Vitals-

Newborn (0 days - 1 month) Temp-37.5-37.7C (99.5-99.9F) HR- 110-160 RR- 30-60 BP-64-78/41-52

Infant (1 month-1 year) Temp- 37.5-37.7C (99.5-99.9F) HR- 90-160 RR- 25-30 64-78/41-52

Toddler (1 year-3 years) Temp- 37.2-37.7C (99-99.9F) HR- 80-140 RR- 25-30 BP- 85-91/37-49

Preschooler (3 years-6 years) Temp- 37.0-37.2C (98.6-99F) HR- 70-120 RR- 20-25 BP- 89-98/46-5

School-age (6 years-12 years) 36.7-36.8C (98.1-98.2F) HR 60-110 RR 20-25 BP 94-106/55-62

Adolescent (12 years-18 years) 36.6-36.8C (98.1-98.2F) HR 50-100 RR 16-20 BP <120/<80

Signs of respiratory distress- tachypnea, poor feeding in infants, retracting, nose flaring, wheezing, stridor
sweating, color changes. Know expected ranges, 02 should be in the high 90s on room air.

Respiratory distress- the desired range is 95-100%, continuous pulse oximeter, below 90s- priority care, open and
patent airway, suction before you apply oxygen- remove secretions before. Give albuterol and then oxygen, sit the
patient up first, patent the airway, and give bronchodilator before CPT. CPT 1-2 minutes at a time, do CPT before
meals.

Adventitious lung sounds- know what sounds you’ll hear and what they mean. A sudden stop of wheezing is bad.

Cool mist tent- add additional oxygen, always cool never warm. During cool mist monitor temperature, decreased
stimulation.

Medication administration- MDI- may need a spacer to help with medication delivery. Education- exhale
everything out, inhale long and slow hold for 5-10 seconds, wait 1 minute before puffs, rinse out to avoid thrush.
Nebulizer- mist, utilize distraction.

Bacterial Epiglottitis- assessment-caused by h.influenza Drooling, Agitation, Inspiratory stridor, Muffled voice,
Tripod position. Labs/DX- Neck radiograph, x ray Nursing implications- Emergency preparedness, protect airway
(avoid tongue blades), Monitor vital signs (continuous pulse oximetry) Education- Medication compliance,
Immunization education, h. influenza (Hib) Medication/TX- Oxygen therapy, IV fluids, Antibiotics-bacterial, Airway
considerations.

Tonsillitis- assessment- Sore throat/Difficulty swallowing, Mouth odor, Snoring, Fever, Inflammation of tonsils.
Labs/Dx- Throat culture Nursing implications- Pain management, Consider medication allergies. Pain control,
Bacterial (antibiotics) vs viral (supportive) Medication/TX- Antipyretics, Analgesics, Antibiotics, Supportive
treatment. Education- Medication dosing, Medication compliance.

Tonsillectomy- Assessment- Signs of bleeding (frequent swallowing) Vital signs, Difficulty breathing. Priority
interventions- Signs of bleeding=frequent swallowing. NPO pre-operatively, Positioning, Pain Management, Diet
considerations (clears, no reds!), Rest and recovery, encourage fluids, monitor I&O. Complications- Hemorrhage,
Dehydration, Chronic infection. Education- discourage coughing/ nose blowing, encourage fluid intake, and when
to contact the provider. Need to have a gag reflex before we give fluids.

Nasopharyngitis-Common cold. Assessment- Nasal inflammation, dryness, irritation, Fever, restlessness. Labs/dx-
Viral Priority interventions- Fever and pain control, Cool mist. Medications/TX- supportive. Education- Home
management, Secretion management, Medication avoidance- avoid cold medication in infants, toddlers, and
preschoolers. At risk for asphyxiation and sedating effects.
Acute streptococcal pharyngitis- Assessment- Pharyngitis & tonsillitis with exudate, Fever. Labs/Dx- Throat
culture/rapid antigen test. Priority interventions- Antibiotic administration, Antipyretics. Medications/TX- Oral
penicillin, Amoxicillin, Fever reducer. Education- Medication dosing, Medication compliance.

