Exam 7
Chapters 38, 44, 48, 49, & 51
Multiple choice- 37
Multiselect- 11
Ordering- 1
Math- 1
Alterations Intracranial Regulation & Neurological Disorders
Glasgow Coma Scale
 The Pediatric Glasgow Coma Scale is a popular scale used to standardize degree of
consciousness. It consists of three parts: eye opening, verbal response, and motor
response
 When assessing LOC in children, consider that the infant or child may not respond to
unfamiliar voices in an unfamiliar environment. Therefore, it may be helpful to have a
parent present to elicit the response.
Neural tube defects
 Serious birth defects of the spine and the brain
 Neural tube defects account for the majority of congenital anomalies of the CNS
 NTDs are serious birth defects of the spine and the brain and include disorders such as
spina bifida occulta, myelomeningocele, meningocele, anencephaly, and encephalocele
 Anencephaly
 A small or missing brain
 Encephalocele
 A protrusion of the brain and meninges through a skull defect
 The neural tube closes between the third and fourth week in utero
 The cause of neural tube defects is not known, but many factors such as drugs,
malnutrition, chemicals, and genetics can adversely affect normal CNS development
 Strong evidence exists that maternal preconception supplementation of folic acid can
decrease the incidence of neural tube defects in pregnancies at risk by 50%
Five states of consciousness
1. Full consciousness
 The child is awake and alert; is oriented to time, place, and person; and exhibits
age-appropriate behaviors
2. Confusion
 Disorientation exists; the child may be alert but responds inappropriately to
questions
3. Obtunded
 The child has limited responses to the environment and falls asleep unless
stimulation is provided
4. Stupor
 The child only responds to vigorous stimulation
5. Coma
 The child cannot be aroused, even with painful stimuli
Nursing management of seizures
 Most seizures are caused by disorders that originate outside of the brain such as a high
fever, infection, head trauma, hypoxia, toxins, or cardiac arrhythmias. Fewer than onethird of seizures in children are caused by epilepsy
 Management- focused on preventing injury during seizures, administering appropriate
medication and treatments to prevent or reduce seizures, and providing education and
support to the child and family to help them cope.
 Instruct parents and caregivers: Place child on one side and open airway, if possible. Tight
clothing and jewelry around the neck should be loosened, if possible. Remove hazards in
the area. • Do not restrain the child. • Do not forcibly open jaw with a tongue blade or
fingers.
 Febrile seizures: most common type of seizure in childhood (usually core temp 39 C or >)
Medications for seizure
 Diazepam is available in rectal form to stop prolonged seizures in children. Useful for
home management; nurses must educate family members on administration and when
to call physician or nurse practitioner. Monitor sedation level, respiratory rate, and for
cessation of seizure activity.
Hydrocephalus and shunts
 Hydrocephalus: an imbalance in the production and absorption of CSF. CSF accumulates
in ventricular system and causes IICP. Congenital or acquired. Classified as obstructive or
non-communicating vs. non-obstructive or communicating.
 Chief complaint (s/s of IICP): Irritability, lethargy, poor feeding, projective vomiting, h/a,
altered LOC
 Therapeutic management: ID early. Prevent tissue damage. Goal is to relieve
hydrocephalus and manage complications. Most often a VP shunt is placed.
 VP Shunt
 s/s of shunt infection/malfunction: elevated vital signs, poor feeding, vomiting,
decreased responsiveness, seizure activity, signs of local inflammation along the
shunt tract. Administering antibiotics is a priority.
Intracranial pressure (ICP) – signs & symptoms of increased pressure
 Sunsetting of the eyes is a s/s of increased intracranial pressure
 Irritability, lethargy, poor feeding, projective vomiting, h/a, altered LOC
 Early signs
 Headache, vomiting (possibly projectile), blurred vision, double vision (diplopia),
dizziness, decreased pulse and respirations, increased BP & pulse pressure, pupil
reaction time decreased & unequal, sunset eyes, changes in LOC, irritability,
seizure activity
 Infants will also see: bulging, tense fontanel, wide sutures and increased head
circumference, dilated scalp veins, high-pitched cry
 Late signs
 Lowered LOC, decreased motor and sensory responses, bradycardia, irregular
respirations, Cheyne-stokes respirations, decerebrate or decorticate posturing,
fixed & dilated pupils
Shunt infections – signs & symptoms
 s/s of shunt infection/malfunction: elevated vital signs, poor feeding, vomiting, decreased
responsiveness, seizure activity, signs of local inflammation along the shunt tract.
