Pediatrics is concerned with the health of

infants, children and adolescents, their

growth and development, and their
opportunity to achieve full potential as
adults.
(Richard E.Behrman in Nelson's Textbook of
Pediatrics)
Characteristics of pediatrics
 Pediatric Respiratory Rates
Age Rate (breaths per minute)
Infant (birth1 year) 3060

Toddler (13 years) 2440

Preschooler (36 years) 2234

School-age (612 years) 1830

Adolescent (1218 years) 1216

 Pediatric Pulse Rates
Age Low High

Infant (birth1 year) 100 160

Toddler (13 years) 90 150

Preschooler (36 years) 80 140

School-age (612 years) 70 120

Adolescent (1218 years) 60 100

 Low-Normal Pediatric Systolic Blood Pressure

Age* Low Normal

Infant (birth1 year) greater than 60*

Toddler (13 years) greater than 70*

Preschooler (36 years) greater than 75

School-age (612 years) greater than 80

Adolescent (1218 years) greater than 90

Fetal period
Neonatal period
Infant period
Toddler age
Preschool age
School age
Adolescence
 From fertilized ovum formed until
to delivery (about 40 weeks)
Feature: easy abortion or
malformation formed by any risk
factors
Health care: pregnant woman and
fetus
Intrauterine life: embryonic and fetal
period
first trimester first 12 wk
second trimester 13 28wk
third trimester 29 40wk
 From umbilical ligation to 28th day after
birth
Features: beginning independent living
The physiological regulation ability and
adaptation to circumstances are very poor.
The morbidity and mortality are very high
Health care: enough nutrition
proper nursing care
prevention of diseases
 The Physicians Role: promoting optimal medical
practices before, during, and after delivery.
(perinatal period)
Routine Delivery Room Care:
Clear mouth and pharynx of fluid
Give the Apgar score
Antiseptic Skin and Cord Care
Maintenance of Body Heat
Breast- or bottle-feeds
 After delivery until 1 year-old
Features: Rapid growth period
Fastest brain growth
Nutrition and energy requirement are more.
Digestion and absorption functions are poor
Passive immunity gradually drops
Health care: Enough nutrition
Prevention of diseases
Basic immunity
 From 1 to 3 year-old
Features: growth becomes slower
more vigorous, contact more objects.
intelligence develops faster
poor ability of identifying damage.
Health care: enough nutrition
Prevention of diseases
Prevention of accident
 3 years old until 6-7 years old
Features: growth becomes slower,
more mature intelligence.
strong desire for knowledge
imitating adults behavior
poor ability to identify damage
character forming.
Health care: enough nutrition
prevention of diseases
prevention of accident
a good habit training
 From 6-7 years old until adolescence
Features: growth becomes relatively steady
more mature intelligence developed
increasing desire for knowledge
decreasing incidence of diseases
Health care: enough nutrition
prevention of myopia and dental caries
prevention of problems in psychology,
emotion and behavior
 From 2nd sexual character appearing until sexual mature
and growth stopped
--Girl: from 11-12 yrs to 17-18 yrs
--boy: from 13-14 yrs to 18-20 yrs
Features: the second fastest period of growth and
development
neuroendocrine regulation unsteady
having problems in psychology, emotion, behavior
Health care: enough nutrition
health care of adolescence
education
NUTRITION

17
 Infant Nutrition
Birth 6 months:
Breast milk is most complete diet
Iron-fortified formulas are acceptable
No solid foods before 4 months*

6 - 12 months:
Breast milk or formula continues*
Diluted juices can be introduced
Introduction of solid foods*(4-6 mo): cereal, vegetables, fruits, meats
Finger foods at 9-10 months
Chopped table foods at 12 months
Gradual weaning from bottle/breast
No honey (risk for botulism)

