NURS340 PEDIATRIC NURSING

Exam 4 Study Guide

Comprehensive review covering dermatological conditions, developmental considerations, neurological disorders, and critical pediatric care concepts

04 Major Sections

30+ Clinical Topics

100% NCLEX Aligned

SECTION ONE

Dermatological Conditions

Common pediatric skin disorders, infections, and nursing management

Atopic Dermatitis (Eczema)

KEY INFORMATION

Atopic Dermatitis: Chronic inflammatory skin condition characterized by intense itching, dry skin, and eczematous lesions. Most common in infants and young children.

Clinical Manifestations

Intense pruritus (itching)
Dry, scaly patches
Red, inflamed skin
Lichenification (thickening) from chronic scratching
Common locations: Face, scalp, extensor surfaces (infants); Flexural areas (older children)

Treatment

Hydration, lotion
Oatmeal bath

Nursing Interventions

Minimize spread, short nails
Decrease itchy fabric
Mild/no soaps, tepid bath
Emollient applied ASAP after bathing

MRSA

KEY INFORMATION

Bacterial, highly transmissible. Contact precautions required.

Treatment

Vancomycin
Bleach baths
Mupirocin

Nursing Interventions

Contact precautions
Separate towels
Disposable razors
Don't squeeze lesions

Infection Control

Precautions, handwashing
Clean commonly used items (stethoscope)
Immunizations

Sun Exposure & Sunburn

Education

Avoid high sun exposure times (10am-2pm)
Sunblock every 2 hours, reapply after water/sweat
Hats, clothing, light colors
Skin coverings for newborns rather than tons of SPF

Tooth Avulsion

EMERGENCY

Tooth Avulsion: "Knocked out" tooth

Treatment

Recover tooth, avoid touching root
Rinse & insert
Dentist ASAP - Full recovery = replaced within 1 hour of injury

Education

Control bleeding, pain management
Reimplantation
Calm approach

Frostbite

KEY INFORMATION

Tissue damage via excessive heat loss, allows ice crystals to form in tissues

Clinical Manifestations

Skin = white/blanches
Feels solid
No sensation

Treatment

Rapid rewarming
Analgesics, sedatives
Skin care
Causes flush = painful!

SECTION TWO

Developmental Considerations

Adolescent development, hospitalized children, and growth stages

Sexual Maturation - Adolescents (Tanner Stages)

KEY INFORMATION

Puberty Assessment: Stage 1 (immature) to Stage 5 (mature)

Females: Breast size & shape, pubic hair
Males: Size & shape of penis/scrotum, pubic hair

TANNER STAGES OF SEXUAL MATURATION

Stage	Females - Breast Development	Females - Pubic Hair	Males - Genital Development	Males - Pubic Hair	Approximate Age
Stage 1 (Prepubertal)	• No breast development • Elevation of papilla (nipple) only • Areola same color as surrounding skin	• No pubic hair • Only vellus hair (fine body hair)	• Prepubertal • Testes, scrotum, penis same size/proportions as early childhood	• No pubic hair • Only vellus hair	Females: <10 years Males: <9 years
Stage 2 (Early puberty)	• Breast bud stage • Elevation of breast and nipple as small mound • Areola diameter enlarges • First sign of puberty in females	• Sparse growth of long, slightly pigmented hair • Straight or slightly curled • Mainly along labia	• Scrotum and testes enlarge • Skin of scrotum reddens and texture changes • Penis size usually unchanged • First sign of puberty in males	• Sparse growth of long, slightly pigmented hair • Straight or slightly curled • Mainly at base of penis	Females: 10-11.5 years Males: 11-12 years
Stage 3 (Mid-puberty)	• Further enlargement of breast and areola • No separation of contours • Breast tissue extends beyond areola border	• Hair darker, coarser, more curled • Spreads sparsely over mons pubis	• Penis lengthens • Testes and scrotum continue to enlarge	• Hair considerably darker, coarser, more curled • Spreads sparsely over pubic area	Females: 11.5-13 years Males: 12-14 years
Stage 4 (Late puberty)	• Areola and papilla form secondary mound • Projects above level of breast • Menarche typically occurs in Stage 4	• Hair now adult-type • Area covered still smaller than adult • No spread to medial thighs	• Penis increases in breadth and develops glans • Testes and scrotum larger • Scrotal skin darker	• Hair now adult-type • Area covered still smaller than adult • No spread to medial thighs	Females: 13-15 years Males: 13-16 years
Stage 5 (Mature adult)	• Mature adult breast • Only nipple projects • Areola recessed to general breast contour	• Adult quantity and type • Distribution forms inverse triangle • Spread to medial surface of thighs	• Adult size and shape • Genitalia mature	• Adult quantity and pattern • Distribution forms inverse triangle • Spread to medial surface of thighs • May spread to linea alba in some males	Females: 15+ years Males: 16+ years

Clinical Notes:

