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Pediatrics 18

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 two-thirds 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).

  • 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 diabetes mellitus type 1 (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 vigorously 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 and 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 two to three years of age.
  • The GI tract has both intake (fluid, minerals, vitamins, etc.) and output functions.
  • Whenever a newborn 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.
  • One Gm of diaper weight = one 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 Genitourinary

  • 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 one 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.
  • UTIs 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 five 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 one 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 findings 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 medication (or opioid) of choice for pain in children with sickle cell disease.

Pediatric Oncology

  • Findings 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.