Administering antibiotics is a priority.
AV malformations
 Arteriovenous Malformation
 Abnormal development of blood vessels in the brain, brain stem or spinal cord. Can
hemorrhage and lead to stroke, neurologic deficits, or even death.
Infectious disorders of the neuro system – viral vs. bacterial meningitis, Reye syndrome
 Bacterial meningitis
 An infection of the meninges (the lining that surrounds the brain/spinal cord).
Serious illness, brain damage, nerve damage, deafness, stroke, death
 Patho: causes inflammation, swelling, purulent exudates, and tissue damage to
the brain
 Assessment- Sudden onset of symptoms; Preceding respiratory illness or sore
throat; Presence of fever, chills; Headache; Vomiting; Photophobia; Stiff neck;
Rash; Irritability; Drowsiness; Lethargy; Muscle rigidity; Seizures. Symptoms in
infants can be more subtle and atypical, but the history may reveal poor sucking
and feeding, weak cry, lethargy, and vomiting.
 Management- Aimed at proper ventilation, reduce the inflammatory response,
and help prevent injury to the brain. Elevate head of bed 15 to 30 degrees.
Minimize environmental stimuli, light, and noise. Isolate the child as required
(Droplet). Administer antibiotics as prescribed. Encourage nutritious diet and
proper hydration.
 Aseptic meningitis
 Most common type of meningitis. Causative organism is usually a virus.
 S/s: Fever; General malaise; Headache; Photophobia; Poor feeding; Nausea;
Vomiting; Irritability; Lethargy; Neck pain; Positive Kernig and Brudzinski signs
 Management: Similar to the nursing care of the child with bacterial meningitis
and will focus on comfort measures to reduce pain and fever. Aseptic meningitis
can be managed successfully at home if the child’s neurologic status is stable, and
he or she is tolerating oral intake
 Encephalitis
 Inflammation of the brain that may also include inflammation of the meninges.
 S/s: Fever; Flu-like symptoms; Altered LOC; Headache; Lethargy; Drowsiness;
Generalized weakness; Seizure activity
 Management: Similar to nursing care for the child with meningitis. Specific
antiviral therapy may be used for diseases caused by the herpes simplex virus.
Teach children and their families how to prevent encephalitis
 Reye syndrome
 A disease that primarily affects children less than 15 years of age who are
recovering from a viral illness. Causes brain swelling, liver failure, and death
 S/s: Severe and continual vomiting; changes in mental status; lethargy; irritability;
confusion; hyperreflexia
 Management: Aimed at maintaining cerebral perfusion, managing and preventing
increased ICP, providing safety measures due to changes in LOC and risk for
seizures, and monitoring fluid status to prevent dehydration and overhydration.
Shaking baby syndrome
 Violent shaking/shaken baby syndrome (SBS), new name (nonaccidental head trauma)
blows to the head, intentional cranial impacts against the wall, furniture, or the floor
 In the U.S. this is the leading cause of traumatic death and morbidity during infancy
 The infant’s large head size and weak neck muscles place him or her at an increased risk
for head trauma due to violent shaking or cranial impacts compared to adults. In
addition, children younger than 3 years of age have a very mobile spine, especially in the
cervical region, along with immature neck muscles. This places them at a higher risk for
injury from acceleration/deceleration injuries, which occur when the head receives a
blow or is shaken. The sudden acceleration causes deformation of the skull and
movement of the brain, allowing brain contents to strike parts of the skull. Bruising of the
brain can occur at the point of impact or at that point distant from the impact where the
brain collides with the skull. Another result of brain movement is hemorrhages in the
brain, which are caused by the shearing forces that may tear small arteries. The child’s
thin skull places him or her at increased risk for skull fractures and penetrating injuries
resulting from head trauma.
