Pediatric GI and Fluids Study Guide

Pediatric GI & Fluids Study Guide​ (NUR 328 – Exam 2, Sefton Lecture) 1. Fluid & Electrolyte Fundamentals — Because Nothing Else Matters if the Kid Is Dry Key Numbers Remember Why 100 / 50 / 20 rule – 100 mL/kg for first 10 kg, 50 mL/kg for second 10 kg, 20 mL/kg for every kg > 20 kg This is your maintenance fluid calculator. A 32 kg child needs 1 740 mL/24 h—you’ll be pimped on this math in clinicals. Degrees of dehydration – mild < 5 % (infant), moderate 5–10 %, severe > 10 % Don’t guess: weigh the kid and trend vitals/LOC. Increased fluid needs – fever, burns, DKA, phototherapy, tachypnea If they’re hot, breathing fast, or glowing under bili-lights, crank up the fluids. Decreased fluid needs – HF, SIADH, renal failure, ↑ICP Over-hydrating these kids is a fast track to the PICU. Assessment pearls ●​ Cap refill, tears, urine output, fontanelle, and weight trends trump isolated lab numbers. ●​ In the ED, start with 20 mL/kg isotonic bolus for moderate–severe dehydration, then reassess. ●​ Oral rehydration therapy (ORT) is magic—give 1 mL per 1 mL stool loss in small sips or via NG; no sugary sodas. 2. Vomit, Poop, & Everything In Between Problem Red-Flag S/Sx Management Priorities Vomiting Bilious? think obstruction; Projectile? pyloric stenosis NPO, prevent aspiration, correct lytes Diarrhea (Acute vs Chronic) >10 days, bloody, wt loss ORT, no antidiarrheals < 2 yr, skin care Constipation Ribbon stools → Hirschsprung “P-fruits,” water > milk, toilet time with feet on stool 3. Structural & Motility Disorders Hirschsprung Disease (Congenital Aganglionic Megacolon) ●​ Patho: No ganglion cells → no peristalsis → functional obstruction. ●​ Signals: Failure to pass meconium < 36 h, distention, bilious vomit, ribbon-like stools. ●​ Nursing Moves: Monitor for enterocolitis (fever, foul diarrhea). Post-pull-through: strict I/Os, ostomy teaching, nothing per rectum. GER vs GERD ●​ Physiologic reflux peaks at 4 mo; reassure parents. ●​ Red flags = FTT, apnea, chronic cough → treat as GERD. ●​ First-line: thickened feeds, upright 30 min, PPI/H2 blocker. Reserve Nissen fundoplication for severe cases; watch for post-op dumping syndrome. Hypertrophic Pyloric Stenosis ●​ Projectile, NON-bilious vomit, visible peristalsis, “olive” RUQ mass. ●​ Prep for pyloromyotomy; keep NPO with NG for decompression; expect rapid feeds post-op. Intussusception ●​ Intermittent pain, currant-jelly stool, sausage mass RLQ. ●​ Air-contrast enema can be both diagnostic & therapeutic—have OR on standby. Malrotation & Volvulus ●​ Sudden bilious vomiting = surgical emergency. 4. Inflammatory & Malabsorption Conditions Disease Path Grind Care Plan Highlights IBD (UC vs Crohn) UC: colon→rectum, continuous; Crohn: mouth→anus, skip lesions. Goal = induce & maintain remission: steroids, biologics, high-protein/cal dense diet, psychosocial support. Celiac Autoimmune villous atrophy to gluten (wheat, rye, barley). Steatorrhea, distention, vit-def. Gluten-free for life—don’t pull gluten before biopsy. Peptic Ulcer H. pylori common; NSAIDs are villains. PPIs, eradicate H. pylori, no NSAIDs; surgery if perforated. 5. Acute Abdomen & Surgical “Do-Not-Miss” List Condition Classic Presentation First-Hour Actions Appendicitis Periumbilical → RLQ pain, fever; sudden pain relief = rupture NPO, IV fluids/abx, avoid heat & laxatives. Meckel Diverticulum Painless rectal bleeding, “currant-jelly,” < 2 yr Prepare for resection; monitor H/H. Gastroschisis / Omphalocele Bowel on the outside (no sac vs sac) Sterile, warm, moist dressing; NGT; silo placement; monitor temp & fluids. 6. Hepatic & Biliary Corner ●​ Biliary Atresia: Jaundice > 2 wks, acholic stools, dark urine, hepatomegaly. Needs Kasai or transplant; give fat-soluble vitamins and medium-chain triglyceride (MCT) formula. ●​ Acute Hepatitis / Cirrhosis: Rest, good nutrition, monitor coag labs, no acetaminophen overload. 7. Clefts, Fistulas & Hernias – Airway Is King Disorder Big Risks Nursing Priorities Cleft Lip/Palate Feeding difficulty, otitis media, speech issues. Pre-op: specialized nipples; Post-op: protect suture (Logan bow), no prone, assess airway. EA/TEF 3 Cs – coughing, choking, cyanosis; frothy saliva. NPO, continuous suction, elevate HOB, IV fluids & abx until surgical repair. Inguinal/Umbilical Hernia Incarceration/strangulation. Teach parents reducibility signs; urgent surgery if non-reducible. 8. Short-Bowel Syndrome (SBS) ●​ Usually post massive resection (e.g., necrotizing enterocolitis, volvulus). ●​ High-calorie TPN initially → gradual enteral feeds; watch liver enzymes (TPN cholestasis). 9. Rapid-Fire Critical-Thinking Drill 1.​ 6-month-old with projectile, non-bilious emesis—priority lab? Serum electrolytes for metabolic alkalosis. 2.​ Child post-appendectomy spikes 39 °C temp, HR 160—first check? Listen for bowel sounds & inspect incision for abscess; then notify provider. 3.​ Infant with Hirschsprung pull-through hasn’t stooled in 24 h & fever 38.5 °C—action? Suspect enterocolitis: call surgeon STAT, start IV broad-spectrum antibiotic orders. 10. Exam Hacks & Mnemonics ●​ ●​ ●​ ●​ “DRY” for dehydration: Decreased output, Reduced tears, sunken Yield (fontanelle) GER vs GERD – add the “D” when it’s Damaging or Dangerous. Rule of TWOs for Meckel: 2 % pop, 2:1 M:F, 2 in long, < 2 yr old. P-Fruits fix Poop – pears, peaches, plums, prunes, pineapple, purple grapes. 11. Priority-Setting Framework (because the NCLEX loves it) 1.​ Airway, then Breathing, then Circulation—but in GI kids, Fluid Volume often competes with Airway. 2.​ Pain can wait until you rule out perforation, hemorrhage, or strangulated bowel. 3.​ Family education is safety—teach ORT recipes and suture-line care like it’s your license on the line. Learning Objectives: ​ Identify the conditions that result in altered fluid requirements. ○​ Conditions That Crank ↑ or ↓ Pediatric Fluid Needs Pump Fluids (↑ requirements) Fever, vomiting, diarrhea, burns, shock, DKA, radiant warmer/phototherapy lights, tachypnea Hold Back (↓ requirements) Heart failure, SIADH, renal failure, mechanical ventilation, ↑ intracranial pressure ○​ Why it matters: If you miss that febrile, tachypneic infant under bili-lights needs extra fluid, the next stop is the PICU. ​ Describe the characteristics of infants that affect their ability to adapt to fluid loss or gain. Why Infants Tank Faster (Physiologic “Uh-Oh” List) ●​ ●​ ●​ ●​ ●​ Higher % total body water (≈ 75 %) and extracellular volume → rapid losses. Higher metabolic & respiratory rate → more insensible loss. Immature kidneys → limited ability to concentrate urine or conserve sodium. Large surface-area-to-mass ratio → evaporative losses. Can’t ask for a drink and have limited glycogen stores.​ Practical take: weigh diapers, trend weight q-shift, and never rely on “he looks fine.” Formulate a plan of care for the infant with acute diarrhea. Nursing Plan of Care – Infant with Acute Diarrhea 1.​ Assessment: frequency/character of stools, hydration status (fontanelle, tears, cap refill), weight trend, stool culture if bloody/persistent. 2.​ Fluid Therapy: ○​ ORT first-line – Pedialyte 50 mL/kg over 4 h, then 1 mL per 1 mL stool loss; syringe or NG if needed. ○​ IV 20 mL/kg isotonic bolus if ≥ moderate dehydration. 3.​ Nutrition: continue breast milk/formula; no sugary sodas or juice. 4.​ Skin Integrity: zinc-oxide barrier cream each diaper change. 5.​ Infection Control: contact precautions until etiology known. 6.