18
 Toddler Nutrition
Able to feed self autonomy & messy!
Appetite decreases- physiologic anorexia
Negativism may interfere with eating
Needs 16 20 oz. milk/day
Increased need for calcium, iron, and phosphorus risk
for iron deficiency anemia
Caloric requirements is 100 calories/kg/day
No peanuts under 3 years of age (allergies)*
Do not restrict fats less than 2 years of age*
Choking is a hazard (no nuts, hot dogs, popcorn, grapes)*
Photo Source: Del Mar Image Library; Used with permission

19
Preschooler Nutrition

Caloric requirements is 90 calories/kg/day

May demonstrate strong taste preferences
4 years old picky eaters
5 years old influenced by food habits of others
Able to start social side of eating
More likely to try new foods if they assist in food
preparation
Establish good eating habits - obesity

20
 School-Age Nutrition
Caloric needs diminish, only need 85 kcal/kg

Foundation laid for increased growth needs

Likes and dislikes are well established

Junk food becomes a problem

Busy schedules breakfast is important

Obesity continues to be a risk
Nutrition education should be integrated into
the school program

21
 Adolescent Nutrition
Nutritional requirements peak during years of maximum growth:
Age 10 12 in girls
Age 14 16 in boys

Food intake needs to be balanced with energy expenditures

Increased needs for:
Calcium for skeletal growth
Iron for increased muscle mass and blood cell development
Zinc for development of skeletal, muscle tissue and sexual
maturation

Photo Source: Del Mar Image Library;

Used with permission
22
 Adolescent Nutrition (continued)

Eating and attitudes towards food are primarily family/peer

centered

Skipping breakfast, increased junk food, decreased fruits,

veggies, milk

Boys eat foods high in calories. Girls under-eat or have

inadequate nutrient intake.

23
Lets Review

The nurse recommends to parents that popcorn and

peanuts are not good snacks for toddlers. The nurses
rationale for this action is:

A. They are low in nutritive value.

B. They cannot be entirely digested.
C. They can be easily aspirated.
D. They are high in sodium.

24
Play is the work of Children

Enhances Motor Skills

Enhances Social Skills
Enhances Verbal Skills
Expresses Creativity

Decreases Stress
Helps Solve Problems

25
Appropriate Play Activities
Infants - Solitary Play, stimulation of senses (music,
mirror)
Toddler - Parallel Play, make believe, locomotion
(push-pull toys), gross & fine motor, outlet for
aggression & autonomy
Preschooler - Associative Play, Imaginary Playmate,
dramatic & imitative, gross & fine motor
School Age - Cooperative Play, rules dominate play,
team games/sports, quiet games/activities, joke
books
Adolescent - Group activities predominate, activities
involving the opposite sex in later years 26
Preparation for Procedures
Allow child to play with equipment
Demonstrate procedure on doll for
young child
Use age-appropriate teaching
activities
Describe expected sensations
Use simple explanations
Clarify any misconceptions
Involve parents in comforting child
Praise/reward child when finished

27
Communicating with Children
Provide a trusting environment
Get down to childs eye level

Use words appropriate for age

Always explain what you are doing

Always be honest
Allow choices when possible
Allow child to show feelings
/talk

28
Health Promotion

Childhood Immunizations
Well child check-ups
Nutrition
Screenings throughout childhood
(APGARS, newborn screenings, lead poisoning, vision/hearing, scoliosis)

Health Teaching

29
Immunizations

Primary prevention of many communicable diseases

Vaccines safety
MMR vaccine and autism (no correlation)
Reactions (pre-medicate with Tylenol)
Live attenuated vaccines (MMR, Varicella)
Weakened form of disease
Body produces immune response
Contraindicated in immunosupressed individuals
Inactivated (killed virus/bacteria or synthetic)
1st dose only primes system- immunity develops after 3rd

30
 Injury Prevention
& Safety Issues
Accidents are the leading cause of death in infants
and toddlers (falls, burns, poisons)
Toddlers and Preschoolers drowning
School-age and adolescents motor vehicle
accidents and firearms
90% of all accidents are preventable!
Safety education is the answer

31
Injury Prevention

Methods of Injury Prevention

Understanding and Applying Growth and
Developmental Principles
Anticipatory Guidance
Childproofing the environment
Educating caregivers and children
Legislation
Precipitating Factors
Potential Outcomes