 Why is the baby upset ?
o • Is the baby hungry?• Is the baby’s diaper dry? • Is the baby cold or hot? • Is the
baby overtired or overstimulated? • Is the baby in pain? • Is the baby sick or
running a fever?
 Try to help the baby relax.
o
• Turn down the lights. • Swaddle the baby. • Walk the baby. • Rock the baby. •
Give the baby a breast, bottle, or pacifier. • Shhh, talk to, or sing to the baby. •
Take the baby for a stroller or car ride.
 Sometimes the baby may continue to cry after all your efforts. If you feel overwhelmed,
frustrated, or angry, focus on keeping the baby safe.
o • Stop what you are doing, take a deep breath, and count to 10. • Place the baby
in a safe place, such as the crib or playpen. • Leave the room and shut the door
and find a quiet place for yourself. • Check on the baby every 5–15 minutes. • Do
not be afraid to call for help; call a friend, relative, or neighbor.
Intracranial bleeds in infants
 Increased risk for preemies
 Periventricular/Intraventricular Hemorrhage: bleeding into the ventricles is most
commonly seen in preterm infants
 Assessment: apnea, bradycardia, cyanosis, weak suck, seizures, high pitch cry, bulging
fontanel, and anemia
 Management: monitoring for S/S of IICP
Patient and family education
 Head trauma:
 Provide support and education for the family of a child who has suffered a head
trauma
 Encourage involvement in the child’s care
 The extent of residual neurologic damage and recovery may be unclear for the
child with a head injury
 This can be frustrating and stressful for parents and family
 Rehabilitation of the child with permanent brain damage is an essential
component of his or her care
Metabolism/Endocrine and Genetic Disorders
Diabetes Type 1 & Type 2
 Type 1: caused by a deficiency of insulin secretion due to pancreatic β-cell damage.
 An autoimmune disorder that occurs in genetically susceptible individuals who
may also be exposed to one of several environmental or acquired factors, such as
chemicals, viruses, or other toxic agents. This damages or destroys the beta cells
of the pancreas, then inadequate insulin secretion. End result; hyperglycemia.
 Type 2: consequence of insulin resistance that occurs at the level of skeletal muscle, liver,
and adipose tissue with different degrees of β-cell impairment.
 Pancreas usually produces insulin but the body is resistant to the insulin, or
inadequate insulin is produced. Results similar to type 1.
 Insulin
 Rapid Acting- Onset 15 minutes; Peak 1-3 hours; Duration 3-5 hoursNovolog/Humalog
 Short Acting- Onset 0.5-1 hour; Peak 2-4 hours; Duration 5-8 hours- Regular
 Intermediate Acting- Onset 2-4 hour; Peak 4-12 hours; Duration 12-24 hours- NPH
 Normal levels are as follows: nondiabetics: 70 to 110 mg/dL; (target levels should
 Education focus:
 Self-measurement of blood glucose; Urine ketone testing; Medication use (Oral
diabetic agents Subcutaneous insulin injection or insulin pump use Subcutaneous
site selection and rotation When to alter insulin dosages Use of glucagon to treat
severe hypoglycemia); Signs and symptoms of hypo- and hyperglycemia;
Treatment for hypo- and hyperglycemia at home or other setting such as school;
Monitoring for and managing complications; Sick-day instructions; Laboratory
testing and follow-up care; Diet and exercise as part of DM management.
Hyperglycemia vs. hypoglycemia – signs & symptoms, treatment
 Hyperglycemia: mental status change, fatigue, weakness, dry flushed skin, blurred vision,
abdominal cramping, nausea, vomiting, fruity breath odor
 Hypoglycemia: Behavioral changes (tearfulness, irritability, naughtiness), confusion,
slurred speech, belligerence, diaphoresis, tremors, palpitations, tachycardia
Pituitary disorders
 Growth Hormone Deficiency: hypopituitarism/dwarfism, poor growth/short stature
 Pathophysiology: failure of ant pituitary to produce suff. growth hormone (GH).