​ Family Teaching: ORS recipe (½ tsp salt + 6 tsp sugar in 1 L clean water), red-flag signs (no urine > 6 h, sunken eyes, persistent vomiting). Identify children at increased risk of developing nutritional disorders. Kids at High Risk for Nutritional Disorders ●​ ●​ ●​ ●​ ●​ Preterm or low-birth-weight infants Chronic diseases: CF, CHD, IBD, renal failure, cancer Malabsorption conditions: celiac, short-bowel syndrome Food insecurity or restrictive diets (fad, vegan without planning) Iatrogenic: long-term parenteral nutrition, prolonged NG feeds​ Screen early: plot weight-for-length/BMI every visit; check vitamin D and iron in exclusively breast-fed infants. Outline a nutritional counseling plan for vitamin or mineral deficiency or excess. Deficiency Iron – pallor, fatigue Counseling Key Points Iron-fortified cereal @ 4–6 mo; 3 mg/kg/day elemental iron if anemic; give with vit C juice, away from milk Excess/Toxicity Counseling Key Points Iron – abdominal pain, black stools Keep supplements locked; max 40 mg/kg = toxic Vitamin D – rickets 400 IU/day all infants; 600 IU/day older kids; encourage fortified milk & sunlight Vitamin A – bulging fontanelle, liver damage Avoid “megadose” multivitamins Folate/B12 – macrocytic anemia (teen vegans) Dark greens, legumes, fortified cereals; consider oral supplement Niacin-flush energy drinks Discuss safe limits, label reading Zinc – poor growth, delayed wound healing Meat, nuts, whole grains; supplement if SBS Fluoride – mottled teeth (fluorosis) Use rice-sized toothpaste < 3 yr; pea-sized after Pro tip: Always ask about OTC gummies—parents may double-dose. Compare and contrast the inflammatory bowel diseases. Inflammatory Bowel Disease Showdown (Crohn vs UC) Ulcerative Colitis Crohn Disease Location Colon → rectum, continuous Mouth → anus, skip lesions Depth Mucosa/submucosa only Transmural, fistulas, strictures Bleeding Common Less common Diarrhea Pain Bloody stool, LLQ cramp Non-bloody, RLQ pain Surgery Total colectomy cures Resection palliative, risk SBS Nursing Priorities High-calorie/protein diet, monitor growth, steroids/biologics, psychosocial support – teens hate ostomies Describe the nursing care of the child with appendicitis. Nursing Care – Appendicitis ●​ ●​ ●​ ●​ Early signs: periumbilical → RLQ (McBurney), low-grade fever, ↑ WBC. Rupture red flag: sudden pain relief → rigid abdomen. Pre-op: NPO, IV fluids, broad-spectrum antibiotics, no heat/laxatives. Post-op: monitor temp/WBC, advance diet when bowel sounds return, ambulate day 1, teach incision care, watch for abscess. Formulate a plan for teaching parents preoperative and postoperative care of the child with a cleft lip or palate. Parent Teaching – Cleft Lip/Palate Repair ​ Pre-op Post-op Practice upright & specialized nipple feeds; burp frequently; encourage bonding & support groups. Protect suture line: Logan bow or elbow immobilizers 7–10 d; cleanse with sterile saline; no pacifiers, spoons, or straws. Explain surgery timing: lip ≈ 3 mo, palate 9–18 mo; need for future speech/ENT follow-up. Feed with soft-tip syringe or cup; rinse mouth with water after feeds; pain control avoids crying → dehiscence risk. Discuss possible ear tubes & dental care. Stress long-term speech therapy and orthodontics. ​ Formulate a plan of care for the child with an obstructive gastrointestinal disorder. Plan of Care – Obstructive GI Disorders ​ Disorder Immediate Focus Definitive Fix Key Nursing Jobs Hirschsprung Monitor distention, no rectal temps Pull-through surgery Ostomy care, watch for enterocolitis (fever, explosive diarrhea). Pyloric Stenosis Correct alkalosis/deh ydration Pyloromyotomy NG decompress, feed 4–6 h post-op; small, frequent electrolyte-rich feeds. Intussusception NPO, IVF, pain control Air enema (diagnostic & therapeutic) Post-enema: document stool passage; recurrence education. Malrotation/Volvulus Surgical emergency Ladd procedure Observe for sepsis, manage ostomy if bowel resected. ​ Identify nutritional therapies for the child with a malabsorption syndrome. ​ Nutrition Rx – Malabsorption Syndromes ●​ Celiac: strict gluten-free (wheat, barley, rye); teach label reading, hidden gluten (soy sauce, meds). Supplement iron, folate, fat-soluble vitamins. ●​ Short-Bowel Syndrome: Transition TPN → elemental enteral feeds ASAP to promote adaptation; high-calorie, medium-chain triglycerides; monitor liver enzymes & central-line infection. ●​ CF Pancreatic Insufficiency: Pancrelipase with every meal/snack, ↑ fat diet, ADEK vitamins. ●​ Lactase Deficiency: Lactase drops or lactose-free formula; calcium & vitamin D supplements. Communicable & Infectious Diseases Pediatric Study Guide​ (NUR 328 Exam 2, Sefton) I. Infection-Control Foundations — “Gloves On, Brain Engaged” Precaution Tier Core Actions When You’ll Use It Standard Hand hygiene before & after contact; gloves with body fluids; mask/eye shield if splash risk Every patient, every encounter. Airborne N95 or PAPR, negative-pressure room Measles, varicella, TB. Droplet Surgical mask within 3 ft Influenza, pertussis, mumps. Contact Gown & gloves, dedicate equipment RSV, C-diff, impetigo, MRSA wounds. Practical tip: Add eye protection for RSV — the sneezes travel. Primary prevention remains king: timely immunization, parent education, and meticulous environmental cleaning stop most outbreaks before they start. II. Nursing Assessment — Spotting Trouble Early 1.​ 2.​ 3.​ 4.​ Exposure history: daycare clusters, sick siblings, travel. Prodrome patrol: fever, malaise, lymphadenopathy often precede rashes. Vaccination status: under-immunized kids are red-flagged for isolation until ruled out. Past infection record: having had varicella once ≠ repeat in immunocompromised relapse. III. Nursing Care Management — Three Pillars Pillar Prevent Spread Key Moves Correct isolation tier, cohort if rooms scarce, teach “vampire cough,” sanitize toys. (CDC, CDC) Prevent Complications Screen immunodeficient/infants early; give VZIG, IVIG, or prophylactic macrolide when indicated. Support Family Symptom relief (antipyretics, fluids), anticipatory guidance on contagious period, reassurance about appearance of rashes/lesions. IV. Rapid-Reference: High-Yield Pediatric Pathogens Disease Incubation / Peak Age Hallmark Signs Isolatio n Red-Flag Complication s Nursing Priorities Conjunctivitis (newborn vs child) 24 h–14 d Purulent discharge (bacterial), watery & crusty (viral), pruritic (allergic) Contact Corneal ulcer, sepsis in neonate Culture if < 30 d; erythromycin eye ointment; hand hygiene; exclude from school 24 h after abx start. Stomatitis (Aphthous, HSV, HFMD) Variable HSV: clustered vesicles; HFMD: oral + palm/sole lesions Contact Dehydration (painful swallow) Magic mouthwash, ibuprofen, popsicles; no lidocaine in infants (seizure risk). (The Guardian, CDC) Hand-Foot-Mouth 3–6 d / < 5 yr Vesicles Contact mouth/hands /feet Encephalitis, nail shedding Hydration; analgesics; may attend school when afebrile and drool-controlled. Fifth Disease (Parvo B19) 4–14 d / 5–15 yr “Slapped-ch eek” rash → lacy exanthem Droplet Aplastic crisis in sickle cell; fetal hydrops Avoid pregnant caregivers; allow return once rash appears (non-infectious). Pertussis 7–10 d / < 6 mo severe Paroxysmal “whoop,” apnea Droplet PNA, seizures Continuous pulse-ox, cluster care, macrolide for patient & contacts. Varicella 10–21 d Dew-drop rash in crops Airborne Secondary bacterial infection, encephalitis Acyclovir within 24 h if immunocomp; oatmeal baths, mittens. RSV 2–8 d / < 2 yr Copious mucus, wheeze Contact/ Droplet Apnea, respiratory failure High-flow O₂, suction; give nirsevimab to eligible infants pre-season. V. Emerging & Re-Emerging Threats 1. Zika Virus — Think Pregnancy & Neurologic Sequelae ●​ Transmission: Aedes mosquito bite, trans-placental, sexual fluids (men carry longer). ●​ Prevention: Long sleeves, DEET 20–30 %, permethrin-treated nets, condom use. CDC advises pregnant women avoid travel to outbreak regions; couples delay conception ≥ 3 months after male exposure. ●​ Nursing Role: Travel history on prenatal intake; fetal ultrasound referrals; community education on vector control. 2. Bed Bugs — Itchy but Insidious ●​ Bites on exposed skin, often linear “breakfast, lunch, dinner.” ●​ Complications: Secondary impetigo, urticaria, insomnia. ●​ Management: Topical steroids, oral antihistamines; teach full-house heat treatment (≥ 120 °F 90 min) and mattress encasements.​ VI. GI-Related Communicable Issues Agent S/Sx Dx Tx / Education Giardia lamblia Greasy, foul stools, FTT O&P or stool antigen Metronidazole 5–7 d; boil water; no diapered toddlers in pools. Enterobius (Pinworm) Nocturnal perianal itch AM tape test Albendazole once, repeat 2 wk; wash linens hot; cut nails. VII. Immunization & Prophylaxis Updates (2024-25)** Pathogen Product Who Gets It Pearl RSV Abrysvo (maternal vax) OR nirsevimab monoclonal Pregnant 32–36 wk (vax) or all infants < 8 mo without maternal vax Hospitalizations in newborns dropped > 70 % first season. Meningococcus Penbraya (MenACWY-MenB combo) Teens needing both MenACWY + MenB same visit Simplifies schedule; same adverse profile as separate shots. Varicella 2-dose series 12–15 mo & 4–6 yr Give ASAP post-exposure if unimmunized (within 3 days). NCLEX trap-buster: Live vaccines (MMR, varicella, nasal flu) are contraindicated in pregnancy but CAN be given to HIV+ kids if CD4 ≥ 15 %. VIII. Critical-Thinking Scenarios 1.​ You admit a 6-week-old with cough, inspiratory whoop, and 92 % O₂.​ Priority: Droplet isolation, continuous pulse-ox, prepare for apnea spells; azithro for baby & all household contacts. 2.​ Febrile toddler with vesicular rash on palms, refusing fluids.​ Action: Institute contact precautions; offer cool liquids, oral anesthetic spray; weigh strictly for dehydration. 3.​ Three NICU discharges due next week during RSV season; moms unvaccinated.