NURS 4520: Peds Exam #1 Blueprint

Chapter Topics Chapter Topics

39 Consent 29 Age-Approp Assess
39 Med Admin 29 Toddler
39 Procedure prep 29 Component priorities
39 Isolation in Children 30 Child Pain Tool
29 Vital signs 30 Preschool Pain
39 Restraint Use 30 Infant pain assess
28 Develop 30 Opioid fear parent
35 Adolescent Develop 30 Pain Meds
28 Erikson 30 Toddler pain assess
28 Growth 35 Adolescent Development
28 Piaget 34 Tanner Stage
28 Development 34 School age safety
28 Gross Motor Development 35 Adolescent develop
28 Types of Play 34 G & D SA injury
29 Teaching family 34 G & D School age
29 Communication 34 School age Toys
29 Assessment Preschool 34 Tanner Stages
30 Pain Assess 34 School Age procedure prep
29 Infant Assess 34 Lice
29 School Age VS 34 ADHD Med effects
35 Anorexia

Chapter 28: Developmental and Genetic Influences

Erikson
● Trust vs mistrust (birth - 1 year)
○ Result: faith, optimism
● Autonomy vs shame and doubt (1-3 years)
○ Result: self control, willpower
● Initiative vs guilt (3-6 years)
○ Result: direction, purpose
● Industry vs inferiority (6-12 years)
○ Result: competence
● Identity vs role confusion (12-18 years)
○ Result: devotion, fidelity

Growth
● Infancy
○ Posterior fontanel closes at 2-3 months
○ Anterior fontanel closes at 12-18 months
○ Weight: doubles at 6 months, triples at 12 months
○ Height increases by 50% at 12 months
○ 6-8 teeth erupt by 1 year
● Toddlers
 ○ Head and chest circumference is equal at 1-2 years
● Preschool
○ Improved fine motor skills

Piaget
● Process by which child becomes acquainted with world & its objects
● Cognitive Stages:
○ Sensorimotor (birth to 2 years)
■ Object permanence ⁠— object exists even if it is not visible
○ Preoperational (2 to 7 years)
○ Concrete operations (7 to 11 years)
○ Formal operations (11 to 15 years)

Development
Infancy ⁠—
● Aware of self separate of others
● Separation, object permanence, and mental representation
● Learns delayed gratification
● Nutrition: Iron-fortified foods, vitamin D, juice/solids at 6 months, weaning starts in
second 6 months
Toddlers ⁠—
● Sensorimotor stage
● Parallel play
● Autonomy vs shame and doubt
● Negativism*
● Toilet training, age appropriate expectations (temper tantrums)
● Ritualism/routines
● Nutrition: 1 C fruit, bite size food pieces, don’t eat/drink while playing or laying down
● Explore limites of capacities
Preschoolers ⁠—
● Preoperational phase
● Social awareness
● Judgement is based on appearances
● Magical thinking*
● Animism*
● Centration*
● Behavior is based on reward and punishment
● Nurse teaching: let child know that they did not cause their sickness or the sickness of
others; sickness is not a punishment
● Nutrition: finicky eating until 5 years old; calcium, iron, folate, vitamin A and C are
needed; 5 servings of fruits and veggies; 1 hour of physical activity

Gross Motor Development

Infant ⁠—

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Toddler ⁠—
● Locomotion and increase eye-hand coordination is developed

Preschool ⁠—
● Fine motor skill will be displayed by activities like copying figures on paper and dressing
independently
GROSS MOTOR SKILL

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Types of Play
● Onlooker play ⁠— watches other children playing but does not join
● Solitary play ⁠— children play alone in close proximity by do not make any effort to play
together
● Parallel play ⁠— toddlers play next to each other but not in a group or with each other,
neither child is influencing each other
○ Example: children making crafts
● Associative play ⁠— children play in a group but without any division of roles,
leadership, or goals. Each child behaves according to their own wishes and ideas
(preschool)
○ Example: two children playing with dolls, playing dress up
● Cooperative play ⁠— organized play with roles and a common goal, there is a
leader-follower dynamic (school age)