Acute laryngotracheobronchitis (Croup)- assessment- Viral- Barking cough, Inspiratory stridor, Retractions. Most
caused by parainfluenza sometimes RSV Labs/Dx- Clinical manifestations, X-ray (steeple sign) Priority
interventions- Cool mist, Continuous pulse oximetry. Oxygen administration. Medication/TX- Nebulized racemic
epinephrine, Corticosteroids (oral/IM/nebulized) IV therapy as needed. Education- Medication education,
Encourage oral intake.

Bacterial Pneumonia- Assessment- High fever, Cough (productive or non-productive) Tachypnea, Retractions, Chest
pain, Adventitious breath sounds, Pale progressive to cyanosis. Labs/DX- X-ray for the presence of infiltrates,
Nasopharyngeal specimens. Priority interventions- Continuous pulse oximetry, Oxygen therapy, Monitor I&O.
Complications- Pneumothorax, Pleural effusion. Medications/Tx- Antipyretics, Antibiotics (for bacterial
pneumonia) CPT, IV fluids. Education- Encourage rest, Promote oral intake and Medication education.

Bronchiolitis (RSV)- Assessment- Runny nose, cough, sneezing, Fever, Pharyngitis, Wheezing, Ear infection,
Difficulty feeding, fever, Dependent on severity. Labs/Dx- Nasopharyngeal swab (ELISA test) Priority interventions-
Oxygen administration, Secretion management, Encourage fluids (PO vs IV) Contact precautions. Repositioning
Medications/Tx- Symptom-specific, Hospitalization for severe cases, Supportive, Palivizumab (specific population)
suction first before oxygen Education- Hand hygiene/illness prevention. Contact precautions OK for fellow RSV
patients to share rooms.

Asthma- Assessment- Full health history, Identify risk factors (family hx, low birth weight, obesity) Dry cough,
Wheezing, Coarse lung sounds, Restlessness, irritability, tachypnea, Chest tightness. Labs/Dx- Pulmonary function
test (standard for diagnosing asthma) Peak Expiratory flow rates (PEFR) -amount of air exhaled in 1 second-zones
established, Allergen testing. Bronchodilators- Short-acting beta-agonists (SABA)- albuterol, levalbuterol,
terbutaline. Acute exacerbations prevent symptoms prior to exercise. Long-acting beta agonists (LABA)- formoterol,
salmeterol. Nighttime prevention, reduce SABA use, used in addition to anti-inflammatories. Anticholinergics-
atropine, ipratropium, Bronchospasm relief. Anti-inflammatory Corticosteroids-methylprednisolone (IV),
prednisone (PO), fluticasone (inhalation) Monitor growth, rinse mouth after inhalation, Leukotriene modifiers-
montelukast- Decrease airway resistance- Mast cell stabilizers-cromolyn- long term control. Monoclonal antibodies-
omalizumab, Moderate-severe persistent that is uncontrolled. Theophylline= Used in PICU setting. Complications-
Status asthmaticus (life-threatening episode of airway obstruction) Respiratory failure Medications/TX- Treatment
should be aimed at prevention of attack. Acute attack: systemic steroids and short-acting bronchodilator/ Chronic
asthma: long-term steroids, long-acting bronchodilators. Long-term medications (controllers): inhaled
corticosteroids. Education- should focus on preventing triggers (allergens, smoke, pet hair, weather, exercise,
stress) and Medication adherence. Teach record-keeping of PEFR results and know their zones. Red zone less than
50% of your personal best- go to ER. Yellow- have an inhaler handy. Green- good to go. Normal readings of peak
flow meters are within 80-100% of the baseline reading. These readings are categorized in the green peak flow
zone, which indicates stable lung function. When the readings are between 50 and 80% of the baseline reading,
they are categorized in the yellow peak flow zone. This zone indicates a worsening in lung function. Anything below
50% of the baseline reading is in the red peak flow zone. Emergency medical treatment is usually required at this
stage.

