoon feed by caregiver, self-feeding using
nger feeding, use of utensils, assistance with knife, cut up food etc)
4. Ea ng rou nes (high chair, bib, bo le, “sippy cup”, toddler spoons, food separated etc...)
5. Use a crea ve age appropriate approach to encourage food / uids (tea par es, decorated cups, crazy
straw, cut out shapes for sandwiches / cheese, incen ves for older kids etc…)
6. Accurate intake assessment is an important nursing interven on

6. Growth Measurements: Be sure to review content / ps & tricks on N173 Skills Checklists related to measurement.
Remember: this content is on the quizzes and midterm. You will prac ce skills related to measurement on Skills Day

a. Height - measure head to heels

1. < 2 years – recumbent (marking on sheets and measuring marks is easiest)
2. 2+ years – standing (be sure they stand up straight)

b. Weight – use same scale (whenever possible) 1kg=2.2 lb

1. < 2 years – weigh nude, zero with linens and diaper
2. 2 years – weigh with a diaper or as few clothes as possible.

c. Head Circumference: up to 2 yrs. (Brain 75% adult by 3 yr.)

Measure across eyebrows, top of ear, occipital

d. Growth Charts: complete weekly for clinical write-ups

1. Select appropriate chart based on age and gender (h p://www.cdc.gov/growthcharts/)
2. Plot height, weight and head circumference in sequen al measurements
3. Iden fy discrepancies between expected and actual values (i.e. < 3rd percen le - FTT, large head in
propor on to wt/ht - ICP etc.)
III. Pediatric Nutri on, Fluids and Meds
A. FAILURE TO THRIVE (FTT)
1. Assessment

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 a. Weight less than 3rd % on the growth chart (may also have low length and head circumference percen les) –
usually appears small for age. Failure to gain wt. at the expected interval (loss of % on the growth curve)
b. Thin sparse hair, bri le nails, abdominal disten on, thin extremi es, sunken features
c. Abnormal bowel habits (cons pa on or diarrhea)
d. Anemia, calcium and/or vitamin de ciencies
e. S/sx of uid & electrolyte imbalance (refer to dehydra on and readings from textbook)
f. Frequent and/or severe infec ons related to decreased immune func on
g. Developmental delay or loss of developmental milestones
● Decreased muscle mass, muscular weakness / hypotonia, listlessness, fa gue.
● Lack of age appropriate social / cogni ve behaviors (lack of stranger anxiety, apathy, extreme compliance, poor
language skills, lack of developmental behaviors - no play, no communica on etc)
● Poor brain development and decreased mental capacity (par cularly if before age 2)

2. Causes / Contribu ng Factors (may be a combina on of factors)

a. Inadequate caloric intake
1. Physical (organic) causes for decreased caloric intake
a. Fa gue, weakness (respiratory, congenital heart, neuromuscular disease etc.)
b. Nausea and poor appe te (chemotherapy, medica ons)
c. Poor suck and swallow coordina on (prematurity, abnormal jaw shape)
d. Craniofacial abnormali es (Cle lip & palate)
e. GI abnormali es (TEF, bowel obstruc on, chemotherapy induced mucosi s)
2. Psychological (non organic) causes for decreased caloric intake
a. Self feeding di cul es
b. Oral aversion and/or power struggles over ea ng (infants / young children)
c. Ea ng disorders (Anorexia nervosa, bulimia) / Other psych disorders
d. Poor dietary habits
3. Family / societal / cultural (non organic) causes for poor nutri onal intake
a. Inability of families to provide food based on economic hardship
b. Poor ea ng rou nes (no high chair, no set ea ng schedule, excessive snacking)
c. Excessive feeding of nutri onally incomplete uids
d. Feeding protein poor / nutri onally incomplete foods
● Infants: water, diluted formula (save $), cow’s milk, powdered milk, juices, low protein “milk”
subs tutes (rice, coconut etc.)
● Older children: providing inexpensive fast foods / convenient foods, nutri onally incomplete
foods (lack of adequate protein)
e. Neglect - failure of parents to provide adequate food

b. Di culty with diges on / absorp on (organic cause)

1. Chronic vomi ng
a. Physical (pyloric stenosis, GE re ux, severe GI infec on)
b. Related to therapy (medica ons, chemotherapy, radia on)
c. Psychological (bulimia, anxiety)
2. Chronic diarrhea
a. Physical (malabsorp on syndromes, CF, formula intolerance, severe GI infec on)
b. Related to therapy (gra vs. host disease, medica ons – laxa ves, an bio cs etc.)
c. Psychological: (self-induced with diet / meds, anxiety etc.)
3. Malabsorp on (Celiac disease, CF, short bowel syndrome)
c. Increased use of calories (usually occurs with inadequate intake (organic cause)
a. Chronic illness causing increased stress leading to increased metabolic rate (respiratory illness, CHD /
CHF, cancer, fever, frequent seizures)
b. Increased need for calories related to disease / healing process (trauma, burns)
c. Excessive exercise (anorexia nervosa)
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 3. DIAGNOSTICS & MANAGEMENT Mul disciplinary team approach based on the cause(s)
a. Child (as developmentally appropriate) & Family
b. Primary care prac oner (NP, MD, pediatrician etc.)
c. Pediatric specialists (GI, neuro, oncology etc. as appropriate based on patho)
d. Nutri onist / die an
e. Pharmacist (par cularly related to TPN and meds related to nutri onal intake)
f. Case manager
g. Pa ent care nurse
h. OT / PT / Speech / Feeding team
i. Social services
j. Clergy and other support
k. Psychologist / psychiatrist
l. Community Support (school, camps, ac vi es etc.)