​ Plan: Schedule nirsevimab before discharge; teach parents to limit visitors and smoke exposure. IX. Test-Day Power Reminders ●​ Match rash pattern + prodrome to disease (e.g., Koplik spots → measles). ●​ Isolation tier is ALWAYS chosen by the most contagious suspected pathogen until ruled out. ●​ Know vaccine side effects vs contraindications; mild URI symptoms never delay routine immunization. ●​ For parasites, “treat the kid and the crib”: hot-wash linens, vacuum carpets, cut nails. ●​ Provide at-least-two teaching points on every discharge question: medication dosing and environmental control. Bottom Line Memorizing bug names won’t cut it—link the route of transmission to the right precaution, anticipate the worst complication, and intervene before labs return. Master these patterns and watch your exam questions fall like dominoes. Go forth, glove up, and keep the kiddos contagion-free. Genitourinary Dysfunction - Study Guide​ (NUR 328 Exam 2, Sefton Lecture) 1. Quick Anatomy & Assessment Refresher What to Inspect/Palpate Why It Matters Kidney area for masses or costovertebral tenderness Flags hydronephrosis, Wilms tumor (don’t palpate hard), or pyelonephritis. Bladder percussion (distention) A full bladder + fever can mimic abdominal pathology. External genitalia (meatus placement, scrotal symmetry) Hypospadias or cryptorchidism caught early prevents later infertility issues. History hot-spots: prior UTIs, voiding patterns, toilet training success, instrumentations/catheters, meds (anticholinergics, abx), family renal anomalies. 2. Normal Urinary Benchmarks Age Group Expected Output Newborn 1–2 mL / kg / hr Child ~1 mL / kg / hr Urinalysis Gold Standard pH 5-9, SG 1.001-1.035, protein < 20 mg/dL, urobilinogen < 1 mg/dL. Never see glucose, ketones, hemoglobin, WBCs, RBCs, casts, or nitrates. 3. Urinary Tract Infection (UTI) Crash Course ●​ Most common pediatric pathogen: E. coli (≈ 80 %). ●​ Host problem: urinary stasis (holding pee, constipation, vesicoureteral reflux). ●​ Red-flags by age ○​ Infant: fever, vomiting, foul diapers, failure to thrive. ○​ Child: dysuria, frequency, suprapubic pain, enuresis relapse. ●​ Diagnostics: clean-catch preferred; catheter or suprapubic tap for infants. Dipstick → microscopic → culture > 100 K CFU. ●​ Treatment: empiric TMP-SMX, cefixime, or amox-clav; adjust to sensitivities. 7–14 days for pyelonephritis. ●​ Nursing pearls: encourage fluids, scheduled voids q3h, cotton underwear, wipe front-to-back, avoid bubble baths, remove Foley ASAP. 4. Vesicoureteral Reflux (VUR) Abnormal retrograde urine flow from bladder → ureters/kidneys; reservoir for bugs → recurrent pyelonephritis. Primary = congenital insertion defect; secondary = post-obstruction. Management ●​ Low-dose bedtime antibiotics until outgrown. ●​ Surveillance VCUG q12–18 mo or after febrile UTI. ●​ Surgical ureteral reimplantation if Grade IV-V or breakthrough infections. 5. External GU Defects Cheat-Sheet Defect Key Points Nursing Care Phimosis Tight foreskin; usually resolves. Gentle hygiene; never force retract; steroid cream PRN. Paraphimosis Retracted foreskin can’t EMERGENCY: manual reduction or OR. return → venous congestion. Hydrocele Fluid in scrotum; transilluminates. Reassure; most resolve by 12 mo; post-op scrotal support if repaired. Cryptorchidism Undescended testis. Orchiopexy 6-12 mo; teach self-exam later; ↑ risk infertility/cancer. Hypospadias Ventral meatus displacement. Repair 6-12 mo; no circumcision pre-op; double diaper to protect cath. Exstrophy-Epispadias Complex Bladder & urethra open on abd wall. Cover with sterile non-adherent wrap, keep moist, prepare staged surgery, meticulous skin care. 6. Disorders of Sex Development (DSD) Ambiguous genitalia often from androgen excess/deficiency. Priority = karyotype, electrolytes (risk adrenal crisis), pelvic US. Provide multidisciplinary team, delay gender assignment until evaluation complete. Support parents; anticipate body-image counseling. 7. Nephrotic Syndrome (Minimal-Change) Age 2–7 yr peak. Hallmarks Massive edema, periorbital → dependent Lab Clues 3+ proteinuria, serum albumin < 2.5, ↑ cholesterol Management 1.​ 2.​ 3.​ 4.​ 5.​ Prednisone 2 mg/kg/day until urine protein-free × 3 days, then taper. Na-restricted, normal-protein diet. Diuretics only for severe edema; consider albumin 25 % IV push-pull. Infection surveillance (loss of IgG & steroid use). Daily weights, abdominal girth, I/O. 8. Acute Post-Strep Glomerulonephritis (AGN) Follows GAS pharyngitis/impetigo 1-3 weeks later. ●​ S/Sx: periorbital edema a.m. → body, tea-colored urine, mild-mod HTN, oliguria. ●​ Labs: ↑ ASO titer, hematuria, mild proteinuria, normal cholesterol. ●​ Care: BP q4h, seizure watch, Na/K restriction if oliguric, diuretics, antihypertensives; no abx unless active strep. 9. Hemolytic-Uremic Syndrome (HUS) Triad = microangiopathic hemolytic anemia + thrombocytopenia + AKI. Trigger = Shiga toxin (E. coli O157:H7), viruses, drugs. ●​ Signs: pallor, bruising, oliguria, vomiting, neuro irritability. ●​ Treatment: manage fluids carefully, control HTN, transfuse PRBCs, start peritoneal or hemo-dialysis for anuria/hyperK. No antibiotics or antimotility with enterohemorrhagic E. coli. 10. Acute & Chronic Renal Failure Acute (AKI) Chronic (CKD) Sudden drop GFR often from dehydration, sepsis, obstruction. Oliguria, hyperkalemia biggest threat, metabolic acidosis, fluid overload. Irreversible GFR decline; causes = congenital anomalies, VUR, chronic glomerulonephritis. Leads to uremia, growth failure, bone demineralization, anemia. Nursing Focus: strict I/O, daily weights, limit K⁺ foods, ECG monitoring, seizure precautions, treat cause. Management: renal diet (low Na/K/P, adequate calories), EPO for anemia, phosphate binders, fluid regulation, prepare for transplant. 11. Dialysis & Transplant Primer Modality Pros Cons / Watch-Fors Peritoneal Dialysis (preferred pedi) Gentle, continuous, can be done at home overnight (CCPD). Peritonitis: cloudy effluent, abd pain → culture; maintain aseptic technique. Hemodialysis Rapid electrolyte removal; good for drug OD, severe hyperK. Need vascular access, 3×/wk trips, risk hypotension & disequilibrium. Kidney Transplant Best long-term growth & lifestyle. Lifelong immunosuppression; infection & rejection surveillance. 12. NCLEX-Style Critical-Thinking Nuggets 1.​ Nephrotic kid gains 1 kg overnight: first check girth & breath sounds, then call for IV albumin order. 2.​ AGN child complains of headache and blurry vision: take BP immediately—anticipate hydralazine. 3.​ Toddler with cryptorchidism scheduled for orchiopexy: teach parents no straddle toys 2 wk and importance of later testicular self-exam. 4.​ UTI culture grows Proteus in uncircumcised male: reinforce gentle foreskin retraction/rinse daily; consider referral for possible circumcision if recurrent. 5.​ HUS patient K⁺ climbs to 6.2 mEq/L: prepare calcium gluconate, insulin-glucose push, and dialysis setup. 13. Test-Day Rapid Review Table Condition Protein ? Blood? BP Edema First-Line Drug UTI ± + leuks/nitrates Normal None TMP-SMX Nephrotic ++++ – Normal Massive Prednisone AGN ++ ++++ (cola) ↑ Periorbital Furosemide/anti-HTN HUS +/– + (hemolysis) ↑ or N Mild Dialysis Final Pep Talk Master the pattern-recognition: strep throat → AGN, edema + proteinuria → nephrotic, shiga toxin burger → HUS, stasis → UTI. Tie every nursing action back to physiology—why you’re restricting sodium, chasing albumin, or pushing fluids. When you can explain it to a parent at 3 a.m. without notes, you’re exam-ready. Hydrate, double-check those drug doses (mg/kg!), and go ace Genitourinary like the renal rockstar you are. Genitourinary - Learning Objectives NUR 328 • Sefton Lecture Learning Objectives: ​ ​ ​ ​ ​ ​ ​ ​ ​ Describe the various aspects of enuresis. Describe the various factors that contribute to urinary tract infections in infants and children. Discuss the preoperative preparation of the child and parents when the child has a structural defect of the genitourinary tract. Demonstrate an understanding of the causes and mechanisms of edema formation in nephrotic syndrome. Outline a nursing care plan for a child with nephrotic syndrome. Compare the child with minimal-change nephrotic syndrome and the child with acute glomerulonephritis in terms of clinical manifestations and nursing care. Contrast the causes, complications, and management of acute and chronic renal failure. List the types of renal dialysis. Recognize signs of kidney transplant rejection. 1. Enuresis — What, Why, and How to Help Aspect Key Points Management Highlights Definition Involuntary voiding ≥ 2 ×/week after age 5 for ≥ 3 months; must be socially significant and not due to meds or disease. —— Types • Primary – child has never achieved dryness.• Secondary – recurrence after ≥ 6 mo dryness (often stress, UTI, or diabetes).