Pediatric Neurology

Abnormal posturing is an ominous sign

A positive Babinski is normal in children until one year of age

Myelinization continues until adolescence

Abnormal CSF findings include: decreased glucose, positive culture, and cloudy appearance

Due to pharmacokinetics and dynamics, common side effect of the majority of anti-convulsants include
drowsiness, ataxia, lethargy, anorexia, nausea. Sometimes dyscrasias or liver damage can occur; hence, these
children need periodic tests of blood and of liver enzymes.

Febrile seizures are generally a one-time event, though there may be a familial predisposition.

Children are more likely than adults to have neuromuscular or extrapryamidal side effects from
psychotherapeutic drugs.

Clinical effectiveness of anticonvulsants varies with the drug's serum level, mechanism of action,
pharmacokinetics and dynamics. The effects also may vary from child to child.

A newborn's brain is about 2/3 the size of an adult's, and reaches 80% adult size in one year.

The sudden appearance of a fixed or dilated pupil is an emergency.

The progression from decorticate posture to decerebrate posturing, and then to flaccid paralysis,
indicates deterioration of neurologic function.

Do not do any diagnostic tests that require head movement until cervical spine injury has been ruled out.

Children with congenital neurological disabilities will often develop complications in other body systems.

Cerebral palsy is a neuromuscular disorder. It may bring with it certain problems in perception,
language, and/or intellectual function.

Acute bacterial meningitis is a medical emergency, requiring swift action and treatment.

The care of the unconscious child focuses on respiratory management, neurological assessment,
monitoring intake and output, providing appropriate medications and evaluating outcomes.

The primary indicator of neurological status is LOC (level of consciousness).

Status epilepticus is an emergent situation.

Do not restrain a child experiencing a tonic-clonic seizure, and never place anything in his mouth.

In head trauma, the primary mechanism of injury is acceleration-deceleration accidents.

Bleeding from the nose or ears calls for evaluation.

 Pediatric Cardiovascular

In a cardiac history, include poor weight gain, chronic respiratory infection, activity intolerance, and
fatigue during eating.

Oxygen is a drug that requires a prescription and frequent monitoring.

Cardiac catheterization serves many purposes: diagnostic, interventional and electrophysiologic. It also
monitors cardiac oxygen saturation, pressure changes and anatomic defects.

CHF signs usually show either left or right sided heart disorders. These signs may include increased
heart rate, adventitious lung sounds, cyanosis, edema, hepatosplenomegaly, and distended neck veins.

Acquired cardiac disorders include bacterial endocarditis, acute rheumatic fever, hyperlipidemia,
Kawasaki disease, and cardiomyopathy.

Electrodes for cardiac monitoring are usually color coded: white (upper right), black (upper left), green
(lower right), and red (lower left).

Black White

Red Green

In cyanotic heart disorders, major concerns are polycythemia or increased hemoglobin and hematocrit.
These can lead to thrombus.

Pediatric Respiratory

The principal functions of the respiratory tract are to allow air movement (ventilation) and exchange
(diffusion) of oxygen and carbon dioxide.

Children's airways are smaller, more flexible and shorter than adult's and are therefore more prone to
obstruction than adults.

Stridor usually indicates an upper airway concern, while wheezing indicates a lower airway disorder.

Conditions that increase or decrease compliance and/or resistance will make breathing harder. Signs of
increased breathing work are tachypnea, retractions, abnormal positioning, shortness of breath and fatigue.

Respiratory rate is an important indicator of respiratory status.

Central cyanosis in a newborn usually means severe hypoxia and possible cardiac etiology.

Acrocyanosis is a common finding in a newborn.

Asthma is not a disease but an inflammatory disorder.

 Asthma is not wheezy bronchitis.

The incidence and severity of respiratory tract infections and disorders is related to the child's age, size,
natural defenses, underlying disorder and agent involved.

After a tonsillectomy child may bleed for up to several weeks.

Epiglottitis, acute tracheitis and status asthmaticus are acute medical emergencies.

The best way to stop the spread of RSV is meticulous hand washing. RSV is transmitted by direct contact
with the fomite.

Pediatric Endocrine

The body secretes hormones at various times during the day (influences of diurnal and circadian
rhythm).

Normal hormone levels are related to age and stage of puberty.

The pituitary gland stimulates target organs to produce specific hormones; when sufficient, these in
return signal pituitary to stop stimulation (negative feedback loop).

Untreated infant hypothyroidism will lead to mental retardation.

Associated terms for hypopituitary function include: short stature, constitutional delay, dwarfism.

A major concern of precocious puberty is rapid bone growth, which can result in early fusion and short
stature.

Children with SIADH develop an expanded circulatory volume but not edema.

Because oral potassium tastes very bitter, mix it with a little strongly flavored fruit juice.

For a child with an endocrine disorder, never discontinue medication abruptly.

The vast majority of children with new-onset IDDM will experience a "honeymoon" period when their
bodies secrete insulin and their need for exogenous insulin decreases.

Blood glucose monitoring by finger-stick reflects glucose currently and for last several hours;
glycosylated hemoglobin levels indicate long-term compliance and true diabetic status.

Never freeze, heat or shake insulin.

When insulin is absent, the body cannot properly metabolize fats, proteins and carbohydrates.

The focus of diabetic management is the inter-relationship of diet, activity and insulin administration.

Pediatric Gastrointestinal
 Infants & children have a much smaller stomach capacity than adults.

Peristaltic waves may reverse occasionally during infancy; gastric esophageal reflux is very common in
infants.

Secretory cells don't reach adult levels until 2-3 years of age.

The GI tract has both intake (fluid, minerals, vitamins, etc.) and output functions.