4. MANAGEMENT / NURSING CONSIDERATIONS:

a. History: dietary history, food choices, dietary habits, appe te, ea ng pa erns, di cul es
b. Assess social situa on and psychosocial barriers to healthy ea ng. Provide nancial support (CCS, WIC, food
stamps, welfare etc) &/or psychological support as needed
c. Physical assessment: look for signs of malnutri on and diseases associated with FTT
d. Promote weight gain: Goal (weight gain at 2-3x normal level un l caught up)
e. Treat underlying disease / condi on causing FTT
f. Provide high calorie / nutri onally complete diet
1. TPN & lipids – wean as enteral route feeds increase
2. Increased concentra on formula (22-30 calories / oz.)
3. Supplements (MCT oil, avocado, Polycose, corn oil, human milk for er)
4. Vitamin supplements
g. Supplement or replace oral feedings - varies for each child (know pt speci c reasons for this)
1. NG / NJ feeds – short term
2. Gastrostomy (gastrostomy tube, bu on type) – long term
3. Con nuous (24 hr or at night) vs. bolus feeds: day me bolus allows “ me o ” disconnect
h. OT/ Speech / Feeding Team – RN to con nue and teach family
1. Neonates – may start with small amount colostrum / breast milk to cheeks
2. Work on sucking re exes - oral exercises, oral s mula on devices etc
3. Posi oning – upright, turned to the side, head and neck support, able to view face
4. Feeding techniques – may need chin support and/or pacing, watching for stress cues
5. Oral desensi za on techniques for infants /children with oral aversion
i. Family teaching / support
1. Proper nutri onal choices based on the child's age and condi on
2. Limi ng foods with li le nutri onal value (“junk” food, limi ng fast food etc)
3. Ea ng rituals (family meals, feeding sugges ons etc) .
4. Avoiding food power struggles (keep meal me posi ve, give choices, incen ves – s cker charts etc)
5. Financial (WIC, food stamps, CCS etc)
6. Psychosocial support

B. Pediatric Fluids and Dehydra on

1 . Fluids:
A. Fluid requirement calcula on (know the formula - see slides and math module), compare with actual intake
B. Accurate I&O. Calculate urine mL/kg/hr (normal 1-3), monitor wt change r/t uids

2. Characteris cs In Children R/T Vulnerability For F/E Altera on

A. Higher _________________ per unit of body weight as compared to adult.
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 B. Higher ___________________________ (twice the adult).
C. Greater ___________________________ (infant 2-3 mes greater).
D. Immature __________________________.
E. Dependent on _____________________ to meet uid needs.
3. Patho of Dehydra on: uid loss →dehydra on / electrolyte imbalance→shock→death

4. Diagnosis:
A. I&O History – type and quan ty of loss, intake
B. Labs (BUN, CR, electrolytes etc.)
C. Signs and symptoms, wt. loss

5. Causes in Infants & Children

A. GI Losses: Vomi ng and diarrhea (most common)
B. Decreased Intake
C. Other contribu ng factors: Skin (fever, swea ng, burns, wounds, edema), Respiratory (tachypnea, secre ons, etc).

6. Common Signs of Dehydra on in Infants and Children

A. Fewer wet diapers than usual
B. No tears
C. Irritability, high pitched cry
D. Di culty waking (lethargy)
E. Tachypnea / respiratory change
F. Sunken fontanel / sunken eyes with dark circles
G. Pale skin, fever , dry skin

7. Severity of Dehydra on
Mild Moderate Severe (shock)
Body weight loss 4-5% (40-50 mL/ kg) 6-9% (60-90 90 mL/kg) >10% (100 mL/kg or more)
Heart rate Slightly ↑ ↑↑ Signi cantly ↑↑↑
Blood pressure Normal Normal Low normal to severe ↓↓
Respira ons Normal Normal or sl. increase Pa ern change
LOC / Neuro
Infant/young child Alert, irritable, restless Restless, irritable, lethargic Lethargic to coma
Older child Alert, restless, thirsty Alert, restless, thirsty Apprehensive to coma
Membranes Moist to sl. dry Dry Very dry to parched
Ant. fontanel Normal Depressed Sunken
Skin turgor Normal ↓ (may feel doughy) Sig. ↓↓
Skin color Normal Pale Gray and mo led
Distal Pulses Normal to sl. decrease. Weak Very weak to absent
Extremity temp Warm to slightly cool Cool Cold
Capillary re ll Normal to slight delay Delay Sig. delay (>2 sec.)
Urine output Normal or slight ↓ ↓↓ (dark yellow, ↑ USG) Sig. ↓↓↓ to no output
Labs Normal BUN & CR. ↑ BUN ↑↑ BUN & CR
8. TREATMENT PRIORITIES FOR CHILDREN WITH DEHYDRATION

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 A. ABC priori es - quickly assess/stabilize respiratory, focus on circula on (HR; BP; peripheral perfusion – pulses, cap
re ll, temperature of extremi es; urine output, LOC)

B. Rehydra on, frequent reassessment

1. Mild Dehydra on – Oral rehydra on therapy with pediatric electrolyte solu on

2. Moderate to severe dehydra on – Vascular access is the priority, IV uid replacement

a. Vascular Access / IV uid replacement is the priority
1. Peripheral route – use largest bore catheter possible
2. Intraosseous route – peripheral route may be di cult with severe dehydra on, do not prolong
a empts with acutely decompensated child (use manual IO needle or newer IO “driver” device)
3. Central route - most secure, used for long-term vascular access needs – use when available (PICC
lines, tunneled central catheters – Broviac, Hickman, implanted infusion device – Port-a- cath,
UVC in neonates)
b. Administer uids
1. NS or LR bolus (mod to severe dehydra on) 20 mL/kg, repeat as needed # bolus, rate of admin
depends on the severity of dehydra on / shock.
2. Maintenance uids + Replacement uids + replace ongoing losses

C. Severe dehydra on with shock (par cularly with sepsis / sep c shock) may require cardiovascular support with
inotropic medica ons. Hypotensive shock = uncompensated shock, pt at high risk for cardiopulmonary arrest, immediate
ac ons including STAT uid bolus as rapidly as possible IV/IO route is ESSENTIAL (may need to PUSH uids via mul ple
routes with hypotension)

