NURS 345 Exam 1 Review List_Complete updated 2025- A+ Guide.

NURS 345 Exam 1 Review List How are kids different from adults?  Pathophysiology (metabolism, growth, development) Assessment strategies for different age groups of pediatric patients Position Sequence Preparation Infant - Before able to sit alone; supine or prone, preferably in parent’s lap; before 4-6 months, can place on examining table - After able to sit alone; sitting in parent’s lap whenever possible; if on table, place with the parent in full view - If quiet, auscultate the heart, lungs, and abdomen - Record heart and respiratory rates - Palpate and percuss same areas - Proceed in the usual headto-toe direction - Perform traumatic procedures LAST (eyes, ears, mouth [while crying) - Elicit reflexes as the body part is examined - Elicit moro reflexes last - Completely undress if room temperature permits - Leave diaper on the male infant - Gain cooperation with distraction, bright objects, rattles, talking - Smile at infant; Use soft, gentle voice - Use pacifier (if used) or bottle with feeding (if bottle feeding) - Enlist parent’s aid for restraining to examine ears and mouth - Avoid abrupt, jerky movements Toddler - Sitting on parent’s lap or standing by parent - Prone or supine in parent’s lap - Inspect body area through play; “count fingers, tickle toes” - Use minimum physical contact initially - Introduce equipment slowly - Auscultate, percuss, palpate whenever quiet - Perform traumatic procedures last (same as for infant) - Have parent remove outer clothing - Remove underwear as the body part is examined - Allow toddlers to inspect equipment; demonstrating the use of equipment is usually ineffective - If uncooperative, perform procedures quickly - Use restraint when appropriate; request parent’s assistance - Talk about examination if cooperative; use short phrases - Praise for cooperative behavior Preschool child - Prefer standing or sitting - Usually cooperative prone or supine - Prefer parent’s closeness - If cooperative, proceed in a head-to-toe direction - If uncooperative, proceed as with toddler - Request self-undressing - Allow to wear underwear if shy - Offer equipment for inspection; briefly demonstrate use - Make up a story about the procedure (I’m seeing how strong your muscles are [blood pressure) - Use the paper-dolltechnique - Give choices when possible - Expect cooperation; use positive statements (“open your mouth”) School-age child - Prefer sitting - Cooperation in most positions - Younger child prefers parents presence - Older child may prefer privacy - Proceed in a head-toedirection - May examine genitalia last in an older child - Respect the need for privacy - Request self-undressing - Allow to wear underwear - Give gown to wear - Explain the purpose of equipment and significance of procedure, such as otoscope to see tympanic membrane, which is necessary for hearing - Teach about body function and care Adolescent - Same as for school age child - Offer option of parent’s presence - Same as an older schoolage child - May examine genitalia last - Allow to undress in private - Give gown - Expose only the area to be examined - Respect the need for privacy - Explain findings during the examination (“your muscles are firm and strong”) - Matter-of-factly comment about sexual development (“your breasts are developing as they should be”) - Emphasize normalcy of development - Examine genitalia as any other body part; may leave to end Normal vs. abnormal behavior for different age groups  Stammering/stuttering is normal for preschool child  Lying can be normal for children Assessment of pediatric patients. Normal vs. abnormal findings.  Growth measurements o Growth charts o Length o Height o Weighto Skin full thickness and arm circumference o Head circumference  Length, height, weight  Circumference measures o Generally, head circumference is larger than chest circumference in most newborns o The head and chest circumferences approximate each other around 12 months of age o Later in childhood, the chest circumference exceeds head size by about 5-7 cm  Physiologic Measurements o Temperature (box 29.9)  For rectal temperatures in children, 37 degrees Celsius to 37.5 degrees Celsius is an acceptable range  For neonates, core body temperature between 36.5 degrees Celsius and 37.6 degrees Celsius is a desirable range  Birth to 2 years- Axillary and rectal  2-5 years old- Axillary, tympanic, oral, and rectal  Older than 5- Oral, axillary, tympanic, temporal artery o Pulse  Radial or brachial  Apical * (count for full 60 seconds) o Respiration (count for full 60 seconds)  Count respirations first.  For infants and young children- count apical pulse. Radial pulse is too fast to count.  Temperature: tympanic, temporal, axillary, oral, rectal  Physiologic Measurements (2) o Pediatric blood pressure (BP) o Measurement devices  Auscultation remains the gold standard method of BP measurement in children under most circumstances  Use of the automated devices is acceptable for BP measurement in newborns and young infants, in whom auscultation is difficult, and in the intensive care setting where frequent BP measurement is needed o Selection of cuff  Choose a cuff with a bladder width that is at least 40% of the arm circumference midway between the olecranon and the acromion o Cuff placement  Upper arm (brachial), lower arm (radial), thigh (popliteal), or ankle (posterior tibial) o BP measurement and interpretation o Orthostatic hypotension  Physical assessment o General appearance o Skin (Ng tube, open areas, lymph nodes)  Normally, the skin texture of young children is smooth, slightly dry, and not oily or clammy o Accessory structures  Childrens scalp hair is usually lustrous, silky, strong, and elastic  Hair that is stringy, dull, brittle, dry, friable, and