HESI Pediatric HESI Review

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• General considerations for  the child:

PEDIATRIC HEALTH ASSESSMENT • General considerations for  the family:

 – Introduce self & allow child some warm-up time

 – Choose quiet setting for  for  assessment

 – Maintain eye contact, bend to child’s level

 – Ask open-ended question question to elicit responses

 – Child is perceptive of caregiver’s nonverbal communication

 – Listen attentively & provide appropriate feedback

 – Respect child’s responses

 – Encourage parents to express express concerns & ask questions

 – Respect need for privacy as appropriate for age  – Incorporate play into assessment as appropriate

 – Communicate importance of  parent’s role in conjunction with health team

 – Use language appropriate to cognitive level

Pediatric HESI Review 1







• Prenatal: Prenatal: Conce Conception ption to birth

• Infan antt

• Inf Infanc ancy: y: Bir Birth th to 12 or 18 months

• Tod oddl dler  er 

 – Neonatal - Birth to 28 days

• Ear Early ly Childho Childhood: od: 1 - 6 yea years rs  – Toddler:

1 - 3 years

 – Preschool:

3 - 6 years

• Pres Presch choo ooll • Scho School ol-a -age ge • Ad Adole olesc scen entt

• Middle Middle Ch Childh ildhood: ood: 6 - 11 years years  – School age

• Later Childh Childhood: ood: 11 - 19 years


 – Prepubertal:

10 - 13 years

 – Adolescence:

13 - 18 years



• General characteristics:

• Gr. & Dev. Milestones:

 – Best health indicator is steady & increasing ht., wt., & head & chest circumference

 – 1-2 mo. smiles

 – Ht. increases 50% over birth length by 12 mo.

 – 3 mo. vocalizes in response to voices

 – Wt. tripled by 12 mo.

 – 4 mo. head control

 – Head & chest circumference equalize during 1st. yr.

 – 4 mo. purposefully grasps objects

 – 2 mo. lifts head from prone position & briefly holds it erect

 – Posterior fontanel closes by 2mo.

 – 4-5 mo. rolls from abdomen to back

 – Anterior fontanel closes by 18 mo.

 – 6-7 mo. sits  – 6-7 mo. anything grasped goes goes into mouth  – 6-7 mo. rolls from back to abdomen

Pediatric HESI Review 2




 – 9 mo. crawls rapidly, keeping belly off floor 

• Psychosocial development: Erikson

 – 9 mo. moves from crawling to sitting position

 – Psychosocial crisis is TRUST vs MISTRUST

 – 9 mo. pulls up

 – Significant other is “maternal” person

 – 9 mo. pincer grasp rather tha than n palmar grasp  – 10. mo walks with support  – 11 mo. stands alone  – 12 mo. walks alone

 – Quality of caregiver-child relationship is crucial factor   – Attentive care shows that needs needs will be met promptly & that life is predictable.  – Consistent delayed needs gratification fosters uncertainty

DEVELOPMENTAL THEORIES • Psychosexual development: Freud  – Oral stage of dev. • Erogenous Erogenous zone zone is mouth, lips, tongue, & teeth

 – Sexual activity takes form of: • Sucking, Sucking, swallowing, swallowing, chewing, chewing, & biting

 – Infant meets world by: • Cryin Crying, g, tasting, sucking, sucking, eating, eating, & early vocalization • Grasping & touching to explore tactile variations in the environment

 – Comfort commonly obtained from a security object

DEVELOPMENTAL THEORIES • Cognitive development: Piaget  – Sensorimotor stage from stage from birth to 18 mo.

SOCIAL DEVELOPMENT • Language:  – Crying 1st means of verbal communication  – Throaty vocalizations by 5 wks.

 – Dev. progresses from reflexive activity to purposeful acts

 – By 8 mo. combined syllables (mama, dada

 – Dev. of intellect & knowledge o of  f  environment gained through the senses

 – by 1 yr. several short words with meaning

 – At completion of stage, infan infantt achieves a sense of object permanence • Retains Retains a mental im image age of the abs absent ent object • Sees sel selff as separa separate te from other others s

 – Soothing tone can be comforting comforting

• Play:  – Facilitates learning  – Learns about environment through through senses of touch, taste, hearing,

SOCIAL DEVELOPMENT  – Dev. motor skills through manipulating toys  – Play is basically solitary

• Socialization:  – Attachment to significant other  other  begins @ birth & becomes increasingly evident after 6 mo  – Stranger anxiety begins around 6 mo.  – Caregiver’s cuddling & warmth can help ease fears  – Discipline & setting limits begins with negative voice, stern eye contact, or timeout

smell, & sight

Pediatric HESI Review 3





• Breast Breast milk milk ha has s followi following ng advantages over cow’s milk:

• Ready to use formula formula sho should uld be refrigerated once open & discarded after 24 hr.

• Finger foods between between 8-10 8-10 mo.

 – Immunologic & antibacterial components not in cow’s milk  – Less risk of allergies  – More easily digested, convenient, & economical

• Whole milk should not be given before 12 mo. • By 6 mo. iinfant nfant ready to hav have e solid foods introduced

• Ideally, Ideally, weaning weaning fr from om breast breast or  bottle begins @ age 6 mo

 – Introduced progressively and one at a time

• Adequate Adequate flu fluid id in intake take reflec reflected ted by:

 – Start with cereal with iron (wheat & mixed last)

 – At least 6 wet diapers in 24 hr.

 – Next fruits, then veggies, and and last meats

• Never micro microwave wave breast milk

 – Avoid hot dogs, nuts, grapes, grapes, carrots, popcorn, peanuts, & hard round candies for fear of choking

• Common Common food food aller allergies gies::  – Cow’s milk,egg, soy products, peanut, chocolate, corn & wheat

• Common Common clinica clinicall ma manifesta nifestations tions of food allergies:  – Abd. pain, diarrhea, nasal nasal congestion, cough, wheezing, vomiting & rashes

 – Juices after 6 mo.

IMMUNIZATIONS • Generally Generally follow an a age-base ge-based d schedule • Contraindicat Contraindications ions include: include:  – Severe febrile illness  – Immunodeficiency  – Known allergy to the vaccine

• See Nursing Pediatric Seminar 

INJURY PREVENTION • See Nursing 2504 Pediatric Seminar PowerPoint Notes

HOSPITALIZATION • Maj Major or stre stresso ssorr is Separation Anxiety  – Seen between 6 mo & 30 mo  – Traumatic for both infant and and parent

• Maj Major or issue issue is that that of  stimulation & regular routine  – Without appropriate stimulation, infant exhibits failure to thrive  – Experiences mainly painful stimuli and interruption of sleeping & eating routine

Pediatric HESI Review 4




• Guidelines for intervention:  – Human contact when p parent arent not available  – Stimulation through soothing voices, music, being rocked, etc.

• Fever   • Iron Defi Deficie ciency ncy A Anem nemia ia

 – UTI  – Respiratory tract infections

• Turn Turn of offf TV

 – Otitis media

• Dim lights lights

 – Viral infections

• One toy o orr activi activity ty @ time

• Associated Associated clinical clinical ffindings indings provide important indications of  seriousness

 – Ensure toys safe, clean & large enough so not to be ingested  – Assure parents of their importance & abilities as caregivers

 – Active with fever of 104.F generally of less concern than lethargic with fever of 102 F

 – Encourage favorite comfort items from home

• Comfor Comfortt measu measures res::  – External cooling • Remov Remove e blanke blankets ts & clothi clothing ng


• Tepid bat baths hs with luke lukewarm warm water   – Avoid rubbing alcohol as can result in too rapid cooling & chilling

 – Antipyretics • Aceta Acetaminop minophen hen & NSAIDS NSAIDS • Never AS ASA A R/T Reye’s syn syndrome drome

 – Maintain adequate fluid intake


• Defi Defined ned as transient disorders of children that occur in association with fever 

• Tur Turn n child child onto onto side side

• > Fever asrectally a bodyor temp. 38 Cdefined (100.4 F) > 37.8 C (100 F) orally

mouth • Allow Allow child child to drool drool

• Reduc Reduction tion of room tem temperat perature ure • Cooling Cooling blanke blankets ts

• Def Defined ined as as a body body temp temp > than 38.0 C (100.4 F) rectally or 37.8 C (100. F) orally • Common Common cause causes s in infancy: infancy:

 – Reduce environmental stimulation



 – Commonly do not recur after initial occurrence (60%)  – Others have 2-3 over the years years stopping by age 5 or 6

• Do not not tr try y to rest restrai rain n • Do not not put anyt anything hing into into the the

 – May use a suction bulb to remove saliva or fluids

• Cal Calll Dr if any any of follow following ing occurs:

 – Average body temp at which which sz occurs is 40C (104F)

 – Sz lasts > 3 min

 – Boys more than girls

 – Child’s neck is stiff 

 – ↑  susceptibility in families

 – Child delirious or difficult to awaken after sz

 – Another sz occurs

Pediatric HESI Review 5


IRON DEFICIENCY ANEMIA • Res Results ults from from inade inadequat quate e supplies of iron to synthesize hemoglobin adequately • Et Etio iolo logy gy::

IRON DEFICIENCY ANEMIA  – Usually related to lg. intake of milk & foods that do not contain supplemental iron

• Assess Assessmen mentt findings findings::  – Pallor 

IRON DEFICIENCY ANEMIA • Lon Long-t g-term erm ther therapy apy::  –  – ↑  intake of iron & ↓ consumption  ↑ intake of cow’s milk

• Tea Teachi ching ng Guideli Guidelines nes::

 – Tachycardia

 – Provide iron-fortified formula if  < 12 mo.