IV. Administering Meds to Children – review slide info for more details
a. Involve parents: the parent will usually have a preferred approach & admin technique. Ask the parent if they
prefer to give and / or will assist with med
b. Be prepared!! Gather all supplies BEFORE approaching the child (med, chaser, straw, etc).
c. Use understandable, familiar non threatening language (hurt, pinch). Avoid calling med candy, don’t use med
admin for punishment
d. For some children who fear syringes or med admin, avoid showing med, syringe etc before you are ready to
give it to a young child
e. Do not place meds or other supplies in the crib / bed or within the child’s reach when prepping and / or
administering meds.
f. Which med to give rst? When administering oral meds to young children, ask the RN / parent for advice. At
mes, it is helpful to allow the child to choose. Give the most important med rst – you may not be able to get
the child to take more than one in a session! If all are equally important, give the best tas ng med rst and the
worst tas ng med last.
g. When administering IV meds to children, keep the pump and tubing away from the child’s reach. Assure a
fearful child that you are just pu ng medicine in the tube and it should not hurt.

V. HEALTH PROMOTION (1 D Slides)

A. HEALTHY PEOPLE 2020 GOALS - SET IN 2010 EVALUATION IN PROGRESS, NEW GOALS BEING ESTABLISHED FOR 2030
● Reduce rate of childhood death all ages from neonatal period through adolescents and young adulthood due to
any cause (birth defects, accidents, suicide, homicide)
● Increase # of infants who were put on their back to sleep from 69% to 75.9%
● Increase propor on of infants who are breas ed
● Reduce propor on of children diagnosed with a disorder through newborn screening who experience
developmental delay requiring special educa onal services (goal 13.6%)
● Increase propor on of young children with au sm spectrum or other developmental delays who are screened,
evaluated, and enrolled in early interven on services
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 ● Increase propor on of children who have access to a medical home from 57.5% to 63.3%
● Reduce, eliminate or maintain elimina on of vaccine preventable diseases (congenital rubella, HiB, Hep B, rubeola,
mumps, pertussis, pneumococcal infec ons, Group B strep
● Reduce the use of an bio cs for ear infec ons in young children
● Achieve / maintain e ec ve vaccina on levels for universally recommended vaccines among young children; most
are at the 90% or greater level. Only 0.6% of children are NOT vaccinated at all
◦ DTaP: goal to increase to 90% children have had 4 doses by age 35 mo
◦ HP 2010 goals showed Hep B was lagging; achieved the goal, last measured above 90%
◦ Rotavirus-diarrhea illness in babies: vaccine rate target for 2020 is 80%
◦ Adolescents Tdap booster target is 80%, varicella goal 90%
◦ HPV vaccine: 2010 was 23% of females age 13-15; goal is 80%, males very low - increase %
◦ In uenza vaccine: goal all for ages 80% (perhaps higher in light what we learned during the COVID pandemic)
● Reduce the occurrence of developmental disabili es
● Reduce the occurrence of spina bi da and other neural tube defects (NTDs)
● Ensure appropriate newborn bloodspot screening, follow up tes ng, and referral to services. Screen for: Endocrine
disorders, Metabolic diseases, Hemoglobin diseases

B. INJURY PREVENTION
1. Assess, implement and teach safety measures based on developmental level.
2. Review speci c safety measures for each age group in McKinney text
● h ps://www.chp.ca.gov/programs-services/programs/child-safety-seats

“Current California Law:

● Children under 2 years of age shall ride in a rear-facing car seat unless the child weighs 40 or more pounds OR is
40 or more inches tall. The child shall be secured in a manner that complies with the height and weight limits
speci ed by the manufacturer of the car seat. (California Vehicle Code Sec on 27360.)
● Children under the age of 8 must be secured in a car seat or booster seat in the back seat.
● Children who are 8 years of age OR have reached 4’9” in height may be secured by a booster seat, but at a
minimum must be secured by a safety belt. (California Vehicle Code Sec on 27363.)
● Passengers who are 16 years of age and over are subject to California's Mandatory Seat Belt law. “

C. SAFETY BASICS – HEALTHCARE SETTING

❑ Always check ID – read ID numbers, birthday and name every me (even when scanning badge)
❑ Label belongings – don’t share items between pa ents
❑ Keep crib rails up at appropriate height, top rails down for toddlers
❑ One hand rule – at all mes (plan ahead, bring what you need to bedside before taking the rail down)
❑ Keep small objects out of reach (toys, pens, syringe caps, etc.). Keep the crib / child away from blind cords and
other things that can tangle. Careful with cords from monitor equipment and IV tubing.
❑ Supervise children playing in rooms, playrooms and hallways. Fall precau ons. Use extra cau on when using items
with wheels (IV poles, wagons, big wheels etc.).

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 VI. PEDIATRIC INJURIES

A. OVERVIEW
1. Uninten onal injury - “Accidents”
● Leading cause of death in children: most are preventable. Injury preven on, safety & supervision using age
appropriate guidelines is key!
● Prevalence of various types of injury / deaths will vary with age: Motor vehicle #1, Followed by su oca on /
asphyxia, drowning, rearms and burns for most age groups

2. Primary Assessment in Pediatric Emergencies (PALS). Assists with iden fying type of problem to respond with the
appropriate interven on
a. Airway
❑ Patent vs Airway obstruc on (par al or full). If full, start FBAO maneuvers!
❑ Audible sounds: stridor, gurgling, cough etc.
❑ Posi oning: tripod, upright, response to reposi on and airway opening (sni posi on)
b. Breathing
❑ Respiratory rate
❑ Increased or decreased work of breathing, nasal aring, use of accessory muscles of respira on
❑ Color & oxygen satura on (if available)
❑ Breath sounds (wheezing, crackles, decreased air movement etc.)
c. Circula on
❑ Skin color (central vs peripheral)
❑ Distal perfusion: extremity temperature, Capillary re ll (<2 sec), peripheral and central pulses
d. Disability
❑ Level of consciousness or ac vity level, Response to s mula on, parental presence
❑ Pupillary response (late nding)
e. Exposure: Body temperature

3. Secondary Assessment: PALS uses SAMPLE to assist with history assessment

○ S = signs and symptoms
○ A = allergies
○ M = medica ons
○ P = past medical history
○ L = last meal
○ E = events (“story” of current illness / recent treatments etc)

3. PEDIATRIC EMERGENCY PREP / RESPONSE

❑ Know where to locate emergency equipment (bag/mask, code cart, code blue bu on). Have correctly sized
emergency equipment available in pa ent’s room – par cularly if high risk.
❑ Know how to use a bag and mask. Review infant and child CPR, FBO relief maneuvers.
❑ Call for help! Do not leave the pa ent! Use call bell if available or send bystander for help.

