Common Vital Signs
Younger kids normally have a _____heart and respiratory rate.
higher
Areas of development include:
Fine motor skills (hand-eye)
Gross motor skills (large muscle)
Language
Social skills
Adaptive skills
What is a febrile seizure and what nursing interventions should be done?
Febrile seizure is triggered by rapid rise in body temp (fever).
Nursing interventions: manage fevers appropriately (meds or cooling methods), educate parents on managing fevers, and antibiotics if due to a bacterial infection.
What data should you collect in your assessment on a peds patient with a respiratory problem?
Gather history of present Illness and past medical history
Fever?
Age? 6 months-3 years more severe reaction
PO intake, vomiting, diarrhea, abdominal pain?
Cough or sore throat?
Nasal blockage or discharge ?
Urine output?
Onset?
A school nurse witnesses a student having a tonic-clonic seizure. What actions should the nurse take? (SATA)
A. Turn the child onto their side
B. Note the start time and duration
C. Place a soft object under the child’s head
D. Insert an oral airway to protect the tongue
E. Remove nearby objects
Turn the child onto their side, Note the start time and duration, Place a soft object under the child’s head, Remove nearby objects
Blood pressure gradually _____ with age.
rises
General assessment for patient with congenital malformations
Always assessing milestones of the patients
Assessment of any obvious physical malformations that are related to the issue.
Surgical intervention
Medications
Family support systems (care-giver role strain)
What is the general definition for cerebral palsy?
Wide range of conditions impacting motor and intellectual abilities of children. Damage done to brain before, during (these are congenital cerebral palsy) or after birth (acquired cerebral palsy).
6 nursing interventions for Children with Acute Respiratory Infections
1. ease the respiratory effort (humidified air & positioning)
2. fever management
3. control infection
4. promote hydration & nutrition
5. provide family support and teaching
6. monitor oxygen and be prepare to suction
The nurse is preparing teaching for parents of a child with cerebral palsy. What education is most important?
A. The child will eventually outgrow the condition
B. Early physical, occupational, and speech therapy is essential
C. Surgery will fully correct motor impairments
D. There is no benefit to supportive device
B. Early physical, occupational, and speech therapy is essential
Early multidisciplinary therapy helps the child reach their functional potential; CP is a lifelong condition.
Newborn HR, RR, and SBP?
100-180 bpm, 30-60 breathes/min, 60-90mmHg
What are the three types of focal seizures?
Focal without impaired awareness: jerking, unusual sensations, altered mentation, NO loss of consciousness
Focal with impaired awareness: lip smacking, chewing, restlessness, NO loss of consciousness
Focal to bilateral tonic/clonic (generalized): partial symptoms leading to loss of consciousness and convulsive movements
Name the types of CP
Spastic (most common): common trait is stiffness in various parts of the body, impairment of motor skills
Dyskinetic: common trait is involuntary slow movements of body parts, oral muscles involved
Ataxic: rapid, repetitive movements, wide gait
Mixed: components of spastic and dyskinetic
No wheezing or hearing nothing is good in an asthma patient. True or false?
False! Very narrowed airways, life threatening.
A child with CF is admitted with increased cough and thick sputum production. What nursing interventions are priorities? (SATA)
⬜ Administer pancreatic enzymes with meals
⬜ Provide airway clearance therapy (CPT or vest therapy)
⬜ Encourage high-calorie, high-protein snacks
⬜ Restrict fluids to prevent aspiration
⬜ Monitor for signs of infection
Administer pancreatic enzymes with meals, Provide airway clearance therapy (CPT or vest therapy), Encourage high-calorie, high-protein snacks, Monitor for signs of infection
CF care includes nutrition, airway clearance, and infection monitoring. Fluids should not be restricted.
Preschool age HR, RR, SBP?
80-120bpm, 20-28 breaths/min, 98-112 mmHg
Once a child hits adolescence, they have the same vitals signs as adults (but lower BP)
What are the five generalized seizures?
Tonic-clonic: muscle rigidity, loss of consciousness, jerking of extremities incontinence
Absence: brief loss of consciousness
Myoclonic: brief isolated jerking movements
Tonic: muscle rigidity
Atonic: loss of muscle tone
Early recognition (Always going back to appropriate milestones)
No cure, so early interventions are imperative
PT
OT
Education
Family Support
Acute Asthma Management
Removal from trigger
Quick relief “rescue” medications
Corticosteroids, PO, IV, Inhaled
Bronchodilators: B-adrenergic agonists
Oxygen therapy
Monitor for response to medications and be prepared for deterioration
A nurse is assessing a 3-month-old infant admitted with bronchiolitis. The vital signs are: Respiratory rate 65 breaths/min, Heart rate 180 bpm, Temperature 38.5°C (101.3°F), Oxygen saturation 89% on room air. Which finding requires the nurse’s immediate priority intervention?
A) Heart rate of 180 bpm
B) Respiratory rate of 65 breaths/min
C) Oxygen saturation of 89%
D) Temperature of 38.5°C (101.3°F)
C) Oxygen saturation of 89%
Oxygen saturation below 90% indicates hypoxia, which requires prompt intervention to improve oxygenation. Elevated heart and respiratory rates are concerning but secondary to the immediate need to address hypoxia. Fever is expected with infection but is not the highest priority.
Normal peds temperature range
36.5-37.5C (97.7-99.5F)
Typical fever is defined at 38C or above
TIME, TIME, TIME!!! (Time the seizure)
Describe the type of seizure taking place
Maintain airway patency (turning to side to avoid aspiration)
Nothing in mouth or restrained
Keep surroundings free and clear of clutter and stuff
Bumper pads, oxygen and suction available in hospital room
Medication management (Diazepam, Clobazam, Keppra, etc.)
Impact of seizures on development and achievement of milestones
Parent education on managing and dealing with seizures at home
What is a general assessment tip to fall back on?
Always go back to patients appropriate milestones
What is Cystic Fibrosis and why is it important for respiratory and GI?
Cystic fibrosis (CF) is a genetic disorder that causes thick, sticky mucus to build up in the lungs, pancreas, and other organs.
Respiratory system: the mucus blocks airways, leading to chronic infections and breathing difficulties.
GI system: obstructs pancreatic ducts, impairing digestion and nutrient absorption. Early diagnosis and management are critical to prevent complications and support growth and lung function.
A nurse is performing a neurological assessment on a 9-month-old infant. The infant does not roll from stomach to back or babble any sounds. What is the nurse’s best action?
A) Document findings as normal for age
B) Refer the infant for further developmental evaluation
C) Encourage the parents to try more tummy time at home
D) Reassess again in 2 months
B) Refer the infant for further developmental evaluation
By 6 months, infants should be rolling and starting to babble. Delay in these milestones may indicate neurodevelopmental concerns that require prompt evaluation and intervention.