GH is vital for postnatal growth. GH stimulates linear growth, bone mineral
density, and growth in all body tissues. Causes from injury/destruction of ant
pituitary gland 2°to tumor, a genetic factor dominant/recessive
inheritance/genetic mutation
 Therapeutic management: supp GH (weekly dosage/ sq). Removal of tumor.
 1st year of GH replacement 8-10 cm of growth.
 Physical examination: linear height <3rd %, higher weight-to-height ratio. Abd fat,
childlike face, prominent forehead, high-pitched voice, delayed sexual maturation,
delayed dentition, poor muscle mass
 Laboratory and diagnostic testing: bone age, CT/MRI to r/o tumors, GH level
 Complications of growth hormone deficiency and therapy
 Altered carbohydrate, protein, and fat metabolism
 Hypoglycemia
 Glucose intolerance/diabetes
 Slipped capital femoral epiphysis (SCFE)
 Pseudotumor cerebri
 Leukemia
 Recurrence of CNS tumors
 Infection at the injection site
 Edema and sodium retention
 Child with growth hormone deficiency displays short stature. Treatment of
primary GH deficiency involves the use of supplemental GH. Primary causes of GH
deficiency include injury to, or destruction of, the anterior pituitary gland or
hypothalamus. Causes include a tumor (e.g., craniopharyngioma), infection,
infarction, CNS irradiation, abnormal formation of these organs in utero, or
damage or trauma during birth or after. It may also be part of a genetic syndrome,
such as Prader–Willi syndrome or Turner syndrome, or the result of a genetic
mutation or deletion. Secondary GH deficiency requires removal of any tumors
that might be the underlying problem, followed by GH therapy. The goal of
growth promotion is for the child to demonstrate an improved growth rate, as
evidenced by at least 3 to 5 in in linear growth in the first year of treatment
without complications. With early diagnosis and treatment, the child has a better
prognosis for reaching a normal adult height. Growth is usually excellent in the
first year of therapy compared to later years (Parks & Felner, 2016). Treatment
stops when the epiphyseal growth plates fuse.
 Hyperpituitarism (Pituitary gigantism)
 Rare, excessive secretion of GH, >95% on growth chart. Could be from a tumor. 78 ft if excessive secretion before closure of epiphyseal plate
 Precocious Puberty
 The child develops sexual characteristics before the usual age of pubertal onset.
 Central precocious puberty, the most common form, develops as a result of
premature activation of the hypothalamic-pituitary-gonadal axis, which stimulates
the pituitary to produce luteinizing hormone, and follicle stimulating hormone
 Education is focused on dealing with self-esteem issues
Turner syndrome
 Female phenotype
 Nursing assessment – webbed neck, low post hairline, wide-spaced nipples, hand/feet
edema, amenorrhea, no secondary sex characteristics, sterility, and perceptual and social
skill difficulties
Congenital Hypothyroidism
 Cretinism, usually from failure of thyroid gland to migrate during fetal development.
Insufficient production of thyroid hormones/body’s metabolic/growth/development
needs not normal.
 Promoting growth: Measure and record growth at regular intervals. Measure thyroid
levels every 2 to 4 weeks until the target range is reached on a stabilized dose of
medication. Obtain tests every 3 to 4 months for the first several years of life, changing to
every 6 to 12 months during adolescence. Monitor for signs of hypo- or hyperfunction,
including changes in vital signs, thermoregulation, and activity level. Provide adequate
rest periods and meet thermoregulation needs.
 A trial off the medication may be performed around the age of 3. Provide adequate rest
periods and meet thermoregulation needs. If the infant’s tongue is unusually large,
observe feeding ability, prevent airway obstruction, and position the infant on the side.
Fluid restrictions or a low-salt diet may be ordered.