B. SUDDEN INFANT DEATH SYNDROME (SIDS) Review www.californiasids.com, www.sids.org

1. SIDS DEFINITION - sudden infant death syndrome.
● Unexplained death of an infant under one year of age. It is NOT accidental su oca on
● ALTE - apparent life-threatening event, also referred to as "near miss SIDS"
2. CHARACTERISTICS ASSOCIATED WITH AN INCREASED RISK FOR SIDS.
● Age: peak incidence between 1 & 4 mo.
● Time of year: peak incidence fall, winter and early spring

3. AAP “SAFE SLEEP” Recommenda ons to prevent SIDS (updated by AAP OCT 2016)

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 h ps://www.aap.org/en-us/about-the-aap/aap-press-room/pages/american-academy-of-pediatrics-announces-
new-safe-sleep-recommenda ons-to-protect-against-sids.aspx
SIDS Preven on Video: h ps://www.youtube.com/watch?v=8NoHPkrHgck&feature=youtu.be
❑ Prenatal care prevents SIDS
❑ Breas eeding - reduced risk of SIDS.
❑ Always place the baby on his or her back for sleep. Daily supervised, awake “tummy me” to facilitate
development & ↓ posi onal plagiocephaly
❑ Always use a rm sleep surface. Do not use wedges or other posi oners in the infant’s crib
❑ Do not use car seats & other si ng devices for rou ne sleep.
❑ NO bumper pads in cribs (doesn’t prevent injury, can cause strangula on / su oca on)
❑ Do not put so objects or loose bedding in the crib (no pillows, blankets, stu ed animals etc.)
❑ Do not cover the infant's head. Avoid overhea ng.
❑ O er a paci er at nap me and bed me (can help reduce risk)
❑ Keep the baby in parents’ room for sleep in his/her bassinet (not parents bed)
❑ Keep the infant immuniza ons up to date (reduces the risk of SIDS by 50%)
❑ Maintain a non-smoking environment for the baby (also no smoking during pregnancy)
❑ Healthcare professionals need to endorse and teach by example. Be aware of what is in the crib while in
the hospital (nurses are o en the worst o enders of not following guidelines!

C. POISONING
1. GENERAL PRINCIPLES OF POISON MANAGEMENT
A. Iden fy Poison: call Poison Control 1-800-222-1222,
B. Stabilize: ABC (airway, breathing, circula on), prevent / treat shock
C. Decontaminate GI Tract (implement ASAP a er poisoning – long delays signi cantly decrease e ec veness of
decontamina on interven ons):
1. Gastric lavage: (not always done). Contraindica ons: corrosives
2. Decrease absorp on: Ac vated charcoal
a. ASAP a er poisoning; a er lavage (if done), may be too late to be e ec ve if too long of a
delay a er inges on (> 1 hr).
b. May try sweetener, straw, opaque covered cup. May need to be administered NG
c. May be too late if inges on was more than 1 -hr prior.
D. An dotes (as appropriate – consult poison control)
E. Intravenous hydra on

2. Common TYPES of poisoning in children

A. Acetaminophen:
1. Contribu ng factors: Easily available (purse, cupboard, unlocked medicine cabinet), adolescent: OTC
medica on, may be used for suicide a empt – teens are high risk.
2. Manifesta on: Liver damage
3. Treatment:
a. General poisoning management
b. An dote: acetylcysteine (Mucomyst), dose based on level and me from inges on

B. Corrosives: acids/ alkali (drain unclogging chemical, detergents, cleaners, dyes etc.)
1. Contribu ng factors: Commonly kept in household under the sink, kitchen, garage, bathroom.
2. Manifesta on: Chemical burns of the mouth, throat, & esophagus; burns to eyes, face etc
3. Treatment: General poisoning management, do not induce vomi ng, do not lavage; ood external burns with
water, may need endoscopy &/or surgical management for severe injuries.

C. Hydrocarbons: (gasoline, lighter uid, paint thinner, oils)

1. Contribu ng factors: Available in household usually in garage, storage shed (or basement)
2. Manifesta on: aspira on pneumoni s, petroleum breath
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 3. Treatment: General poisoning management except do not induce vomi ng

D. Lead: (Plumbism) ½ life is 20 years

1. Possible contaminants from lead containing items: vulnerability increases if the child has pica
a. candy/food made in pots glazed with leaded glazes, foods canned outside US
b. lead based paint (homes built before 1978 – may be exposed during remodel, re-paint)
c. toys made with leaded paint (may be well known brands manufactured in other countries)
d. old pipes (lead in metal seals / faucets), lead solder, leaded gas
e. family member occupa on that includes working with lead (mining / foundries etc).
f. folk remedies (Azarcon/Greta)
2. Manifesta on: symptoms may be vague with an insidious onset:
a. Neurological ( under age 6 most vulnerable to brain damage): learning disabili es, speech, language &
behavior problems, progressive encephalopathy, coma, death r/t severely toxic levels (> 100mcg/ dl)
b. ↓ muscle growth & coordina on
● bone damage bone marrow (↑ bone density, lead lines in long bones, anemia),
● renal and hearing damage
3. Assessment
○ Irritability, fa gue, malaise
○ Loss of appe te, weight loss
○ Abdominal pain, vomi ng, cons pa on
○ Unusual paleness (pallor) from anemia
4. Treatment: General poisoning management, chela on therapy as needed
5. Preven on: avoid lead containing items, CDC rec. screen between 6 months-6 years