Cystic Fibrosis- Assessment- Meconium ileus at birth, Respiratory manifestations based on severity.
Gastrointestinal manifestations (frothy stool, delayed growth, nutritional deficiencies) High sodium and chloride
content in secretions. Labs/Dx- Sweat chloride test (diagnostic test) CXRAY/Abdominal Xray, Pulmonary function
tests, Stool analysis, Blood panel (to detect deficiencies) Sputum culture (infection detection) Priority
interventions- Pulmonary management (airway clearance, bronchodilator, antibiotic therapy, oxygen) GI
management (high protein/calorie diet, pancreatic enzymes, vitamin supplementation, stool softeners, dehydration
considerations) Endocrine management (blood glucose monitoring) Medications/Tx- Respiratory medications-
SABA, LABA, anticholinergics, Antibiotic therapy- tobramycin, gentamicin (may be given IV or aerosol) Pancreatic
enzymes- given with meals/snacks, can be sprinkled on food if unable to swallow. Vitamins- daily multivitamin,
vitamins A,E,D,K. May need to add salt to diet. CPT- before meals, albuterol prior to open airways. Important they
are getting immunizations.

Cardiac catheterization- Open heart or intra-cardiac catheterization surgery remains the chief cure for congenital
heart disease. Access for catheterization is frequently obtained in the femoral vein OR artery but radial or neck
access can also be used. Pre-procedure: Vital signs, perform a nursing hx, Provide teaching, Check for allergies to
iodine & shellfish, Provide NPO status 4-6 hours prior to the procedure, Locate & mark dorsalis pedis & posterior
tibial pulses on both extremities, make sure they do not have an infection, Administer pre-sedation as prescribed
based on age, height, weight, condition, & type of procedure. Procedure- a radiopaque catheter is peripherally
inserted & threaded into the heart via fluoroscopy. Contract medium (may be iodine-based) is injected & images of
the blood vessels & heart are taken as a medium is diluted & circulated throughout the body. Post-procedure
Assess HR & RR for 1 full minute, Assess sedation, Assess pedal pulses for equality & symmetry, Assess temperature
& color, Monitor for hypoglycemia, Provide continuous cardiac monitoring & oxygen, Assess insertion site (femoral
or antecubital area) for bleeding &/or hematoma, Prevent bleeding by maintaining the affected extremity in a
straight position for 4-8 hours (preferably supine) Monitor for complications (infection, bleeding, & thrombosis)
Don’t want to see pale or coolness. Fluids- flush out the dye.

Digoxin/Diuretics- Digoxin- improves myocardial contractility, Check HR before administration for 1 min, Monitor
pulse and hold for low HR; monitor for therapeutic blood levels, Toxicity (bradycardia, nausea, vomiting) Diuretics-
eliminate excess fluid (potassium-wasting) Monitor electrolytes- daily weights, Encourage high potassium diet, daily
weights, will hear decreased crackles.

Oxygen- giving too much oxygen can cause too much exacerbation. Potent vasodilator- pulling additional blood
where it doesn’t need to go. Can cause blindness in young infants and can also cause met. acidosis. May need to
titrate with pediatric heart defects.