 – Lethargy

 – Limit cow’s milk to < 24 oz/d if 

 – Full-term's iron stores adequate for 1st. 5-6 mo.

 – Irritability  – Hb. < 9 g/dL

 – Premie or infant from multiple birth, iron stores adequate for only 2-3 mo.

 – Impaired cognitive ability ( a longterm consequence)

> 12 mo.  –  – ↑  intake of iron-rich foods  ↑ intake  – Administer iron in 3 divided doses between meals

 – Inadequate dietary inta intake ke of iron  – Insufficient iron stores

• Pa Path thol olog ogy: y:

 –  – ↑  susceptibility to infection  ↑ susceptibility

• Give with with vitamin C-rich C-rich fluids fluids • administer administer with with dropper placed placed @ back of mouth, away from teeth

 – Occurs around 9 -24 mo.

• Expect Expect black, tarry tarry stools



• General characteristics:

• Sids • Sha Shaken ken Baby Baby S Syndr yndrome ome • Meni Mening ngit itis is • Atopic Dermatitis Dermatitis (Eczema) (Eczema) • Se Seiz izur ures es

• Refer to RNSG 2504 Pediatric PowerPoint Notes


 – Physical growth & weight slower   – Characteristic protruding abdomen results from underdeveloped abdominal muscles  – Bow-legged since legs bear the wt. of the relatively lg. trunk  – Anterior fontanel closes between 12-18 mo.  – Fine motor skills include: • Und Undres ressin sing g • Drawing Drawing simple simple lines lines • Buil Building ding simple simple things things

Pediatric HESI Review 6


PHYSICAL GROWTH & DEVELOPMENT • Gr. & Dev. Milestones:  – 12-15 mo. walks  – 15 mo. climbs stairs  – 18 mo. climbs  – 2 yrs. runs  – 3 yrs. walks backward & hops on 1 foot  – 3 yrs. throws a large ball  – 3 yrs. puts on simple clothes  – 3 yrs. walks on tiptoe  – 3 yrs. achieves fairly good bowel & bladder control

DEVELOPMENTAL THEORIES • Psychosexual development: Freud

DEVELOPMENTAL THEORIES • Psychosocial development: Erikson

DEVELOPMENTAL THEORIES • Erikson, cont:  – Begins to master:

 – Psychosocial crisis is Autonomy vs Doubt & Shame

• Diffe Differenti rentiation ation of self from others others

 – Significant other is the “paternal” person

• Control Control of bodily bodily functions functions • Communicat Communication ion with words words

 – Psychosocial theme is “To hold

• Acquisition of socially socially acceptable behavior 

on; to let go”  – Ready to give up dependence dependence to assert his budding sense of  control, independence & autonomy  – Often continues to seek a familiar  security object during times of  stress

DEVELOPMENTAL THEORIES • Cognitive development: Piaget

• Separation Separation from from parents parents

• Egoc Egocentric entric interactio interactions ns with others

 – Negativism Negativism  - often says “no”, even when means “yes” to assert independence  – Ritualism helps child venture out & away from safety of parents  – Has temper tantrums

DEVELOPMENTAL THEORIES • Moral development: Kohlberg

• Erogenous zone is anus & buttocks

 – Sensorimotor phase between phase between 12 & 24 mo.

 – Makes judgments on basis of  avoiding punishment or obtaining a reward

• Sexual ac activity tivity centers on expul expulsion sion & retention of body waste

 – Preoperational phase from about about 2 yrs - 4 yrs.

 – Discipline patterns affect moral development

 – Anal stage of dev.

 – Conflict between “holding on on”” & “letting go” gradually resolves as bowel training progresses

 – Egocentric thinking  – Focuses on the here & now  – Absolute thinking - perceives things as good or bad, right or  wrong  – Increased use of language & dramatic play

• Physical punishment & withholding privileges tends to give toddler a negative view of morals • Withdrawin Withdrawing g love & affections affections as punishment leads to feeling of guild • Appropriate Appropriate disciplina disciplinary ry actions include providing simple explanations, praising appropriate behavior, & using distraction when the toddler is heading for danger 

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SOCIAL DEVELOPMENT • Language:  – Begins to use short senten sentences ces  – Has a vocabulary of abou aboutt 300 words by 2 yrs  – Tends to ask many “what” questions

SOCIAL DEVELOPMENT • Samples of saf safe e toys to prov provide ide opportunities for exploring the environment:

 – Stranger anxiety  – Large animals

 – Housekeeping toys

 – Loud noises

 – Is the major socializing medium  – Typically Typically parallel  parallel

 – Cloth books

 – Short attention span cau causes ses him to change toys often

 – Simple musical instruments

 – Encourage caregivers to assure child of their return when need to leave & to follow through • Leave a familiar object belonging to them to assure a return

 – Medical play kits helpful  – Provide for activity in a safe & supportive environment  – Use simple explanations to allay fears

 – Going to sleep

• Effects of Hospitalization  – Primary issue = Separation  – May interpret being in hospital or  painful procedures a punishment for something he did “bad”  – Regressive behaviors

 – Continues to separating from parents

• Guidelines for intervention:

 – Loss of parents - Separation Separation  Anxiety

 – Blocks

 – Toy telephone  – Wooden puzzles


• Common Fears:

 – Play dough

 – Containers

• Play:


NUTRITION & FEEDING • Most Most toddl toddlers ers pr prefer efer to feed feed themselves • At risk risk for aspiration aspiration of small foods not easily chewed • Most Most exper experien ience ce “foo “food d jags” • Most experi experience ence episode episodes s of  physiologic anorexia R/T alternating periods of fast & slow growth

NUTRITION & FEEDING  – Prepare foods attractively  – Limit concentrated sweets & empty calories  – Set child @ high chair @ family family table  – Allow sufficient time to eat, but remove food when toddler begins playing with it  – Avoid using food as a reward or  punishment

• Feeding Feeding su sugges ggestio tions: ns:  – Provide basic 4 food groups in small portions  – Offer limited number of foods @ time

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• General characteristics:

• Lead Lead Pois Poisoni oning ng

• Refer to RNSG 2504 Pediatric PowerPoint Notes


 – Coordination & muscle strength ↑ rapidly  – Handedness clearly established by 4 yrs.  – Appears taller & thinner   – Grows 2.5 - 3 inches /yr.  – Gains 5 lb/yr   – Can use scissors successfully & tie shoelaces  – 20 teeth present • By 5 yrs may begin begin to lose deciduous deciduous teeth • By 5 yrs may have first first permanent permanent teeth (molars)

DEVELOPMENTAL THEORIES • Psychosocial development: Erikson

DEVELOPMENTAL THEORIES • Psychosexual development: Freud

 – Psychosocial crisis of Initiative vs Guilt

• Phallic stage of development

 – Significant other is the family

• Sexual pleasur pleasure ec centers enters on the genitalia & masturbation

 – Psychosocial theme is “To make, to make like, to play”  – Dev. a conscience & guilty feelings  – Is energetic, enthusiastic, & ha has s an active imagination  – Uses simple reasoning & can tolerate longer periods of delayed gratification

• Oedipal stage occurs, occurs, ma marked rked by jealousy & rivalry toward same-sex parent & love of the opposite-sex parent  – By late preschool period, this typically resolves & a strong identification with the same-sex parent

DEVELOPMENTAL THEORIES • Cognitive development: Piaget  – Still in Preoperational thought • Forms concept concepts s not as complete complete or  logical as adult’s • Makes simple simple classification classifications s • Reasons Reasons from specific specific to specific specific

 – Thinking remains egocentric, becomes magical  – Judgements dominated by perception & are illogical  – Magical thinking  – Animism • Perception that all objects have life & feeling