depigmented may suggest poor nutrition o Lymph nodes  In children, small, nontender, moveable nodes are usually normal Tender, enlarged, warm, erythematous lymph nodes generally indicated infection or inflammation close to their location o Head and neck  The posterior fontanel closes normally by 2 months old, and the anterior fontanel fuses between 12 and 18 months old  Note any unusual facial proportion, such as an unusually high or low forehead; wide or close set eyes, or a small, receding chin  The neck is normally short, with skinfolds between the head and shoulders during infancy; the neck lengthens during the next 3-4 years o Cranial nerves only for neuro focused exam o Eyes  External structures  When the eye is open, the upper lid should fall near the upper iris  When the eyes are closed, the lids should completely cover the cornea and sclera  Conjunctiva should appear pink and glossy  The sclera should be clear  Cornea should be clear and transparent  Pupils should be round, clear, and equal  Lens is not visible through the pupil  Internal structures  Funduscopic examination (get otoscope and look into eyes)  Optic disc should be round or oval o Vision testing  Ocular alignment  Normally by 3-4 months old, children can fixate on one visual field with both eyes simultaneously  Visual acuity in children  Visual acuity in infants and difficult to test children  Peripheral vision  Children normally see 50 degrees upward, 70 degrees downward, 60 degrees nasalward, and 90 degrees temporally  Color vision o Ears  External structures  Internal structures  Positioning the child  Otoscopic examination  Auditory testing  Under 2- Pull pinna down & back o Nose o External structures  The nose should lie in the middle of the face, with each side exactly symmetric on both sides of the imaginary line o Internal structures  There should be no discharge from the nose o Is there any drainage? Are the nares patent? o Mouth and throat o Internal structures Plaque is a sign of poor dental hygiene and indicates a need for counseling  Gums should be pink  Tip of the tongue should normally extend to the lips or beyond  Arch of the palate should be dome shaped o Chest  Does it seem appropriate?  Is it sunken in? o Lungs  Auscultation  Listen to breath sounds o Heart o Auscultation  Origin of heart sounds (S1, S2)  Differentiating normal heart sounds  Heart murmurs- physiologic vs pathologic o Diaphragm = higher pitched o Abdomen o Inspection o Auscultation o Palpation o Genitalia o Male genitalia  Circumcised vs. uncircumcised  Is it swollen?  Does the penis appear normal? o Female genitalia o Anus o Back and extremities o Spine o Extremities o Joints  Valgum = knock knee  Varum = bow legged o Muscles o Neurologic assessment o Cerebellar function o Reflexes o Cranial nerves Developmental milestones for pediatric patients. See tables in textbook. (noted in PPTs as well). Infants Promoting Optimal Growth and Development:  Biologic development  Proportional changes o 5- to 7-oz weight gain per week o *Doubling of birth weight by age 6 monthso *Tripling of birth weight by age 1 year o Height increases by 1 inch per month x 6 months o Growth in “spurts” rather than gradual pattern  Children with asthma (or chronic diseases) may have delayed growth Maturation of Systems:  Slowing of respiratory rate  Slowing of heart rate  Hematopoietic changes  Head growth o Babies and infants will grow into their head o Related to familial issues  Differentiation of the nervous system  Maturation of digestive processes  Maturation of immunologic system  Thermoregulation o Body’s surface area will increase  Maturation of renal function  Increase in auditory acuity and perception o Babysee app Fine Motor Development:  Grasping object: ages 2 to 3 months o If they are only grabbing things with one hand, they could have a neurological issue or cerebral palsy o A kid is not right or left handed until age 5  Transferring object between hands: age 7 months  Pincer grasp (picking up cereal): age 10 months  Removing objects from container: age 11 months  Building tower of two blocks: age 1 year Gross Motor Development:  Head control o When you pull a baby from lying to sitting and their head falls back  Depends on the gestation of the child  Head lag should disappear by 2 months (40 week gestation)  Rolling over o Age 5 months: abdomen to back o Age 6 months: back to abdomen  Sitting: age 7 months; Counts even if the baby is tripoding  Move from prone to sitting position: age 10 months  Locomotion o Cephalocaudal direction of development o Crawling: ages 6 to 7 months o Walking with assistance: age 11 months  Creeping = holding things to walk o Walking alone: age 1 year  Even if they only take a few steps then fall downNeurologic Reflexes: Reflex When it presents When it goes away  Moro reflexWhen you startle the baby, their arms will go back and in  Tonic neckWhen a baby’s head is turned to one side, the arm on that side stretches out and the opposite arm bends up at the elbow  Palmar grasp- You put something in their hand and they grab it  Babinski- The Babinski reflex occurs after the sole of the foot has been firmly stroked. The big toe then moves upward or toward the top surface of the foot. The other toes fan out. Babinski reflex is one of the normal reflexes in infants and in children up to 2 years old  Blinking and turning- When the baby blinks and turns at sound  Rooting- When you touch their cheek and they open their mouth and follow the direction of the  Stepping- You hold the baby up and they step  Handedness- Using the left or right hand Psychosocial Development:  Developing a sense of trust (Erikson) o Infants trust that their comfort needs will be met  Feeding  Stimulation o Mistrust  Occurs when gratification of needs is delayed  If they are hungry and don't