Heart Failure- Inadequate cardiac output is mostly caused by congenital heart defects. A combination of left-sided
& right-sided is usually present. Left-sided Failure- Usually systolic (pulmonary hypertension) increased pulmonary
blood flow, Crackles & wheezes, Cough, Dyspnea, Grunting, nasal flaring & retractions (infants), Periods of cyanosis,
Tachypnea. Right-sided Failure- Usually diastolic (backing up to the body) decreased pulmonary blood flow, Ascites,
Hepatosplenomegaly, Jugular vein distention, clubbing (chronic sign), Oliguria, Peripheral edema, esp. dependent &
periorbital, Weight gain. Assessment, early signs- Tachycardia (esp. during rest & slight exertion) Tachypnea, Failure
to thrive, dyspnea, weight loss, Profuse scalp diaphoresis (esp. infants) Fatigue & irritability, Sudden weight gain,
edema, Temp/Cool extremities, Respiratory distress, Hypoxia/hypoxemia/cyanosis. Interventions- Monitor for early
signs of HF, VS, Temp, I&O, Weight, Edema, Elevate HOB, provide low dose O2, Cluster care, reduce O2
consumption, provide small, frequent feedings, increase calories, console patient, NG or feeding devices.

L/R heart failure= both will have Tachycardia

Ductal/shunt-dependent defects- O2 saturations of 70%-80% must be maintained for ductal-dependent defects.

Kawasaki Disease- Systemic vasculitis (inflammation of blood vessels in the body) of unknown etiology, Serious
cardiac complications can develop (aneurysms) S/S (acute phase): High fever with a sore throat (not reduced by
antipyretics), Red eyes, dry eyes (xerophthalmia), Red chapped/cracked lips, Red oral mucus membranes, Red,
strawberry tongue, Red, swollen, peeling palms of hands/soles of feet, Enlargement of cervical lymph nodes,
Cardiac manifestations (dysrhythmias, myocarditis) Dx: Recent strep or viral infection, Echocardiogram, CBC, CRP,
elevated liver enzymes Tx- Gamma globulin (IVIG) therapy, NO live vaccines for 11 months. High dose aspirin,
Acetaminophen Education-Avoid live immunizations for 11 months, S/S of bleeding. Educate about bleeding, avoid
injury, use a soft bristle toothbrush.
Rheumatic Fever-Strep Inflammatory disease of the heart, blood vessels, joints, & CNS. Caused by GABHS
(untreated or partially treated) S/S- Muffled heart sounds, pericardial friction rub, Chest pain, Non-tender
subcutaneous nodules, Fever: low-grade fever that spikes in the late afternoon, polyarthritis- joint pain, Non-
pruritic macular rash on the trunk and inner surfaces of extremities, Chorea (involuntary muscle movements)Dx:
Elevated antistreptolysin-O titer (gold-standard) Positive throat culture for GABHS, CRP elevation Tx- Administer
antibiotics, Aspirin for joint relief. Education-Need prophylactic antibiotics prior to any surgical or dental procedure

Patent Ductus Arteriosus (PDA)- Failure of fetal shunt to close, increased pulmonary blood flow. Floods the lungs
S/S: Left to right shunting of blood-typically acyanotic, Machine-like murmur, upper sternal border, Infant may or
may not be symptomatic of HF, Widened pulse pressure & bounding pulses, Increased work of breathing or apnea.
Labs/Dx: Echo, ECG (shows an enlargement of left heart chambers), X-ray. Meds/Tx- Indomethacin (prostaglandin
inhibitors) (to close PDA) PDA ligation, Occlusion by cardiac catheterization.

Ventricular Septal Defect (VSD)- Hole in the septum between right & left ventricles. Left to right shunting of blood-
typically acyanotic. increased pulmonary blood flow. S/S of Left-sided HF Loud, harsh murmur (or thrill) at the
lower left sternal border. Labs/Dx-Echo, ECG (large left atrium), X-ray. Tx- Repaired within 6-12 months of life or
infant weighing >2000 grams, Digoxin, diuretics, Open repair (sternotomy) Cardiac catheterization, Suture, or patch.

Atrial Septal Defect (ASD)- An atrial septal defect (ASD) is a hole in that septum, increasing pulmonary blood flow.
S/S: Left to right shunting of blood-typically acyanotic, Loud, harsh murmur with fixed, split-second heart sound,
upper sternal border, Infant may or may not be symptomatic of CHF. Labs/Dx- Echo, ECG (shows enlargement of
right atrium & ventricle), X-ray Tx-Open repair (sternotomy) Cardiac catheterization, Suture or patch, Low dose
aspirin 6 months post-procedure.