D. MAGNETS:
1. Powerful magnets can cause severe GI damage if swallowed. Magnets a ract to each other in GI tract, can lead
to tearing of intes nal wall.
2. Teach families to keep all toys with magnets out of the reach of infants and toddlers

E. NEAR DROWNING (Orange / San Diego coun es have very high rates due to warm weather / pools)
1. Pathophysiology: Swallowing water and panic leads to vomi ng, aspira on, laryngospasm, hypoxia, seizures, brain
cell damage, and death. “Dry” drowning involves laryngospasm. Irreversible brain damage occurs a er 4-6 minutes
of submersion. Severe hypothermia may provide some brain protec on in some cases.

2. Assessment and Management: ICU care

a. Cardiovascular / Neurological Resuscita on – post arrest, hypoxic ischemic injury (HII)
● If the child survives full arrest drowning with HII, he/she will most likely have cardiac, pulmonary,
neurological, renal, GI, GU, &/or immune (infec on) related complica ons.
● Neurological damage is usually the most devasta ng – par cularly if the child is le in a persistent
“vegeta ve state” with minimal brain func on remaining.

b. Psychosocial Care – collaborate with physicians, social worker, clergy, psychology, child life (for siblings) and
other members of the team. Families need informa on and me to grieve
o Shock, disbelief, guilt, blame. Families experience stages of grieving (each in their own way / ming):
denial, anger, bargaining, depression (acceptance rare)
o DNR / Withdrawal of life support or transi on to having a severely disabled child

2. Preven on of drowning and near drowning accidents in childhood. SUPERVISION is #1

Pools, hot tubs, fountains, waterscapes etc; THREE barriers needed including: SUPERVISION, gate with self-closing
latch, secure cover (child cannot crawl beneath)
1. Supervision: Pools, water play areas, beach, boa ng / water sports: designated “water watcher” / life
guard, ota on devices, swimming lessons
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 2. Other preven on strategies:
❑ Locks and Latches: Door locks / alarms, toilet latches, faucet covers etc (be aware that kids are cra y
and will nd ways to work around these)
❑ Consider all water sources: fountains, buckets, coolers, ponds, deep puddles etc.
❑ Supervise bathing (it can happen in an inch of water!). Get towel before beginning
3. CPR Classes: Everyone should learn this!

F. CHILD MALTREATMENT (CHILD ABUSE) – SELF STUDY

1. Overview:
A. Child maltreatment occurs within all socioeconomic classes, ethnici es, religious a lia ons etc.
B. Legal duty to report (not try or convict) any SUSPECTED child abuse or neglect
C. Outward appearances may not be reality
D. Physiological and psychosocial behaviors that may indicate poten al signs of various types of child
maltreatment (abuse and neglect).

1. TYPES OF ABUSE
A. Physical Abuse
1. Psychosocial behaviors
a. Apathy, distant from parent or does not cry / protest with exam or strangers (developmental level)
b. Withdrawn, vacant stare, depression
c. Aggressive behavior (extreme)
d. Inappropriate a en on seeking behaviors
e. Di culty with rela onships
2. Physical assessment
a. Physical injuries not consistent with history
b. Frequent “accidents”, labeled as “accident prone”
c. Wounds, bruises or fractures in mul ple stages of healing
d. Evidence of delay in treatment (infec on etc)
e. Unexplained or suspicious burns
1. Circumference sock or glove
2. Donut shape (pressure)
3. Small round burns (cigare es)
4. Odd shaped burns (iron etc.)
5. Burns on bu ocks
f. Characteris c bruises, lacera ons, fractures, disloca ons
1. Slap marks or long thin linear scars or bruises on face, shoulders, bu ocks or back
2. Mul ple or spiral fractures
3. Facial or nose fractures
4. Mul ple disloca ons

B. Neglect
1. Psychosocial assessment
a. Unsuitable clothing for season (no coat, socks, shoes etc.)
b. Prolonged lack of supervision
c. Permission or no no ce of dangerous ac vi es or condi ons
d. Poor concentra on, poor school performance
2. Physical assessment
a. Failure to thrive / malnutri on
b. Poor hygiene (dirty skin / hair, dirt under nails, odor etc)
c. Bald patches on back of skull (infants)
d. Skin condi ons &/or infec ons

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 C. Emo onal abuse
1. Psychosocial assessment
a. Withdrawal, depression
b. Aggression
c. Hyperac ve or disrup ve behavior
d. Habit disorders (rocking, sucking, bi ng, moaning etc.)
e. Sleep disturbances
f. Psychological problems (obsessive, compulsive, hysteria, phobias, hypochondria, suicidal)
g. Learning disorders, speech or developmental delay
2. Physical assessment
a. Failure to thrive
b. Self in icted wounds (cu ng, branding etc.)
c. May have signs of sexual ac vity / STD

D. Sexual abuse
1. Psychosocial assessments
a. Withdrawal, social isola on, depression
b. Running away from home
c. Missing school, poor school performance
d. Inappropriate or bizarre behavior
e. Aggression
f. Promiscuity, unusual sexual behavior or knowledge
g. Ea ng disorders (anorexia, bulimia, obesity)
h. Sleep disturbance, nightmares, locks bedroom door
i. Substance abuse
j. Suicidal idea on, suicide a empt
2. Physical assessments (may not necessarily be a sign of abuse but should be considered)
a. Di culty walking
b. Stained underwear (blood, feces etc.)
c. Trauma to genital or anal area (tears, bruises, bleeding etc.)
d. Painful urina on
e. Sexually transmi ed disease, UTI

E. Munchausen Syndrome by Proxy: Injury falsi ed or in icted by caretaker and seeking a en on for problem. Most
o en presents with decreased LOC, bleeding, infec on, apnea, seizures, diarrhea, vomi ng, fever, rash.

