NRS104 PEDS

• Sudden unexplanned death syndrome of an infant younger than 1 year old
• Most death associated with sleep" Crib death"
• First leading cause of postneonatnal death btw 1& 12 mos
• Peak age of incident: 2-3 mon
• 3th leading cause of infant deaths (birth-12 mos)

• UNKNOWN. Other unexplaned apnea and factors are:
• Sleep prone (Respirator muscle are constricted)
• Bedding
• Viral respiratory or botulism infection
• Pulmonary edema
• Brain stem abnormality. Deficiency of neurotransmitter
• HR abnormalities
• Distorded famalial breathing pattern
• Decrease arousal responses
• Possible lack of surfactant in alveola
• Low social economic status
• Highly incidence of male than female

• Preterm Babies; Multiple birth rate
• Babies who are placed to sleep prone position
• Infants of adolescent mother or close spaced pregnancies
• Underweighted infants
• Infants with apnea, brochopulmonary dysplasia, twins, CNS & respiratory disorders
• Greater incidence: N-A, A-A, Hispanic
• Infants of narcotic-dependent mother
• Subsequent siblings of 2 or more SIDS victims

• Dishelved bed, with blankets over head & huddled in a corner
• Mouth and Nostril: Forthy, blood tinge fluid
• Position: Lying down in secretions
• Complete bowel & bladder incontinence

• ASK only FACTUAL questions (When, How?)
• AVOID any remarks suggestion responsibility
• LET the perents HOLD, TOUCH, & ROCK the baby
• ALLOW them to say good-bye
• STRESS that death isn't their fault

AUTOPSY

• Pulmonary edema
• Petechiae in lungs
• Chronic hypoxia dues to Inflammation and Other minor changes
• R/O suffocation and aspiaration as a cause of death

• Turmoil Phase: 1 week post death
• (behavior: structure thinking is common)
• Impact Phase: disorganized thought
• Home visit RN as soon as after death
• Reassure other children in the family
• Frightening of the birth of another child
• Referrals to support group for a year or more

All newborns should be put to sleeps on their back (supine position) (AAP, 1992)

• Infants: Appearant Life-Threatening Event (ALTE)
• New baby: sleeping study precaution within first 2 weeks of life
• --Child placed on home apnea monitoring/or cardiopulmonary monitor machine

• Supine position
• Firm sleep surface
• No Soft objects, Toys, Loose Bedding near sleeping area
• Avoid letting the baby overheated during sleeping
• Think about using a clean, dry pacifier when placing baby down to sleep

Spritual Stress

• Educating family of newborns: risk for SIDS
• Educating regarding PRONE sleep positions in infants from birth-6mos age
• Use of appropriate bedding and dangers of co-sleeping (pet, stuffed animals)
• Modeling appropriate behavior in hopsital
• Provide emotional support
• Recommended attending support groups
• Recommended learning CPR in the future
• Prevention of Positional Plagiocephaly: vary infants head positions

• Infant: Apneic, gently stimulate the trunk by patting or rubbing it
• Infant prone: turn to back and flick the feet
• No response: begin CPR and activate EMS-call 911
• NEVER vigoriously shake the child
• No more than 10-15 seconds are spent on stimulation before implementing CPR

National Fundraiser & SIDS awareness day

• PERRLA
• • Pupils
• • Equal
• • Round
• • Reactive
• • Light
• • Accommodation

• Shows the structures of the back
• of the eyeball or (fundus)
• • Fundus apparent as “Red
• reflex”
• • Optic disc: creamy pink

Area with greatest concentration of visual receptors

Fovea centralis

• It is vital for early detection of vision and life threatening abnormality: cataract, gloscoma, abnormality with retina and any systemic
• diseases
• Red Reflex should be: Brilliant, uniform reflection of red
• Older children’s RR are deepper pigmented and Infant is ighter

• Leukokoria
• Absent RR
• Bruckner reflex: symmetry of the reflex

Tests for Amblyopia & Strabismus

• 3 years old
• (AAP recommended as early as possible)

Preschool E Chart (Tumbling E)

Lazy eye: Reduced visual acuity in one eye

• One eye does not receive sufficient stimulation
• Child uses only “one” eye while “resting” other
• Central vision fails to develop if prolonged; or if developed, it fades

• Poor vision in affected
• Misaligned eye

• Correctable if treated early
• Ambylopia: before age 6
• After age 6: correction is diminished

• Good eye: cover by patch
• (force the child to use the poor eye)
• Remove patch one hour each day
• (prevent the good eye become ambylopia)
• Eyedrops