32
 Pediatric Poisonings
Highest incidence occurs in children in 2-year-old age group and
under 6 years of age

Major contributing factor improper storage, allowing children to

play with bottles rattling of pills, drink syrups, toxic portion
of plants.
Teach parents about proper storage
Knowledge of plants in household, and keep away from infants
and children who might chew

Emergency treatment depends on agent ingested

Teach parents to have poison control number available
Refer to appropriate method according to substance ingested

First Intervention is to call POISON CONTROL CENTER

33
Types of Poisonings

Lead Poisoning

Salicylate Poisoning

Acetaminophen Ingestion

34
 Lead Poisoning
Major environmental health concern
Found in older homes (built before 1978), lead-contaminated
soil, water through lead pipes, lead-based paint in ceramics
products, Mexican candies made in lead containers
Body rapidly absorbs lead specially in periods of rapid
growth most harmful to children under 6 years
Absorbed in GI tract and accumulates in bones, brain,
kidneys
Low levels in blood can cause behavioral/learning problems,
mid-levels anemia-like symptoms and skeletal growth
interference, and high levels can be fatal from CNS edema
and encephalopathy
Diet high in fat, low in iron & calcium can increase lead
absorption
Intervention=teaching for prevention.
35
Salicylate Poisoning

Can be acute or chronic ingestion

S/S = nausea, disorientation, vomiting, dehydration,
hyperpyrexia, oliguria, coma, bleeding tendencies,
tinnitus, seizures
Nursing interventions = activated charcoal, sodium
bicarbonate for metabolic acidosis, external cooling
measures for hyperpyrexia, anticonvulsant and
seizure precautions (think patient safety!), vitamin K
for bleeding, possible hemo (NOT peritoneal)
dialysis

36
Acetaminophen Poisoning

Most common drug poisoning in children

Acute ingestion
S/S start as nausea, vomiting, pallor, sweating hepatic
involvement (jaundice, confusion, coagulation problems, RUQ
pain)
Treatment is activated charcoal first, then the antidote N-
acetylcysteine (Mucomyst) PO every 4 hours for 17 doses after
a loading dose given

Always assess Level of Consciousness (LOC) before

administering PO med!

37
Physical Assessment of Infant

Assessment is NOT in the head-to-toe manner

When quiet, auscultate heart, lungs, abdomen
Assess heart & respiratory rates before temperature
Palpate and percuss same areas
Perform traumatic procedures last
Elicit reflexes as body part examined
Elicit Moro reflex last
Encourage caretaker to hold infant during exam
Distract with soft voice, offer pacifier, music or toy

38
 Physical Assessment of Toddler

Inspect body areas through play count fingers and

toes
Allow toddler to handle equipment during assessment
and distract with toys and bubbles
Use minimal physical contact initially
Perform traumatic procedures last
Introduce equipment slowly
Auscultate, percuss, palpate when quiet
Give choices whenever possible

Photo Source: Del Mar Image Library; Used

with permission
39
Physical Assessment of Preschooler

If cooperative, proceed with head-to-toe

If uncooperative, proceed as with toddler
Request self undressing and allow to wear underpants
Allow child to handle equipment used in assessment
Dont forget magical thinking
Make up story about steps of the procedure
Give choices when possible
If proceed as game, will gain cooperation

Photo Source: Del Mar Image Library; Used with permission

40
Physical Assessment of School-Age
Child

Proceed in head-to-toe
May examine genitalia last in older children
Respect need for privacy remember modesty!
Explain purpose of equipment and significance
Teach about body function and care of body

41
 Physical Assessment of the
Adolescent
Ask adolescent if he/she would like parent/caretaker
present during interview/assessment
Provide privacy
Head-to-toe assessment appropriate
Incorporate questions/assessment related to
genitals/sexuality in middle of exam
Answer questions in a straightforward, non-
condescending manner
Include the adolescent in planning their care

