NCLEX-RN: Pediatric Nursing


Focus topic: Pediatric Nursing

The respiratory system accomplishes pulmonary ventilation through the process of inspiration and expiration. The act of breathing involves a complex chemical and osmotic process in which oxygen is taken into the lungs and carbon dioxide, the end product, is given off.

Pediatric Nursing: Pulmonary System Assessment

Focus topic: Pediatric Nursing

A. History.

  • Perinatal history—maternal problems, infections, illnesses, smoking.
  •  Gestational age—length of hospitalization, pulmonary problems, neonatal intensive care unit (NICU) stay.
  •  Respiratory problems since birth—exposures, frequent infections, hospitalizations, chronic diseases, cough, smokers in household.

B. Inspection.

  • Observe respiratory rate and effort (know normal rates for age).
  •  Assess skin color—pale, pink, mottled, dusky, cyanotic.
  •  Assess level of consciousness and interaction with environment.
  •  Observe for drooling, unwillingness to swallow, inspiratory stridor, and signs of upper airway obstruction.
  •  Evaluate signs of respiratory distress—nasal flaring, head bobbing, tachypnea, cough, audible wheezing, grunting, retractions, decreased oxygen saturation.
  •  Evaluate sputum and secretions from nose and eyes.
  •  Assess chest expansion for symmetry, and shape of chest.
  •  Observe nail beds for color and clubbing.

C. Palpation.

  •  Evaluate areas of tenderness over chest.
  • Assess lymph nodes.
  •  Assess respiratory excursion and tactile fremitus.

D. Percussion.

  •  More useful in older children.
  •  Should hear resonance over lung surfaces.
  •  Note location of any areas of dullness (consolidation); percuss margins.

E. Auscultation.

  •  Using diaphragm, systematically evaluate lungs from apices to bases, comparing side to side.

Pediatric Nursing

  •  In infants and young children, auscultate in axillae comparing side to side; allow infant/ child to sit in lap of caregiver.
  •  Note quality of respirations, depth, rate, crackles, or wheezes, any abnormal finding.

F. Hydration.

  •  Color and moistness of mucous membranes and secretions.
  •  Assess skin turgor.
  •  Evaluate for bulging or sunken fontanelles.
  •  Assess recent intake and output.

G. Current symptoms.

  •  History of illness/onset/recurrences.
  • Medications taken; therapies used.
  •  History of asthma/wheezing.
  •  Immunization status; recent exposures.

Anatomic Differences in Pediatric Respiratory System

A. Larynx is more cephalad and anterior.
B. Decreased airway size—smaller diameters are more susceptible to change due to swelling and secretions.
C. Narrowest point of the airway is at cricoid cartilage rather than at larynx.
D. Fewer number of airway divisions and alveoli.
E. Ribs are oriented more in horizontal plane.
F. Poorly developed intercostal muscles (thin chest walls).

Physiological Differences in Pediatric Respiratory System

A. Infants are obligate nose breathers until 4–6 weeks of age.
B. Primary muscle of respiration is the diaphragm (“belly breathers”).
C. Decreased tidal volume and functional reserve volume.
D. “Stiffer” lungs (with more compliant chest walls).
E. Higher basal metabolic rate (BMR) and oxygen consumption relative to body surface area.

F. Infants are at high risk for heat and volume loss from high respiratory rates.
G. Increased susceptibility to infective organisms.

Pediatric Nursing:System Implementation

Focus topic: Pediatric Nursing

A. Monitor for signs of respiratory distress.

  •  Early signs.
    a. Increased respiratory rate (tachypnea).
    b. Nasal flaring, head bobbing.
    c. Retractions.
    d. Tachycardia.
    e. Decreasing SaO2.
  •  Late signs.
    a. Cyanosis.
    b. Dyspnea.
    c. Decreased level of consciousness.
    d. Bradycardia.

B. Ensure patency of airway—administer oxygen as ordered.

  •  Monitor O2 saturation levels.
  •  Provide postural drainage, coughing, deep breathing, chest physiotherapy, and suctioning to aid in the removal of secretions.
  •  Provide cool mist for humidifying air.

C. Maintain IV and/or oral fluid levels.
D. Administer antibiotic therapy if bacterial infection is present.
E. Administer antipyretic medication, such as Tylenol (acetaminophen) or Advil (ibuprofen), tepid sponge baths, or cooling mattress.
F. Ensure adequate rest and provide a less stressful environment.
G. Organize nursing care to give adequate rest periods.
H. Support family and prepare for discharge.

Pediatric Nursing: Upper Airway Obstructive Conditions

Focus topic: Pediatric Nursing

Pediatric Nursing: Laryngotracheobronchitis (“Croup”)

Focus topic: Pediatric Nursing

Definition: Viral croup is a syndrome caused by a variety of inflammatory conditions of the upper airway. Viral croup is the most common. More commonly seen in children less than 3 years old.