Pediatric HESI Review 9


DEVELOPMENTAL THEORIES • Moral development: Kohlberg


 – Conscience emerges

 – Talks incessantly

 – Obey rules out of self-interest

 – Engages in long monologues, even if no one is listening

 – An “eye for an eye” guides th their  eir  behavior 

SOCIAL DEVELOPMENT • Play:  – Big task is learning to relate with age-mates  – Play mainly associative mainly associative

 – Asks many “why” questions

 – Understands concept of of sharing

 – Begins to use self-control & tries to be “good” to avoid feelings of 

 – Tend to boast & exaggerate exaggerate

 – Needs regular socialization with age-mates

guilt  – Little understandings of reaso reasons ns for rules

 – By 5 yrs. speak in sentences of  adult length & use all parts of  speech

• Decid Decides es whether whether to break rul rule e depending on punishment

 – May stutter as ideas come faster  than speech

 – Family’s religious beliefs & customs are important & can be deeply meaningful & comforting

SOCIAL DEVELOPMENT • Common Fears:  – Has more fears than @ any other  time  – The dark  – Being left alone, especially @ bedtime

 – Enjoy rhymes

• Usually disappears spontaneously spontaneously iif  f  child not pressured

SOCIAL DEVELOPMENT • Effects of hospitalization:  – Primary issue is body mutilation • May think he caused illness or injury because he way “bad” • Feels loss loss of contr control ol over usual usual routines • May exhibit regressive regressive behaviors behaviors

 – Fears injury & pain

 – Ghosts

 – Afraid of intrusive procedures & have a literal interpretation of  words

 – Pain

• Dress-up Dress-up cloth clothes es • Housekeepi Housekeeping ng to toys ys • Doll Dolls s & other toys that that encourage encourage pretending • Bikes & climbing climbing toys toys for big muscles • Paper & crayons crayons for creativi creativity ty

 – Animals, especially big dogs  – Body mutilation

 – May have an imaginary friend  – Play & activity suggestions:

• Often imagine imagine things things are worse than they are

SOCIAL DEVELOPMENT • Guidelines for intervention:  – Reassure not to blame for  for  hospitalization  – Preparation for any medical procedure • Do not overload overload with with too much info info

 – Medical play  – Encourage expressive play • Provi Provide de for playroom playroom & toys in room room

 – Be consistent  – Involve parents in care  – Allow for regressive behavior   – Encourage independence in ADL  – Watch medical vocabulary • “Fix “Fix”” in inst stea ead d of “t “tak ake e ou out” t”

Pediatric HESI Review 10




• Head Head Lice Lice • Pi Pin n worm worms s • ADHD ADHD (Attent (Attention ion-Def -Defici icitt Hyperactivity Disorder) • Commun Communica icable ble Dis Diseas eases es • Im Impe peti tigo go

• General characteristics:


 – Girls often grow faster than boys  – Appears thinner & more graceful graceful than preschoolers  – Musculoskeletal growth leads to greater coordination & strength • Muscles Muscles still iimmature mmature & can can be injured from overuse

 – Lungs & alveoli fully mature, so ↓ resp. infections

• Refer to RNSG 2504 Pediatric PowerPoint Notes

 – Eustachian tube more downward downward so ↓ otitis media  – All 20 deciduous teeth lost & replaced by 28 of 32 permanent teeth

PHYSICAL GROWTH & DEVELOPMENT  – Puberty begins • Sex ed educati ucation on a mus mustt  – Responsible sexuality & dangers  – such as Aids, pregnancy, ST STDs Ds

DEVELOPMENTAL THEORIES • Psychosocial development: Erikson  – Psychosocial crisis of  industry  industry vs inferiority  – Significant others expand to include school & instructive adults  – Sense of industry grows out of of a desire for real achievement  – Engages in tasks & activities he can carry out  – Learns rules & how to compete with others

DEVELOPMENTAL THEORIES • Psychosexual development: Freud  – Latency period, period, extending from about age 5 through 12, represents a stage of relative sexual indifference before puberty & adolescence  – Dev. of self-esteem closely linked with a dev. sense of industry in gaining a concept of one’s value & worth

 – Play is cooperative  – School activities important

Pediatric HESI Review 11


DEVELOPMENTAL THEORIES • Cognitive development: Piaget  – Stage of concrete operations  – Marked by inductive reasoning, logical operations  – Can distinguish fact from fanta fantasy sy  – Concept of time becomes clear 

DEVELOPMENTAL THEORIES • Moral development: Kohlberg  – Increased desire to please others others  – Observes & to some extent, internalizes standards of others  – Wants to be considered “good” “good” by those whose opinions matter to him

 – Does not deal with abstr abstractions actions or  socialized thinking  – Asks questions

• Play:  – Becomes more competitive & complex


 – Rules & rituals important  – Coordination & motor skills improve as child given opportunity to practice  – Enjoy active sports & games as well as crafts & fine motor  activities  – Enjoy activities requiring balance & strength

• Group activities, activities, including including team team sports consume much time & energy • More knowledgeabl knowledgeable e about about b body ody & social dev. centers on body & its capabilities • For Formal mal & infor informal mal clubs clubs

SOCIAL DEVELOPMENT • Guidelines for intervention:

 – Failure @ school

 – Encourage to talk about interests

 – Bullies

 – Allow to help with self care & treatments

 – Intimidating teachers

 – Give opportunities to make choices whenever possible

 – Team sports  – Secret clubs, gangs

• Pee Peerr relation relationshi ships ps gain gain in importance

• School very import important; ant; favorit favorite e teachers serve as role models

 – Collecting & sorting objects (eg., baseball cards, Beanie Babies)



• Effects of Hospitalization:  – Common fears include: • Disability Disability & possibly possibly death death • Unknown Unknown events & proc procedures edures

 – Still a need for comfort from caregivers & parents

• Loss of control control & independence independence

 – Reassure that crying is OK

• Interruption Interruption of dail daily y routine

 – Peer interaction important

 – Primary issue is control

• Cards, Cards, vis visits, its, etc

 – Loss of contact with peers big big issue  – School routines interrupted

Pediatric HESI Review 12




• General characteristics:

• Appen Appendi dici citis tis • Rh Rheum eumat atic ic fev fever  er 

• Refer to RNSG 2504 Pediatric PowerPoint Notes


 – Rapid rate of physical  – Encompasses puberty • Girl Girls s begin between between ages 8-14 yrs  – Complete within 3 yrs

• Boys begin begin between between ages 9-16 9-16 yrs  – Complete by age 18 - 20

 – Hormonal changes  – Sexual maturity reached  – Most girls reach “reproductive maturity 2-5 yrs after onset of  menstruation  – Ultimately ht., wt., & body build build influenced by diet, exercise, & heredity

DEVELOPMENTAL THEORIES • Psychosocial development: Erikson

DEVELOPMENTAL THEORIES • Psychosexual development: Freud

DEVELOPMENTAL THEORIES • Cognitive development: Piaget

 – Psychosocial crisis is is identity  identity vs role confusion

 – In the genital stage

 – In developmental stage of formal operations

 – Significant others are the pee peers rs

 – zone Focus in on genitals as erogenous erogenous

 – Energy focused within the self, & the adol. is described as egocentric or self-absorbed

 – A time of heightened sexual drive drive

 – Moves from deductive to abstract abstract reasoning

 – Try on new roles in transition & experiment with the environment until finding a role that fits  – Lack of commitment R/T changing interests

• Experiences Experiences conflict conflict betwee between n own need for sexual satisfaction & society’s expectations

 – Core concerns include body image dev. & acceptance by the opposite sex

 – Thinks beyond the present & forms theories about everything  – Develops a systematic approach to problems

• Illustrated Illustrated by pare parents nts buyin buying g expensive equipment & having it given up next yr 

Pediatric HESI Review 13


DEVELOPMENTAL THEORIES • Moral development: Kohlberg  – Marked by the development of an individual conscience & a defined set of moral values  – Control of conduct is now internal  – Dev. a respect for law & orde order  r 

SOCIAL DEVELOPMENT • A period period o off rebelli rebellion on & uncertainty as the adol. defines an identity separate from parental authority • Peer relati relationships onships become all important for advice & support • Being Being foun found d attr attract active ive b by y members of the opposite sex is important • Group parties & dates dates occupy occupy much of the social time • Automobile Automobile ownership ownership important important • A job & ea earnin rning g mo money ney important

SOCIAL DEVELOPMENT • Effects of Hospitalization:  – Primary issue is body image • SelfSelf-esteem esteem,, independ independence ence & body image are negatively impacted when hospitalized

 – Fears loss of control through enforced dependency & loss of  identity  – Fears bodily injury & pain  – Inability to gain independen independence ce from family  – Adjustment required R/T separation from peers & lack of  emotional support

SOCIAL DEVELOPMENT • Guidelines for intervention:  – Allow to participate in treatment decisions & have as much control as possible  – Respect privacy & confidentiality  – Provide opportunities for  expression of feelings  – arrange for age-compatible roommate, if possible