 Observe for signs of thyroid hormone overdose (irritability, rapid pulse, dyspnea,
sweating, and fever) or ineffective treatment (fatigue, constipation, and decreased
appetite). L-Thyroxine is an oral medication and is not available in a liquid form. The pill
form must be crushed for infants and young children. It can be mixed with a small
amount of formula or breast milk and placed in the nipple, but it should not be placed in
a full bottle of formula or breast milk because the infant will not ingest all the medication
if he or she does not finish the bottle. The medication can also be mixed with a small
amount of liquid and given with a dropper. Medication absorption is affected by soybased formulas, fiber, calcium, and iron preparations and antacids including infant drops
such as simethicone
Down’s Syndrome – risk factors for other illnesses
 Risk factor for hypothyroidism & secondary diabetes
 Trisomy 21 or Down syndrome – 1: 800; increased incidence w/ maternal age
 Pathophysiology: nondisjunction prior to @ conception; presence of 3 chromosome 21 in
all cells
 Nursing assessment - Some degree of intellectual disability
 Characteristic facial features
 Other health problems (e.g., cardiac defects, visual and hearing impairment,
intestinal malformations, and an increased susceptibility to infections).
 Therapeutic management – support optimal G&D
 Managing complications – CHD in 40 - 60 % children; leukemia 10 – 30 x greater;
increased GI disorders, > 60% have hearing loss, thyroid dysfunction, atlanto-axial
instability (C1&C2)
 Early intervention therapy
Alteration in Mobility/Neuromuscular or Musculoskeletal Disorders
Nursing implications for children in casts, including complications
 Compartment syndrome
 5 P Circulation Assessment: Pain, Pulse, Pallor, Paresthesia (pins & needles
sensation), Paralysis
 Assisting with cast application: color (note cyanosis or other discoloration), movement
(can they move fingers & toes), sensation (do they have loss of sensation), edema, quality
of pulses. Assist w/ cast application by distracting or comforting the child
 2 finger space between the cast & arm. If not present, new swelling has occurred since
application of the cast
 Cast removal: the loud noise of the cast saw may frighten the child
 Notify provider for signs of compromise:
 Increased pain, increased edema, pale or blue color, skin coolness, numbness or
tinging, prolonged capillary refill, decreased pulse strength (or absence of pulse),
home cast care teaching
Fracture assessment
 Pathophysiology – often r/t trauma; growth plate vulnerable frequent site; increased
vascularity & decreased mineral content-softer, children’s bones often bend instead of
breaking
 Nursing assessment – investigate humeral, femoral spiral fx, child abuse
 Health history – past, present, s/s (point tenderness is one of the most reliable
indicators)
 Physical examination - gentle
 Inspection, observation, and palpation. Point tenderness is a dependable
indicator.
Traction
 Skin Traction
 Application of force: To the skin via strips or tapes secured with ace bandages or
traction boots
 Length of treatment: usually limited
 Amount of force: less
 Skeletal Traction
 Application of force: To the body part directly by fixation into or through the bone
 Length of treatment: allows for longer periods of traction
 Amount of force: more
 Caring for the child in traction
 Distraction, visits, age-appropriate toys, weights hang freely, pin care, skin care,
etc.
 Preventing complications
 CMS checks, aseptic pin care, skin, GI & pulmonary assessments, etc
 TRACTION (Care of patient in traction)
 Temperature (extremity and infection)
 Ropes hang freely
 Alignment
 Circulation check (5 Ps)
 Type and location of fracture
 Increase fluid intake
 Overhead trapeze
 No weights on bed or floor
Hip dysplasia
 Pathophysiology: laxity of newborn’s hip structural changes r/t femoral head/acetabulum
displacement; >females
 Therapeutic management: maintain reduction, Pavlik harness if < 6 mo; > 6 months
surgical corrections, spica cast
 Nursing assessment: Health history- family hx, female gender, oligohydramnios or breach
birth, native American or eastern European, other congenital deformities
 “Clunk” w/ Ortolani & Barlow maneuver
 Assessment: Assess for asymmetry of thigh and gluteal folds, assess for unequal knee
height related to femur shortening, note limitation in hip abduction, positive
Trendelenburg sign: note pelvis/hip drops when leg is raised, assess for “clunk” with the
Ortolani maneuver
 Pavlik harness used to keep the knees flexed and hips abducted to allow the hips to grow
normally in a child with developmental dysplasia of the hip.