Chapter 29: Communication and Physical Assessment

Teaching family
●
Communication
○ Communicating with families
■ direct the focus using guiding statements
■ use silence gives the person to think about their response and cue the
interviewer to go slower
■ empathy
● ability to understand what the other person is going through
■ best way to deal with a situation is to handle it before it becomes a
problem → anticipatory guidance
■ to achieve high levels of anticipatory guidance nurses must consider
● base interventions on the needs of the family, not the professional
● view family as competent of ability to be competent
● provide opportunities for the family to become competent.
● Communicating with Children
○ the single most important factor to consider is the child's developmental stage
○ Infants:
■ Typically use nonverbal communication and vocalization.
■ They may smile, coo, or cry.
■ Loud noises/sudden movements are often scary.
○ Early Childhood:

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 ■ Children at this age are egocentric (they see things only in relation to
themselves and their point of view), so communication focus is on them.
■ Everything is direct and concrete (They will take “sneeze your head off”
as a literal statement due to lack of abstract thinking process).
■ Use simple and direct language rather than phrases that they might
misinterpret.
○ School Age Years:
■ These kids rely less on what they see and more on what they know when
faced with new problems.
■ They want to know “why” things exist, why they are used, and the
purpose of these things.
● Ex: when taking BP let the child operate the bulb and explain to
them that you “want to see how far the arrow moves when the cuff
squeezes your arm”
■ Kids this age have a higher concern with body integrity, so encourage
children to voice their concerns so that you as the nurse can provide
reassurance.
○ Adolescence:
■ Children in this age range fluctuate between child and adult like thinking.
■ Sometimes it may be a confusing situation on whether to speak to the
adolescent alone or with the parent.
■ If time is limited, express that to the family so they do not think you are
choosing sides when you speak more to one family member than the other.
■ Privacy and confidentiality are important b/c it is consistent with
development of autonomy and maturity.
■ These kids can also have opposing feelings compared to their parents, so
allow both parties to express themselves.
Vital signs
Respiratory Systolic Blood Weight in
Age Group HR Weight in kilos
Rate Pressure pounds

Newborn 30 - 50 120 - 160 50 - 70 2-3 4.5 - 7

Infant (1-12
20 - 30 80 - 140 70 - 100 4 - 10 9 - 22
months)
Toddler (1-3
20 - 30 80 - 130 80 - 110 10 - 14 22 - 31
yrs.)
Preschooler
20 - 30 80 - 120 80 - 110 14 - 18 31 - 40
(3-5 yrs.)

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School Age
20 - 30 70 - 110 80 - 120 20 - 42 41 - 92
(6-12 yrs.)
Adolescent
12 - 20 55 - 105 110 - 120 >50 >110
(13+ yrs.)

Assessment Preschool

Infant Assess

School Age VS
● Respiratory Rate
○ 20-30
● HR
○ 70-110
● SBP
○ 80-120
● weight
○ 20-42kg
○ 41-92
Age-Approp Assess

Toddler

Component priorities

Chapter 30: Pain Management

Child Pain Tool
Behavioral Pain Measures
● Generally used for children from infancy to 4 years of age
● More time-consuming than self-reports because they depend on a trained observer to
watch and record children’s behaviors that suggest discomfort, such as—
○ Vocalization, facial expression and body movements
● Behavioral pain measures are most reliable when used to measure short, sharp procedural
pain or when assessing pain in infants and young children
● The FLACC Pain Assessment Tool
○ An interval scale that includes 5 categories—
■ Facial Expression
■ Leg Movement
■ Activity
■ Cry