“Squint” or “Cross eye”—Misalignment of eyes

• Unbalanced muscle control
• Visual axes are not parallel so the brain receives 2 images and ambylopia results
• Resting position of one eye:
• Divergent (turned out)
• Convergent (turned in)

Infants eyes are may crossed occasionally until 6 weeks of ages = normal but eventually disappear but if they continue pass these age needs for referral. However, if infant demonstrate constant Strabimus then better referral immediately)

• See double
• Suppression
• Anomalous retinal correspondence

• Squinting of eyelids together or frowning
• Difficulty with focusing one distance to another
• Inaccurate judgment in picking up objects
• Inability to see print or moving objects clearly
• Tilts head to one side

Constant Assessment strabismus before 6 weeks of age older than that need immediate referral

• Exotropia (eye turning out)
• Esotropia (eye turning in)
• Hypertropia (eye turning up)

• Best detected when child examine’s a nearby object
• Cover test (if pseudostrabismus)
• Corneal light reflex (Hirshberg’s)
• Strabismus: most usual typefound in children

• Eye exercise (orthoptics)
• Occlusion therapy
• Glasses
• Patching
• Surgery
• Injections of botulinum

• Soreness 1-3 hr post
• Antibiotic oint 2-3 days post
• Pain on eye movement: 1st post-op day >2 yr: pain
• and antiemetics
• “Foreign body sensation”
• Red eyes: 1-2 weeks post

• Penetrating wounds
• Result of sharp instruments
• Propulsive objects
• Powerful contusion (blunt trauma)
• Non-penetrating wounds
• Foreign object
• Laceration
• Blow from blunt object

“Black Eye” result of Trauma

• Use flashlight to check for gross hyphema
• Apply ice 1st 24 h if nohyphema present: decreases swelling
• Refer to opthalmologist stat if hyphema
• Have child rest with eyesclosed

• Is Inflammation of conjunctiva
• Newborns: chlamydia trachomatis (inclusion conjunctivitis)
• N. gonorrhea (ophthalmis neonatorium: most serious)
• HSV-- ocular damage
• Recurrent conjunctivitis-- nasolacrimal duct obstruction
• Chemical conjunctivitis-- instillation

• Bacterial: PINKEYE
• Viral
• Allergic (allergy season)
• Foreign body conjunctivitis
• Hemorrhagic

• Crusting: waking-up in the morning
• Matting: crustiness and stuck/matted or glue together
• Flame and swollen-
• Burning and itching
• Photophobia

• Fluoroquinolones: Best ophthalmic antibiotic agent. Approved for children 1yr & older
• Ciloxan, Ocuflox, Quixin
• Vigamox-- new 4th gen
• Fluoroquinolone
• Ointment
• No corticosteroids-- reduces ocular resistance to bacteria

• Keep eye clean
• Administer ophthalmic agents
• Eye care
• Warm, moist compresses

• Signs: serious conjunctivitis
• Reduction or loss of vision
• Ocular pain
• Photophobia
• Exophthamalmos
• Decreased ocular mobility
• Corneal ulceration
• Unsual patterns of inflammation
• Refer to ophthamologist immediately

• "SCOR"
• Semicircular canal
• Cochlea
• Oval Window
• Round window

• "TAME"
• Tympanic membrane: eardrum
• Auditory Ossicles (Incus, Malleus, Stappe)
• Middle Ear Cavity
• Eustachian Tube

• Observe:
• -Proper alignment
• - Opening to ear canal
• - Area in front of the ear forderma sinus or skin tag
• -Ear lobes for redness ordrainage
• Assess ear for hygiene
• Touch the pinna & Watch for evidence ofpain

• Straighten ear by
• Pulling pinna gently down &back in children <3
• Pulling pinna gently up and back >3

Translucent, light pearly pinkish to greyish

should reflect at about the 5 or 7 o’clock position

• External Otitis
• Otitis Media
• – Acute (AOM)
• – with Effusion (OME)
• – Chronic OM
• Greater than 3 months=Can lead to hearing loss/delayed speech

• Inflammation of the middle ear
• Incidence: highest in winter months
• Bacterial OM: Preceded by a viral respiratory infection
• Viruses most likely to precipitate OM: RSV and influenza
• Age: 6-36 months of age & again at 4-6 yrs
• High incidence: homes where parents smoke

Eustachian tube is short, wide, straight and lies in a horizontal plane

• Three most common bacteria causing AOM:
• 1. Strep pneumoniae,
• 2. H. influenza &
• 3. Moraxellacatarrhalis
• Relationship b/w OM & infant feeding methods