Torticollis
 Tightness of sternocleidomastoid muscle; plagiocephaly
 Nursing assessment: limited movement on affected side, mass
 Nursing management: neck stretching exercises toward unaffected side, turning head
both ways; prevent plagiocephaly (common side effect- flat spot on baby’s head)
Muscular dystrophy medications
 Benzodiazepines- Monitor sedation level. May cause dizziness. Paradoxical excitement
may occur. Assess for improvements in spasticity.
 Baclofen- Assess motor function. Monitor for a decrease in spasticity. Observe for mental
confusion, depression, or hallucinations.
 Corticosteroids- Administer with food to decrease GI upset. May mask signs of infection.
Do not stop treatment abruptly or acute adrenal insufficiency may occur. Monitor for
Cushing syndrome.
Duchenne muscular dystrophy
 Inherited conditions/progressive muscle weakness/wasting (limb and trunk first)
 Patho: Absence of dystrophin, a protein that is critical for maintenance of muscle cells
 Therapeutic management: No cure. Corticosteroids slow progression. Ca supplement.
Antidepressants. Braces. Preventing contractures.
 Nursing assessment: Health history- pregnancy/delivery hx, devel. Milestones, functional
status, freq. resp infections, etc.
 Physical examination: inspection and observation- ability to rise from floor, auscultation
and palpation- heart/lungs, muscle strength
 Gower Sign: To assume an upright position, the child must first roll onto his hands and
knees, then he must bear weight by using his hands to support some of his weight, while
raising his posterior. (Indicative of Duchennes)
 Electromyography (EMG), serum creatine kinase (elevated w/ muscle wasting), muscle bx
(def dx), DNA testing
Myelomeningocele repair
 Most severe neural tube defect
 Spina bifida cystica, dx in utero. Spinal cord may end at point of defect; absent
motor/sensory function.
 Long term complication: paralysis, orthopedic deformities, bladder/bowl incontinence,
multiple surgeries
 Teaching should begin immediately in the hospital. Teaching should include positioning,
preventing infection, feeding, promoting urinary elimination through clean intermittent
catheterization, preventing latex allergy, and identifying the signs and symptoms of
complications such as increased ICP. Due to the chronic nature of this condition, longterm planning needs to begin in the hospital.
 Fluoroscopy- Allow a parent or family member to accompany the child.
 Myelography- Observe for signs of meningeal irritation.
 Computed tomography- If performed with contrast medium, assess for allergy. Encourage
fluids after procedure if not contraindicated.
 Electromyography- Requires insertion of short needles into the muscles. Sedation or
analgesia may be ordered
 Arthrography- Should not be performed if joint infection is present. The joint should be
rested for 12 hours. Apply cold therapy afterward and assess for swelling and pain
Common Diagnostic test for Neuro
 CBC, creatine kinase
 Radiographs
 Fluoroscopy, arthrography
 Myelography, electromyography (EMG), muscle biopsy
 Nerve conduction testing
 CT, MRI, ultrasound
 Genetic testing
Scoliosis
 Prominence of one scapula, pronounced hump, measure height iliac spine; forward
bending, uneven curve at waist
 Pathophysiology – 65% idiopathic, adolescence
 Therapeutic management – early screening, prevent progression, surgery if curves > 45
deg
 Nursing management
 Encouraging compliance with bracing – 23 hours/day; peer influence, family
environment, shower when brace off-skin integrity, cotton t-shirt
 Promoting positive body image – encourage verbalization, clothing, talking to
other young people
 Providing preoperative care – teaching what to expect, TCDB, possible autologous
blood donation
 Providing postoperative care - frequent CMS, neuro checks, log-rolling, PRBC
administration, foley, Hemovac, bedrest - gradual position changes w/
ambulation
Spinal cord injuries
 Injury to the spinal cord that results in the loss of function
 Assessment: inability to move/feel, numbness, tingling, and weakness, loss of voluntary
movement below the level of the lesion, inability to breathe, if injury is at a high cervical
vertebra
 Nursing management will be like management of the adult with a spinal cord injury and
will focus on optimizing mobility, maintaining skin integrity, promoting bladder and bowel
management, promoting adequate nutritional status, preventing complications
associated with extreme immobility such as daily skin integrity assessment, contractures
and muscle atrophy, managing pain, and providing support and education to the child
and family.