42
Fever
Causes Often unknown, may be due to dehydration, most
often viral induced
Danger in infants is febrile seizures most common between
3 months to five years. The seizure is a result of how quickly
the temperature rises.
Hydration (20mls/kg is formula for bolus)
Antipyretics acetaminophen or ibuprofen
Cooling measures avoid shivering
Tepid bath
Remove excess clothing and blankets
Cooling blankets/mattresses

NO ICE PACKS!
43
 Pediatric Differences
Fluid & Electrolyte
Percent Body Water compared to Total Body Weight:
Premature infants: 90% water
Infants: 75 - 80% water
Child: 64% water
Higher percentage of water in extracellular fluid in infants
Infants and toddlers more vulnerable to fluid and
electrolyte disturbances
Concentrating abilities of kidneys not fully mature until 2
years
Metabolic rate is 2-3 times higher than an adult
Greater body surface area per kg body weight than adults;
dehydrates more quickly

44
 Dehydration
Types:
Isotonic Most common; salt and water lost. Greatest
threat Hypovolemic Shock
Hypotonic Electrolyte deficit exceeds water deficit-
physical signs more severe with smaller fluid losses
Hypertonic Water loss higher than electrolyte
Vomiting leads to metabolic alkalosis
Diarrhea leads to metabolic acidosis

LAB WATCH: monitor sodium, potassium, chloride,

carbon dioxide, BUN, and creatinine

45
 Assessment of Dehydration
Skin gray, cold, mottled, poor to fair, dry or clammy
Delayed capillary refill
Mucous membranes/lips dry
Eyes and fontanels sunken
No tears present when crying
Pulse and respirations rapid
Irritability to lethargy depending on cause and severity,
not responsive to parent and/or environment

46
Dehydration:
Nursing Interventions
Daily weight, I/O
Assess hydration status
Assess neurological status
Monitor labs (electrolytes)
Rehydrate with fluids both PO and IV (20 mls/kg of NS)
Diet progression: Pedialyte modified Bread-Rice-Apple
Juice-Toast (BRAT) Diet-for-age (DFA)
Skin care for diaper rash
Stool output (Amount, Color, Consistency, Texture - ACCT)
HANDWASHING!
Priorities: fluid replacement & assess for S/S of shock

47
Diarrhea

Often specific etiology unknown, but rotavirus is most

common cause of gastroenteritis in infants and kids
Dont forget contact precautions!!
Leading cause of illness in children younger than 5
May result in fatality if not treated properly
History very important
Treatment aimed at correcting fluid imbalance and treating
underlying cause
Metabolic acidosis = blood pH < 7.35

48
Vomiting

Often result of infections, improper feeding

techniques, GI blockage (pyloric stenosis),
emotional factors
Management directed toward detection, treatment
of cause and prevention of complications
Metabolic alkalosis = blood pH >7.45

49
Pain Assessment: Infants

Assessment of pain includes the use of pain

scales that usually evaluate indicators of pain
such as cry, breathing patterns, facial
expressions, position of extremities, and state
of alertness

Examples: FLACC scale,

NIPS scale

50
 Pain Assessment: Toddlers

Toddlers may have a word that is

used for pain (owie, boo-boo,
ouch or no); be sure to use term
that toddler is familiar with when
assessing.

Can also use FLACC scale, or

Oucher scale (for older toddlers)

51
 Pain Assessment:
Preschoolers

Think pain will magically go

away
May deny pain to avoid
medicine/injections
Able to describe location and
intensity of pain
FACES scale, poker chips and
Oucher scale may be used
Photo Source: Del Mar Image Library; Used
with permission

52
Pain Assessment:
Older Children
Older children can describe pain with
location and intensity

Nonverbal cues important, may

become quiet or withdrawn

Can use scales like Wongs FACES

scale, poker chips, visual analog
scales, and numeric rating scales

53
PEDIATRIC
MEDICATION
ADMINISTRATION
Bowden & Greenberg
General Guidelines
of all medications on the market today do not
have a documented safe use in children.
Children are smaller than adults and medication
dosage must be adjusted.
Children react more violently.
Drug reactions are not predictable.
The impact on growth and development must be
considered when giving drugs to children
Double checking is always best
Pediatric Drug Administration