Tricuspid Atresia- Failure of the tricuspid valve to develop, No communication between right atrium and right
ventricle. Right to left shunting- cyanotic. Ductal dependent- need to remain open, Prostaglandin E1 – maintains
patency, opens vessels (continuous infusion) Decreased pulmonary blood flow. S/S of Right-sided HF, Cyanosis,
dyspnea, tachycardia seen in newborn, Chronic hypoxia (clubbing) in older kids Labs/Dx-Echo, ECG, Xray. Tx-
Prepare for surgery, 3 stages dependent on severity, Glenn procedure, Fontan procedure, Tetralogy of Fallot-
Coarctation of the Aorta-

Transposition of the Great Arteries (TGA)- The pulmonary artery leaves the left ventricle, and the aorta exits from
the right ventricle. No communication exists between the systemic and pulmonary circulation. Decreased
pulmonary blood flow S/S- Presents within 24 hours after a birth-Cardiac emergency, Profound cyanosis, PDA
dependent-need to remain open, Prostaglandin E1 (continuous infusion) Heart murmur, Cardiomegaly. S/S of HF,
Upper extremities have decreased O2 sats versus lower extremities, Especially in right arm, Dx-Echo, ECG, Xray. Tx-
Repair of defect within 2 weeks of life. Surgery.

Teratology of Fallot- TET spell- hyper cyanotic, drive knees to chest. Pulls all the blood from the extremities, and
goes to the core to go to the lungs.

Normal blood flow- 1) body –> 2) inferior/superior vena cava –> 3) right atrium –> 4) tricuspid valve –> 5) right
ventricle –> 6) pulmonary arteries –> 7) lungs –> 8) pulmonary veins –> 9) left atrium –> 10) mitral or bicuspid valve
–> 11) left ventricle –> 12) aortic valve –> 13) aorta –> 14) body

Right side- respiratory, responsible for oxygenating the blood.

Fetal blood flow-

 -Blood enters the right atrium, the chamber on the upper right side of the heart. When the blood enters
the right atrium, most of it flows through the foramen ovale into the left atrium.
 -Blood then passes into the left ventricle (lower chamber of the heart) and then to the aorta, (the large
artery coming from the heart).
 -From the aorta, blood is sent to the heart muscle itself in addition to the brain. After circulating there, the
blood returns to the right atrium of the heart through the superior vena cava. About two thirds of the
blood will pass through the foramen ovale as described above, but the remaining one third will pass into
the right ventricle, toward the lungs.
 -In the fetus, the placenta does the work of breathing instead of the lungs. As a result, only a small
amount of the blood continues on to the lungs. Most of this blood is bypassed or shunted away from the
lungs through the ductus arteriosus to the aorta. Most of the circulation to the lower body is supplied by
blood passing through the ductus arteriosus.
 -This blood then enters the umbilical arteries and flows into the placenta. In the placenta, carbon dioxide
and waste products are released into the mother's circulatory system, and oxygen and nutrients from the
mother's blood are released into the fetus' blood.-At birth, the umbilical cord is clamped and the baby no
longer receives oxygen and nutrients from the mother. With the first breaths of life, the lungs begin to
expand. As the lungs expand, the alveoli in the lungs are cleared of fluid. An increase in the baby's blood
pressure and a significant reduction in the pulmonary pressures reduces the need for the ductus
arteriosus to shunt blood. These changes promote the closure of the shunt. These changes increase the
pressure in the left atrium of the heart, which decrease the pressure in the right atrium. The shift in
pressure stimulates the foramen ovale to close.
 The closure of the ductus arteriosus and foramen ovale completes the transition of fetal circulation to
newborn circulation.