 Teaching topics to prevent SCI: vehicular safety, seat belt and age-appropriate safety seat
use, bicycle, sports, and recreation safety, prevention of falls, violence prevention,
including gun safety, water safety, including the risk of diving
Take folic acid preconception and during pregnancy.
Children with cerebral palsy may benefit from wearing ankle-foot orthotics to provide support
needed for independent or assisted walking.
The Ilizarov Fixator is a circular apparatus usually used for complicated lower extremity fractures.
The pins are smaller in diameter, more like wires, than those used in other fixators.
Pediatric Emergencies
Barotrauma prevention
 The child in respiratory distress may ventilate poorly, hypoventilate, or tire and become
apneic. In this case, the child may require assistance with ventilation through bag-valvemask (BVM) ventilation. Do not overventilate or bag aggressively, to avoid barotrauma.
Air leak (thus reducing the oxygen delivered to the child). Reduced cardiac output (CO)
(due to increased intrathoracic pressure and increased cardiac afterload). Air trapping.
Barotrauma (trauma caused by changes in pressure). Nurses must be mindful of their
technique during bagging, not exceeding the recommended respiratory rate or providing
too much tidal volume to the child. Ventilate the child in a controlled and uniform
manner, providing just enough volume to result in a chest rise.
Respiratory arrest in children
 Greater risk
 Smaller airways and underdeveloped immune systems
 Lack of coordination leading to choking
 Possible progression to cardiopulmonary arrest
 Many children in respiratory distress often are most comfortable sitting upright, as this
position helps to decrease the work of breathing by allowing appropriate diaphragmatic
movement. In contrast, a child with a decreasing level of consciousness may need to be
placed in the supine position to facilitate positioning of the airway. The infant may
benefit from a small towel folded under the shoulders or neck.
ABCs
 Primary Survey: Airway, Breathing, Circulation
 Secondary Survey: Disability, Exposure
Broselow tape
 Child’s wt est using measurement of ht, tape is color coded w/ corresponding-colored
drawers on cart
Shock in children – signs & symptoms
 SHOCK IS THE RESULT OF DRAMATIC RESPIRATORY OR HEMODYNAMIC COMPROMISE.
 CAN BE CLASSIFIED AS COMPENSATED OR DECOMPENSATED.
 IMPAIRED CARDIAC OUTPUT, IMPAIRED SYSTEMIC VASCULAR RESISTANCE (SVR), OR A
COMBINATION OF BOTH CAUSES SHOCK.
 INFANTS AND YOUNG CHILDREN DIFFER FROM ADULTS IN THAT THEIR CARDIAC OUTPUT
DEPENDS ON THEIR HEART RATE, NOT THEIR STROKE VOLUME.
 THE MOST COMMON TYPES OF SHOCK ARE HYPOVOLEMIC (“COLD SHOCK”), SEPTIC
(“WARM SHOCK”), CARDIOGENIC, AND DISTRIBUTIVE.
 SIGNS AND SYMPTOMS INCLUDE PALLOR, HYPOTENSION, BRADY- OR
TACHYDYSRHYTHMIAS, RESPIRATORY DISTRESS, DELAYED CAPILLARY REFILL, WEAK
DISTAL PULSES
 Impaired CO, impaired systemic vascular resistance (SVR), or a combination of both
causes shock. CO is equal to HR times ventricular stroke volume (SV) (CO = HR × SV). SV is
how much blood is ejected from the heart with each beat. SV is related to left ventricular
filling pressure, the impedance to ventricular filling, and myocardial contractility. In
children who have shock-related increased SVR, CO will fall unless the ventricle can
compensate by increasing pressure. In cardiac insufficiency, the child’s heart will have
impaired ability to compensate for the increased afterload.
Patient and family education
Therapeutic Communication