Pediatric drug therapy should be guided by the childs

age, weight and level of growth and development
The nurses approach to the child should convey the
impression that he or she expects the child to take the
medication
Explanation regarding the medications should be based
on the childs level of understanding
 The nurse must be honest with the child regarding the
procedure
It may be necessary to mix distasteful medication or
crushed tablets with a small amount of honey,
applesauce, or gelatin
Never threaten a child with an injection if he refuses
an oral medication
All medications should be kept out of the reach of
children and medications should never be referred to
as candy
Oral Medications

GI tract provides a vast absorption area for meds.

Problem: Infant / child may cry and refuse to take the

medication or spit it out.
Oral Medications

Do not use if child has vomiting, malabsorbtion or

refusal
Kids < 5 find it difficult to swallow tablets
Use suspension or chewable forms
Divide only scored tablets
Empty capsules in jelly
Do not call medication candy
 Nursing Intervention
Infant:
Place in small amount of apple sauce or cereal
Put in nipple without formula
Give by oral syringe or dropper
Have parent help
Never leave medication in room for parent to give later.
Stay in room while parent gives the p.o. medication
Nursing Interventions

Toddler:
Use simple terms to explain while they are getting
medication
Be firm, dont offer to have choices
Use distraction
Band-Aid if injection / distraction
Stickers / rewards
Nursing Intervention

Preschool:
Offer choices
Band-Aid after injection
Assistance for IM injection
Praise / reward / stickers
 Nursing Intervention

School-age
Concrete explanations, do not just say it wont hurt
Choices
Interact with child whenever possible
When the child is old enough to take medicine in tablet or capsule
form, direct him or her to place the medicine near the back of the
tongue and to immediately swallow fluid such as water or juice
Medical play
Nursing Interventions

Adolescent
Use more abstract rationale for
medication
Include in decision making especially for
long term medication administration
Nursing Alert

For liquid medications, an oral syringe or

medication cup should be used to ensure
accurate dosage measurement.
Use of a household teaspoon or tablespoon
may result in dosage error because they
are inaccurate.

Bowen & Greenberg

 Oral Medications
Hold child / infant hands away from face
For infant: give in syringe or nipple
DO NOT ADD TO FORMULA
Small child: mix with small amount of juice or fruit, give
in syringe or allow the child to hold the medicine cup and
drink it at own pace if he/she is big enough
Parent may give if you are standing in the room
Oral Medication: older child

TIP: Tell the child to drink juice or mild after

distasteful medication. Older child can such the
medication from a syringe, pinch their nose, or
drink through a straw to decrease the input of
smell, which adds to the unpleasantness of oral
medications.
 Intramuscular Medications

Rarely used in the acute setting.

Immunizations
Antibiotics
IM Injection: interventions

TIP: Tell the child it is all right to make

noise or cry out during the injection.
His or her job is to try not to move the
extremity.
IM Injection Sites

Vastus Lateralis

Deltoid

Dorsogluteal
 Eye Drops

Eye:
Pull the lower lid down
Rest hand holding the dropper with the
medication on the childs forehead to
reduce risk of trauma to the eye.
Ear Drops

In children younger than age 3 years the

pinna is pulled down and back to
straighten the ear canal

In the child older than 3 years, the pinna is

pulled up and back.
 Nose drops
Act as vasoconstrictors excessive use may be harmful
Discontinued after 72 hours
Congested nose will impair infants ability to suck
Give 20 minutes before feeding
Have tissue paper
Keep childs head below the level of shoulders for 1 to 2
minutes after instillation
Rectal

Usually sedatives and antiemetics

Use little finger
Insert beyond anal sphincter
Apply pressure to anus by gently holding buttocks
together until desire to expel subsides
Intravenous Medications

IV route provides direct access into the vascular

system.
Adverse effects of IV medication administration:
Extravasation of drug into surrounding tissue
Immediate reaction to drug
IV Medication Administration

Check your institution's policy on which drugs must

be administered by the physician and which must
be verified for accuracy by another nurse.
All IV medications administered during your
pediatric rotation must be administered under
direct supervision of your clinical instructor.
IV Medication Administration

Check for compatibilities with IV solution and other

IV medications.
Flush well between administration of incompatible
drugs.
IV medications are usually diluted.
Nursing Alert

The extra fluid given to administer IV medications

and flush the tubing must be included in the
calculation of the childs total fluid intake,
particularly in the young children or those with
unstable fluid balance.