A. Obtain accurate history—ascertain if rhinitis and cough have preceded croup for several days.
B. Assess for gradual onset, then barking cough and inspiratory stridor—usually for 3–7 days, worse at night.
C. Assess for mild elevation in temperature (below 102°F/38.8°C).

Pediatric Nursing: Symptoms of Upper Airway and Lower Respiratory Tract Obstruction

Focus topic: Pediatric Nursing

Pediatric Nursing

D. Observe for hypoxemia, decreasing SaO2 (resulting in anxiety and restlessness).
E. Assess for cyanosis, a late sign, which may indicate complete airway obstruction.

A. Plan for home treatment if no inspiratory stridor.

  •  Instruct parents in signs of airway obstruction.
    a. Tachypnea.
    b. Increased anxiety.
    c. Pallor, mottling, or cyanosis (circumoral or around eyes).
  •  Instruct parents in providing cool mist therapy. Steam from the shower is less desirable, but may be effective.

B. Treatment.

  •  For moderate to severe croup that doesn’t respond to cool mist and PO fluids, oral or inhaled steroids may be prescribed.
  •  For severe croup, Vaponefrin, a nebulized racemic epinephrine treatment, is administered.
  • Children should be observed in the emergency department (ED) or clinic setting for 1–2 hours after receiving Vaponefrin because of the risk of “rebound.”

C. Provide hospital care for acute onset with inspiratory stridor.

  •  Monitor vital signs every 1–2 hours; check temperature frequently if in cool mist tent.
  •  Check respiratory status at least hourly, depending on severity of distress.
  •  Monitor accompanying signs and symptoms.
    a. Respiratory rate.
    b. Grunting, flaring, retracting.
    c. Stridor.
    d. Color.

e. Auscultation of breath sounds.
f. Restlessness.
g. Use of accessory muscles.
h. Oxygen saturation (pulse oximetry).

  • Obtain baseline ABG/CBG (capillary blood gases), CBC, and throat culture, if ordered.
  •  Provide cool humidified air or oxygen as ordered.
  •  Check oxygen saturations frequently or continuously via pulse oximetry, to keep above 93–94%.
  • Monitor hydration status.
    a. Encourage cool fluid PO intake (cool fluids will help decrease inflammation).
    b. If respiratory rate (RR) > 60 and NPO, administer adequate intravenous fluids; if RR < 60 and will take fluids, give fluids carefully to maintain hydration, clear liquids as tolerated; supplemental IV.
    c. Maintain patency of IV.
    d. Monitor urinary output, specific gravity, and skin turgor.
  •  Treat fever with Tylenol or Advil.
  •  Place on cardiorespiratory monitor if signs of hypoxia or impending respiratory failure.

Pediatric Nursing

Pediatric Nursing: Epiglottitis

Focus topic: Pediatric Nursing

Definition: An acute bacterial infection of the epiglottis, may occasionally be of viral origin. Usually caused by Haemophilus influenzae type B or Streptococcus pneumoniae. May produce severe upper airway obstruction.


A. Observe that illness occurs most frequently in young children, 3–7 years of age who are seen leaning forward in a tripod position.
B. Ascertain if illness was preceded by an upper respiratory infection.
C. Assess for rapid onset with marked inspiratory stridor and retractions, cough, muffled voice. (The four Ds: dysphonia, dysphagia, drooling, distressed respiratory efforts).
D. Assess for high temperature (100–104°F or 37.7–40°C).
E. Evaluate difficulty in swallowing as manifested by excessive drooling and refusal to take liquids.


A. Prepare for lateral neck films stat to confirm diagnosis. Keep child in upright and “sniffing” position. Supine position may cause occlusion of the airway and respiratory arrest.
B. Never use restraints; never use a tongue blade or place anything into pharynx.
C. Do not elicit a gag reflex—may cause further spasm of epiglottis and complete airway obstruction.
D. Prepare child for the operating room if elective intubation is to be done under anesthesia.
E. Maintain tracheostomy set/intubation tray at bedside.
F. Provide cool oxygen mist at all times.
G. Monitor vital signs with respiratory status continuously.

  •  Respiratory rate, stridor, color, restlessness.
  •  Auscultate breath sounds; evaluate use of accessory muscles.
  •  Place on continuous cardiorespiratory monitor and pulse oximetry.

H. Monitor hydration status. Keep child NPO.

  •  Start IV (after airway is secure).
  • Check urinary output, specific gravity, skin turgor, tears.

I. Administer broad-spectrum antibiotic after IV line secure and patent.
J. Monitor temperature and administer antipyretics.
K. Droplet isolation for 24 hours after start of antibiotic therapy.
L. Maintain endotracheal tube patency if intubation necessary.

Pediatric Nursing: Tonsillitis and Adenoiditis

Focus topic:  Pediatric Nursing

Definition: Infection and inflammation of the palatine tonsils and adenoids. Primary causes are Group A betahemolytic Streptococcus and viruses.


A. Assess for difficulty swallowing or breathing.
B. With adenoiditis, child is unable to breathe through nose and must mouth-breathe (may be noisy, snoring at night).
C. Observe for fever, sore throat, and anorexia.
D. Assess for general malaise and dehydration.
E. Assess for pain in ear and recurring otitis media.
F. Evaluate indications for possible surgery.