• Nocturnal-only vs Diurnal vs Mixed. —— Etiology “4 P’s” PMATURATION (small bladder, deep sleep), PSYCH (stressors, ADHD), PHYSIO (constipation, UTI, OSAS), POLYURIA (diabetes, renal concentrating defect). —— Work-up UA/UCx, voiding diary, r/o constipation & sleep apnea. —— Interventions 1. Motivational charts & scheduled voiding.2. “Enuresis alarm” (1st-line evidence).3. Desmopressin 0.2 mg HS for camps/exams; watch H2O intake.4. Oxybutynin if daytime urge/overactive bladder. Teach: limit fluids 1–2 h pre-bed, double-void, treat constipation aggressively. 2. UTI in Infants & Children — Why They Happen So Easily Most critical host factor = urinary stasis Contributing Factors Details & Clinical Pearls Anatomic Short female urethra; uncircumcised male foreskin; congenital obstruction; VUR Functional Infrequent voiding (“holding”), constipation compressing bladder neck, neurogenic bladder. Behavioral Bubble baths, tight nylon underwear, abuse-related perineal contamination. Instrumentation Foley catheters, clean-catch mishaps, frequent caths. Sexual Activity “Milking” bacteria into urethra in adolescents; teach post-coital voiding 3. Pre-op Prep for Structural GU Defects (Hypospadias, Bladder Exstrophy, etc.) Nurse-Led Tasks Rationale Explain staged repair timing (usually 6–12 mo for hypospadias; newborn for exstrophy covering). Reduces parental anxiety. No circumcision before hypospadias repair. Foreskin used for tissue graft. Baseline renal US/voiding cystourethrogram if high-grade defect. Checks upper-tract damage. Teach double-diaper or stent care; demo catheter irrigation. Prevents dislodgement & infection. Psychosocial support: anticipate altered body image, need for long-term follow-up. Encourages bonding & adherence. 4. Nephrotic Syndrome — Why Edema Explodes 1.​ Glomerular membrane becomes permeable → massive proteinuria. 2.​ ↓ Serum albumin lowers plasma oncotic pressure. 3.​ Fluid shifts to interstitial space → edema; renal hypoperfusion triggers RAAS, adding Na⁺/water retention, worsening edema . 4.​ Liver compensates with ↑ lipoprotein synthesis → hyperlipidemia.​ 5. Nursing Care Plan — Minimal-Change Nephrotic Syndrome (MCNS) Nursing Dx Interventions Desired Outcomes Excess fluid volume r/t ↓ oncotic pressure Daily weights & abd girth; strict I&O; elevate edematous limbs; moderate Na⁺ restriction when marked edema. Edema reduced, weight stable. Risk for infection r/t steroids & IgG loss VS & WBC trend; hand hygiene; limit sick visitors; pneumococcal & flu vax. Afebrile, no new infections. Imbalanced nutrition (less than) Encourage protein-rich snacks once in remission; small, attractive meals. Maintains growth percentiles. Disturbed body image Age-appropriate explanation of moon-face/edema; involve child in clothing choices. Verbalizes acceptance. Knowledge deficit: meds Teach parents prednisone schedule & taper, possible immunosuppressants, dipstick for protein at home. Demonstrates correct med administration 6. MCNS vs Acute Glomerulonephritis — Side-by-Side Feature MCNS AGN (post-strep) Age peak 2–7 yr 6–7 yr Onset Gradual edema Sudden hematuria / HTN Edema Massive, generalized Periorbital → dependent Urine Protein 4+, frothy; few RBCs Cola-colored; RBC & mild protein BP Normal or slight ↑ Marked ↑ Labs ↓ Albumin, ↑ Chol, normal C3 Normal albumin, ↓ C3 early Key Rx Prednisone, possible diuretics Fluid/Na⁺ limit, antihypertensives Nursing Priorities Prevent infection, fluid balance, steroid teaching BP q4-6 h, seizure watch, manage edema 7. Acute vs Chronic Renal Failure Acute (Kidney Injury) Chronic (Kidney Disease) Causes Dehydration, sepsis, nephrotoxins, obstruction Congenital anomalies, VUR, glomerulopathies Main Threats HyperK⁺, fluid overload, seizures Uremia → growth failure, osteodystrophy, anemia Course Sudden, potentially reversible Progressive, irreversible Management Treat cause, strict I&O, manage K⁺ (Ca gluconate/insulin-glucose), renal-friendly nutrition Renal diet (low Na⁺/K⁺/P), EPO, growth hormone, prepare for dialysis/transplant Complications Hyponatremia water intoxication Cardiac failure, endocrine & skeletal effects 8. Dialysis Options Type Pediatric Advantages Key Watch-Fors Peritoneal (CAPD/CCPD) Gentle fluid shifts, home-based, preserves school routine Peritonitis (cloudy effluent), hernias, weight gain Hemodialysis Rapid correction in severe hyperK⁺, drug OD, unstable AKI Hypotension, disequilibrium, need vascular access Continuous Renal Replacement (CRRT) ICU, hemo-unstable infants Clotting of circuit, anticoagulation management 9. Kidney Transplant Rejection — Red-Flag Signs ●​ ●​ ●​ ●​ ●​ Fever > 38 °C Graft tenderness or swelling over flank ↑ Serum creatinine & ↓ UO after initial good function Weight gain & edema (fluid retention) HTN or sudden rise in BP​ Early detection → high-dose steroids, antithymocyte globulin; reinforce lifelong immunosuppressant adherence.​ Quick Recall Mnemonics ●​ “LEAK” for nephrotic: Lipid ↑, Edema, Albumin ↓, Kids 2-7. ●​ “PHAROH” for AGN manifestations: Proteinuria, Hematuria, Azotemia, RBC casts, Oliguria, Hypertension. ●​ “PERI-preferred” dialysis for PEDIatrics (Peritoneal). Use the tables for side-by-side differentials, master the fluid math, and tie every intervention back to the pathophysiology—then watch GU questions fall like dominos on exam day. Pediatric Immunizations - Study Guide​ NUR 328 Exam 2 | “Hot Sheet” + Sefton Slides integrated with 2025 CDC updates 1. Foundations of Safe Vaccine Practice Step Key Actions Source 1. Consent & Education Hand parents the current VIS before drawing up vaccine; answer questions and document edition/date. 2. Five “R” Safety Check Right patient, Right vaccine, Right dose, Right route, Right site + expiry/lot # scan. 3. Admin Technique Vastus lateralis < 3 yr; deltoid ≥ 3 yr; 22–25 g needle; aspirating not required. Rotate sites. 4. Documentation Vaccine, lot, site, VIS date, provider signature; report AEFI to VAERS. (CDC, CDC) 5. Cold Chain Store 2-8 °C; never refreeze thawed varicella/MMR-V; log fridge temps BID. CDC schedule notes (CDC) 2. Know Your Products — Live vs Non-Live | Live-attenuated | MMR, Varicella, Rotavirus, Intranasal Flu | Contraindications: pregnancy, severe immunocompromise, prior anaphylaxis. |​ | Inactivated / Recombinant / Toxoid | DTaP/Tdap, IPV, Hib, Hep A & B, PCV15/20, HPV, MenACWY/MenB, COVID-19 mRNA, RSV mAb (nirsevimab) | Give even if mild illness present.| Clinical Pearl – Separate live vaccines by ≥ 28 days if not given on the same day. 3. 2025 Routine Schedule Snapshot (Birth → 18 yr) Age Vaccines Due Series Size Birth Hep B #1 (within 24 h if mom HBsAg +) 3-dose 2 mo DTaP-IPV-Hep B combo, Hib #1, PCV #1, Rotavirus #1 DTaP 5; Hib 3-4; PCV 4 4 mo Repeat above (#2) — 6 mo DTaP #3, PCV #3, Hib #3, Rotavirus #3 (if RV5), Hep B #3, start annual Flu/COVID Flu ≥ 6 mo all kids 9 mo Assess for RSV mAb seasonally (nirsevimab) — 12-15 mo MMR #1, Varicella #1, PCV #4, Hib #4, Hep A #1 MMR/Var 2; Hep A 2 15-18 mo DTaP #4 — 4-6 yr DTaP #5, IPV #4, MMR #2, Var #2 — 11-12 yr Tdap, HPV (2-dose if < 15 yr), MenACWY #1 HPV 2–3 16 yr MenACWY #2, MenB (or combo Penbraya) MenACWY 2 Annual Influenza (IIV or LAIV if age/live-OK), COVID-19 updated formulation — Reference table condenses 2025 ACIP schedule . 4. Catch-Up & Special Situations ●​ Minimum intervals never reset—continue series. ●​ Preterm infants: immunize by chronological age except Hep B if birth weight < 2 kg (delay until 1 mo unless mom HBsAg +). ●​ Immunocompromised: avoid live vaccines; give inactivated on time; consider extra pneumococcal (PPSV23). ●​ Maternal RSV vaccine (Abrysvo) at 32-36 wk GA or infant nirsevimab, not both. (CDC)​ 5. Contraindications vs Precautions (High-Yield Table) Absolute Contraindication Example Anaphylaxis to prior dose/component Neomycin allergy → hold MMR/Var. Severe immunodeficiency SCID → defer live vaccines. Pregnancy Live vaccines (MMR, Var, LAIV). Intussusception history Rotavirus vaccine. Precautions (delay, not withhold): moderate/severe illness, recent IVIG (live vaccines), evolving neurologic disorder for DTaP. 6. Adverse Event Recognition & Response Event Timeline Actions Syncope (Tdap, HPV) Immediately to 15 min Seat/observe teens; trend BP. Fever ≥ 39 °C, seizure (DTaP) 0-3 days Antipyretic, reassure; not a contraindication. Anaphylaxis < 30 min IM epinephrine 0.01 mg/kg (max 0.5 mg); activate EMS; VAERS report. Intussusception (Rota) 1 wk Refer for US/air-contrast enema. 7. Vaccine-Specific Nuggets for Exams Vaccine Unique Take-away Hep B First dose ≤ 24 h of life to curb perinatal spread. DTaP vs Tdap DTaP < 7 yr (higher diphtheria); Tdap ≥ 7 yr (booster). Hib Protects against epiglottitis & sepsis in < 5 yr olds. Pneumococcal Use PCV15/20 routine; give PPSV23 only if high-risk after 2 yr. HPV-9 Start 2-dose series at 11–12 yr; can give as early as 9 yr for abuse risk. MenACWY + MenB (Penbraya) New combo simplifies senior high-school visit. COVID-19 2024-25 XBB.1.5 Annual single dose ≥ 6 mo; 2-dose primary if never vaccinated. File Source 8. NCLEX-Style Drill (Test Yourself) 1.