get fed  If they are sitting in a diaper and don't get changed o Social modifications  Grasping  If a baby grows up in a culture that wears jewelry, their grasping will be more advanced  Biting  If a baby is breastfed, they might bite more o You cannot spoil an infant (crying is their only way to communicate) Cognitive Development:  Sensorimotor phase (Piaget)o Birth to age 1 month: use of reflexes o Ages 1 to 4 months: primary circular reactions o Ages 4 to 8 months: secondary circular reactions o Imitation- Child drops the toy, looks at you, you pick it up, they do it again o Play o Affect o Coordination of second schemas Development of Body Image:  Concept of object permanence is acquired o You hide a toy under a blanket and they try and look for it o 7-9 months o Pulls the moms shirt down to get to the milk  Development of body image parallels sensory motor development  Anesthetic and tactile experiences are children’s first perceptions of their bodies  By end of first year, children recognize that they are distinct from parents Social Development:  Attachment  Reactive attachment disorder (RAD) o Can be attached to people besides the parents  Separation anxiety  Stranger fear  Language development o First word is dada or baba  Play Temperament:  Infants’ behavioral style  Strong biological component o May be modified by the environment and family o Could be from copying the family; Don't develop their own temperament until 6-7 years old Coping with Concerns Related to Normal Growth and Development:  Fear of separation and strangers (9 months)  Alternative child-care arrangements  Setting limits and discipline o Positive reinforcement  “You washed your hands that's great”  If they don’t do it right do it with them  Thumb-sucking and use of a pacifier* o No pacifier until 2-3 weeks of age (when breastfeeding is fully established)  Teething o Varies on genetics  AAP and the American Academy of Family Physicians recommend delaying pacifier use until breastfeeding is established. ToddlersPromoting Optimal Growth and Development:  “The terrible twos”  Ages 12 to 36 months  Intense period of environmental exploration  Temper tantrums/obstinacy/negativism Biological Development:  Proportional changes o Weight gain slows to 4 to 6 lb/year o Birth weight should be quadrupled by age 2½ years o Height increases about 3 inches/year o Elongation of legs rather than trunk (makes the child clumsy) o Growth is steplike rather than linear  Sensory Changes o Visual acuity of 20/40 is acceptable o Hearing, smell, taste, and touch continue developing o All senses are used to explore environment  Maturation of Systems o Most physiologic systems are relatively mature by the end of toddlerhood o Upper respiratory infections, otitis media, and tonsillitis are common among toddlers (6-8 per year is the norm) o Body temperature is maintained (let the baby go out without a coat) (they can’t get sick from being cold) o Child is physiologically able to control elimination o Defense mechanisms of skin are intact  Gross and fine motor development o Locomotion o Refinement of coordination  Between ages 2 and 3 years o Fine motor development o Improved manual dexterity  Ages 12 to 15 months o Throwing ball  By 18 months  Evaluate eyes if child is not alternating feet when going up and down stairs Psychosocial Development: Developing sense of autonomy (Erikson) o Autonomy vs. shame and doubt o Negativism o Ritualization, which provides sense of comfort  Keep them on schedule o Id, ego, superego/conscience Cognitive Development:  Sensorimotor and preoperational phase (Piaget) o Cognitive processes develop rapidly between ages 12 and 24 months o Tertiary circular reactions  Active experimentation  Applying knowledge to new situations  Learning spatial relationships  Tertiary circular reactions  •13-18 months o Differentiates self from objects o Causal relationships o Learning spatial relationships o Object permanence  Early symbolic thought o 19 to 24 months o Imitation of behaviors o Domestic mimicry o Concept of time is still embryonic Spiritual Development:  Evolution of spirituality often parallels cognitive development  Family and environment influence a child’s perception of the world  Intuitive-projective phase is experienced o Fowler’s faith construct  Spiritual routines can be comforting Development of Body Image:  Development of body image parallels cognitive development  Child refers to body parts by name  Child recognizes words used to describe appearance o Adults should avoid negative labels about physical appearance  Child recognizes gender differences by age 2 years Development of Gender Identity:  Exploration of genitalia is common o Genital fondling can occur o Parental reaction should be accepting  Gender roles are understood by toddler o Playing “house” o Gender identity is formed by age 3 years AAP Recommendations for care of transgender and gender-diverse children: Take a “gender-affirming” nonjudgmental approach  Increase access to care  Strengthen the family model  Provide gender-appropriate healthcare  Family based therapy  Help with insurance selection  Advocate in community, policy, and law to support these children Language:  Level of comprehension increases  Ability to understand increases  Comprehension is much greater than the number of words a toddler can say  At age 1 year, child uses one-word sentences  By age 2 years, child uses multi word sentences Personal Social Behavior:  Toddlers develop skills of independence  Skills for independence may result in determined, strong-willed, volatile behaviors  Skills include feeding, playing, dressing, and undressing self  Toddlers develop concern for the feelings of others Play:  Magnifies physical and psychosocial development  Interaction with others: becomes more important  Parallel