  •  Surgery is performed only when necessary because tonsils are thought to have protective immunologic functions; it is delayed until age 3 years to allow the structures of the mouth and throat to grow larger.
  •  Assess for difficulty in swallowing, indicating enlargement of tonsils or adenoids.
  •  Assess for repeated episodes of tonsillitis, indicating infection (at least three in 1 year).
  •  Observe for signs of respiratory distress.
  • Evaluate for hearing, chronic otitis media.


Pediatric Nursing:Preoperative Interventions

Focus topic: Pediatric Nursing

A. Review lab work (CBC, Hgb, Hct, bleeding and clotting time), serologic tests, and throat culture (should not have an active infection at the time of the surgery).
B. Obtain complete health history, including history of allergies.
C. Provide emotional support and preoperative teaching for the child (for same-day outpatient procedure).

  •  Hospital admission processes.
  •  The operative procedure and recovery room.
  •  Ensure that written consent if obtained prior to procedure.

Pediatric Nursing:Postoperative Interventions

Focus topic:  Pediatric Nursing

A. Maintain in prone or Sims’ position until fully awake to facilitate drainage of secretions and prevent aspiration. Then change to semi-Fowler’s.
B. Avoid suctioning and coughing to prevent hemorrhage.
C. Observe for signs of postoperative bleeding and shock.

  •  Restlessness.
  •  Alterations in vital signs (increased pulse, decreased blood pressure, increased respiration).
  •  Frequent swallowing (caused by blood dripping down the back of throat).
  •  Excessive thirst due to fluid loss and inability to swallow fluids.
  •  Vomiting of bright red blood (coffee ground appearance is “old” blood).
  •  Pallor.

D. Maintain calm, quiet environment to prevent anxiety.
E. Provide ice collar.
F. Encourage fluids.

  •  Encourage cold fluids, Popsicles, ice chips, or any food or liquid child will take. Avoid red Popsicles or fluids; may mask bleeding.
  •  Do not use straws.

G. Administer analgesics for pain as ordered.
H. Discharge teaching.

  •  Avoid highly seasoned or irritating food.
  •  Activity limitations.
  •  Use of analgesics—use around the clock in the first 24 hours.
  •  Signs of bleeding—most likely to occur in the first 24 hours or 7–10 days later when sloughing occurs. Avoid coughing, gargling, and clearing the throat.
  •  Signs of infection (temperature > 101°F or 38.3°C). Note that “bad” breath and a whitish appearance to the throat is to be expected after the surgery.

Pediatric Nursing: Acute Otitis Media

Focus topic: Pediatric Nursing

Definition: A common complication of an acute respiratory infection that occurs when edema of the upper respiratory structures traps the infection in the middle ear.


A. Etiology: viruses and bacteria such as Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis most often associated with an upper respiratory tract infection or nasal congestion from allergies.
B. Children living with smokers and who attend day care have significant increase in acute otitis media (AOM) episodes.
C. AOM primarily results from dysfunctional Eustachian tubes with retention of secretions in the middle ear.
D. Incidence is greatest from 6 months to 3 years old, slightly more frequent in boys and most often in winter months.


A. Assess for fever and associated upper respiratory infection.
B. Observe for pulling or rubbing of one or both ears.
C. Observe for crying, irritability, restlessness, lethargy, and anorexia.

D. Monitor for language delays in young children with frequent acute otitis media since the drainage of fluid (effusion) from the middle ears resolves over a period of weeks.

A. Supervise use of antibiotics.

  •  Children have usually been treated with antibiotics for acute otitis media.
    a. AAP (American Academy of Pediatrics) recommends that children be treated a high or double dose of Amoxil (amoxicillin), which is 80 or 90 mg/kg/day.
    b. If the Amoxil doesn’t work after 48–72 hours or if the child has a fever at or above 102.2°F or 39°C, then high-dose Augmentin (amoxicillin and clavulanate) or Augmentin ES (extra strength) should be used.
  •  Because of increasing bacterial resistance to antibiotics and fewer Streptococcus pneumoniae ear infections due to use of the pneumococcal vaccine (PVC-13), current guidelines are to delay antibiotic treatment for 48–72 hours after diagnosis for children 6 months to 2 years with nonsevere illness while treating symptomatically (see B below).

B. Administer analgesics and/or analgesic ear drops for pain, and Tylenol (acetaminophen) or Advil (ibuprofen) for fever.
C. Advise parents that during the course of the infection the child may have a conductive hearing loss.
D. Maintain adequate diet and fluid intake.
E. Provide education and support if myringotomy and/or insertion of tympanostomy (pressure equalizing; PE) tubes is necessary for chronic otitis infection, recurrent otitis media, and conductive hearing loss.
F. Parents of infants should be taught to never put child in bed with a bottle, to never prop a bottle, and to feed infants in upright position.
G. Strongly encourage family members to keep child’s environment smoke free.




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