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 ■ Consolability
o Measures each behavior on a 0-10 scale
● Pain measurement tool recommended for use in critical care settings is the COMFORT
Scale
○ Unobtrusive method of measuring distress in unconscious and ventilated pts
○ Scored 1-5 for each category
○ Score 17-26 indicates pain control
○ 8 indicators
■ Alertness
■ Calmness/agitation
■ Respiratory response
■ Physical moment
■ Blood Pressure
■ Heart Rate
■ Muscle Tone
■ Facial tension
Self-Report Pain Rating Scales
● Self-report measures are most often used for children older than 4 years of age
● Smiling faces on pain assessment scales can result in inadequacies of the pain rating
○ Simple, concrete anchor words, such as “no hurt” to “biggest hurt” are more
appropriate
● Faces Pain Scale
○ Consists of 6 faces depicting increasing gradation of pain severity from 0-5
○ Use for ages +4
● Wong-Baker FACES Pain Rating scale
○ Consists of 6 cartoon faces ranging from a smiling face for no pain to a tearful
face for most pain
○ Most preferred and widely used in children’s hospitals
● Numeric Rating Scale (NRS)
○ For children 8 years and older
○ Most widely used in clinical practice due to ease of use
● Visual Analogue Scale (VAS)
○ Uses descriptors along a line that proves a highly subjective evaluation of pain
and other symptoms
○ Often used with older children and adults
● Oucher
○ For children from 3 to 13 years of age
○ Consists of six photographs of a white child's face representing “no hurt” to
“biggest hurt you could ever have;” also includes vertical scale with numbers
from 0 to 100

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 ○ 3 scales
■ Numeric Scale
■ Photographic scale
■ General Scale
Multidimensional Measures
● Pain charts or pain drawings are used to obtain info regarding g the location of pain and
have been well validated for children 8 and up
● The Adolescent Pediatric Pain Tool (APPT)
○ Assesses pain location, intensity and quality
○ An instrument with an anterior and posterior body outline
● Pediatric Pain Questionnaire (PPQ)
○ A pain instrument to assess pt. and parental perceptions of the pain experience in
a manner appropriate for the cognitive-developmental level of children and
adolescents
○ 8 areas of inquiry—
■ Pain history, pain language, colors children associate with pain, emotions
child experiences, the worst pain experiences, the ways child copes with
pain, positives aspects of pain, and the location of their current pain
○ 3 components—
■ VASs
■ Color-corded rating scales
■ Verbal descriptors to promote info about the sensory, affective and
evaluative dimensions of chronic pain
Preschool Pain
● FACES scale (+4 ages), FLACC scale
● Time-wasting/stalling behavior
● Muscular rigidity

Infant Pain Assess

Pain in Neonates (Infant pain assessment)
● Crying associated with pain is more intense and sustained
● Facial expression of discomfort is the most consistent and specific characteristic
o Eye squeeze, brow bulge, open mouth and taut tongue
● CRIES
o Pain assessment tool for premature and full-term infants in the NICU
▪ Ages 32 weeks of gestation to 20 weeks postterm
o CRIES
▪ Crying
▪ Requiring increased oxygen
▪ Increased vitals

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 ▪ Expression
▪ Sleeplessness
o Each indicator is scored from 0-2 (for possible total of 10); pain score over 4 is
significant
● Neonatal Pain, Agitation, and Sedation Scale (NPASS)
o Measures pain or sedation in preterm infants after surgery
o Based on 5 criteria—
▪ Cry/irritability
▪ Behavior/state
▪ Facial expression
▪ Extremities/tone
▪ Vital signs
Opioid Fear Parent
● Parents may fear addiction
● Nurses responsibility to address & reassure parent that risk is low
● Addiction or psychological dependence implies a “cause-effect” kind of thinking which infants &
children do not have the cognitive ability to make cause-effect association.

Pain Assess
● Self-report and awareness of location of pain occurs at age 4
● Assess location, duration, quality, and severity of pain

Pain Meds
● Max dose for ibuprofen Motrin or children's Advil is 30 mg/kg/day Or 3200 mg/day
● Naproxen: children less than 2 years of age: 5-7mg/kg/dose every 12hrs, Max 20 mg/
kg/day (numbers are slightly different on the screen shot)
● Fentanyl: ages +12
● Select the least traumatic route for administration
○ IM injection and intranasal not recommended for children
○ Oral: takes 1-2 hours to reach peak effect; do not use for rapid relief
○ Topical: 60 min prior to IV insertion or biopsy
○ IV Bolus: rapid control in 5 minutes (rapid relief)
● Give medications routinely and preemptively