play o Playing next to each other but not interacting  Imitation o Copying somebody  Tactile play  Selection of appropriate toys Coping with Concerns Related to Normal Growth and Development:  Toilet training  Sibling rivalry  Temper tantrums  Negativism  Regression Toilet Training:  Assessing readiness for toilet training o Voluntary sphincter control o Able to stay dry >2 hr o Fine motor skills to remove clothing o Willingness to please parents o Curiosity about adult or sibling’s toilet habits o Impatient with wet or soiled diapers Temper Tantrum:  Temper tantrums o Ignore attention seeking behavioro Intervene immediately o Normal part of toddlerhood but can be a sign of other problems- if…  <1 yr or >4 yr  Associated with aggressive/violent behavior  Occur regularly at school  Other concerns (sleep or feeding issues)  Breath holding or fainting Promoting Optimum Health During Childhood:  Nutrition o Phenomenon of “physiologic anorexia”  You feel like they are not eating anything o Nutritional counseling o Dietary guidelines o Vegetarian diets  Complementary and alternative medicine  Sleep and activity o Sleep problems  Dental health o Regular dental examinations o Removal of plaque o Fluoride o Dietary factors o Early childhood caries Safety Promotion and Injury Prevention:  Motor vehicle safety o Car seat restraints (age 8 and under) o Motor vehicle–related injuries  Drowning o Only need an inch of water to drown  Burns  Accidental poisoning  Falls  Aspiration and suffocation  Bodily injury Accidentally Poisoning:  Most frequently ingested poisons o Cosmetics and personal care products o Medications o Household cleaners o Foreign bodies and miscellaneous substances (avoid button batteries)  Principles of emergency treatment o Advise parents to call Poison Control Center (PCC) before initiating interventions o Assessment o Gastric decontamination o Prevention of recurrenceHeavy Metal Poisoning:  Lead poisoning o Causes of lead poisoning o Child is hyperactive (looks like ADHD) o Pathophysiology and clinical manifestations o Diagnostic evaluation o Anticipatory guidance o Screening for lead poisoning o Therapeutic management  Chelation therapy  Medication given IV that binds w the lead and gets it out of the body  Prognosis o Nursing care management Preschool Promoting Optimal Growth and Development:  The preschool period: ages 3 to 5 years  Preparation for most significant lifestyle change: going to school  Cooperative interaction with other children  Experience of brief and prolonged separation  Use of language for mental symbolization  Increased attention span and memory Biologic Developments:  Physical growth slows and stabilizes  Average weight gain remains about 5 lb/year  Average height increases 2½-3 inches/year  Body systems mature and stabilize; can adjust to moderate stress and change Gross and Fine Motor Skills:  Gross motor (larger motor skills) o Walking, running, climbing, and jumping well established  Fine motor (drawing, writing) o Refinement in eye-hand and muscle coordination o Skillful manipulation (dressing, drawing) Psychosocial Development:  Developing sense of initiative (Erikson) o Chief psychosocial task of preschool period o Feelings of guilt, anxiety, and fear: may result from thoughts that differ from expected behavior o Development of superego (conscience) o Learning right from wrong/moral development Cognitive Development:  Readiness for school  Readiness for scholastic learning  Typically ages 5-6 years  Preoperational phase (Piaget)o Spans 2-7 years o Preconceptual phase: ages 2-4 years o Intuitive thought phase: ages 4-7 years o Shifting from egocentric thought to social awareness o Ability to consider other viewpoints  Language continues to develop  Concept of causality begins to develop  Concept of time is incompletely understood  “Magical thinking” is used frequently Moral Development:  Preconventional or premoral level (Kohlberg); Not tested o Basic level of moral judgment o Punishment and obedience orientation o Naïve instrumental orientation o Very concrete sense of justice and fairness  Preschoolers will lie for no reason Development of Body Image:  Increasing comprehension of “desirable” appearances  Aware of racial identity, differences in appearances, and biases  Poorly defined body boundaries o Children fear that if skin is “broken,” all blood and “insides” can leak out o Intrusive experiences are frightening Development of Sexuality:  Child forms strong attachment to opposite-sex parent while identifying with same-sex parent  Modesty becomes a concern  Child demonstrate limited sex-role ideation, “dressing up like Mommy or Daddy”  Sexual exploration is more pronounced  Questions arise about sexual reproduction Personal-Social Behavior:  Ritualism and negativism of toddlerhood diminish  Child can dress self  Child is willing to please  Child has internalized values and standards of family and culture  Child may begin to challenge family’s code of conduct Play: (Look at definition in textbook)  Associative play o Group play without rules  Imitative play  Imaginative play o Imaginary playmates  Dramatic play  Mutual play Coping With Concerns Related to Normal Growth and Development:  Preschool and kindergarten o Developmental screening tool to assess readiness for schoolo Importance of infection control in school setting o Introduction of child to school and teachers Sex Education:  Find out what children know and think o This information helps ascertain what the child wants to know o Use correct anatomic words o Be honest  Masturbation is common at approximately 4 years of age o Private act Fears:  Dark  Being left alone  Animals (large dogs)  Ghosts  Sexual matters (castration)  Objects or people associated with pain Aggression:  Behavior that attempts to hurt person or destroy property  May be influenced by biologic, sociocultural, and familiar variables  Factors that increase aggressive behavior: gender, frustration, modeling, and reinforcement Speech Problems:  Most critical period is between 2 and 4 years of age  Failure to master sensorimotor integration may result in o Stuttering o Stammering  Prevention and early detection are crucial  Stuttering/stammering are common between 2-5 yrs.  