​ An 8-week-old preterm (1.8 kg at birth) returns for vaccines. Which are due?​ DTaP, IPV, Hib, PCV, and Rota — defer Hep B #2 until 1 mo chronological age because BW < 2 kg. 2.​ Mom at 34 wk gestation got Abrysvo. What about baby’s RSV dose at 1 mo?​ Not indicated — maternal vaccine provides trans-placental protection; skip nirsevimab this season. 3.​ Teen faints post-HPV vaccine hitting her head. First action?​ Assess airway and place supine with legs elevated — manage vasovagal syncope, then vitals. 9. Memory Aids ●​ ●​ ●​ ●​ “B DR HIP” — Birth: Hep B; 2 mo: DTaP, Rota, Hib, IPV, PCV. “Two-Four-Six, Lick the Sticks” — 2-4-6 mo core vaccines. Live = “My Very Rash Rooster Flew” — MMR, Varicella, Rotavirus, R (intranasal) Flu. Men A once at Adolescence; Men B for Big kids (16 yr). 10. Final Check-List for Clinicals & Exams ●​ ●​ ●​ ●​ ●​ Quote the age, interval, and route for every core vaccine. Decide contraindication vs precaution in under 30 seconds. Know which vaccines come in series of 3, 4, or 5 — common test trick. Tie administration errors back to documentation — lot #, site, VIS. Highlight new ACIP additions (RSV mAb, Penbraya, COVID schedule). Master these tables, recite the schedule by breakfast, and interpret contraindications like second nature—then both the exam and the vaccine fridge will feel easy to manage. Pediatric Pain Assessment & Management Study Guide NUR 328 – Sefton | use alongside skills checklists and facility policies 1. Developmental Pain Physiology — Why It Hurts Differently ●​ Neonates transmit pain along unmyelinated C-fibers; inhibitory pathways mature ~ 6 mo. ●​ Persistent, untreated pain “rewires” stress responses → higher cortisol, altered pain thresholds later in life. ●​ Infants cannot increase stroke volume—tachycardia is the first physiologic clue. 2. Age-Appropriate Pain Behaviors & Red Flags Age Observable Cues Notes for Exams Preterm / Neonate HR↑ 10–20 bpm, BP↑, O₂ ↓, brow bulge, naso-labial furrow, high-pitched cry Rigid, thrashing limbs appear after 26 wk gestation. Older Infant Crying, deliberate withdrawal, seeks comfort Look for consolability after procedure. Toddler / Preschool Loud screaming, limb flailing, “Stop!” Also may bite, hit, or hide. School-Age Time-wasting (“Wait, I’m not ready”), muscle rigidity Able to describe type & location. Adolescent Less vocal/physical resistance, verbal “You’re hurting me” Watch for body image concerns with PCA pumps. 3. Selecting the Right Pain Scale Tool Population / When Scoring & Action NPASS (Neonatal Pain, Agitation, & Sedation Scale) Preterm & term neonates in NICU 0–10; treat ≥ 4. FLACC (Face, Legs, Activity, Cry, Consolability) 2 mo – 7 yr or non-verbal any age 0–10; assess q 4 h & 30 min post-intervention. Wong-Baker FACES ≥ 3–4 yr, verbal Child points to face (0–10). Numeric Rating (0–10) ≥ 8 yr, cognitively intact Anchor 0 = no pain, 10 = worst. APPT (Adolescent Pediatric Pain Tool) ≥ 8 yr, chronic/complex pain Marks location, quality, intensity on body diagram. Non-Communicating Checklist / PICIC Cognitive impairment Caregiver input essential. Exam tip: know cut-off ages (FLACC < 7 yr, FACES starts at 3–4 yr). 4. Acute vs Chronic / Recurrent Pain Framework Acute Chronic / Recurrent Duration < 3 mo ≥ 3 mo or episodic ≥ 3 ×/yr Goal Rapid relief, support procedure Restore function, mood, sleep Assessment Extras Procedural pain plan, post-op monitoring Pain diary, functional disability inventory Include academic, social, and sleep impact in every chronic-pain note. 5. Non-Pharmacologic Toolbox (First-Line Adjuncts) Age Group Evidence-Based Interventions Neonate Containment/swaddling, non-nutritive sucking, sucrose 24 % (2 mL max), skin-to-skin (kangaroo). Infant–Toddler Rocking, soft music, distraction bubbles, facilitated tucking. Preschool–School -Age Guided imagery, medical play, deep-breathing, cold/warm packs. Adolescent VR games, mindfulness apps, CBT techniques, collaborative decision-making. 6. Pharmacologic Management — Know Your Numbers Stepwise Approach 1.​ Non-opioids:​ Acetaminophen 10–15 mg/kg PO q4–6 h (max 75 mg/kg/day).​ Ibuprofen ≥ 6 mo: 5–10 mg/kg PO q6–8 h (max 40 mg/kg/day). 2.​ Opioids (moderate–severe):​ Morphine 0.05–0.1 mg/kg IV q2–4 h; watch RR < 12.​ Hydromorphone 0.01 mg/kg IV q3–4 h when fluid-restricted. 3.​ Co-analgesics: gabapentin for neuropathic pain (5 mg/kg/day in 3 doses, titrate), ketamine sub-dissociative 0.2 mg/kg IV for burns; local anesthetics (EMLA 1 h pre-stick). Patient-Controlled Analgesia (PCA) ●​ 5–6 yr and able to understand cause-effect. ●​ Basal + demand or demand-only settings; parent-button never substitutes child activation. ●​ Continuous pulse-ox; sedation scale q 2 h first 24 h. Epidural & Caudal Blocks ●​ Check dermatome level every shift; report numbness ≥ T4 (respiratory compromise). ●​ Infusion counts as “continuous opioid” for Narcan orders. Naloxone Rescue ●​ 0.1 mg/kg IV (max 2 mg) slow push; may repeat q 2 min up to 10 mg. ●​ Rebound pain → resume analgesia once RR > 12. 7. Special Populations ●​ Cognitive / Communication Impairment: rely on caregiver baseline; use Non-Communicating CPC or r-FLACC. ●​ Critically Ill/Paralyzed: vital sign changes may be only clue—trend HR, BP, ventilator dys-synch. ●​ Cultural Considerations: some families view overt pain expression as weakness—offer scales that allow non-verbal rating (e.g., color bar). 8. Nursing Accountability & Exam Gems 1.​ Assess → intervene → reassess within 30 min IV or 1 h PO; document same scale used. 2.​ Double-check wt-based doses every shift; update when weight changes ≥ 10 %. 3.​ For repeated procedures (dressing changes), pre-medicate at least one half-life before start. 4.​ Educate parents that addiction risk is < 1 % when opioids used short-term for legitimate pain. 5.​ Report unrelieved pain to provider—advocacy is an RN standard. 9. Quick-Reference Tables (print for clinical clipboard) ●​ Pain Scales by Age & Score Interpretation ●​ Opioid Equianalgesic Chart (Morphine = 1; Hydromorphone = 5) ●​ Non-pharm Cheat Sheet per Developmental Stage Final Take-Home Pain is the fifth vital sign, but in peds it’s often the least obvious. Master your scales, pair non-pharm comfort with timely weight-based meds, and document like a lawyer was watching. If you can explain why a 2-month-old on morphine needs continuous SpO₂ and how sucrose works on the endogenous opioid pathway, the exam—and your patients—are in good hands. Pediatric Pain - Study Guide NUR 328 | aligns with Sefton “Pain” slides & current evidence-based guidelines 1 Measures Used to Assess Pain in Children Pain is multidimensional—always try for at least two of these three angles: Dimension What You Actually Do Key Clues Self-report (gold standard when developmentally possible) Ask the child to rate, point to a face, draw on a body outline, or describe in words. Reliable from ≈ 3–4 yr onward if language is adequate. Behavioral observation Score posture, facial expression, cry, consolability, and activity with tools such as FLACC or r-FLACC. Critical for non-verbal, sedated, or cognitively-impaired children. Physiologic indicators Trend HR, BP, RR, SpO₂, palmar sweating, and intracranial pressure (ICU). Least specific—use only to support other findings. Exam tip: On test items, if the child can reliably self-report, that trumps physiologic cues. 2 Pain-Assessment Tools at a Glance Age / Situation Tool Scale Details When to Reassess < 37 wks GA – Term NICU NPASS 0–10 (pain/agitation) 30 min after intervention 0–7 yr or non-verbal any age FLACC 0–10 (5 behavior domains) IV med → 15–30 min; PO → 30–60 min ≥ 3 yr verbal Wong-Baker FACES 0–10 faces Same scale, same interval ≥ 8 yr cognitively intact Numeric/Visual Analog 0–10 line — Cognitive impairment r-FLACC, NCCPC-R 0–10; caregiver input — Chronic/complex APPT, Ped-IMMPACT diary Intensity + quality + location Each clinic visit Memorize cut-off ages (FLACC < 7 yr; FACES starts ≈ 3 yr) for NCLEX-type distractors. 3 Essential Strategies to Reduce Pain Pillar Core Nursing Actions Evidence Highlights Anticipate & Prevent Pre-procedural planning (topical anesthetic 30–60 min before stick, sucrose 2 mL for neonates, distraction setup). Sucrose reduces neonatal pain scores by ≥ 40 % in > 20 RCTs. Non-pharmacologic Adjuncts • Swaddling/skin-to-skin (neonates) • Guided imagery, VR, blowing bubbles (≥ 4 yr) • Parent presence & facilitated tucking • CBT for chronic pain Cochrane reviews show kangaroo care drops procedural HR spikes; VR cuts burn-dressing pain by ~30 %. Pharmacologic Ladder 1. Non-opioids (acetaminophen 10–15 mg/kg; ibuprofen 5–10 mg/kg if ≥ 6 mo) 2.