SOCIAL DEVELOPMENT • Degree Degree of sexu sexual al intimac intimacy y experienced depends, to a large part, on peer group codes & the adolescent’s expectations & value system  – Needs accurate, complete information on sexual matters  – Must know how pregnancy pregnancy occurs and how it is prevented

• Co Comm mmon on ffea ears rs::  – Relationships with persons of  opposite sex  – Homosexual tendencies  – Ability to assume adult roles

SOCIAL DEVELOPMENT • When When possible possible,, provide provide for  for  special activity area limited to adolescent use • brought Allow Allow favori favinorite te foods foods to be be • App Approac roach h with with caring caring,, understanding, & acceptance

 – Have phone @ bedside bedside  – Encourage to wear own clothing  – Use scientific & medical terminology to prepare for  procedures

Pediatric HESI Review 14


INJURY PREVENTION • Are risk-takers & often do not consider safety before acting • Contribute Contribute substantially substantially to the the number of motor vehicle accidents through:  – Inexperience & poor judgment  – Reckless driving or speeding  – Driving under the influence of  alcohol or other drugs  – Failure to use safety belts  – Peer pressure for unsafe driving practices

INJURY PREVENTION • Particularly Particularly prone to sw swimming imming & diving accidents, and safety of  these areas must be taught • Needs instruction instruction as to how to avoid sports injuries • Smokin Smoking g & use o off alco alcohol hol & other drugs should be discouraged • Other Other issu issues es::


• Refer to RNSG 2504 Pediatric PowerPoint Notes

 – Body piercing  – Tattoos  – Suntanning






Pediatric HESI Review 15




• Resp. infections infections easily easily spread from one structure to another  within the resp. tract  – R/T the contiguous nature of the mucous membrane lining the entire tract

• Resp infections infections account account for the majority of acute illness in children  – Etiology influenced by age, season, living conditions, & preexisting medical problems

• Most Most infec infection tions s caus caused ed by viruses

OVERVIEW • Poo Poorr toleranc tolerance e of nasal nasal congestion - esp. in infants who are obligatory nose breathers until 2-4 mo. • Increased Increased susc susceptibilit eptibility y to ear  infection R/T shorter, broader, & more horizontally positioned eustachian tubes • Increased Increased seve severity rity of resp. resp. symptoms R/T smaller airway diameters

OVERVIEW • In Infa fant nts s ↓ 3 mo have lower  infection rate R/T protective function of maternal antibodies • Rate ↑ between 3- 6 mo, & continues to remain high during toddler & preschool yrs.  – Amount of lymphoid tissue ↑ throughout middle childhood & repeated exposure to organisms gives increasing immunity as children grow older 

• Children Children exhibit exhibit a response response to to resp. infection with systemic symptoms (diarrhea, fever, etc)



 – May be absent in the NB  – Greatest @ 6 mo to 3 yrs.  – May be high, even with mild infections  – May dev. febrile sz. • Uncommon Uncommon after after 3 - 4 yr.

• Anorexia:  – Common  – Freq. initial evidence of illness  – Often extends into convalescence convalescence

• Res Resp. p. rate hig higher  her 

Pediatric HESI Review 16


ASSESSMENT • Vomiting:  – Sm. Children vomit readily with illness  – May be a clue to onset of infection • May prec precede ede other si signs gns by sev several eral hr.

• Diarrhea:  – Usually mild, but may become severe  – Often accompanies viral resp, infections  – Is a frequent cause o off dehydration

ASSESSMENT • Abdominal Pain:  – Common complaint

• Nasal Blockage  – Sm. passages of infants easily blocked by mucosal swelling & exudation  – Can interfere with respiration & feeding in infants  – May irritate upper lip & skin surrounding nose

• Cough:

ASSESSMENT • Respiratory Sounds:  – Sounds associated with respiratory disease: • Co Coug ugh h • Hoa Hoarse rsenes ness s • Gr Grun unti ting ng • Stri Strido dor  r  • Wh Whee eezi zing ng

 – Auscultation: • Wh Whee eezi zing ng • Cra Crackl ckles es • Absence Absence o off sou sound nd

 – Common feature  – May persist several months after  disease

ASSESSMENT • Sore Throat:  – Frequent complaint of older  children  – Young children (unable to describe sym.) may not complain even when highly inflamed  – Often leads to refusal to take oral fluids or solids



• Overall physical should focus on following:

 – Dyspnea, stridor, grunting, nasal nasal flaring, head bobbing (infant)

 – Alertness, changes in mental status

 – Sputum  – Bad breath

 – Activity level & complaints of  fatigue  – Skin color changes, particularly cyanosis  – Respiratory rate & pattern & apnea  – Retractions: presence, location, & severity  – Adventitious lung sounds  – Cough, productive or  nonproductive

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• Advise Advise family family to seek medica medicall evaluation is:  – Breathing becomes difficult  – Abdominal pain develops  – Sore throat pain is so severe th that at child is unable to eat or drink

• Prolonged Prolonged fe fever ver or appearan appearance ce of fever during early convalescence is a sign of  secondary bacterial infection & should be reported ASAP

IMPLEMENTATION • Ease respiratory efforts

• Children Children with severe severe res respirator piratory y distress should not be given anything by mouth to prevent aspiration & to ↓ the work of  breathing


• Early signs of inpending airway obstruction include:  –  – ↑  P&R  ↑ P&R  – Retractions  – Flaring of nares in infants  –  – ↑  restlessness  ↑ restlessness

IMPLEMENTATION • Prevent spread of infection

IMPLEMENTATION • Promote hydration

 – Moisture to soothe inflamed membranes

 – Careful handwashing!  – Remove affected children from

 – IV fluids if not able to maintain adequate po fluids

 – Hummidification / nebulilization / p  – Use of O2

contact with other children  – Isolation procedures

 – Encourage fluid intake • Sm. amts. amts. adequate of favorite fluids flu ids @ freq.

 – Parent at bedside

 – Antibiotic therapy if indicated

• Promote rest • Promote comfort  – Nose drops & throat irrigations  – Decongestants  – Use of either hot or cold compresses  – Antipyretics  – Cough suppressants

 – Encourage good chest physiotherapy

• Reduce temperature  – Antipyretics, (ibuprofen or  acetaminophen)

intervals • Use of high-calori high-calorie e liquids  – Juices  – Water flavored with Jello, etc  – (Do not use if diarrhea present)

• Oral rehydratio rehydration n solutions solutions  – Infalyte or Pedialyte for infants  – Sports drinks such as Gatorade for older 

 – Cool environment

 – Do not awaken to give fluids

 – Remove clothing & blankets

 – Observe freq. of voiding  – Strict I&O

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• Asthm hma a

• Provide nutrition  – IV fluids while loss of appetite  – Do not urge food o on n anorexic children as may precipitate N&V or an aversion to feeding  – Offer sm. feedings of foo foods ds such as gelatin, soup, & puddings


• Family support & home care

• Cy Cysti stic c fibr fibrosi osis s • Croup ups s • Ot Otiti itis s med media ia • Pn Pneu eum mon onia ia • Respiratory Respiratory Syncytial Syncytial Virus • To Tons nsill illiti itis s

 – Recognize parental concern & need for info. & support

 – Explain therapy & child’s behavior 

• Refer to RNSG 2504 Pediatric PowerPoint Notes

 – Encourage family-centered care  – Ensure family knows S&S of  Resp. complications




• Dysfunction Dysfunction of the GI tract tract can cause significant problems with the exchange of fluids, electrolytes & nutrients • Problems Problems can can affect affect overall overall health, growth & development • Chi Childr ldren en easily easily becom become e dehydrated if vomiting &/or  diarrhea a symptom • Meeting Meeting nutri nutrition tional al needs needs a major goal  – Use ht & wt to determine determine  – Many conditions chronic & extend over lifetime

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OVERVIEW • Diarrhea Diarrhea & vomiting vomiting occur occur m more ore frequently in children  – More prone to fluid & electrolyte imbalances

• Dehydration Dehydration most comm commonly only results from abnormal fluid losses such as from excessive


• Most important basic nursing assessments:  – Measurements of intake & output output  – Measurements of height & weight weight  – Abdominal examination  – Stool & urine tests  – Abdominal pain

vomiting or diarrhea

 – Bowel sounds  – Urinary output  – Stool output  – Fever   – Dietary history


ASSESSMENT • NURSING ALERT • In any instance instance in which which severe severe abd. pain is observed, the nurse must be aware of the danger of  administering laxatives or  enemas as such measures stimulate bowel motility & ↑ the risk of perforation