Boys > girls, +Genetic link, Usually resolves in childhood  Encourage the child to speak slowly and breathe. Resist finishing the word/sentence.  Causes of speech problems: hearing loss, dev delay, autism, lack of stimulation, Promoting Optimal Health During the Preschool Years:  Nutrition o Caloric requirements: approximately calories per day o Fluid requirements: approximately 100 mL/kg, depending on activity and climate o Food fads, strong tastes: common o Amount of food: varies greatly from day to day o Obesity in young children: has increased dramatically  Should not be forced to clean plate- can lead to over eating and obesity. But, may not allow to eat later if child did not eat what was offered. Most 3-4 year olds still struggle with sitting though an entire family meal. Sleep Activity:  Sleep: 12 hours per nighto Infrequent naps o Waking during the night: common  Motor activity levels: remain high o Emphasis on fun and safety o Readiness to participate in sports o Sedentary activity such as TV and computer time: should be limited Sleep Problems:  Thorough assessment of sleep problems  Nightmares  Sleep terrors  Encouragement of consistent bedtime ritual  Slowdown of activity before bedtime Dental Health:  Eruption of deciduous teeth: complete  Professional care and prophylaxis  Fluoride supplements  Assistance and supervision of brushing o Flossing by parents  Limiting cariogenic foods Safety Promotion and Injury Prevention:  Safety education  Increase in pedestrian–motor vehicle accidents  Education concerning safety and potential hazards  Appropriate protection o Bicycle helmets o Protective equipment  More coordinated but still clumsy.  Falls, street/parking lot safety. Anticipatory Guidance: Care of Families:  Child care focus shifts from protection to education o Verbal explanations of how to avoid danger  Children begin questioning previous teachings of parents  Children begin to prefer companionship of peers  Children enter school Communicable Diseases of Childhood:  Erythema infectiosum (fifth disease)  Roseola infantum  Scarlet fever Erythema Infectiosum:  Fifth disease- Erythema Infectiosum  School age kids  Transmission: resp secretions, blood products- communicability is before s&s are present S/S: slapped cheek, proximal->distal spread  Supportive treatment- antipyretics, analgesics Roseola Infantum:  Roseola- aka. 6th disease  Transmission- nasal/buccal/conjunctival mucosa  Usually children <3 yrs, peak age 6m-15m  Incubation: 5-10 days  Macular-papular rash appears on trunk and spreads distally, lasts 1- 2 days  Supportive treatment- antipyretics Scarlet Fever:  Associated with strep  Direct contract with infected person, droplet  Incubation: 2-5 days  Communicable: 10 days  S/S: high fever, sore throat, HA, vomiting, abd pain, sand paperylacey rash  Tx: Amoxicillin for strep infection, supportive for rash, antipyretics, analgesics  Push fluids, complete abx, School-Age Child Promoting Optimal Growth and Development:  “School age” generally defined as ages 6 to 12 years  Physiologically begins with shedding of first deciduous teeth; ends at puberty with acquisition of final permanent teeth  Gradual growth and development  Progress with physical and emotional maturity Biologic Development:  Middle childhood o Height increases by 2 inches/year o Total height gain is 1-2 feet o Weight increases by 2-3 kg/year  4.5-6.5 lbs/yr o Boys and girls differ little in size  Average 6 yr old: 46#, 45 “  Average 12 yr old: 88#, 59”  Proportional changes o Movements more graceful than those of preschoolers o Skeletal lengthening and fat diminution (long bones grow at a faster rate) o Increased muscle tissue o Decrease in head circumference related to height o Change in facial proportions o The age of “loose teeth”  Maturation of Systems o Bladder capacity increases o Heart is smaller in relation to rest of bodyo Immune system is increasingly effective; Typical preschool age children will have 6-8 respiratory infections per year; School age is 2-3/years o Bones continue to ossify (harden) o Physical maturity is not necessarily correlated with emotional and social maturity  Prepubescence o Preadolescence is the period of 2 years before age 13 o Prepubescence typically occurs during preadolescence o Age at prepubescence varies from 9 to 12 (girls about 2 years earlier than boys) o Puberty begins at approximately age 10 in girls and age 12 in boys Psychosocial Development:  Latency period (Freud) o Precedes heterosexual fascination that occurs in puberty o A time of tranquility o Relationships revolve around same-sex peers o This time is the “latency” period of psychosexual development  A sense of industry (Erikson) o Stage of accomplishment o Eagerness to develop skills and participate in meaningful and socially useful work o Acquisition of sense of personal and interpersonal competence o Growing sense of independence o Peer approval: a strong motivator o Expectations should be individualized o Do not prejudge  EX: schools in Dublin GA  Sense of inferiority (Erikson) o Feelings may derive from self or social environment o Feelings may occur if child is unable or unprepared to assume the responsibilities associated with developing a sense of accomplishment o All children feel some degree of inferiority regarding skill(s) they cannot master Cognitive Development:  Concrete operations (Piaget) o Uses thought