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Toddler Pain Assess
● Subjective:
○ Loud crying/screaming, thrashing
○ Verbal expression “ow”
○ Lack of cooperation and avoidance of stimuli
○ Clings to significant person and requests physical comfort
● FLACC scale

Chapter 34: School Age

G & D: Injury
● Bodily harm
○ Nonviolent conflict resolution
○ Disturbances in sleep/appetite
○ Suicidal thoughts
○ Risk of sexual predators
● Burns
○ Fire safety
○ Avoid tanning beds
● Drowning
○ Do not swim alone
● Motor-vehicle injuries
○ No texting and driving
○ Dangers of substance use and driving
● Substance use disorder
○ Ask about alcohol, tobacco, marijuana use
○ Discuss risks of smoking
○ Emphasize short term effects of substance use (school/work)

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G & D School Age
● Physical Development
○ Weight: gain 2-3 kg/year
○ Height: 5 cm/year
○ Prepubescence:
○ Onset begins around the age of 9 years (particularly in girls)
○ Rapid height and weight growth occurs
● Differences in the rate of growth and maturation between boys
and girls becomes apparent
○ Visible sexual maturation is minimal in boys
○ Permanent teeth
○ Bladder capacity differs (greater in girls than boys)
○ Immune system improves
○ Bones continue to ossify
● Cognitive Development
○ Piaget: concrete operations
○ Perceptual to conceptual thinking
○ Masters the concept of conservation
○ Learn to tell time
○ Able to see the perspective of others and solve problems
● Psychosocial Development
○ Erikson: industry vs inferiority
○ Allows child to provide meaningful contributions to society
○ Sense of accomplishment through the ability to cooperate and compete with
others
○ Children should be challenged with tasks and work through individual differences
○ Peer pressure, popularity, conformity
○ Sensitive to social pressure
○ Same-sex companions ⁠— begin to show interest in opposite sex near end of
school-age
● Moral development: Early School Age
○ Doesn't understand reasoning behind rules and expectations
○ Believe that what they think is wrong and what others tell them is right
○ Judgement guided by rewards and punishment
○ Sometimes interpret accidents as punishment
● Moral development: Later School Age
○ Able to judge intentions of an act and the consequences
○ Understands different POV ⁠— not just right vs wrong
○ Treats others as they like to be treated

School Age Toys

● Nonviolent video games ● Board games
● Books ● Jump rope
● Music ● Collecting items

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 ● Bike riding ● Organized sports

School Age procedure prep

Position
● Prefer sitting
● Cooperative in most positions
● Younger child prefers parent's presence
● Older child may prefer privacy
Sequence
● Proceed in head-to-toe direction.
● May examine genitalia last in older child.
Preparation
● Respect need for privacy.
● Request self-undressing.
● Allow to wear underpants.
● Give gown to wear.
● Explain purpose of equipment and significance of procedure, such as otoscope to see
eardrum, which is necessary for hearing.
● Teach about body function and care.

Lice
● Pediculosis capitis (head lice) is the most common in children
● Teach parents:
○ Primary prevention: do not share hats, combs, clips, towels
○ Fine tooth comb, wash objects with hot water
■ Comb hair every day until no more nits/lice
○ Med: pediculicide, permethrin 1% cream rinse (Nix)
■ 2nd treatment in 7 days

ADHD Med: effects

● Do not take stimulants if child has tics/Tourette’s syndrome
● Monitor for side effects, including: appetite loss, abdominal pain, headaches, sleep
disturbances, and growth velocity
● Closely monitor blood pressure and growth

Tanner Stage
● Girls
○ Stage 1: no pubic hair, same appearance as childhood (immature)
○ Stage 2: sparse growth of straight, downy slight pigmented hair. Breast bud
stage= small elevation & enlarge areola diameter
○ Stage 3: hair darker, coarser, spread sparsely over pubis & forms triangle.
Further enlargement w/ no separation of contour