​ Opioids for moderate/severe (morphine 0.05–0.1 mg/kg IV)​ 3.​ Co-analgesics (ketamine 0.2 mg/kg IV; gabapentin for neuropathic) | WHO & AAP endorse weight-based step-up; morphine remains first-line IV opioid for kids. |​ | Reassess & Document | Same tool, within the drug’s onset window; escalate if score > goal; chart scale, score, intervention, and response. | Documentation errors are the #1 cause of peds pain-care citations. |​ 4 Common Pediatric Pain Scenarios Category Procedural Classic Examples Nursing Watch-Fors Heel sticks, IV starts, immunizations, lumbar puncture Combine topical anesthetic + sucrose/distraction; educate parents to coach deep breaths. Post-operative Tonsillectomy, appendectomy, orthopedic pinning Multimodal meds around-the-clock first 24 h; watch for OSA kids on opioids. Acute Illness / Injury Otitis media, fractures, burns Treat underlying cause and pain; burns benefit from low-dose ketamine during dressing changes. Chronic / Recurrent Sickle-cell vaso-occlusive crises, migraines, functional abdominal pain, juvenile arthritis, cancer pain Give scheduled baseline analgesia plus PCA for breakthrough; integrate school re-entry plans and CBT. End-of-life Oncology and metabolic disorders Escalate opioids irrespective of ceiling; focus on comfort, not vitals. 5 Evidence Behind Key Interventions Strategy Level of Evidence Take-Home Oral sucrose or glucose for minor procedures in neonates Level I (systematic reviews) Safe, rapid, synergistic with non-nutritive sucking. EMLA (lidocaine-prilocaine) cream before venipuncture Level I Needs 60 min occlusive dwell; observe for blanching. NSAIDs vs opioids post-tonsillectomy Level II Ibuprofen equal analgesia, fewer nausea episodes than morphine; no ↑ bleed risk. Virtual Reality for burn dressing changes in school-age children Level II–III (small RCTs) Reduces self-reported pain and heart-rate spikes by ≈ 30 %. Gabapentin for neuropathic pain in oncology Level III (prospective cohorts) Improves sleep and reduces morphine use; start 5 mg/kg/day. Kangaroo care during heel lance Level I Lowers PIPP scores > 2 points; advise skin-to-skin ≥ 10 min pre-stick. Rapid-Fire NCLEX-Style Checks 1.​ Which pain scale for a 5-month-old post-circumcision? — FLACC (behavioral). 2.​ Child on morphine PCA at 0.02 mg/kg demand reports pain 8/10 with RR 18. Next action? — Administer nurse-controlled bolus or contact provider to increase dose (don’t wait for oversedation). 3.​ Best evidence-based adjunct for heel stick in preterm infant? — 2 mL oral 24 % sucrose + pacifier. 4.​ What warrants naloxone in a 12-yr-old? — RR < 10/min or O₂ sat < 90 % despite stimulation, not just pinpoint pupils. Memory Hooks ●​ “ABC of Peds Pain” – Assess (right scale) → Bust it (multimodal) → Check again (reassess). ●​ FLACC parts = Face, Legs, Activity, Cry, Consolability. ●​ Opioid Rescue Dose = 10 % of 24-h total opioid requirement given Q 1 h PRN. Bottom Line Choose the right tool, hit pain hard before it hits the kid, and prove it worked with timely reassessment. Link every intervention to evidence—you’ll impress preceptors and ace the exam. Integumentary Dysfunction — Junior-Level Master Study Guide Based on Sefton Ch. 50 slides & current pediatric standards 1. Bacterial Skin Infections Impetigo contagiosa ●​ Pathogen – Staph aureus ± GAS. ●​ Classic look – moist red vesicles → honey-colored crust around nose & mouth. ●​ Nursing focus ○​ Wash lesions with warm soapy water 3×/day; remove crusts gently. ○​ Topical mupirocin; oral cephalexin if multiple lesions. ○​ No school until 24 h on antibiotics; dedicate towels. Cellulitis ●​ Deep dermal infection → erythema, swelling, warmth, pain. ●​ Draw skin borders; check q 2 h for spread. ●​ IV cefazolin if periorbital, joint, or systemic S/Sx. 2. Contact & Allergic Dermatitis Condition Triggers Key Nursing Orders Irritant contact Saliva, soaps, wipes Remove agent, thick emollient barrier, 1% hydrocortisone for itch. Allergic (Poison ivy/oak/sumac) Urushiol oil Flush skin < 10 min with isopropyl alcohol or dish soap; topical steroid 2–3×/day; teach wash pets & clothes. 3. Fungal Infections (Tinea & Candida) Site Presentation 1st-Line Therapy Tinea capitis Alopecia patch + “black dots” Oral griseofulvin 6-8 wk with fatty food; selenium shampoo 2×/wk. Tinea corporis (“ringworm”) Annular scaly plaque Topical clotrimazole bid × 2 wk, continue 1 wk after clear. Tinea pedis Pruritic maceration b/t toes Keep feet dry, antifungal spray; cotton socks. Candidiasis Beefy red diaper rash, oral thrush Nystatin suspension oral; topical nystatin or clotrimazole to groin. 4. Drug-Related Rashes Any new med + rash = stop drug, notify prescriber. Document onset, distribution, and associated symptoms. Fixed drug eruption recurs at same site — photograph for records. 5. Arthropod & Animal Exposure Issue Hallmark Nursing Priorities Scabies (Sarcoptes) Burrows, web spaces, nocturnal itch Permethrin 5 % neck-to-toe, repeat 1 wk; wash linens hot; treat contacts. Pediculosis capitis Nits ≤ ¼ inch from scalp Permethrin 1 %, wet-comb; seal non-washables 14 days. Hymenoptera stings Local pain/swelling Scrape stinger, cold pack, antihistamine; EpiPen if systemic. Tick → Lyme ≥ 36 h attached, target rash Remove with tweezers, clean site; doxycycline (≥ 8 yr) or amoxicillin 14 days. Teach permethrin clothing. Animal bites Break skin Irrigate copiously, prophylactic amox-clav, verify tetanus & rabies risk. 6. Pediatric Dermatitis Spectrum Type Patho & Look Management Diaper dermatitis Moist friction; satellite yeast spots signal Candida. Frequent air time, zinc-oxide barrier; add nystatin if yeast. Atopic dermatitis (eczema) Filaggrin defect → dry itchy plaques; regional age pattern. Daily lukewarm bath, heavy emollient within 3 min, topical steroid for flares, antihistamine HS. Seborrheic (“cradle cap”) Greasy yellow scales scalp/eyebrows. Mineral-oil massage + soft brush; ketoconazole shampoo if persistent. 7. Acne Vulgaris Driven by testosterone & sebum. Start with gentle cleanse bid → 1.​ 2.​ 3.​ 4.​ Topical retinoid nightly (pea-size). Add benzoyl peroxide am. Oral doxy 100 mg bid if inflammatory. Isotretinoin for nodulocystic: monitor lipids, LFTs, iPLEDGE birth-control. 8. Pediatric Burns Classifying Injury ●​ Extent — use Lund-Browder chart, not adult Rule-of-Nines. ●​ Depth ○​ Superficial: red, dry, blanches. ○​ Partial-thickness: moist blisters. ○​ Full-thickness: leathery, white/brown, painless. First-Hour ABCs 1.​ Airway – look for singed brows, hoarse voice → early intubation. 2.​ Breathing – high-flow 100 % O₂, carboxy-Hb level. 3.​ Circulation – Parkland: 4 mL × kg × %TBSA LR; give half in 8 h. Target UO ≥ 1 mL/kg/h. 4.​ Warm room, sterile drapes; analgesia IV morphine q 2 h PRN. 5.​ Tetanus booster if > 5 y since last. 6.​ Infection: topical silver sulfadiazine except on face (< 2 mo contraindicated). 9. NCLEX-Style Rapid Comparisons Topic Impetigo Testable “Red-Flag” Return if lesions near eye — orbital cellulitis risk. Poison Ivy Systemic steroids only if > 20 % body or facial/genital involvement. Scabies Persistent itch ≤ 4 wk after treatment is normal, not reinfestation. Acne Topical clindamycin without benzoyl peroxide ↑ resistance — always pair them. Burns Sudden restlessness or falling SpO₂ after facial burn = airway edema → call anesthesia stat. 10. Study Hacks & Memory Triggers ●​ ●​ ●​ ●​ “Honey crust = Money (penicillin) must.” Tinea names: Capitis (head), Corporis (body), Pedis (feet). Pediculosis process: Treat → T (comb) → Trash bags → Teach family. Burn fluids: “Four times weight times burn gives four hours half-bag.” Final Pep Talk Skin problems look messy, but the patterns are simple: identify the critter, break the chain of spread, protect the barrier, and watch fluids like a hawk when the barrier’s lost. Drill the drug names, practice the Parkland math, and you’ll crush both the exam and the next panicked parent who messages you about a mysterious rash. Integumentary Disorders & Burns - Lecture Objectives NUR 328 | aligns with Sefton Ch. 50 slide deck 1. Bacterial vs Viral Skin Infections Disorder Key Manifestations Management Nursing Focus Impetigo contagiosa (S. aureus / GAS) Honey-crust papules, pruritus, local lymphadenopathy Topical mupirocin; oral cephalexin if multiple lesions Soak & debride crusts TID; no school × 24 h after abx start; separate linens Cellulitis Rapid erythema, edema, warmth, pain ± fever IV cefazolin or clindamycin for systemic cases Outline borders; neuro-checks if limb; elevate & warm compress Folliculitis / Furuncle Pustule at hair follicle → tender nodule Warm compress; topical clinda; I&D