• Obt Obtain ain accur accurate ate weight weights s • IV fl fluids uids / TPN ifif unable unable to ingest sufficient fluid/foods orally • Monitor Monitor IV replacement replacement therapy, therapy, checking IV site frequently • Monitor Monitor hydratio hydration n status status with strict I&O • Mai Maintai ntain n skin skin integri integrity ty  – Provide good hygiene  – Skin care  – Carefully washing & drying diaper  area with every change

• Pro Promot mote e comfort comfort

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IMPLEMENTATION • If postope postoperative, rative, monitor monitor fo for  r  wound infection • Not Note e & record record freq frequenc uency y& characteristics of stools • Monitor Monitor abdom abdominal inal girth girth to assess for increasing distention  – Distended abd. ↓ resp. efforts

• Prepar Prepare e child child & parents parents for  procedures & treatments  – Surgery  – Ostomies  – Enemas  – Bowel preps  – TPN etc


IMPLEMENTATION • Support parents by e encour ncouraging aging them to express feelings & concerns • Promote Promote a positive positive sel self-conc f-concept ept in older child by allowing to express feelings about the disorder &/or dietary restrictions • Offer pacifier pacifier while while infant infant is NPO NPO • Preven Preventt infe infecti ction on by goo good d handwashing & appropriate isolation • Ref Refer er paren parents ts & c child hild to to nutritional counseling & various appropriate community agencies


• Mega Megaco colo lon n

• Pylori Pyloric c stenos stenosis is

• Bi Bilia liary ry atre atresi sia a

• Rota Rotavi viru rus s

• Gastro Gastroeso esopha phageal geal reflux reflux

• Esophag Esophageal eal atresia atresia

• Ce Celia liac c diseas disease e • Lac Lactos tose e intoler intoleranc ance e

• Ano Anorec rectal tal malforma malformation tions s

• Fai Failur lure e tto o tthriv hrive e • Int Intuss ussusc uscepti eption on • Nec Necrot rotizin izing g enteroc enterocolit olitis is • Int Intuss ussusc uscepti eption on • Cl Clef eftt lip & pala palate te • Cr Crohn ohn’s ’s diseas disease e • Ulc Ulcera erativ tive e colit colitis is


• Refer to RNSG 2504 Newborn Congenital Conditions and Pediatric PowerPoint Notes


Pediatric HESI Review 21  

OVERVIEW • Kidney Kidney de devel velopme opment nt not complete until end of 1st. year 


 – Can’t concentrate or dilute urine urine well  – Newborn more prone to developing severe acidosis  – Sodium excretion ↓ in infancy


• In the newborn, newborn, urin urinary ary tract disorders generally associated with malformations of other body systems

ASSESSMENT • Health history findings possibly pointing to renal dysfunction in the neonate:  – Poor feeding  – Failure to thrive  – Frequent urination  – Crying on urination  – Poor urinary stream

ASSESSMENT • Health history findings possibly pointing to renal dysfunction in the infant:

ASSESSMENT • Health history findings possibly pointing to renal dysfunction in the older child:

• Persi Persistent stent di diaper aper rash rash

 – Poor appetite  – Vomiting

• FoulFoul-smell smelling ing urine urine

 – Excessive thirst

 – Same findings as neonate PLUS: • Straining Straining on uri urinatio nation n • Pall Pallor  or  • Fe Feve ver  r 

 – Incontinence  – Frequent urination

 – Dehydration

 – Painful urination

 – Convulsions

 – Bloody urine

 – Rapid respirations (acidosis)

 – Fatigue

 – Enlarged kidneys or bladder 

 – Abd., flank, or back pain

 – Other anomalies

 – Swelling of the face

Pediatric HESI Review 22  

ASSESSMENT • Older Older child child (cont.) (cont.)  – Edema  – Hypertension  – Growth failure  – Seizures

ASSESSMENT • Physical assessment might reveal signs & symptoms suggestive of renal dysfunction such as:  – Abnormal rate & depth of  respirations  – Hypertension

ASSESSMENT • Physical assessment cont.  – Early signs of uremic encephalopathy • Le Letha tharg rgy y • Poor conc concentrati entration on • Con Confus fusion ion

 – Signs of congenital anomalies

 – Fever   – Growth retardation

• Hypospadia Hypospadias s or Epis Epispadia padias s • Ear anomalies anomalies (low-set, (low-set, floppy, floppy, malformed)

 – Abdominal distention

• Prominent Prominent epic epicantha anthall folds

 – Signs of circulatory congestion

• Beak-like Beak-like nose

• Peripheral Peripheral cy cyanosi anosis s

• Small Small c chi hin n

• Slow cap cap refill refill time time • Pall Pallor  or  • Peripheral Peripheral edema


ASSESSMENT • NURSING ALERTS • A child child who who exhibi exhibits ts the the following should be evaluated for UTI:  – Incontinence in a toilet-trained child  – Strong-smelling urine  – Frequency &/or urgency

• Use of Fleet Fleet enemas enemas in children children with acute or chronic renal failure is potentially lethal R/T hyperphosphatemia


• Accura Accurate te measure measuremen mentt of  weights • Accura Accurate te measure measuremen mentt of blood pressure • Accura Accurate te measure measuremen mentt of  intake & output • Prepare Prepare children children & parents parents for  tests, collection of urine samples, & other procedures • Observe Observe characte characteristic ristics s of u urine rine collected & perform tests on urine collected • Administer Administer meds as ordered ordered

Pediatric HESI Review 23  




 – Assess for fluid volume deficit by monitoring:

• Assess Assess ur urinar inary y stat status us by observing appearance & color of  urine, & noting S&S such as:

• Help improve improve child’s selfconcept by providing positive feedback, emphasizing strengths, & encouraging social interaction & pursuit of interests

•  ↑  edema • Daily Daily abdominal abdominal gi girth rth • Dai Daily ly wei weight ght

 – Frequency

• Dai Daily ly I&O

 – Burning

• Blood pressure pressure

 – Enuresis

 – Prevent skin breakdown • Freque Frequent nt positi position on change changes s • Providing Providing go good od skin ca care re • Scrotal Scrotal supports supports in bo boys ys

 – Maintain or improve nutritional status  – Monitor for signs of infection

 – Urinary retention

• Ref Refer er child child & fami family ly to community health resources

 – Flank pain

• If post-op, post-op, monitor for w wound ound infection • Provid Provide e support support to family family by answering question & providing information about diagnosis, tests, & treatments

GENITOURINARY TRACT DISORDERS • Exstro Exstrophy phy of of bla bladder  dder 


• Vesicoureter Vesicoureteral al reflux (VUR) • Undesc Undescende ended d testicl testicle e • Hypos Hypospa padia dias s • Epis Epispa padi dias as • Nephrot Nephrotic ic syndr syndrome ome • Acute Acute glo glomer merulon ulonephr ephriti itis s

• Refer to RNSG 2504 Pediatric PowerPoint Notes


Pediatric HESI Review 24  



• In 1st year of extrauteri extrauterine ne life, the number of brain neurons ↑ rapidly • Brain weight doubles by end end of  first year & triples by age 6 yrs. • CNS myelin myeliniza ization tion,, which enables progressive neuromuscular function, follows the cephalocaudal & proximodistal sequence

ASSESSMENT • Components of pedi. neuro. exam:  – General • Af Affe fect ct • Socia Sociall interacti interaction on • Denve Denverr Devel Developmen opmental tal Screenin Screening g Test • Emoti Emotional onal state

 – Head circumference  – Fontanel assessment in infants  – Mental status • LOC • Ori Orient entati ation on • Reaso Reasoning ning abil ability ity • Memo Memory ry

ASSESSMENT  – Sensory status • Visi Vision on • Hear Hearin ing g • Ta Tast ste e • Smell Smell & touch touch • Cranial Cranial nerve fun function ction

 – Motor function • Muscle Muscle tone • Stre Streng ngth th • Gait abnorma abnormalitie lities s • Post Postur ure e

 – Cerebellar status • Bala Balanc nce e • Coo Coordi rdinat nation ion

 – Reflexes


ASSESSMENT • Periodic neurologic checks should include:  – Vital signs  – LOC  – Eyes: • Pup Pupil il siz size e • Equ Equali ality ty • Reaction Reaction to ligh lightt • Extra Extraocula ocularr movements movements • Corneal Corneal reflex • Visual Visual distu disturbanc rbances es

 – Motor & sensory function  – Head circumference & fontanel fontanel inspection in infants  – Reflexes

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• Clinical manifestations of ↑ ICP in an infant & young child commonly include:

• Clinical manifestation of ↑ ICP in an older child commonly include:


 – Irritability & restlessness

 – Headache

 – Tense, bulging anterior font fontanel anel in child < 18 mo.