processes to experience events and actions o Develops understanding of relationships between things and ideas o Is able to make judgments on the basis of reason (“conceptual thinking”) o Masters the concept of conservation (start thinking about the world and recycling) o Develops classification skills (sort things by color, texture, size) Moral Development:  Development of conscience and moral standards (Kohlberg) o Ages 6-7: reward and punishment guide choices o Older school age: child is able to judge an act by the intentions that prompted it o Rules and judgments become more founded on needs and desires of others o Will lie to get out of punishment Spiritual Development:  Children think in very concrete terms  Children are avid learners with a desire to know their God Children expect punishment for misbehavior  Children may view illness or injury as punishment for a real or imagined misdeed Social Development:  The peer group is extremely important  Identification with peers is a strong influence in achieving independence from parents  Sex roles are strongly influenced by peer relationships Social Relationships and Cooperation:  Clubs and peer groups o Formation of formalized groups (typically exclude others) o Bullying  Relationships with families o Parents are primary influence in shaping child’s personality, behavior, and value system o Increasing independence from parents is primary goal of middle childhood o Parents need to be adults, not friends  Poor relationships with peers or identification with a group leads to bullying.  Most often occurs at school.  Also occurs in cyber-bullying. Play:  Rules and rituals  Team play- division of labor, collaboration, common goal  Quiet games and activities  Ego mastery Developing a Self-Concept:  Children develop conscious awareness of a variety of self-perceptions (abilities, values, appearance)  Significant adults can help children experience success  Positive self-concept leads to feelings of self-respect, self-confidence, and happiness  An idea of self related to others.  Includes body image, sexuality and self esteem. Developing a Body Image:  In general, children like their physical selves less as they grow older  The head is the most important part of the body (hair and eye color)  Body image is influenced by significant others  Increased awareness of “differences” may influence feelings of inferiority (e.g., hearing or visual defects)  Body image is influenced by significant others (parents, peers). Development of Sexuality:  Sex education o Sex play curiosity is normal during preadolescence o Peers vs parents for primary source of information  Nurse’s role o Sex is a normal part of growth and development o Sex vs. sexuality Sex is the act o Values, problem solving skills o Open communication Coping With Concerns Related to Normal Growth and Development:  School experience o Entrance to school is a sharp break in the structure of the child’s world o School is second only to the family as socializing agent o Values of the society are transmitted in school o Peer relationships become increasingly important  School experience o Teachers o Parents  “Latchkey children” o Children that go home by themselves and unlock the door  Limit setting and discipline  Dishonest behavior  Stress and fear (when they get caught)  No legal age limit for children to be home alone in Virginia.  Exaggeration is common at this age to impress others. By middle childhood- they can decipher fact and fantasy. Younger kids may lie to escape punishment and older kids may lie to meet expectations Promoting Optimal Health During the School Years:  Nutrition o Importance of balanced diet to promote growth o Quality of diet related to family’s pattern of eating o Developing a taste for a variety of foods o Want to increase calcium and vitamin D (bone growth) o “Fast food” concerns o MyPlate  Sleep and rest o Sleep averages 9-11 hours/night during school age but is highly individualized o Children may resist going to bed at ages 8-11 o Children aged 12 years and up are generally less resistant to bedtimes o Children 8-11y do not realize they are tired and/or FOMO. If they are allowed to stay up, they will be tired the following day. o Sleep helps children grow (growth hormone surges when sleeping) Exercise and Activity:  Sports o Controversy regarding early participation in competitive sports o Concerns with physical and emotional maturity in competitive environment  Acquisition of skills o Children generally like competition  Television, video games, internet o Includes cell phones o Significant amount of time with media o Media influences attitudesDental Health:  Eruption of permanent teeth  Good dental hygiene  Prevention of dental caries  Periodontal disease  Malocclusion- When teeth do not meet properly affecting chewing  Dental injury  Dental avulsion: replacement/reattachment Altered Growth and Maturation:  Often a result of simple physiologic delay (“constitutional”)  Endocrine dysfunction  Chromosome aberration  Chronic disease (e.g. malabsorption, asthma)  Stress  Poor nutrition Tall vs. Short:  Tall stature o May cause anxiety, perceived social handicap o Gender perceptions r/t height o Use of estrogens to control height if initiated before menarche o Use of hormonal therapy is controversial  Short stature o May be first manifestation of underlying disorder o May be of no consequence to health o Most common cause is malnutrition (worldwide) o R/t chronic disease, endocrine dysfunction, primary gonadal failure School Phobia:  Defined as extreme reluctance to attend school for a sustained period of time as a result of severe anxiety or fear of school related experiences  AKA. “school refusal” or “school avoidance”  Most common in ages older than 10 years  Physical symptoms  Symptoms subside after staying at home  No s/s on weekends or holidays  Nursing considerations Enuresis:  Urinary incontinence  Primary versus secondary  Detailed history and physical exam  Treatment o Education, behavior modification, reassurance o Medications o Complimentary and alternative medicine  Nursing care management o Be supportive, encouraging, and patient o Educate parentso Open communication Encopresis:  Bowel incontinence  Primary - Secondary - Psychogenic  Assessment and detailed history  Treatment o Rule out structural issue o Determine cause o Dietary modifications o Behavior therapy and/or psychotherapeutic intervention  Nursing care o Education o Bowel retraining o Family support Pediculosis Capitis:  Commonly found around the skull base and behind the ears. Can be at school with nits but not live infestations.  