PRN Discourage squeezing; chlorhexidine wash for athletes Staph Scalded Skin Diffuse tender erythema → bullae, + Nikolsky IV nafcillin, fluid support Handle gently, burn-style sterile dressings Varicella (VZV) Crops of pruritic vesicles, trunk first Acyclovir within 24 h if >13 yr or immunocomp. Airborne isolation; mittens; oatmeal bath HSV I/II (gingivostomatitis, HSV-1 lips, HSV-2 genital) Painful clustered vesicles on erythematous base PO acyclovir QID × 7d Hydration, soft diet, topical lidocaine > 6 yr Molluscum contagiosum Flesh-colored umbilicated papules Curette, liquid nitrogen, or observe Teach no sharing towels; cover for sports Verruca (warts, HPV) Hyperkeratotic papules, interrupt skin lines Salicylic acid daily × weeks, liquid nitrogen q 2–3 wks Keep dry; tape occlusion speeds resolution 2. Poison Ivy, Oak, Sumac (Urushiol Dermatitis) Phase Manifestations Treatment Nursing Pearls Sensitization (0–24 h) Erythema, mild itch Immediate wash with isopropyl alcohol or dish soap; remove clothing Oil binds skin in ≤ 10 min—speed matters Vesicular (1–2 d) Linear serous vesicles, severe pruritus Mid-potency topical steroid bid × 14 d; oatmeal soaks; antihistamine HS Systemic prednisone × 14 d if facial/genital or ≥20 % TBSA Dry/crust (1–3 wks) Yellow crust, lichenification Emollients, continue antihistamine Clean under nails; wash pets & gear 3. Bites & Stings — What to Recognize, What to Do Agent Hallmark Findings Complications Immediate Care / Follow-up Mosquito / Flea Pruritic papules, / Chigger grouped (chigger at waist/ankle) Secondary impetigo Cool compress, calamine, antihistamine Bee / Wasp / Fire ant Painful wheal → edema Anaphylaxis Scrape stinger; cold pack; IM Epi 0.01 mg/kg if systemic Tick (Ixodes) Firm attach > 36 h; ± erythema migrans Lyme, RMSF Remove with tweezers; doxy ≥ 8 yr 4 mg/kg/day × 10 d or amox younger; watch 30 days Black Widow Target bite → muscle cramps, HTN Neurotoxicity Ice; IV opioids & benzos; antivenin if severe Brown Recluse Painless bite → violaceous center, bull’s-eye, necrosis Hemolysis, DIC rare Cold, elevate, dapsone if severe; surgical debride delayed Centruroides Scorpion Intense local pain; neuro signs (roving eye, drool) Resp distress Ice; antivenom PRN; airway support Cat/dog bite Puncture/tear, crush tissue Pasteurella cellulitis, tendon injury Copious irrigation, amox-clav 5–7 d, tetanus & rabies review 4. Animal-Related Skin Disorders Disorder Manifestations Nursing Care Cat-scratch (Bartonella) Papule → regional lymphadenitis wks later Oral azithro 5 d; warm compress; analgesia Ringworm from pets Tinea corporis/capitis Treat child & pet; oral griseofulvin capitis Rabies exposure Puncture + salivation animal Soap/water 15 min; HRIG + vaccine day 0-3-7-14 5. Dermatitis & Acne Care Condition Hallmark First-Line Treatment Teaching Points Diaper dermatitis Erythema convex surfaces, sparing creases Zinc-oxide barrier; air time Add nystatin if satellite lesions Atopic (Eczema) Dry pruritic flexural plaques Daily lukewarm bath + emollient; topical steroid for flares; antihistamine HS Identify triggers; wet-wrap for severe Seborrheic (“Cradle cap”) Greasy yellow scalp scales Mineral-oil soak + soft brush; ketoconazole shampoo if recalcitrant Reassure self-limiting Acne vulgaris Open/closed comedones ± inflammation Step-up: benzoyl peroxide → topical retinoid → oral doxy/mino → isotretinoin Avoid oil cosmetics; sunscreen; iPLEDGE rules 6. Burns — Pathophysiology & Types Pathophysiology ●​ Coagulation zone (necrosis) – center. ●​ Stasis zone – ischemia, salvageable if perfused. ●​ Hyperemia zone – vasodilation, recovers.​ Systemic in ≥ 20 % TBSA: capillary leak (massive edema), hypovolemia, hypermetabolic state, immunosuppression.​ Burn Categories By Depth Appearance Sensation Healing / Grafting Superficial Red, dry, blanches Painful 3–5 d, no scar Partial-thickn ess Moist blisters, blanches Very painful 10–14 d (superficial) or 3+wks (deep) Full-thickness Leathery, white/brown, no blanch Painless (nerves destroyed) Needs graft By Cause Key Considerations Thermal (flame, scald) Most common pediatric; assess for inhalation in closed-space fires Electrical Hidden entrance/exit; risk arrhythmia, myoglobinuria Chemical Alkali worse (liquefaction necrosis); brush powders before irrigation Inhalation Singed hair, soot sputum, voice change; early intubation 7. Nursing Care of Burns (Pediatric Focus) Phase Priority Actions Benchmarks Emergent (0-72 h) Airway + 100 % O₂; Parkland LR 4 mL × kg × %TBSA (give ½ in first 8 h); insert foley; warm environment; IV morphine 0.1 mg/kg q2 h; tetanus booster UO ≥ 1 mL/kg/h; HR < 160 infant / < 120 teen Acute (wound closure) Daily hydrotherapy; silver dressings or mupirocin face; nutritional goal 1.5–2 × BEE calories & >1.5 g/kg protein; PT/OT ROM start day 1 Serum pre-albumin rising; no graft infection Rehabilitative Pressure garments 23 h/day to prevent hypertrophic scars; moisturize healed skin; psychosocial support Independence in ADLs; body-image coping Infected graft = discoloration, odor, ↑ pain—culture and start broad IV abx. Quick Recall Aids ●​ “Rule of Palm” = child’s palm ≈ 1 % TBSA for scattered burns. ●​ Scabies order: Permethrin → Pajamas wash → Partner treat → Pruritus normal 2–4 wks. ●​ Brown Recluse mnemonic: Loxosceles = Livid + Lethal. Review these pattern tables until you can retrieve interventions without notes; that level of fluency translates directly to exam points and safe bedside care. Cognitive & Sensory Impairment - Study Guide NUR 328 • Sefton Cognitive & Sensory Deck (Ch. 50) 1 | Conceptual Foundations Term Operational Definition Exam Triggers Cognitive Impairment (CI) Significant limitation in intellectual and adaptive functioning with onset < 18 yr. Watch wording: “intellectual disability,” “global delay.” Sensory Impairment Partial or total loss of hearing or vision that interferes with growth, development, or safety. Comorbid with prematurity, TORCH infections. 2 | Etiology & Early Red-Flags Domain High-Yield Causes Early Behavioral Signs Cognitive Intra-uterine infection, trauma (peri/post-natal), metabolic disease, chromosomal (e.g., Trisomy 21, Fragile X), extreme prematurity, severe malnutrition. No eye contact, poor feeding, diminished spontaneous activity, absent response to voice. Hearing Recurrent otitis media, TORCH, ototoxic meds, noise exposure. No babble by 6 mo, startles only to tactile, monotone speech. Vision Retinopathy of prematurity, congenital infections, trauma. Absent tracking, hand-fluttering at face, photophobia. 3 | Syndrome Spotlights Condition Cardinal Features Priority Nursing Interventions Down Syndrome Upslant palpebral fissures, flat nasal bridge, single palmar crease, hypotonia, wide sandal gap; congenital heart disease common. Support family at diagnosis, monitor cardiac & thyroid, promote hypotonia-safe feeding, encourage early-intervention therapy. Fragile X Long face, large ears, macro-orchidism, moderate CI, autism-like behaviors. Early speech/OT, meds for behavior (e.g., stimulants, SSRIs), genetic counseling. Autism Spectrum Disorder (ASD) Impaired social reciprocity, restricted interests, repetitive behaviors; sensory processing issues. Routine screening (18 & 24 mo), structure/visual schedules, minimize stimuli in hospital, caregiver presence. 4 | Nursing Care Principles for CI 1.​ Early Intervention: refer at first suspicion—maximizes neuronal plasticity. 2.​ Teach Self-Care: task-analysis; one-step commands. 3.​ Facilitate Communication: sign language, picture exchange (PECS), augmentative devices. 4.​ Play & Exercise: large-motor activities; ensure safety. 5.​ Socialization & Discipline: consistent limits, positive reinforcement. 6.​ Sexuality Education: concrete language, consent concepts. 7.​ Hospitalization: orient slowly, allow familiar objects, involve family in ADLs. 8.​ Prevention: folic acid, rubella vax, avoid alcohol/drugs in pregnancy, lead screening.​ 5 | Hearing Impairment Quick Sheet Degree Decibel Loss Management Slight–Mild 16–40 dB Preferential classroom seating, speech therapy. Moderate–Severe 41–70 dB Hearing aids, FM system. Severe–Profound > 71 dB Cochlear implant, sign language immersion. Nursing Actions ●​ Face child, speak clearly, use visual aids. ●​ Verify hearing-aid battery daily. ●​ Preventive: treat OM promptly, avoid ototoxic drugs during pregnancy.​ 6 | Visual Impairment Essentials Etiologies Infections, prematurity (ROP), trauma, congenital cataract/glaucoma. Interventions Orient to environment (clock-face method), maintain routines, use touch/voice cues, ensure safe pathways. Screen all children regularly; early referral prevents amblyopia. 