 – Anorexia

 – High-pitched cry

 – Vomiting, often projectile without nausea

 – Change in feeding ha habits bits  – ↑  –  ↑ Occipital  Occipital frontal circumference

 – Cognitive, personality, & behavioral changes

 – Crying with cuddling & rocking

 – Diplopia, blurred vision

 – “Setting sun” sign

 – Seizures

elimination must be closely monitored because of their  constipating effect

fixed & dilatedemergency pupil is a neurosurgical • 3 key reflexes reflexes that that demonstrat demonstrate e neurologic health in infants are:  – Tonic-neck  – Withdrawal reflexes



• When opioids are used, bowel

• The sudde sudden n appeara appearance nce of of a

 – Moro

 – Macewen’s (“cracked pot”) sign in an infant with unfused crainal sutures


• Lack of rrespons esponse e to painful stimuli is abnormal & must be reported immediately


• Monitor Monitor vital vital s signs igns • Measure Measure occi occipital pital frontal circumference as ordered • Assess Assess neurologic neurologic status status & assess all signs of ↑ ICP • Encourage Encourage parents parents to e expres xpress s their feelings, fears, & anxieties • Pro Promot mote e parent-i parent-infa nfant nt relationship:  – Encourage parent participation participation with ADLs  – Encourage cuddling & tactile stimulation

Pediatric HESI Review 26  

IMPLEMENTATION • Provide Provide fa family mily teaching teaching wi with th special emphasis of:  – Infection control  – Recognizing early S&S of ↑ ICP  – Bladder & bowel management  – Shunt management

IMPLEMENTATION • Help preven preventt skin skin / sa sac c breakdown • If post-op, post-op, monitor for w wound ound infection • Institute Institute procedu procedures res for Latex Latex allergy prevention


 – Developmental needs  – Effects of immobilization & ways to minimize them  – Need for lifelong care

• Assess Assess family’s family’s a ability bility to care care for  infant, & refer for further  assistance if necessary

NEUROLOGIC DISORDERS • Neural Neural tub tube e defec defects ts  – Spina bifida occulta  – Meningocele  – Myelomeningocele

• Hy Hydr droc oceph ephalu alus s • Do Down wn syn syndr drom ome e

• Refer to RNSG 2504 Newborn Congenital Conditions & Pediatric PowerPoint Notes





Pediatric HESI Review 27  

OVERVIEW • The most most frequent frequent reasons for  immobility are congenital defects • The majo majorr ef effec fects ts of  of  immobilization are:  – Loss of muscle strength, endurance, & muscle mass  – Bone demineralization leading to osteoporosis  – Loss of joint mobility & contractures  – Decreased metabolism

• Muscle Muscle dis disuse use,, over time, time, affects all other systems of body

OVERVIEW • Treatment Treatment for for these these disor disorders ders often involves immobility  – Casts  – Traction  – Body frames

• Impact Impact of immobi immobility lity d depends epends in large part on the child’s developmental level • Play, social interac interaction, tion, & sel selffcare help the immobilized child gain self-esteem & independence & promote normal growth & development

OVERVIEW • Bon Bone e growth growth occur occurs s at th the e epiphyseal plate, a very vascular area  – These cells highly sensitive to the influence of growth hormone, estrogen, & testosterone  – During adolescence, the epiphyseal plate converts to bone & growth stops  – This is an area susceptible to injury through fracture, crushing or  slippage  – Damage to this area can disrupt disrupt bone growth

OVERVIEW • Because Because a child’s child’s bones are still still growing:  – Some bony deformities due to injury can be remodeled or  straightened  – Some deformities can progress with growth

• Bec Becaus ause e a child’s child’s bones bones are more plastic:  – More force required to fracture a bone

• A child’s child’s bones bones heal heal much much faster  faster  than adult’s

OVERVIEW • Psychological effects of  effects of  immobilization commonly include:  – Altered body image  – Altered perception of external environment  – Sensory deprivation  – Impaired mastery of  developmental psychosocial tasks


Pediatric HESI Review 28  




• Initial assessment should obtain a complete health history of problems pertaining to this system, focusing on:

• Clinical manifestations of  prolonged immobilization may immobilization may include:


 – Joint contractures & pain

 – Trauma

 – Muscle atony & weakness

 – Delayed walking or other  developmental abnormalities

 – Fatigue

 – Pain  – Structural abnormalities

 – Delayed healing

 – Any physical limitations or lifestyle alterations imposed by the problem

 – S&S of thrombus formation

 – Mobility aids used

 – Diminished reflexes  – Orthostatic hypotension

• Numbness, Numbness, tingling, tingling, change change in sensation & loss of motion are sym. of neurologic impairment & should be evaluated immediately • The 5 “Ps” of ischem ischemia ia from from vascular (circulatory) injury are:

 – Anorexia

 – Pain


 – Constipation

 – Pallor


 – Pulselessness

ASSESSMENT • NURSING ALERTS • A fracture fracture should be st strongly rongly suspected in a small child who refuses to walk • Skeleta Skeletall trac traction tion is NEVER NEVER released by the nurse, nor are weights lifted that are applying traction • A plastic plastic bag bag of frozen frozen v veg.suc eg.such h as peas, serves as a convenient ice pack for soft tissue injuries

ASSESSMENT • NURSING ALERTS • The class classic ic S&S of Pulmonary Embolii are: Embol  – Chest pain  – Dyspnea  – Petechial hemorrhages of the chest & shoulders

• Treat the dyspnea dyspnea by elevating elevating the head & administering O2


Pediatric HESI Review 29  




• Protect Protect skin skin integrity integrity by turning frequently & inspecting for early signs of breakdown

• Promot Promote e norm normal al urinar urinary y elimination by monitoring freq. & amt. of urination & assessing for  bladder distention

• Help maintain maintain a adequate dequate cardiac cardiac output by changing position freq., & providing active or  passive range of motion exercises

• Promote Promote adequate adequate hydrat hydration ion b by y offering favorite drinks • Promot Promote e good nu nutri trition tion by by offering high-protein, high caloric foods in sm., freq., & attractively arranged servings • Promot Promote e no norma rmall bo bowel wel elimination by keeping child well hydrated, including fiber in diet, & providing for privacy @ toilet

IMPLEMENTATION • Preven Preventt contr contract actures ures b by y maintaining proper body alignment, minimizing flexed positions, & providing active & passive ROM • Promote Promote self-car self-care e by allowin allowing g child to help plan daily routines, select foods, determine the time for bathing, select clothing, etc. • Promote Promote no normal rmal growth growth & dev. by providing regular social contact & diversional activities

• Promote Promote normal normal activity activity as condition & restrictive devices allow • Provide diversional diversional activ activities ities spaced with adequate rest • Help preve prevent nt resp respira irator tory y complications through good hydration & changing position freq.

• Help prevent prevent urinary tract infections through good hydration, promotion of frequent voiding, provision of acid-ash foods ( cereal, fish, poultry, cranberry or apple juice & meats)

IMPLEMENTATION • Promote Promote effectiv effective e coping coping by providing play therapy, anticipatory teaching, & explanations physical devices restrictions & of restraining • Provid Provide e patient patient & famil family y teaching while in hospital & for  home care • Prepare Prepare child & family family for each procedure & planned therapy • Ref Refer er family family to to support support organizations


Pediatric HESI Review 30  



• Developmenta Developmentall dys dysplasia plasia of the hip (DDH)

• Refer to RNSG 2504 Newborn Congenital Conditions and Pediatric PowerPoint Notes

• Clu lubf bfoo oott • Ce Cereb rebra rall pal palsy sy • Muscul Muscular ar dy dystr stroph ophy y • Juvenile Juvenile rheumatoid rheumatoid arthrit arthritis is


• Sc Scol olio iosi sis s • Legg-Calve’ Legg-Calve’ Perthes Perthes diseas disease e • Os Osteo teomy myeli eliti tis s • Fr Frac actu ture res s • Tr Trac acti tion on

OVERVIEW • Blood consis consists ts of liquid plasma plasma & formed elements:


 – Erythrocytes  – Leukocytes  – Thrombocytes

• RBCs primarily primarily transport transport O2 to & CO2 away from body tissues • Typica Typicall lifes lifespan pan of R RBC BC = 120 days • WBCs protect the bo body dy ag against ainst infection • There There are 5 types types of WBCs WBCs

OVERVIEW • Platelets Platelets contain coagulation coagulation factors & help regulate homeostasis through a sequence of events known as the coagulation process • The major blood-forming blood-forming organs are bone marrow, the lymphatic system & the reticuloendothelial system • Chi Childr ldren en with hematolog hematologica icall dysfunction commonly undergo a multitude of invasive diagnostic tests, procedures, & treatments

Pediatric HESI Review 31  


OVERVIEW • Chi Childr ldren en with hematolog hematologica icall dysfunction commonly depend on others for care & support • During the 1s 1sr. r. 6 mo. mo. of llife, ife, fetal fetal hemoglobin is gradually replaced by adult hemoglobin, & it is only after this that hemoglobin disorders can be diagnosed