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 ○ Stage 4: pubic hair denser & curled, less condensed to area. Projection of areola
& papilla, forms secondary mound
○ Stage 5: hair spreads to thighs. Mature configuration, projection of papilla
● Boys
○ Stage 1: no pubic hair, same as childhood (immature)
○ Stage 2: initial enlargement of scrotum & testes, reddening & texture changes,
sparse growth of long straight slight pigmented pubic hair
○ Stage 3: increase in penis & scrotum size, mainly length, hair darker, curlier &
spread throughout pubic
○ Stage 4: increase in diameter of penis & glands; glands are larger & broader,
scrotum darker in color; pubic hair increases and curly, stays in area
○ Stage 5: penis, testes, scrotum are adult size; hair spreads to thighs (mature)

School Age Safety

● Bike helmet ⁠— teaching
● Skateboard/scooter safety
● ************

Chapter 35: Adolescent

Adolescent Development
● Physical Development:
● Final height achieved during puberty
● Acne
● Girls stop growing after 2 years of menarche; boys stop growing at 18-20 years
old
● Female sexual maturation: (in order)
1. Breast, 2. Pubic hair, 3. Axillary hair, 4. Menstruation
● Male sexual maturation: (in order)
1. Testicular enlargement, 2. Pubic hair, 3. Penile enlargement, 4. Axillary
hair, 5. Facial hair, 6. Vocal changes
● Cognitive Development
○ Piaget: formal operations
○ Think through more than two categories of variables
○ Can evaluate the quality of their own thinking
○ Maintain attention for longer periods of time
○ Imaginative and idealistic
○ Think beyond current circumstances ⁠— abstract thinking
● Psychosocial Development
○ Try different roles to develop their identity
○ Group identity: become part of a peer group that influences behavior
○ Peer relationships act as support system, relationships are more stable and
longer lasting
○ Parent child relationships change to allow independence

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 ○ Swing in emotions are common ⁠— outward expression of emotion
○ Stability of emotions/anger develops later in adolescence
○ Middle adolescence: introspection
● Sexual identity:
○ Same sex frends that can involve sexual experimentation
○ Self-exploration
○ Friendships to intimate relationships
○ Late adolescence: sexual identity through integration of sexual experiences,
feelings, and knowledge
● Health perceptions:
○ Views themselves as invincible to risky behavior

Anorexia
● Note: normal BMI range is 18.5–24.9 (women)
● Body weight <85% of expected norm
● What to look for: low BP, weakness/fatigue, plays with food, amenorrhea, bradycardia,
thin hair, brittle nails, constipation, lanugo, joint swelling, hypothermia, prolonged QT
interval
○ Pregnancy test if prolonged amenorrhea
● Perfectionist, high achiever, wants control
● DSM: fear of gaining weight, strong need to control environment, emancipation, elevated
liver function, leukopenia, preoccupation with food depressive symptoms, social
withdrawal, irritability, insomnia
● Tests: SCOFF score ≥ 2
○ Do you make yourself sick because you feel full?
○ Do you worry that you’ve lost control over how much you eat?
○ Have you recently lost more than 14 pounds in a 3 month period?
○ Do you believe that you are fat when others say you are too thin?
○ Would you say that food dominates your thoughts?
● Nursing management:
○ Comprehensive cardiac evaluation
○ Restore nutrition, re-establish normal eating behavior
● Warning: refeeding syndrome ⁠— cardiovascular, neurologic, and
hematologic complications that occur when nutritional replacement is
given too rapidly; give phosphorus with meals
○ Maintain weight
○ One-on-one supervision at meals
○ Multi-vitamins
○ High fiber, low sodium
○ Weight checks
○ Watch for complications: electrolyte imbalances, urinary tract problems, cardiac
arrest, orthostatic hypotension