Passed from sharing combs, playing with hair, laying down on the bus Scabies:  Affects all ages and socioeconomic levels.  Transmitted through prolonged close contact.  Itchy, maculopapular rash.  Treated with scabicide- Elimite. Apply from neck to soles before bed. Wash off after 8-14 hours. Repeat in 1-2 weeks.  Wash linens in hot water and dry in hot heat. Tinea Corporis/Capitis:  Ringworm  Can treat topically unless in the hair. Then it requires oral griseofulvin for 6 weeks.  May return to school but should keep lesions covered.  Good handwashing and don’t scratch to prevent spread to other areas and people.  Tinea capitis = cradle cap Molluescum Contagiosum:  Spread through infected persons or contaminated items.  Will usually resolve on its own.  Can be treated with medications/procedures if necessary.  Common places = Face, arms, legs, eyes Adolescent Promoting Optimum Growth and Development:  Transition between childhood and adulthood  Characterized by rapid physical, cognitive, social, and emotional maturation  Generally defined as beginning with the appearance of secondary sex characteristics and ending with cessation of body growth at 18-20 yearsTerms:  Puberty: development of secondary sex characteristics  Prepubescence: period of approximately 2 years before onset of puberty; preliminary physical changes occur  Postpubescence: period of 1-2 years after puberty; skeletal growth is complete; reproductive functions become well established Biologic Development:  Primary sex characteristics o External and internal organs necessary for reproduction  Secondary sex characteristics o Result of hormonal changes: voice change, hair growth, breast enlargement, fat deposits o Play no direct role in reproduction Hormonal Changes of Puberty:  Anterior pituitary gland and hypothalamus play a role  Hormones stimulate gonads  Gonads secrete sex-appropriate hormones o Secreted by ovaries, testes, and adrenal glands o Produced in varying amounts by both sexes throughout the lifespan o Maturation of gonads produces biologic changes of puberty Sex Hormone:  Estrogen o “Feminizing hormone” o Low quantities during childhood o Increases during prepubescence o Boys: gradual production throughout maturation o Girls: increases until about 3 years after menarche o Girls: levels then remain at this maximum throughout reproductive life  Androgens o “Masculinizing hormones” o Secreted in small and gradually increasing amounts for up to 7-9 years o Then rapid increase in both sexes; in boys, rapid increase continues until age 15 years o Responsible for rapid growth in early teen years o Testosterone: secreted by testes; in boys, levels reach maximum at maturityo Early signs = very angry for no reason Sexual Maturation:  Tanner stages of sexual maturity o Stages of development of secondary sex characteristics and genital development o Defined as guide for estimating sexual maturity o Occur in an orderly sequence  Girls o Thelarche: appearance of breast buds; ages 9-13 years’ will typically have menarche in 2 years o Adrenarche: growth of pubic hair on mons pubis; 2-6 months after thelarche o Menarche: initial appearance of menstruation, approximately 2 years after first pubescent changes; average age, 12 years 4 months in North America  Boys o First pubescent changes: testicular enlargement, thinning, reddening, and increased looseness of scrotum; ages 9½-14 years o Penile enlargement, pubic hair growth, voice changes, facial hair growth o Temporary gynecomastia in one third of boys; disappears within 2 years Physical Growth:  Sexual maturation accompanied by dramatic increase in growth (will see growing pain)  Adolescent growth spurt o 20%-25% of total height achieved during puberty o Usually occurs within 24 to 36 months  Characteristic sequence of changes Psychosocial Development:  Sense of identity (Erikson) o Early adolescence: group identity vs. alienation o Development of personal identity vs. role diffusion o Sex role identity o Emotionality Cognitive Development:  Formal operations period (Piaget)  Abstract thinking o Formal operationso Thinking beyond present o Mental manipulation of multiple variables o Concern about others’ thoughts and needs Moral Development:  Internalized set of moral principles (Kohlberg) o Questioning of existing moral values and relevance to society o Understanding of duty and obligation, reciprocal rights of others o Concepts of justice, reparation o Understanding right vs. wrong and standing up for what you believe in Social Development:  Goal: to define identity independently from parental authority  Much ambivalence  Intense sociability; intense loneliness  Acceptance by peers Relationships with Parents:  Roles change from protection/dependency to mutual affection/equality  Process involves turmoil and ambiguity  Teenager struggles between privileges and responsibility  Emancipation from parents may begin with rejection of parents by teenager Health Concerns of Adolescence:  Emotional well-being o