F. Shaken Baby Syndrome h p://aboutshakenbaby.com/

1. Vigorous shaking causing severe whiplash type injury.
2. Leads to intracranial damage (cerebral edema and increased ICP) and intraocular damage (re nal hemorrhage).
3. O en leads to severe brain damage and brain death
4. Preven on: teaching families how to cope with crying, “Never Shake Your Baby” educa on

2. CHARACTERISTICS OF PARENTS, CHILDREN, AND ENVIRONMENTS THAT MAY PRESENT AS CAUSE FOR CHILD
MALTREATMENT
A. Families at Risk
1. Isola on from community / social groups
2. Compe on for emo onal resources (a ec on, a en on, nurturing)
3. Altered family roles
4. Lack of trust (inside and outside family)
5. Unstable family environment (substance abuse, mental illness etc.)
6. Aggression used for con ict resolu on
7. Altered communica on pa erns (threats, mixed messages, nonverbal expression)
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 8. Rigid, tradi onal family rules and roles
9. Dominant family member who controls with manipula on, in mida on, aggression
10. Family history of abuse
11. Exposure and/or child care by individuals who would inten onally (abuse) or uninten onally (neglect) harm the
child (pedophile, hx. violent acts, substance abuse, mental illness, poor coping skills, unrealis c age related
expecta ons, poor supervisory skills etc.)

B. Children at Risk
1. Premature infants - altered bonding
2. Chronic illness
3. Frustra ng behaviors:
a. Infants with irritability, poor feeding and/or high pitched cry
b. Children with ADHD, learning disabili es, very ac ve and/or destruc ve
4. Aggressive, de ant, disobedient, psychological illness
5. Family pa erns: birth order, gender etc
6. Passive child
7. Family “scapegoat”

3. NURSING CONSIDERa ONS RELATED TO CARING FOR MALTREATED CHILDREN AND THEIR FAMILIES AND THE
PREVENTION OF CHILD MALTREATMENT.
A. Through assessment for (physical signs)
B. Detailed history (behavioral signs)
C. Report any suspected case
D. Team approach: social services, physician, psychology, child life etc.
E. Address child's injuries
F. Provide physical comfort measures
G. Provide emo onal support
H. Support and teaching for family
I. Maintain objec ve, suppor ve approach (avoid tempta on to be the judge and jury)
J. Protect the child's safety (maintain police hold, visita on restric ons etc.)

4. RESOURCES AVAILABLE TO ASSIST MALTREATED CHILDREN & THEIR FAMILIES.

A. Na onal / Regional Agencies: Examples - Commi ee to Prevent Child Abuse, Parents Anonymous, American Bar
Associa on for Domes c Violence, Center for the Protec on of Sexual and Domes c Violence, Violence
Awareness Handbook, Na onal Domes c Violence Hotline
B. Local Agencies

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 VII. Pediatric COMFORT - PAIN

Learning Ac vi es:
1. Review the notes provided in this document.
2. Read sec ons in McKinney Chapters 35 and 39 related to pediatric pain.
3. Review N173 Pediatric Comfort Assessment and Management Slides
4. Locate and prac ce using pain scales listed below
5. Iden fy key strategies for pain management for pa ents of various ages

I. COMFORT ASSESSMENT
a. Most commonly used Pediatric Pain tools are FACES and FLACC - Pediatric Pain Scales - FACES and FLACC
b. Pain / Seda on Assessment tools based on assessment of characteris cs / behaviors (Infant Pain Assessment
tools) Determine an infant's pain level by assessing for key physiologic indicators of pain (heart rate, blood
pressure, facial expression, body posture etc.)
1. FLACC Scale: Scores facial expression, leg movement and posi on, ac vity level, cry, and ability to console on a
0-2 scale: For infants, preverbal or nonverbal children
2. N- Pass: neonatal assessment tool: neonatal pain agita on & seda on
3. Neonatal pain assessment website
4. Ramsay Seda on Scale (used for pediatric pa ents under seda on - ICU, procedures etc)

b. Pediatric Pain Self-Assessment tools:

1. The Oucher (Beyer): Laminated poster with 10 photographic faces of children in pain. Next to each is a
numerical scale ranging from 0 - 100. Children rank their pain level by selec ng the face of the child that best
matches how they are feeling. Older children may also use the numerical scale to rank their pain. The tool is
available in versions: Caucasian, Hispanic and African-American. Appropriate for children aged 3 - 12. Research
indicates that this tool is one of the most accurate.
2. Wong-Baker Faces Pain Ra ng Scale, commonly called “Faces” pain scale: Widely used scale - similar to The
Oucher. Line drawings of 6 faces range from a face with a large smile indica ng "no pain" to a face with large
frown and tears indica ng "the worst pain". A numerical scale from 0 - 5 accompanies the faces. It is used for
a similar age group as The Oucher.
3. Visual Analog Scale (VAS): line with numbers from 1 - 10 along scale. Number 1 indicates "no pain" and
number 10 indicates "worst pain". Children rank their pain along the scale. Appropriate for older school aged
children and adolescents who are able to understand the abstract concept of increasing numbers.
4. Descrip ve Pain Assessment: Words such as "sharp, dull, burning" describe pain quality. Words such as "none,
mild, moderate, severe" describe pain quan ty. Give children pictures of body outlines or ask to point on their
own body to iden fy pain loca on. Descrip ve assessment is appropriate for children who are able to
understand. May be used in children as young as 5 with explana on and prac ce.

