Nursing tricks that make pediatric nursing stick

Gross motor: 2 months — holds head up. 4 months — rolls front to back. 6 months — sits with support. 9 months — pulls to stand. 12 months — walks independently. 18 months — runs. 2 years — goes up stairs. Fine motor: 3 months — grasp reflex disappears. 6 months — transfers objects. 9 months — pincer grasp (thumb + forefinger). 12 months — releases objects intentionally. Language: 2 months — coos. 6 months — babbles. 12 months — 1–3 words (mama, dada). 18 months — 10+ words. 2 years — 2-word phrases. 3 years — 3-word sentences. 4–5 years — sentences, strangers understand speech.

Hepatitis B: birth, 1–2 months, 6–18 months. DTaP (diphtheria, tetanus, pertussis): 2, 4, 6 months, 15–18 months, 4–6 years. IPV (polio): 2, 4 months, 6–18 months, 4–6 years. Hib: 2, 4, 6 months, 12–15 months. PCV13: 2, 4, 6 months, 12–15 months. MMR (measles, mumps, rubella): 12–15 months, 4–6 years. Varicella: 12–15 months, 4–6 years. Hep A: 12–23 months (2 doses). Contraindications to live vaccines (MMR, Varicella): immunocompromised, pregnancy, severe egg allergy (MMR). Mild illness (cold) is NOT a contraindication. Anaphylaxis to previous dose = absolute contraindication.

Febrile seizures: 6 months–5 years, occur when temperature rises rapidly (usually >38.8°C/102°F). Simple febrile seizure: generalized, <15 minutes, resolves spontaneously, no focal deficit. Complex: >15 min, focal, or multiple in 24 hrs. Management DURING seizure: protect from injury (lower to floor, padding), position on side (recovery position), loosen clothing, time the seizure, do NOT put anything in mouth, do NOT restrain. AFTER seizure: assess LOC, check temperature, administer antipyretics, reassure parents. Rectal diazepam (Diastat): if seizure >5 min. Not associated with epilepsy development in most simple cases. Parents need education — very frightening to witness.

Epiglottitis (bacterial — Hib, now rare due to vaccine): sudden onset, high fever, severe sore throat, drooling (cannot swallow), tripod position (leaning forward, neck extended), muffled voice, toxic appearance. Do NOT examine throat (laryngospasm risk), do NOT put child supine, do NOT use tongue depressor. Call provider immediately, prepare for intubation, X-ray shows 'thumbprint sign.' Croup (viral — parainfluenza): gradual onset, low grade fever, barking/seal-like cough, inspiratory stridor, worse at night. X-ray: steeple sign (subglottic narrowing). Treatment: cool mist, racemic epinephrine (aerosol), dexamethasone (steroid), calm environment.

Mild (<5% weight loss): dry mucous membranes, slightly decreased UO, thirsty. Moderate (5–10%): tachycardia (compensatory), decreased skin turgor (pinch test — tents), sunken eyes and fontanelle (infants), decreased UO, no tears when crying. Severe (>10%): hypotension (LATE — decompensated), mottled skin, cap refill >3 seconds, lethargy/irritability, absent tears. Oral rehydration: mild-moderate — Pedialyte (NOT water, juice, or sports drinks — wrong electrolyte balance). IV fluids: severe or unable to tolerate oral — NS or LR bolus 20 mL/kg. Monitor: weight (most accurate), UO (1–2 mL/kg/hr adequate), skin turgor.

Sickle cell: autosomal recessive, HbS — sickle-shaped RBCs obstruct vessels. Vaso-occlusive (pain) crisis: most common — severe pain in bones/joints/chest. Triggers: dehydration, infection, cold, stress, hypoxia. Aplastic crisis: parvovirus B19 infection → bone marrow suppression → severe anemia. Sequestration crisis: blood pools in spleen → rapidly enlarging spleen, hypovolemic shock (most dangerous, especially in infants). Nursing management for all crises: IV hydration (dilutes blood, prevents sickling), oxygen (maintain SpO2 >95%), analgesia (opioids — do NOT withhold due to addiction concerns), warm compresses (not cold — vasoconstriction worsens). Hydroxyurea: reduces frequency of crises.

Infant: SIDS prevention — back to sleep, firm mattress, no loose bedding/pillows/toys, no co-sleeping. Never leave alone on elevated surface. Car seat rear-facing until 2 years. Toddler (leading cause of death: unintentional injury): poisoning (lock up meds/cleaners — Poison Control 1-800-222-1222), drowning (never leave alone near water — even bathtub), falls (stair gates, window guards). School-age: bicycle helmets, safety in sports, stranger danger, firearm safety. Adolescent: motor vehicle accidents (#1 cause of teen death), alcohol/drugs, suicide (#2), firearms. Parents: always know where firearms are stored — lock and store separately from ammunition.

Pyloric stenosis: hypertrophy of pylorus → obstruction of gastric outlet. Age: 2–6 weeks, first-born males most common. Signs: projectile (forceful, non-bilious) vomiting after EVERY feeding, child remains hungry (feeds eagerly), visible peristaltic waves, olive-shaped mass in RUQ. Metabolic alkalosis (hypochloremic): losing HCl in vomit → pH↑, Cl↓, K↓. Diagnosis: ultrasound. Treatment: IV fluids to correct metabolic alkalosis FIRST, then surgical pyloromyotomy (Ramstedt procedure). Post-op: small, frequent feedings starting 4–6 hrs after surgery. Prognosis: excellent with surgery.

Bacterial meningitis: most common organisms — Neisseria meningitidis (teens, outbreaks), S. pneumoniae. Signs: classic triad — fever + headache + nuchal rigidity (stiff neck). Also: photophobia (sensitive to light), phonophobia, altered LOC, Kernig's sign (pain/resistance on knee extension with hip flexed), Brudzinski's sign (involuntary knee flexion when neck flexed). Petechial/purpuric rash: meningococcal meningitis — may progress rapidly to septic shock (Waterhouse-Friderichsen syndrome). Treatment: antibiotics immediately (do NOT wait for LP if patient unstable), dexamethasone (reduce inflammation), isolation (droplet for meningococcal — first 24 hrs antibiotics). LP: cloudy CSF, high WBC (neutrophils), high protein, low glucose.

Asthma: most common chronic disease in children. Triggered by: URI (most common in children), allergens, exercise, cold air, smoke. Assessment: expiratory wheezing, prolonged expiration, tachypnea, nasal flaring, retractions (intercostal, subcostal, sternal), accessory muscle use, SpO2. Peak expiratory flow: green >80%, yellow 50–80%, red <50% of personal best. Medications: SABA (albuterol/Ventolin): rescue inhaler — use FIRST before exercise or at onset. ICS (inhaled corticosteroid — fluticasone): controller, rinse mouth after (prevents thrush). Children need spacer with MDI. Theophylline: narrow therapeutic index, monitor levels. Status asthmaticus: severe attack not responding to albuterol → IV magnesium sulfate, possible intubation.

Children compensate well — SpO2 may be normal until they are severely compromised. Assess EARLY signs: Nasal flaring (nostrils widen with each breath), Grunting (physiologic PEEP — keeps alveoli open), Retractions (skin pulls in during inhalation): subcostal (below ribs), intercostal (between ribs), suprasternal (above sternum) — more retractions = more severe. Head bobbing (infants — uses neck muscles), Seesaw breathing (chest caves in, abdomen rises — severe, paradoxical). Stridor: inspiratory = upper airway (croup, epiglottitis). Wheeze: expiratory = lower airway (asthma, bronchiolitis). Always position for comfort — never force a position. Tripod position (leaning forward on hands) = severe distress.