• Secondary smoke
• Formula feeding [positioning]
• Day care
• Pacifier: > 6 mos

• Follows an URI
• Acute ear pain “Otolgia
• Pull or tug at affected ear (Infant or very young)
• Yellow, red, inflammed, full/bulging TM
• Fever, n/v /d
• Cold “rhinitis"
• Irritability & fussiness
• Otorrhea

Ear drum perforation

• TM-- reddened, inflammed, purulent discolored effusion and a bulging, full, opacified immobile membrane
• Decreased mobility on pneumatic examination
• Tympanocentesis
• Tympanometry

• Fever/Analgesic (acetaminophen (Tylenol),
• ibuprofen (Motrin) [>6 mos.]
• Topic anesthetic drops
• Antibiotics: Amoxicillin (Amoxil): DOC
• IM ceftriaxone (Rocephin)
• Surgery
• – Myringotomy
• – Tympanostomy tube [PE tubes] placement
• -- Adenoidectomy

• Identification of symptoms
• Pain and fever mgmt.; medications; instillation of topical anesthetic
• Parent & child teaching
• Administration of IM antibiotics (some cases)
• Emotional support
• Nursing care following myringotomy, tympanostomy tube placement &adenoidectomy

• Pull the ear down and back to instill eardrops in infants/toddler (↓3 years pull ↓)
• Pull the ear up and out (back) to instill inolder children (↑ 3 years pull ↑)
• Have medication at room temperature

• Inflammation of external ear canal
• “Swimmer’s ear”
• Causative organism: Pseudomonas and Candida

• Itching of canal
• Pain
• Small amt. drainage
• Sensation that ear: blocked or full
• Fungal infection-- brown or black (entire canal)
• Inflammation from foreign object--white or graydebris around object
• skin under object-- moist, red and eroded.

• TM visualization
• Weber test
• Audiogram
• Tympanogram

• Antibiotics
• Ear drops: hydrocortisone
• Antipyretic
• Burow’s or acetic acid solution
• Ear plugs for swimming
• No foreign objects into ear

• Keep ear dry
• Avoid swimming and hair wetting
• Insert ear plugs (showering)
• Do not use Q-tips
• Reinforce complete antibiotic therapy

• Fluid in the middle earspace without symptoms ofacute infection
• Occurs as a result ofchronic OM
• Fluid in ear-- sterile, thick, tenacious: “glue-like”
• Peaks spring & fall allergies

• Muffled hearing
• Feeling of pressure in ear
• Light reflex: distorted
• TM: tends to retract

• Mild: antihistamine/nasaldecongestant
• Adenoidectomy
• Tubal myringotomy

• Medication compliance as ordered
• Emotional support
• Encourage parents to notify school nurse of problem
• Remind child/parent that water should not enter theear
• Hair washings with ear plugs in place
• Swimming-- depends

Cerumenex

• Measures body fat with Lange calipers
• Most common site for measuring skinfold thickness--
• Triceps
• Subscapula
• Suprailiac
• Abdomen
• Apper thigh

• Detailed drawing or anatomically correct doll: preschoolers/older children learn about body
• Paper-doll technique: teach children about bodypart being examined

• Examine PAINFUL AREAS LAST–
• In emergency situation:
• Examine vital functions (Airway, Breathing &Circulation) & Injured area FIRST

• Holding up head steadily (6 mos head lag well established or not)
• Sitting alone without support
• Walking without assistance
• Meaningful speech
• Present grade in school
• Scholastic performance
• Friends/interactions with others (Loner children are not healthy)

• Physical growth parameters
• Weight
• Height (length)
• Arm/ Head circumference
• Skinfold thickness

• National Center for HealthStatistics (NCHS): most commonly used
• – Percentile curves that illustrate distribution of selected body measurement in children.

• > 95 percentile: overweight
• > 85th & <95percentile: at risk for being overweight

• Ht & wt percentiles widely disparate:
• Ht in 10th percentile
• Weight in 90th percentile, esp. with above average skinfold thickness

• Wall-mounted stadiometer: most accurate measurement
• Measurement taken when child is standing upright

Size Variations

• Supine (recumbent length)
• Until 24 mos. old (or 36 mos. if using the chart for birth-36mos)
• Children measured for recumbent length: weighted on an infant platform scale in lying position.