II. Developmental Considera ons

A. Infants
1. Comfort ndings related to infants
● Neonates and infant's neuroanatomic and neuroendocrine systems are capable of transmi ng pain
impulses. It is a myth that infants do not feel pain!
● Studies link unrelieved and/or severe pain in neonates with increased complica ons
● Long-term e ects of pain during infancy have been found.
● Infants who need analgesia may be di cult to comfort.
● A sleeping or quiet infant may be in pain

2. Comfort assessment in infants determined using behavioral and physiologic cues. Refer to nonverbal pain
scales (FLACC, neonatal pain tools etc)
● Cry (assess intensity and dura on)
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 ● Facial expression (grimace, tension etc.)
● Vital signs (tachycardia, hypertension, decreased oxygen satura on)
● Body movements (arching, drawing up of knees, kicking legs, waving arms, pulling on ears, pulling away
from painful s muli, etc.)
● Sleep pa ern disturbance
● Poor feeding, failure to thrive (poor weight gain)

3. Assess the poten al sources of pain and/or agita on in neonates and infants.
● Iden fy poten al causes of pain (e.g. surgery, invasive lines and equipment, disease processes). Does the
infant have a reason to feel pain?
● Rou ne infant needs are typically communicated with crying / movement (soiled diaper, hunger, need for
posi on change, uncomfortable body temperature etc.).
● Overs mula on can lead to agita on. The immature nervous system of neonates and some infants
prevents e ec ve ltering of s muli. Premature infants and cri cally ill children are par cularly
vulnerable. In addi on to seda on and analgesia, decreasing environmental noise, light and unnecessary
s mula on may be helpful. Group cares while assessing the infant's ability to tolerate ac vity.
● "Air hunger" / hypoxia from bronchospasm, pulmonary hypertension or other physiologic causes may
manifest as restlessness or agita on. If hypoxia is a suspected cause of agita on, use seda on and
narco c analgesics with cau on. These may relax the airways, leading to improvement in ability to
ven late but can also depress respiratory drive leading to worsening hypoxia. Narco cs for children with
respiratory distress is usually only given in the ED / ICU where the child can be intubated and mechanically
ven lated if needed.
● Sepsis / acute illnesses in infants may present as behavior change. Parents may report crankiness, "colic",
sleeplessness, irritability and/or poor feeding pa erns.
● Acute neurological condi ons (e.g. meningi s, hydrocephalus) may present as agita on progressing to
lethargy. Rapid assessment and management of the disease process is cri cal to preven ng complica ons.
● Brain injury / damage may lead to hypersensi vity to s mula on with chronic, prolonged agita on.
Classic behaviors of restlessness, posturing, arching, high-pitched cry, and lack of response to usual
comfort measures. Individualized treatments using seda on, analgesia, pa erning, ventral pressure and
limi ng s muli are o en helpful.
● Changes in rou ne, sleep pa erns, and diet may result in increased restlessness / crying. Before
medica ng restless infants, a empt to maintain the infant’s the normal rou ne, diet and sleep schedule
while hospitalized.
● Reac ng to physical restraint with increased movement and crying beginning in infancy. Avoid restraining
infants unless necessary. Use tucked blankets and posi oning as needed to protect IV's and other medical
devices as necessary.

B. Toddlers
1. Comfort is primarily assessed using nonverbal cues while listening for any verbal expressions of discomfort. Ask
parents what word the child uses to indicate pain (ex. “owie” or “boo-boo”). Use this word while poin ng to body
areas when reques ng a rma on from the child (does it hurt here?).
2. Agita on from hypoxia (“air hunger”) may be seen with respiratory illnesses. Assess respiratory status and
carefully determine the cause of agita on. Treat lung pathology with respiratory interven ons. Avoid using
seda on / analgesics whenever possible .
3. Acute illness may result in increased “crankiness” and demanding behaviors. Comfort measures and/or
behavioral modi ca on techniques may be helpful. Keep requests simple and related to events.
4. Stranger anxiety begins at 6 months and con nues into the toddler age group. Anxiety and fear is increased when
unfamiliar adults are associated with discomfort. Engage the child through play and interac ng with parents.
Solicit the parent's assistance in comfor ng the child. A empt to eliminate the source of anxiety / fear (ex. white
coat).
5. Separa on anxiety from parents and familiar adults is a major cause of stress in toddlers. Facilitate liberal
visita on of family. Consider allowing parents presence during procedures. Parents should be placed in a loca on
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 that does not interfere with procedures. Give parents speci c instruc ons and demonstra on regarding the
needed posi ons in and behavior during an invasive procedure. ("Talking gently and helping your child hold s ll
by holding his hand would be best. Do you have any ques ons or would you like to to hold him?")
6. Changes in rou ne, sleep pa erns, and diet can create confusion and agita on in the toddler. Promote the
toddler’s normal sleep rou ne, schedule, and provide food preferences as possible. Allow familiar objects (favorite
blanket, doll) in health care se ngs. Encourage families to bring in pictures, favorite books, videos and other
comfort objects.
7. Most children including infants will react to physical restraint by pulling against the restrained extremity. Toddlers
and older children may react with fear and increased agita on. Use only when absolutely necessary. Medica on
may be needed to keep the child s ll for procedures.
8. Stress from overs mula on and exhaus on can occur when the toddlers' pain and/or anxiety and are not kept
under control. Using comfort measures and “safe” mes for uninterrupted sleep can serve to alleviate the cycle of
pain, agita on, stress, anxiety and fear.

C. Early Childhood (preschool age)

1. Comfort is assessed using available verbal input as the child is able to express along with nonverbal pain cues.
Ask the child to indicate the area of pain by naming the body part or poin ng. Have the child rate the pain using a
pain scale (ex. “Faces” self ra ng pain scale).
2. Developmental backsliding, decreased coopera veness and increased whining can occur in children of this age
group when they are not feeling well. Behavioral approaches (limit se ng, rewards, providing comfort measures)
may be helpful.
3. Fear of mu la on and fantasy peaks in the preschool aged child. Fear of inanimate objects and of imagined loss
of body parts is frequent. Avoid words that will be interpreted literally: “a s ck in your arm” may be interpreted as
“a tree branch in my arm” or “a cut your leg” may be interpreted as “cut o my leg”.
4. Allow the child me to process his/her fears. Allow rest and provide comfort between invasive and/or painful
procedures. Incorporate medical play and procedure prepara on techniques whenever possible to allow the child
to work through his / her feelings. Allow the child to play with medical equipment such as BP cu s, surgical masks,
tape, syringes and other safe objects to demys fy them prior to use.