Whenever a child coughs, chokes and turns blue with feeding, suspect tracheoesophageal fistula.

Any newborn failing to pass meconium stool within the first 24 hours of life and who is prone to
constipation or decreased frequency of stooling in the first month of life, should be evaluated for Hirschsprung's
Disease.

The treatment of metabolic acid-base disturbance is oriented toward correcting the underlying problem.

Dehydration can lead to shock.

Dehydrated infants and children face greater morbidity risk than adults because children differ in body
composition and metabolic rate, and their fluid-regulation systems have not matured.

Potassium should only be added to IV fluids when the urine output is sufficient.

1 Gm of diaper weight = 1 cc of urine.

When assessing diarrhea or constipation, remember the acronym ACCT: amount, color, consistency, and
time (duration).

Bilious vomiting indicates source below the ampulla of Vater.

Pediatric Genito-urinary

The kidney's function is to maintain, in equilibrium, the composition and volume of body fluids.

Kidney function in an infant is nearly that of an adult by 12 months of age.

Children with urine output less than 1 ml/Kg/hour should be closely monitored for possible renal failure.

Acute renal failure should be suspected in a child with decreased urine output, edema and/or lethargy,
and who is dehydrated, recovering from surgery or in shock.

In managing HUS, the goals are to control hematologic manifestations and any renal complications.

UTI management aims to eliminate the underlying cause, detect and correct abnormalities, and prevent
recurrences.

The effects of hypokalemia or hyperkalemia can be devastating.

UTI's are extremely common in young children, girls more than boys.
 In a child with ambiguous genitalia, the criterion for choice of gender and rearing is not genetic sex, but
the infant's anatomy.

Pediatric Musculoskeletal

Since many musculoskeletal disorders begin with trauma, it is important to assess ABC (airway,
breathing and circulation) first.

Open fractures increase the risk of infection.

Immobilization has multi-system effects.

For a child with a fracture, it is important to assess the 5 P's of ischemia:

1. Pain and point of tenderness

2. Pulse -distal to the facture

3. Pallor

4. Paresthesia

5. Paralysis

Children with structural defects/disorders require regular follow-up evaluation until they reach skeletal
maturity.

Children in casts or traction need to be monitored for alterations in skin integrity routinely.

Children under 1 year of age generally do not experience fractures.

Because children's soft tissues are so resilient, dislocation and sprains are less common.

Pediatric Temperature-Related

The extent of a burn injury is expressed as percentage of total body surface area (TBSA)

The larger the percentage of TBSA that is burned, the greater the risk for burn shock.

In managing alterations in skin integrity, it is necessary to individualize the type of treatment and
medications to the particular causative agent.

If you wouldn't put it into an eye, don't put it into a wound.

Wounds heal by the process of moist wound healing and occlusion.

Dry wounds do not heal.

Wound debridement promotes healing and prevents infection.

 Immediate care for a major burn is ABC: airway establishment and patency, breathing and absence of
respiratory distress, and circulation with fluid initiation.

Potassium should not be administered during the initial oliguric phase of a burn injury, but should be
added when diuresis occurs.

Pediatric Hematology

For a child with altered platelet function or bleeding disorder, do not administer acetylsalicylic acid
(aspirin, ASA) or take rectal temperatures. Perform invasive procedures very cautiously.

Children with low WBC may not exhibit common signs of infection such as purulent drainage. In a
febrile client with granulocytopenia, give antibiotics immediately because this child risks rapid, overwhelming
sepsis.

Morphine is the narcotic of choice for pain in children with sickle cell disease.

Pediatric Oncology

Signs and symptoms of pediatric malignancies vary according to the child's age, location and type of
tumor, and extent of disease

Cure rate is improving for most types of pediatric malignancies; however the late effects of treatment are
of increasing concern and incidence.

Children typically have longer treatment plans than adults due to their increased metabolic rate and rate
of cell turnover.

Leukemia affects not only the blood, but can metastasize to major organ systems (extramedullary
disease), including the central nervous system.

Nursing care includes monitoring the child for the development of acute complications of treatment
including fever, bleeding, and anemia.

Pediatric oncologic emergencies include: acute tumor lysis syndrome, superior vena cava syndrome,
septic shock.

PREGNANCY
Normal labor progress in active labor is 1.2cm/hr for primiparas and 1.5cm/hr for multiparas

Prolonged labor at any stage should be evaluated for fetal, pelvic or uterine dysfunction

Pain and anxiety can impede labor progress

Vaginal birth is the birth method of choice and interventions should be directed at accomplishing that
goal

Cesarean birth is utilized to rescue the infant when fetal, pelvic or uterine dysfunction cannot be
overcome

Maintenance of a calm, soothing environment is necessary

 Efficient and effective gathering of supplies and personnel is imperative

Maintain eye contact and verbal contact with woman to provide support

Assist mother to birth as slowly as possible to prevent maternal/newborn trauma

Be prepared to assist newborn transition to extrauterine environment

Anticipate predisposing factors for prolapsed cord

Gentle displacement of cord with sterile glove to relieve pressure

Inform and support mother in emergency

Prepare for expeditious birth - vaginal or cesarean

Surgical intervention has associated complications of increased infection, increased postoperative

hemorrhage, increased morbidity and potential of increased mortality

Surgical delivery of the newborn reduces mechanical compression of the chest. It may potentiate
respiratory difficulties in the newborn such as Transient Tachypnea of the Newborn.

Surgical delivery is to be avoided except to rescue the fetus or to alleviate maternal morbidity

Severe postpartum hemorrhage may result in organ failure, DIC, and/or mortality

Estimation of bleeding is critical

Uterine massage is the first line of defense against excessive hemorrhage

Oxytocins are used to contract the uterus