• Health history questions should focus on:


 – Bleeding or bruising tendencies  – Medication use  – Family history of bleeding problems

• Physical assessment findings of possible hematologic problems include:  – Skin: • Pallor, flushing, jaundice, purpura, petechiae, ecchymoses, cyanosis, brownish discoloration


ASSESSMENT  – Eyes: • Jaundiced sclera, co conjunctival njunctival pallor, retinal hemorrhage, blurred vision

 – Mouth: • Gingival Gingival & mucosal mucosal pallor 

 – Lymph nodes: • Lympha Lymphadenop denopathy, athy, tenderne tenderness ss

 – Cardiac: • Tachy Tachycardi cardia, a, murmurs murmurs,, signs & symptoms of congestive heart failure

 – Pulmonary: • Tachy Tachypnea, pnea, orthopnea, orthopnea, dyspn dyspnea ea

 – Neurologic: • Heada Headache, che, vertigo, vertigo, irritabil irritability, ity, depression, impaired thought processes, lethargy

ASSESSMENT  – Gastrointestinal:


• Anorexia, Anorexia, hepato hepatomegaly megaly,, splenomegaly

 – Musculoskeletal: • Weight Weight loss, decreased decreased muscl muscle e mass, bone pain, joint swelling, pain

• Never administer administer aspirin aspirin or any aspirin-containing compound to the child with hemophilia

Pediatric HESI Review 32  




• Relieve Relieve pain by assess assessing ing the the child’s need for pain medication & provide prescribed medication

 – Application of pressure &/or cold  – Administration of factor VIII or  other substances

• Monitor Monitor for signs of infection infection

• Position Position the child for maximu maximum m comfort

• Encourage Encourage optimal optimal nutrition nutrition

• Implem Implement ent therap therapeuti eutic c measures as appropriate which may include:

• Support the child child & family by allowing them to ventilate their  fears, concerns & anger 

 – Oral & IV fluids  – Electrolyte replacement to counter  acidosis caused by hypoxia  – O2 therapy to promote adequate adequate oxygenation

• Pro Provid vide e patient patient & fami family ly teaching, covering:  – Disease process, including genetic aspects & early recognition

 – Immobilization devices


IMPLEMENTATION  – Home management of chron chronic ic condition  – Prevention of crisis or bleeding episode ( Injury prevention )  – Measures to control bleeding  – Pain control

• Encourage Encourage ch child ild & family to lead as normal a lifestyle as possible • Ref Refer er the famil family y to sup suppor portt groups

• Sic Sickle kle cell cell an anemia emia


• He Hemo moph phil ilia ia

• Refer to RNSG 2504 Pediatric PowerPoint Notes

Pediatric HESI Review 33  

OVERVIEW • Congenital heart disease is the most common form of  cardiac disease in children






• Dev Develop elopmen mental tal delays delays ofte often n occur in children with cardiac disorders, particularly cyanotic

• Heart defect defects s are are des described cribed as either Acyanotic Heart Defects or  Cyanotic Heart Defects

heart defects • Act Activi ivity ty limitati limitations ons may be essential, but may be difficult to impose

• Acyanotic heart defects are defects are congenital defects in which no deoxygenated (or poorly oxygenated) venous blood enters systemic arterial circulation

 – Any time there is a defect connecting systemic & pulmonary circulation,blood will go from high to low pressure (path of least resistance)  – Normally pressure is higher in systemic circulation, so blood will be shunted from systemic to pulmonary circulation

• With many many de defec fects, ts, an o older  lder  child may be allowed to self-limit activities according to how he feels • Surgical Surgical proced procedures ures will be required to repair the defect

• Oxygenated Oxygenated blood is shunted shunted from systemic to pulmonary circulation

• The cardiovascula cardiovascularr s system ystem’s ’s basic function is to pump oxygenated blood to tissues & remove metabolic waste products from tissues • Valves Valves withi within n the heart heart & pressure differences between the four heart chambers regulate blood flow through the heart & into systemic circulation

 – Blood leaving aorta is completely oxygenated  – Increased blood volume on right side of heart results in hypertrophy of right ventricle  – Most acyanotic heart defects will will result in CHF

Pediatric HESI Review 34  

OVERVIEW • Types Types of acy acyanot anotic ic defects defects include:  – Left to right shunting tthrough hrough an abnormal opening: • PDA PDA,, ASD, ASD, VSD

 – Obstructive lesions that restrict ventricular outflow: • Aortic va valvular lvular stenosis, pulmonic stenosis, coarctation of aorta

OVERVIEW • Cyanotic heart defects are defects are congenital heart defects in which deoxygenated blood enters systemic arterial circulation • Blood Blood enter entering ing periphe peripheral ral tissues has much lower O2

OVERVIEW • In over over 90% of c congenita ongenitall heart heart defects, the exact etiology is unknown • The primary primary cause of congestiv congestive e heart failure in the 1st 3 years of  life is congenital heart disease

• Types Types of cyanot cyanotic ic defects defects include:  – Tetralogy of Fallot, Tricuspid atresia, transposition of the great vessels, truncus arterios,  – total anomalous pulmoary venous communication, hypoplastic left hear heartt s ndro ndrome me

OVERVIEW • The reas reasons ons for for CHF CHF are basically :  – 1. The heart is unable to me meet et the body’s oxygenation & nutritional needs due to: • Exces Excessive sive volum volume e • Exces Excessive sive pressure pressure load on the heart heart

 – 2. Diminished myocardial functioning

OVERVIEW • The major major d diagnos iagnostic tic te test st for  for  cardiac disorders is cardiac Catheterization which Catheterization  which provides the following information:

 – O2 saturation in heart chambers chambers  – Pressures within chambers  – Changes in cardiac output  – Anatomic abnormalities

• Post-Catheteri Post-Catheterization zation care:  – Check extremity distal extremity distal to cath site for color, temp., pulse, & cap. refill  – Keep extremity distal to cath. site extended for 6-8 hr.

OVERVIEW  – Check pressure dressing over site for bleeding  – Monitor heart rate for signs of  Bradycardia, tachycardia, & dysrhythmia  – Monitor intake & output

Pediatric HESI Review 35  

ASSESSMENT • Health history findings of  significance include:


 – Family history of congenital heart disorders

ASSESSMENT • Significant physical assessment findings may include:  – Failure to thrive

 – Presence of murmurs & age @ which first noted

 – Frequent resp. infections

 – Feeding problems, including problems, including

 – Periorbital & peripheral edema

fatigue or diaphoresis during feeding & poor weight gain  – Respiratory difficulties, difficulties, including tachypnea, dyspnea. SOB, cyanosis & freq. URI  – Chronic fatigue or exercise intolerance

 – Cyanosis  – Respiratory difficulties  – Color changes: • Pall Pallor or or cyanos cyanosis is  – Persistent or intermittent

 – Pulse alterations • Tachycardia Tachycardia or bradycard bradycardia ia • Dys Dysrhy rhythm thmias ias • Diminishe Diminished d peri peripheral pheral pulses pulses

ASSESSMENT  – Activity intolerance  – Hypotension or unequ unequal al blood pressure in arms & legs  – Abdominal distention, hepatomegaly, splenomegaly  – Clubbing of fingers & toes  – Murmurs, bruits, thrills  – Squatting  – Hypoxic spells (“tet” spells R/T transient cerebral ischemia)





• Electro Electrodes des fo forr car cardiac diac monitoring are often color  coded: white for right, green (or  red) for ground, & black for left

• Infants Infants rarely rarely receive receive > than 1 ml (50ug or 0.05 mg) of Digoxin.  A higher dose is an immediate warning of a dosage error 

• O2 is a drug drug & iis s on only ly administered with an appropriate order 

• Chest Chest tube tube draina drainage ge > than than 3 ml/kg/hr for more than 3 consecutive hours is excessive & may indicate post-op hemorrhage

• Thera Therape peuti utic c serum digoxin levels range levels  range from 0.8-2 ug/L. Signs of toxicity - bradycardia & vomiting

Pediatric HESI Review 36  

ASSESSMENT • NURSING ALERTS • The early signs of CHF are:  – Tachycardia, especially during rest & slight exertion  – Tachypnea



• Help ↓ cardiac workload  – Organize nursing care to provide for periods of uninterrupted rest  – Prevent excessive crying in infants  – Provide diversional activities that involve limited energy expenditure for older children

 – Sudden weight gain

 – Encourage parents to stay with infant to provide holding, rocking, & cuddling to help infant sleep more soundly