Females: Menarche (first period) typically occurs in Tanner Stage 4, approximately 2-2.5 years after breast budding begins
Males: First ejaculation (spermarche) typically occurs in Tanner Stage 3-4
Growth Spurt: Females peak in early Stage 3; Males peak in Stage 4
Assessment: Breast/genital development and pubic hair are assessed separately - adolescent may be at different stages for each
Privacy: Always assess privately and with sensitivity; explain what you're assessing and why
Concern: Puberty before age 8 in girls or 9 in boys = precocious puberty; No signs by age 13 in girls or 14 in boys = delayed puberty

Nursing Interventions

Educate on STIs, puberty, sexuality, contraception
Nutrition, exercise, safe weight control
Issues: Hormones, acne, scoliosis, gynecomastia

Routines for Hospitalized School-Age Child

CREATING STRUCTURE

Key Interventions

Create a daily schedule (in patient room)
Plan times for treatment/medications, nutrition, schoolwork, exercise, play, TV, hobbies
Direct communication, use of games for learning, realistic questions
Have what they need to cope/understand - plan with parents
Special toys/objects per attachment

Fears

Internal + external bodily injuries (surgery & pain/stitches after)
Risk for separation from parents
Loneliness, boredom, isolation, depression
Stress & regression increases need for parents

Parent & Teen Communication

What Contributes to Poor Communication

Too much/too little time together
Lack of supervision
More time with peers
Parent expectations/style

Educate Parents

Teen is unpredictable, struggling for independence
Sensitive, misunderstood
Love their friends, strong need to belong

ENCOURAGE PARENTS TO

Accept/respect
Be involved
Avoid criticism/risky behavior
Promote learning
Clear & reasonable rules
Increase independence, privacy
Acknowledge feelings
LOVE!

Self-Identity: Adolescents

DEVELOPMENTAL TASK

Forming stable, coherent picture of oneself that integrates past + present experiences to gain sense for future

Components

Self-worth, ideas for future
Norms (culture/environmental)
Autonomy, sexuality, intimacy
Achievement

Ego Development Stages (Ages 12-18)

ADOLESCENT DEVELOPMENT BY STAGE

Stage	Physical	Cognitive/Emotional	Social/Identity	Behavioral Characteristics
Early Adolescence (12-14 years)	• Rapid body changes • Growth spurts • Clumsy coordination • Puberty begins/progresses	• Concrete thinking predominates • Beginning abstract thought • Increased day-dreaming • Lacks impulse control • Mood swings	• Conformity to peer group • Same-sex friendships primary • Defining independence from family • Preoccupied with body changes • Self-conscious about appearance	• Testing boundaries • Seeking peer approval • Comparing self to others • Experimentation begins • Privacy increasingly important
Middle Adolescence (15-16 years)	• Physical maturation continues • Most rapid growth completed • Sexual characteristics developing • Body image concerns peak	• Abstract thinking developing • "Imaginary audience" thinking • Feelings of omnipotence & invincibility • Risk-taking mentality • "It won't happen to me"	• Defining sexual identity & orientation • Intense peer relationships • May have romantic relationships • Concerned with appearance • Complaints about interfering parents • Maximum parent-teen conflict	• Peak risk-taking behaviors • Strong need for independence • Experimentation increases • May challenge authority • Peer influence strongest
Late Adolescence (17-18 years)	• Physical maturation nearly complete • Adult body proportions • Coordination improved • Less preoccupied with body	• Firmer identity • Able to delay gratification • Able to think ideas through • Capable of useful insight • More developed sense of humor • Able to express ideas in words	• Stable interests developing • Moral/ethical/spiritual values develop • Mutual relationships with opposite sex • Giving/sharing in stable relationships • External romance • More comfortable with self	• Emotional stability • Caring & compassionate • Pride in work • Caring for self • Constancy of emotion • Planning for future • More realistic thinking

Erikson's Stage: All of adolescence (12-18 years) = Identity vs. Role Confusion

Task: Develop coherent sense of self and role in society
Success: Strong sense of identity, fidelity to beliefs and people
Failure: Role confusion, inability to commit, identity diffusion
Key Question: "Who am I and where am I going?"

QUICK REFERENCE

High-Yield Facts for Exam

CRITICAL "NEVER" STATEMENTS

NEVER give children aspirin (Reye's syndrome risk)
NEVER give infants honey before age 1 (botulism risk)
NEVER use children/family as translators (use professional interpreters)
NEVER tell siblings "they went away" or "they're sleeping" (use clear language)

CRITICAL TIME FRAMES

24 hours	Isolation for suspected meningitis (minimum)
24-48 hours	Monitoring after near drowning (delayed complications)
30-35 minutes	Status epilepticus = medical emergency
1 hour	Tooth avulsion - must reimplant within 1 hour
2 years	Seizure-free before discontinuing meds (+ normal EEG)
80-85%	Spina bifida patients develop hydrocephalus

OPPOSITES TO REMEMBER

TETANUS = RIGID (muscles stiff, locked, spastic, patient alert)
BOTULISM = FLOPPY (hypotonic, weak, decreased reflexes)
Decerebrate → Decorticate = IMPROVEMENT (Reye's syndrome)
Bacterial meningitis = HIGH fever, very ill, bacteria in CSF
Viral meningitis = Moderate fever, less ill, NO bacteria in CSF