• By gender and prematurity if appropriate
• <5th or >95th percentile

• Measure with appropriate size balance beam scale that measures wt to the nearest 10 g (0.35 oz.) for infants & 100g (0.22 lb) for children.
• Balance scale before weighing by setting at 0
• Birth-36 mos charts used: weight nude
• Older children: wearing underpants or a light gown(*remember respect privacy of all children)
• Children measured for recumbent length--weighted on aninfant platform scale in lying position
• Maximum asepsis--cover scale with a

• Measure up to 36 months
• In any child whose head is questionable
• Measure at its greatest circumference, slightly Above the eye brows
• Pinna of ears
• Around occipital prominence at the back of the skull

• Birth-2y: (AR) axillary; rectal (if definitive one is needed for infant over 1month)
• 2-5 y: (OATR) oral, axillary, tympanic, rectal (if definitive temp needed)
• 5 y: (OAT) oral, axillary, tympanic

Apical pulse

Children > 3 y through adolescent

• If cuff too small: falsely High
• If cuff too large: falsely Low

• Below 90th percentile: Normotensive BP
• Between 90th & 95th percentile: prehypertension
• Over 95th percentile: Hypertension

• Systolic B/P decrease of at least 20 mm Hg
• Diastolic B/P decrease of at least 10 mm Hg within three minutes of standing

• Syncope (fainting)
• Vertigo (dizziness) or lightheadedness
• Decreased blood flow to the brain: (cerebral hypoperfusion)
• Occurs with sudden changes from sitting to standing to lying

• Hypovolemia (diuretics)
• Vasodilators
• Prolonged immobility or bedrest
• BP measurements: child supine then standing

Palmar crease with line of V shape, may indicate/associate with mental challenge or down syndrome

Wryneck (torticollis)

Hyperextension of the head (opisthotonos) w/pain on flexion: serious sign of meningeal irritation => Refer for medical evaluation immediately

• Any masses detected in the neck, report them for further investigation.
• Large masses can block the airway.

• Encouraging opening of mouth
• – Perform examination in front of mirror
• – Let child first examine someone else’s mouth & then examine child’smouth
• – Instruct child to tilt head back slightly, breathe deeply via the mouthand hold breath.

• Size,
• Shape
• Symmetry
• Movement
• Breast development
• Bony landmarks formed by theribs and sternum.

• Anterior axillary line (vertical from anterior axillary fold
• Mid axillary line (vertical from apex of axillary)
• Posterior axillary line (vertical from posterio axillary fold)
• Scapular line
• Vertebral line

• 2 lungs: 1 Left & 1 Right
• 2 Right lobes
• 3 Left lobes
• 10 Segments on Right lung
• 8 Segments on Left lung (less segment b/c of the heart)

• Normal = BBV
• Bronchial: over trachia
• Bronchiovesicular: over main bronchi
• Vesicular: over lesser bronchi, bronchioles, and lobes

• Vesicular: Heard over entire surface of lung except major bronchi
• Bronchovesicular:
• -- Anteriorly over mainstem bronchi on either side of the sternum(manubrium)
• -- Posteriorly (b/w upper intrascapular) regions where trachea & bronchi birfurcate
• Bronchial: Heard over trachea near suprasternal notch
• Abnormal breath sounds (ABS):
• Adventitious sounds: heard along with ABS are
• -- Bronchi: snoring in the chest
• --Crackle: air , moist, russling of leaves
• --Wheeze: musical sound
• --Stridor: crowling sound, repiratory obstruction

Most lateral cardiac impulse that may correspond to the apex.

• Lateral to the LMCL & 4th ICS in children: < 7 yrs
• At the LMCL & 5th ICS: children > 7 yr

At Area of most intense pulsation. LMCL at 5th ICS

Brisk: less than 2 seconds

• S1 & S2: normal heart sounds: “lub-dub”
• S1: closure of tricuspid and mitral valve(Atrioventricular valve (AV)
• S2: closure of the pulmonic and aortic valve(Semilunarvalve)

• Split of both sounds in S2 is distinguishable and widens during inspiration
• (physiologic splitting: normal finding)

Fixed splitting in which S2 does not change during inspiration, is an important diagnostic sign of atrial septal defect.

• S1: louder at apex in mitral & tricuspid area
• S2: louder near base of heart in pulmonic & aortic area

2 positions: sitting & reclining

Genu Varum (toodlers who have bowleg)

Genu Valgum

• Dorsiflexion: big toe and Fanning toes
• During Infancy: Normal
• After one year: Abnormal

• Tests for cerebellar function:
• – Romberg test
• – Finger-to-nose test
• – Heel-to-shin test

• CN III: Oculomotor
• CN IV: Trochlear
• CN VI: Abducent
• CN VIII: Vestibulocochlea

• Tests extraocular eye movements
• Indicates functioning of CN III, IV, VI