 – Respiratory distress

 – Minimize stressors

 – Profuse in infantsscalp sweating, especially  – Fatigue & irritability

 – Keep warm

• Observ Observe e for & assist assist iin n managing CHF

IMPLEMENTATION • Help maintain maintain optimal nutritio nutritional nal status by:  – Provide small, frequent meals if  child tires easily  – In infants use soft nipples to ↓ work during feeding; gavage feedings may be necessary • Limit Limit feedin feedings gs to 45 min o or< r< • Antic Anticipate ipate infant’s infant’s hunge hungerr to avoid avoid crying • Feed in se semi-ere mi-erect ct position position • Burp frequently frequently • Obser Observe ve for vomiting vomiting & diarrhea if  high-caloric formula ordered • Dai Daily ly wei weight ghts s

IMPLEMENTATION • Prepar Prepare e child/fam child/family ily for  diagnostic studies & surgery • Help prev prevent ent in infec fection tions s  – Careful handwashing  – Avoid contact will sick persons  – Ensure immunizations up to date

• Promot Promote e norm normal al growth growth & development

IMPLEMENTATION • Eva Evaluat luate e fluid fluid statu status s  – Strict I&O  – Daily weights  – Assessing for edema & severe diaphoresis  – Monitor electrolyte values

• Provide Provide fa family mily membe members rs with appropriate discharge teaching

• Administer Administer m meds eds & monito monitorr for  side effects

 – Medications

• Help ↓ child’s & family’s anxiety & ↑ understanding by providing information on medical & sur sur ical ical trea treatm tmen ents ts

 – When to call doctor 

 – Activity restrictions  – Diet & nutrition  – Wound care  – Follow-up appointments

Pediatric HESI Review 37  

IMPLEMENTATION • Observ Observe e for & assist assist iin n managing resp. distress : cough, tachypnea, tachycardia, retractions, grunting, nasal flaring,cyanosis





 – Administer O2 as ordered  – Positioning to ease breathing  – Administer meds as ordered

• Administer Administer meds as ordered ordered • Monitor Monitor flu fluid id statu status s  – Strict I&O  – Daily weights

• Preven Preventt in infec fection tions s

OVERVIEW • Cancer Cancer is the leading leading c cause ause of  death from disease in children from 1-14 yrs • Leukemia Leukemia is the most most frequent frequent type of childhood cancer, followed by tumors of the CNS • In recent recent y years ears survival survival rates rates have ↑ so that > 70% of all children with malignant neoplasms treated @ major  centers will survive > 5 years

• Classificat Classification ion is by ttissue issue of  origin:  – Blood & related cells: • Leukem Leukemias ias • Lympho Lymphomas mas

 – Connective tissue: • Fibrosarcoma - originating iin n fibrous tissue • Osteosarcom Osteosarcoma a - originating originating in boneproducing cells • Ewing’s Ewing’s sacroma, sacroma, originating originating in midshaft of long bones & flat bones

 – Muscle tissue • Rhabdomyos Rhabdomyosarcoma arcoma

 – Nerve tissue: • Neuroblast Neuroblastoma oma - originating originating from neural crest during embryonic dev. • Glioblastoma - originating originating from glial cells • Retin Retinobla oblastoma stoma - originating originating in the retinal tissue

 – Renal tissue: • Wilm’s Wilm’s tumor (nephr (nephroblas oblastoma) toma) originating in the kidneys

• The child child & family family adjust adjust to the process of living with a lifethreatening illness • Child’s reaction reaction depends depends on his age

Pediatric HESI Review 38  

OVERVIEW • Int Interv erventi entions ons used: used:  – Surgery: • Usefu Usefull for di diagnos agnosis is • Used ffor or tumo tumorr remova removall • Often use used d in conjunc conjunction tion with radiation &/or chemotherapy

 – Chemotherapy: • Primar Primary y form of treatment treatment • Protoc Protocols ols combi combine ne drugs to allow fo for  r  optimum cell cycle destruction with minimum toxic effects & ↓ resistance by cells to the agent

 – Radiation: • May be curat curative ive or pallia palliative tive

OVERVIEW  – Biologic Response Modifiers (BRMs): • Uses monoclonal monoclonal ant antibodi ibodies es and other agents • Changes host’s biologic response response to tumor cells

 – Bone marrow transplant: • Transfused Transfused marro marrow w or stem cells produce functioning nonmalignant blood cells • Ty Type pes: s:  – Autologous Autologous  - transplanted with own harvested marrow  – Syngeneic Syngeneic - transplanted between identical twins

 – Induction • Goal to remove most most of tumor  tumor  • Often the most most intensive intensive phase phase • Side effects effects of treatment potentiall potentially y life-threatening

 – Consolidation • cells Goal is to eliminate any remaining

 – Maintenance • Goal is to keep keep child child cancer free free • Uses chemo chemo & may last for several several yrs.


 – Observation

• Treatm Treatment ent is comple complete: te: may contin continue ue in this stage indefinitely

• Stages of tr treatmen eatmentt co consist nsist of:

 – Allogeneic Allogeneic - transplanted from a nonidentical donor 


• Goal is to mo monitor nitor @ int intervals ervals fo for  r  evidence of recurrent disease & complications of treatment



• Specific Specific c clinical linical findings vary depending on particular body system involvement • Cardinal S&S of cancer in children include:  – Unusual mass or swelling  – Unexplained paleness & loss of  energy  – Sudden tendency to bruise  – Persistent, localized pain or  limping  – Prolonged, unexplained fever or  or  illness

Pediatric HESI Review 39  


ASSESSMENT  – Frequent headaches, of often ten with vomiting  – Sudden eye or vision changes  – Excessive, rapid weight loss


• Help child child cope with intrusi intrusive ve procedures  – Provide information geared to developmental level & emotional readiness  – Use medical play  – Allow child some control in situations where possible

• Pro Provid vide e patient patient & fami family ly teaching covering:  – Diagnosis & nature of disorder   – All treatments & procedures  – Side effects of chemo & radiation radiation

IMPLEMENTATION • Sup Support port child child & paren parents ts  – Acknowledge feelings & encourage communication  – Provide contact with another  parents or an organized support group  – Try to keep life as normal as possible  – Always tell the truth

• Minimize effects of treatment:  – Skin breakdown • Keep clean & dry • Do opt wash off radia radiation tion marki markings ngs • Avoid topical agents with al alcohol cohol

IMPLEMENTATION  – Bone marrow suppression: • Decreased Decreased RBCs  – Provide frequent rest activities

• Decreased Decreased WBCs  – Monitor temperature elevations  – Evaluate any potential site of in infection fection  – Good handwashing a MUST  – Isolate from children with know known n communicable disease

• Decreased Decreased pl platele atelets ts  – Make environment safe  – Avoid use of salicylates  – Select activities that are phys physically ically safe

 – Interpret peripheral blood counts counts to guide specific interventions & precautions

IMPLEMENTATION  – Nausea & vomiting • Administer Administer antiemetics antiemetics as ordered before chemo & repeat PRN • Ensure Ensure adequate adequate oral intake intake or  administer IV fluids as necessary

 – Alopecia • Advise Advise to buy wig before hair falls falls out • Help choose choose caps caps or hats to wear 

 – Stomatitis • Inspect Inspect mouth & rectum rectum daily • Meticulous Meticulous oral oral hygiene hygiene • Use soft-sponge soft-sponge toothbrush, toothbrush, cottoncottontipped application “Toothettes” to avoid trauma • App Apply ly li lip p bal balm m • Local anestheti anesthetics cs to ulcerated areas

Pediatric HESI Review 40  

IMPLEMENTATION • No juices containing ascorbic ascorbic acid & hot or spicy foods • Avoid le lemon mon glyce glycerin rin swab ( irrita irritate te eroded tissue • Avoid hyd hydrogen rogen peroxide peroxide (delay (delays s healing by breaking down protein) • Admin Administer ister meds meds as ordered (antiinfectives & analgesics) • Wash per perineal ineal ar area ea after eac each h toileting • Apply pro protecti tective ve skin barri barriers ers to perineal area • No rec rectal tal or o oral ral tem temps ps

• Lippincott’s Lippincott’s Review Series. (1992) Pediatric Nursing. Philadelphia, Lippincott • Wong, Wong, Donna Donna (1999). (1999). Nur Nursing sing Care of Infants and Children . (6th ed). St Louis, Mosby • Ashwill, Ashwill, J. J.& & Droske, Droske, S. (1997) (1997) Nursing Care of Children: Principles and Pracatice. Philadelphia, W.B. Saunders Company

IMPLEMENTATION  – Nutritional deficits • Measure Measure height & weight frequently frequently • Provi Provide de small, freq frequent uent meals • Provide high-calorie, high-protein supplements

• Assist Assist chil child d in interac interacting ting with with peers • Assist Assist fam family ily discuss discuss fears & anxiety about procedures & prognosis


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