TESTABLE ASSESSMENTS

Glasgow Coma Scale

Score of 15 = BEST
Three categories: Eye opening, Motor response, Verbal response
Pediatric version for children under 2

Nuchal Rigidity

Hallmark sign of meningitis (older children)
Qualitative assessment - cannot measure
Difficulty/inability to flex neck forward

Bulging Fontanelles

Sign of increased ICP in infants
Assess when infant is calm (crying = normal bulging)

SHUNT MALFUNCTION = EMERGENCY

Signs parents MUST know:

Fever
Inflammation along shunt tract
Abdominal pain
Vomiting
Changes in LOC

MEDICATION HIGHLIGHTS

Phenobarbital	Give with Vit D + folic acid, can give with milk
Phenytoin (Dilantin)	Give with Vit D + folic acid, DO NOT give with milk
Diastat	Rectal diazepam - first line for status epilepticus
Versed	Intranasal midazolam - second line status epilepticus
Ativan	IV lorazepam - third line status epilepticus (emergency)
Accutane	HIGHLY TERATOGENIC - effective contraceptives required

SPINA BIFIDA CLASSIFICATION

Type	Definition	Clinical Presentation	Neurological Impact	Treatment	Prognosis
Spina Bifida Occulta ("Hidden")	• Mildest form • Failure of vertebral arch fusion • Meninges NOT involved • Spinal cord intact and normal • Often undiagnosed	SKIN INDICATORS: • Sacral dimple • Dark tufts of hair • Port wine nevus/angiomas • Lipomas in sacral area Usually asymptomatic	• Usually NONE • Normal neurological function • No paralysis • Bowel/bladder control normal • May have tethered cord in some cases	• Usually no treatment needed • Monitor for signs of tethered cord • May need surgery if tethering occurs • Parent education about what to watch for	Excellent • Normal life expectancy • Normal activities • Most people never know they have it
Meningocele	• Moderate form • Meninges (sac) protrudes through vertebral defect • Does NOT contain neural tissue • Spinal cord and nerves normal	• Visible sac on back • Filled with CSF • Covered with meninges and skin • Can occur anywhere along spine • Most common in lumbar-sacral area	• Usually minimal neurological deficits • May have minor weakness • Bowel/bladder function usually intact • Risk of hydrocephalus lower than myelomeningocele	• Surgical repair to close defect • Usually done in first few days of life • Protect sac pre-op (moist, sterile) • Prone positioning pre-op • Monitor for infection	Good to Excellent • Near-normal function • May have minor limitations • Good quality of life
Myelomeningocele (Most severe)	• Most severe form • Both meninges AND spinal cord/nerve roots protrude • Neural tissue exposed or covered by thin membrane • Usually accompanied by Chiari II malformation	• VISIBLE SAC containing neural tissue • May leak CSF • High infection risk • Most common site: lumbosacral • Level of defect determines impairment severity	SIGNIFICANT neurological deficits: • Paralysis below defect level • Loss of sensation • Neurogenic bowel/bladder • 80-85% develop hydrocephalus • May have Arnold-Chiari malformation • Orthopedic deformities common	PRE-OP: • PROTECT SAC (moist, sterile) • Prone position • Prevent infection • Monitor head circumference SURGERY: • Close defect within 24-48 hours POST-OP: • Watch for increased ICP • May need VP shunt • Lifelong management	Variable • Depends on lesion level • Requires lifelong care • Multiple surgeries common • Mobility aids often needed • CAN have good quality of life with support • Many complications possible

CRITICAL POINTS:

80-85% of myelomeningocele patients develop hydrocephalus - often requires VP shunt placement
Latex allergy: HIGH RISK in ALL types - use latex-free equipment from birth
Level of lesion = level of function: Higher lesions = more impairment
Folic acid prevention: 400 mcg daily BEFORE pregnancy reduces risk by 70%
Pre-op priority: PROTECT THE SAC - keep moist, sterile, prone position

SKIN INDICATORS OF SPINA BIFIDA OCCULTA (Know These)

Sacral dimple
Port wine nevus or angiomas
Dark tufts of hair in sacral area
Lipomas in sacral area

PRE/POST-OP MYELOMENINGOCELE

Pre-Op

PROTECT THE SAC - warm, moist, sterile saline
PRONE POSITION
Warming bed
Frequent stool cleaning/hourly diapers
Head circumferences

Post-Op

NO MORE SAC! Now surgical incision
Keep prone or side-lying for feeds
Watch for increased ICP (contents now internal)
Monitor for SIDS risk (prone positioning)
Can breastfeed (position carefully)
Continue head circumferences

LATEX ALLERGY IN SPINA BIFIDA

High risk due to repeated exposures

Foods that cross-react: Banana, avocado, kiwi, chestnuts

Use latex-free equipment for ALL procedures

END OF STUDY GUIDE

Good Luck on Your Exam!

Remember: Focus on KEY concepts highlighted throughout this guide