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Chapter 39: Pediatric Variations of Nursing Interventions
Consent
● Requirements
○ person must be capable of giving consent (over the age of majority & is
competent)
○ supplies with information needed to make a decision
○ acts voluntarily when exercising freedom of choice
● separate informed consent must be given for each procedure or diagnostic test
● assent
○ child or adolescent has been informed about the treatment & is willing to permit it
to be done
● physicians responsibility to gain consent
● nurses responsibility to witness signature of person granting consent
Med Admin
● administering liquids to infant
○ place med in mouth with a spoon, plastic cup, dropper or syringe (w/o needle)
○ place syringe on the side of infants tongue and administer in small amounts
○ never add medication to infants formula or baby food
Procedure prep
● For most procedures, focus of care is psychological preparation of the child and family
○ Preparation for procedures decreases anxiety, promotes cooperation, supports
coping skills and facilitates a feeling of mastery in a potentially stressful event
○ For painful procedures sensory procedural information and helping the child
develop coping skills (relaxation or imagery) are most effective
○ Follow age-specific guidelines for preparation (p. 1069 and 1071-71)
● Establish trust and provide support
○ Establishing a positive relationship with a child makes gaining cooperation easier
○ No painful procedures should occur during the first visit
● Parental presence and support
○ Nurse should assess the parents’ preferences for assisting, observing or waiting
outside the room and the child’s preference for parental presence
● Provide an explanation
○ Age appropriate explanations reduce anxiety
○ Before the procedure, explain what is to be done and expected of the child
■ Should be short, simple and at the child’s level of comprehension
○ Allow children to handle items involved in their care to develop familiarity to these
items and reduce fears

Isolation in Children (?)

● Children cannot play with other children/peers and participate in school while in the
hospital

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Restraint Use
● Use least restrictive method
● Not needed when staff/parents are around
● Before initiating a behavioral restraint, the nurse should assess the patient's mental,
behavioral, and physical status to determine the cause for the child's potentially harmful
behavior
● Behavioral restraints for children must be reordered:
○ Every 1 hour for children younger than 9 years of age
○ Every 2 hours for children 9 to 17 years of age
○ Orders for adults 18 years of age and older are required every 4 hours
● Assessment components include signs of injury associated with applying restraint,
nutrition and hydration, circulation and range-of-motion of extremities, vital signs,
hygiene and elimination, physical and psychological status and comfort, and
readiness for discontinuation of restraint
● Types of restraints
○ Mummy Restraint and swaddle
■ When an infant or small child requires short-term restraint for examination
or treatment that involves the head and neck, a papoose board with
straps or a mummy wrap effectively controls the child's movements
○ Jacket restraint
■ Sometimes used to keep the child safe in various chairs.
■ Jacket is put on the child with the ties in back so the child is unable to
manipulate them.
■ useful as a means for maintaining the child in a desired horizontal position
■ The long tapes, secured to the understructure of the crib, keep the child
inside the crib
○ Arm and Leg Restraints
■ Used to restrain one or more extremities or limit their motion
■ disposable wrist and ankle restraints
■ must be appropriate to the child's size and padded to prevent undue
pressure, constriction, or tissue injury; and the extremity must be
observed frequently for signs of irritation or impaired circulation.
■ The ends of the restraints are never tied to the side rails because
lowering the rail will disturb the extremity
○ Elbow Restraint
■ Used to prevent the child from reaching the head/face ⁠— cleft lip, palate
surgery
■ extend from just below the axilla to the wrist and are sometimes referred
to as “no-no's”
○ A shoulder strap to prevent slipping may be used in an awake, active older infant
or toddler to prevent slippage, but should not be used when sleeping.

Vaccine by Age (ATI)

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Age Vaccine

Birth Hepatitis B

6 weeks Rotavirus (RV); Diphtheria, tetanus, &

acellular pertussis (DTaP); Haemophilus
influenzae type b (Hib); Pneumococcal
conjugate (PCV13); Inactivated poliovirus
(IPV)

2 months Meningococcal conjugate (MenACWY)

9 months Meningococcal conjugate (MenACWY)

6 months Inactivated influenza vaccine (IIV)

12 months Haemophilus influenzae type b (Hib);

Measles, mumps, rubella (MMR);
Varicella (VAR); Hepatitis A (HepA);

9 years Human papillomavirus (HPV)

10 years Meningococcal (MenB)

11 years Tetanus, diphtheria, and acellular

pertussis (Tdap); tetanus and diphtheria
(Td)

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