7 | Care of the Hospitalized Child with Sensory Loss ●​ Safety: low-clutter room, call light within reach. ●​ Consistency: same staff when possible; announce entry/exit. ●​ Communication: interpreter or sign-fluent RN for Deaf; large-print or Braille materials for Blind. ●​ Independence: involve child in self-med admin, choice-making. 8 | Exam-Level Differentials Feature Down Syndrome Fragile X Autism Hypotonia ✔ ± ± Large ears — ✔ — Single palmar crease ✔ — — Social reciprocity deficits ± (mild) ± ✔ 9 | NCLEX-Style Critical Thinking Cues 1.​ No startle to loud sound in 4-mo-old → schedule full audiology eval — not “watch and wait.” 2.​ Hospitalize teen with ASD for appendectomy → place in private room, limit staff changes, use picture schedule for pre-op teaching. 3.​ Feeding infant with Down Syndrome → use small straight-handled spoon and push food to back/side of mouth (protruding tongue & hypotonia). 10 | Memory Anchors ●​ “HEADS” for Down Syndrome findings: Hypotonia, Epicanthal fold/flat nose, Atlantoaxial risk, Duodenal atresia, Single palmar crease. ●​ “LARGE” for Fragile X: Large ears, Autism-like, Repetitive speech, Giant testes, Extended face. ●​ CI Nursing 4 P’s: Predictable routine, Picture cues, Positive reinforcement, Parent partnership. Review these tables until you can recite etiology, hallmark signs, and first nursing action without looking—exactly what the exam (and real patients) will demand. Cognitive & Sensory Impairment — Objective-Focused Study Guide NUR 328 – Use with Sefton “Cognitive & Sensory” slides and ATI pediatrics text 1 | Classifications of Intellectual Disability (ID) DSM-5 and AAIDD use IQ + adaptive-function deficits in three domains: conceptual, social, practical; severity is based on adaptive support needs, not IQ alone. Traditional IQ Band* Current Severity Label Practical Description (Support Needed) 50-70 (≈ 2-3 SD below mean) Mild Independent ADLs; academic level ≈ grade 6; needs guidance for complex tasks. 35-49 Moderate Performs self-care with prompting; vocational training with supervision. 20-34 Severe Limited verbal skills; constant supervision; focuses on habit-training. < 20 Profound Totally dependent; motor & sensory impairments common; intensive supports. *IQ thresholds vary slightly across tests; always pair with adaptive-skills assessment. 2 | Definition of Developmental Delay Failure to achieve ≥ 2 developmental milestones (gross or fine motor, language, social, cognitive, self-help) expected for chronological age after appropriate correction for prematurity. Often used < 5 yr when formal IQ testing is still unreliable. 3 | Nursing Interventions for Children with Cognitive Impairment (Promoting Optimal Development & During Hospitalization) 1.​ Early Intervention Referral at first suspicion (PT/OT/ST, special education). 2.​ Task Analysis: break skills into 1-step chunks; use repetition and positive reinforcement. 3.​ Consistent Routine & Visual Schedules to lessen anxiety. 4.​ Augmentative Communication (sign, PECS, speech-generating devices). 5.​ Self-Care Training: let child attempt dressing, feeding; adaptive utensils. 6.​ Safe, Stimulating Play: large-motor toys, sensory bins; modify environment not activity. 7.​ Socialization: integrate with typically-developing peers; model appropriate behavior. 8.​ Discipline: immediate, consistent limits focusing on behaviors, not child. 9.​ Hospital Care ○​ Admit with parent if possible; familiar objects from home. ○​ Use the child’s communication tools; give choices when possible. ○​ Prepare for procedures with simple pictures or demonstration on doll. ○​ Keep same staff; cluster care to reduce overstimulation. ○​ Address pain with behavioral scales (r-FLACC) and caregiver input. 4 | Down Syndrome (Trisomy 21) — Major Biologic & Cognitive Features System / Area Hallmark Findings Craniofacial Flat nasal bridge, epicanthal folds, Brushfield spots, small ears, protruding tongue. MSK & Growth Hypotonia, hypermobility, short stature, atlanto-axial instability (~15 %). CV Congenital heart defects (~50 %; AV canal, VSD). GI Duodenal atresia, Hirschsprung disease, celiac risk. Endo & Immune Hypothyroidism, leukemia risk, earlier Alzheimer pathology. Cognitive IQ typically 35-70 (mild-moderate); relative strength in socialization, receptive language; delays in expressive language & fine motor. Nursing Interventions — Down Syndrome ●​ Airway/Feeding: Use small, straight-handled spoon; feed to side and back of mouth (large tongue, hypotonia). ●​ Thermoregulation & Skin: Wrap well; moisturize dry skin creases. ●​ Infection Prevention: Rinse mouth after feeds; monitor for respiratory infections (small nares, hypotonia). ●​ Cardiac/Spine Precautions: Obtain baseline EKG/ECHO; screen at 3-5 yr for atlanto-axial instability before gymnastics or anesthesia. ●​ Vision/Hearing: Annual eye/ear exams — high cataract, OM incidence. ●​ Family Support: Provide up-to-date resources; emphasize developmental potential; connect to parent support groups. 5 | Fragile X Syndrome — Core Characteristics Domain Classic Findings Appearance (post-puberty) Long narrow face, large protruding ears, macro-orchidism (males). Behavior/Cognition Moderate ID, delayed speech, echolalia, autism-like social anxiety, hand-flapping, ADHD. Inheritance X-linked dominant with reduced penetrance; carrier females may show subtle learning issues. 6 | Classifications of Hearing Impairment & Speech Effect Degree (Better Ear dB Loss) Functional Description Impact on Speech/Language 16-25 (Slight) Hears spoken voice at 1 m if quiet. May miss fricatives; usually normal speech. 26-40 (Mild) Hears at 3 m. Delayed articulation, soft voice. 41-70 (Moderate) Needs loud speech ≤ 30 cm. Clear speech delays; benefits from hearing aids. 71-90 (Severe) Hears loud voice at ear level. Profound speech impairment without amplification. > 90 (Profound) Perceives only vibration. Relies on visual/manual language; spoken speech difficult. Nursing Interventions — Hearing Impairment ●​ Communication: Face child, speak clearly, use normal rate; supplement with sign or cued speech as indicated. ●​ Environment: Reduce background noise; preferential classroom seating; flashing alarms. ●​ Device Care: Check hearing-aid battery daily; dry earmold overnight. ●​ Hospitalization ○​ Provide certified interpreter for consent/teaching. ○​ Light or touch child’s shoulder before speaking. ○​ Use pictures/written schedules; closed-caption videos. ○​ Encourage use of personal amplification devices during procedures.​ 7 | Common Pediatric Visual Impairments ●​ Refractive Errors – myopia, hyperopia, astigmatism. ●​ Amblyopia (“lazy eye”) – unilateral decreased acuity from abnormal cortical development. ●​ Strabismus – misalignment (esotropia/exotropia). ●​ Cataract – congenital infection, metabolic disease. ●​ Glaucoma – congenital angle anomaly. ●​ Retinopathy of Prematurity (ROP) – preterm oxygen injury. ●​ Trauma – sports, MVC.​ Nursing Interventions — Visual Impairment ●​ ●​ ●​ ●​ ●​ Orientation & Mobility: Introduce self each entry; describe room “clock method.” Safety: Keep furniture placement constant; low clutter; side rails up. Communication Aids: Large-print, Braille, audio materials; magnifiers. Play & Learning: Tactile toys, contrasting colors, auditory cues. Hospitalization ○​ Explain procedures step-by-step before touch. ○​ Allow hands to explore equipment. ○​ Assign consistent staff; announce exit. 8 | Autism Spectrum Disorder — Key Nursing Interventions Area Action Environment Private room; dim lights; minimize noise, abrupt schedule changes. Communication Use simple concrete language; visual supports (PECS, timers); allow extra processing time. Family Involvement Parents remain primary caretakers for routines, de-escalation techniques. Behavioral Strategies Positive reinforcement; ignore harmless stereotypies; offer fidgets. Procedural Prep Social stories or picture sequence; schedule procedures at predictable times; consider pre-visit hospital tour. Safety Monitor for elopement; allergy and sensory triggers noted on chart; wear medical alert if non-verbal. Pain & VS Use familiar pain scale (e.g., numeric or faces) or caregiver interpretation; may show atypical pain responses. Quick-Memory Chart Objective Mnemonic Key Detail Down Syndrome traits HEADS Hypotonia, Epicanthal fold, Atlanto-axial risk, Duodenal atresia, Single crease Fragile X traits LARGE Large ears, Autism-like, Repetitive speech, Giant testes, Extended face CI Nursing pillars 4 P’s Predictable routine, Picture cues, Positive reinforcement, Parent partnership Hearing-loss levels S-M-M-P Slight, Mild, Moderate, (severe &) Profound Use this objective-aligned guide to structure review sessions; rehearse definitions, compare tables side-by-side, and practice writing nursing plans until each intervention feels automatic.