D. Middle Childhood (school age)

1. Comfort is assessed using verbal report along with nonverbal behaviors. Have the child use a pain assessment
tool (ex. Oucher, faces scale, poker chip, glasses scale). Ask child to locate the area of pain and describe the
intensity if they are able. Watch for regression and anxiety.
2. Moral thinking (it’s my fault, I was bad) creates guilt in the school-aged child. Help children understand that they
are not responsible for the illness.
3. Loss of privacy, loss of body image, fear of death, and fear of mu la on / torture may be issues. Careful
explana ons, use of medical play, drawing, role-playing with dolls or puppets and storytelling are strategies to
encourage the child to discuss fears.
4. Loss of control, fear of the unknown and the an cipa on of pain / discomfort creates an overall sense of anxiety
in the child. Providing safe zones, honesty (ex. it will hurt but only for a minute), and choices (ex. which arm is
used for blood draw) helps the child develop a sense of trust and control.
5. Acute illness resul ng in developmental regression, clinging to parents, refusal to communicate and inability to
console may be indicators of stress and anxiety in this age group. Familiar, trusted adults are most successful in
helping the child control anxiety.
E. Adolescents
1. Comfort is usually assessed using verbal informa on while watching for nonverbal cues (similar to adults) .
Respec ng and ac ng on the teens report of pain is cri cal to a trus ng rela onship between healthcare provider
and teenage pa ent. Descrip ve Pain assessment tools can help iden fy the quan ty, quality, frequency and other
pain characteris cs.
2. Adolescents with serious illnesses and chronic pain may become depressed and socially withdrawn as a result of
chronic stress, loss of control, altered body image and a decreased sense of well being. Support by trusted adults /
peers may be helpful.
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 3. Social or cultural pressures (to be ‘cool’, mask fears) can result in con ic ng verbal and nonverbal cues. Non-
judgmental and con den al listening can help the teen feel safe in discussing their anxiety.
4. Some adolescents will request pain meds without nonverbal signs of pain. Pain is what the pa ent says it is.
Avoid the tempta on to judge the pain as “fake” or the child as “seeking” meds for pleasure.

III. Non-Pharmacological Approaches to Comfor ng and Calming Infants and Children.

A. Infant / Toddler / Early Childhood:
1. “Snug as a bug in a rug”: Swaddling restricts arm and leg movements and conserves heat. Some believe this
mimics the constricted, warm environment of the womb. This method is rou nely used with newborns. If
swaddled, the infant should be closely monitored. The AAP guidelines for infant bedding and posi oning
recommend against ght swaddling for sleep, especially above the level of the chest to . Use bundling prac ces
with cau on. Always keep airway management a priority when posi oning and selec ng bedding.
2. “Rock a bye baby”: Con nuous rocking produces ves bular s mula on crea ng a soothing mo on. Rock using a
rocking chair, infant swing (never leave una ended), bouncy seat, specialty rocking bed or holding the infant face
down on caregiver’s forearm with gentle rocking mo on.
3. “Pat-a-cake”: Gentle but rm pa ng on the back or bu ocks creates ventral pressure. This type of pressure can
also be accomplished by rm pressure on the trunk or head. This is be er tolerated than light stroking of
extremi es, hands and feet in babies with immature neurological systems.
4. “Lullaby and good night, go to sleep now”: Gentle music produces a sense of calm in the child and caregiver.
Infants may be comforted by a gentle heartbeat sound. The noxious s muli of busy hospital environmental sounds
can be diminished with soothing, relaxing music. Headphones or small speakers may be used. If parents are
present, give them permission and privacy (if prac cal) to sing
5. “Bed me Stories”: The soothing voice of a trusted caregiver produces a calming e ect for children. Reading
stories also helps children divert their a en on from the source of anxiety and/or pain. Reading a favorite story
also provides comfort.
6. "Linus' Blanket": Objects from home such as a favorite blanket, or stu ed animal can help an anxious toddler feel
more secure and provide comfort.
7. "Where's the Paci er?": Sucking on a paci er, breast feeding, bo le feeding o en help to calm an unhappy infant
or toddler.
8. "Where's MOM and DAD?": Young children rely on their parents to provide for basic needs. Frequently, the child's
parent is most e ec ve with comfor ng their child. They know what works and the child trusts THEM! Facilitate
parental presence.
9. "Play it again Sam" : Toddlers and young children are o en comforted and distracted from their pain with a
familiar and comfor ng electronic game, ac vity or video…some mes over and over!
B. Early and Middle Childhood / Adolescent
1. "Play is the Work of the Child": Children use play, story telling, imagina ve play, and drawing to work through
their feelings. Provide opportuni es for medical play with dolls / stu ed animals and medical equipment, drawing
and imagina ve play.
2. "What Pain?": Distrac on is an excellent method of taking a child's mind o a painful or anxiety-producing event.
Select developmentally appropriate ac vi es that cap vate the child's a en on (video games, arts and cra s,
favorite movie, play etc).
3. "Going on Vaca on": Imagery works well for older children and adolescents. Have the child focus on a relaxing and
pleasant experience (i.e. oa ng on a ra on a sunny day.)
4. "Breathe!": The simple act of breathing deeply has been shown to increase oxygena on and decrease both pain
and anxiety. Children in pain may hold their breath as a way of a emp ng to protect themselves from pain.
Remind them to BREATHE! Try using incen ve spirometer, party blowers or bubble soap with younger children.
5. "Squeeze my Hand": Providing a hand to squeeze or using of exible balls, modeling clay or other so objects may
help a child through a painful procedure.
6. "Technology Tricks": Biofeedback, electrical s mula on and other techniques have been used successfully in
children as well as adults.

25
N173 Week 1 Lecture Notes Pediatric Fundamentals MWolff/ASmith Update Fa23 5/23
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