Bowden & Greenberg

Nursing Alert

Hourly assessment
Documentation
Patency, infiltration, inflammation, rate, pain, LTC
Use mini/micro drip chamber for control
IV Medications

IV push = directly into the tubing

Syringe pump = continuous

administration

Buretrol = used to further dilute

drug
IV push

Medication given in a portal down the tubing

meds that can be given over a 1-3 minute period of
time.
Lasix: diuretic
Morphine sulfate: pain
Demerol: pain
Solu-medrol: asthmatic
Syringe pump

Accurate delivery system for administering very

small volumes
ICU
NICU
IV Buretrol

Buretrol acts as a second chamber

Useful when controlling amounts of fluid to be infused
Useful for administering IV antibiotics / medications that
need to be diluted in order to administer safely
Example:

John is a pediatric client in a hospital in

which the policy is to place all children on IV
therapy on a buretrol and to only fill the
buretrol no more than two-three hours worth
of fluid. The nurse fills the buretrol to 90
ml at 10 a.m. If Johns IV is running at 34 ml
per hour, how long will it be before the nurse
will need to fill it again?
Calculate:

90 ml 34 (ml/hr) = 2.65 hrs However,

0.65 hrs = ? minutes.
1 hr 0.65 hr
=
60 min X min
1x = 39.00

X = 39
 Answer = 39 minutes Add this to the 2
hours. 10 a.m. + 2 hr 39 minutes = 12:39
p.m.

Answer: At 12:39 p.m. the buretrol will need

more fluid added so that air does not get into
the tubing.
Central Venous Line

A large bore catheter that are inserted either

percutaneously or by cut down and advanced into
the superior or inferior vena cava
Umbilical line may be used in the neonate
Used for long term administration of meds
Used for chemotherapy
Total parental nutrition
Type of fluid

Glucose and electrolytes

Maintenance
Potassium added
Crystalloid: Normal Saline or lactated ringers
Fluid resuscitation
Acute volume expander
Colloid: albumin / plasma / frozen plasma
Complications

Infiltration
Catheter occlusion
Air embolism
Phlebitis
Infection
Infiltration

Infiltration: fluid leaks into the subcutaneous tissue

Signs and symptoms:
Fluid leaking around catheter site
Site cool to touch
Solution rate slows are pump alarm registers down-
stream-occlusion
Tenderness or pain: infant is restless or crying
Catheter Occlusion

Fluid will not infuse or unable to flush

Frequent pump alarm
Flush line
Check line for kinks
Air embolism

The IV pump will alarm when there is air in the

tubing
Look to see that there is fluid in the IV bag or buretrol
Slow IV rate
Remove air from tubing with syringe
Phlebitis

Often due to chemical irritation

When medications are given by direct intravenous
injection, or by bolus (directly into the line) it is
important to give them at the prescribed rate.
Always check the site for infiltrate before giving an
IV medication
Signs and symptoms: phlebitis

Erythema at site
Pain or burning at the site
Warmth over the site
Slowed infusion rate / pump alarm goes off
Reason for pump alarm

Needs to have volume re-set

Needs more IV solution in bag or buretrol
Kinked tubing at infusion site
Child lying on tubing
Air in tubing
Infiltrated at site of infusion
Clinical Pearls

If alarm states upward occlusion

Look at IV bag
Look at fluid level in buretrol
Look to see if ball in drip chamber is floating
If alarm states downward occlusion
Look to see that all clamps are open
Look to see if line is kinked
Irrigate with normal saline or heparin