Mood swings o Emotional control o Coping skills  Intentional and unintentional Injuries o Leading cause of death-motor vehicle accidents o Lack of driving experience o Immaturity o Reckless driving o Alcohol o Cell phone use  Intentional and unintentional Injuries o Second leading cause of death- suicide o Third leading cause of death- homicide (FIRST cause today), most by firearms (BUT this is rising rapidly!) o Risk-taking abilities o Feeling of indestructibility  Dietary habits related to: o Puberty and growth spurts o Peer acceptance o Concern for physical appearance o Lifestyle  Hypertension  Hyperlipidemia- Check lipids around 16 for healthy adolescents  Immunizations Body Art  Sleep deprivation and insomnia Special Health Problems:  Disorders of the male reproductive system o Varicocele  enlargement of veins in the scrotum, feels like a bed of worms o Epididymitis  Inflammation of the tube at the back of the testicle that stores and carries sperm.  Epididymitis is often caused by a bacterial or sexually transmitted infection.  Pain and swelling in the testicle are common.  Treatment usually is antibiotics. Rarely, pus may need to be drained or part or all of the coiled tube may be surgically removed o Testicular torsion  A twisting of the male organ that makes hormones and sperm (testicle).  When the testicle rotates (testicular torsion), it twists the cord supplying blood to the loose bag of skin (scrotum) beneath the penis. This may occur after vigorous activity, a minor injury to the testicles, or sleep.  Sudden, severe pain and swelling in the testicle are symptoms.  Surgery is required. Treated promptly, the testicle can often be saved. A longer wait may affect fertility. o Gynecomastia  Swollen male breast tissue caused by a hormone imbalance.  Male breast tissue swells due to reduced male hormones (testosterone) or increased female hormones (estrogen). Causes include puberty, aging, medications, and health conditions that affect hormones.  Symptoms are breast tissue swelling and tenderness.  Treatment focuses on managing the underlying condition. Health Problems with a Behavioral Component:  Substance abuse o Drug abuse, misuse, and addiction  Voluntary behaviors  Culturally defined o Drug tolerance and physical dependence  Involuntary physical responses o Motivation  Usually begins with experimentation Infant sleep safetyNewborn and infant feeding  Nutrition o First 6 months of life: human milk should be the only food (or formula) o Second 6 months  Selection and preparation of solid foods  Start with rice cereal  Introduction of solid foods  Normal for food to be pushed out of the mouth because of the sucking reflex  Weaning from breast or bottle  You wean when you are ready  Recommendation- Breastfeeding for the first year of life Appropriate snacks and nutrition for different age groups. Birth to 6 months old (breastfeeding or bottle feeding) - Most desirable complete diet for the first half of the first year - A recommended supplement is oral Vitamin D - In exclusively breastfed infants 4 months and older, recommend an iron supplement of 1mg/kg/day until iron-rich complementary foods are introduced Formula - Iron fortified commercial formula is a complete food for the first half of the first year - Requires fluoride supplements when the concentration of fluoride in the drinking water is below 0.3 ppm after 6 months old - Evaporated milk requires supplements of vitamin C, iron, and fluoride 4-12 months old (solid foods) - May begin to add solids by 4-6 months old - First foods are strained, pureed, or finely mashed- Finger foods such as teething crackers, raw fruit, or vegetables can be introduced by 6-7 months old - Chopped table food or commercially prepared junior foods can be started by 9-12 months old - With the exception of cereal, the order of introducing foods is variable; a recommended sequence is fruit, then vegetables, and then meat - Introduce one food at a time, usually at intervals 4-7 days, to identify food allergies - Introduce solids when the infant is hungry - Begin spoon feeding by pushing food to back of tongue because of infants natural tendency to thrust the tongue forward - Use a small spoon with a straight handle; begin with 1 or 2 tsp of food ; gradually increase to 2-3 tsp per feeding - As the quantity of solids increases, decrease the quantity of milk to prevent overfeeding. Limit formula or milk to approximately 960 mL (32 oz) daily and fruit juice to less than 6 oz daily - Never introduce foods by mixing them with the formula in the bottle Cereal-Start at 4-6 months old - Introduce commercially prepared fortified infant cereals and administer daily until 18 months old - Rice cereal is usually introduced first because of its low allergenic potential - Parents can discontinue supplemental iron when iron-fortified cereal is given Fruits and Vegetables (start at 6-8 months) - Applesauce, bananas, and pears are usually well tolerated - Avoid fruits and vegetables marketed in cans that are not specifically designed for infants because of variable and sometimes high lead content and addition of salt, sugar, or preservatives Meat, Fish, and Poultry- Start at 8-10 months old - Avoid fatty meats - Prepare by baking, broiling, steaming, or poaching - Include organ meats such as liver, which has a high iron, vitamin A, and vitamin B complex content - If soup is given, be certain all ingredients are familiar to child’s diet - Avoid commercial meat and vegetable combinations because their protein content is low Eggs and cheese- Start at 12 months old - Serve egg yolk hard boiled and mashed, soft-cooked, or poached - Introduce egg white in small quantities (1 tsp) toward the end of the first year to detect an allergy - Use cheese as a substitute for meat and as finger food Erikson’s StagesPiaget’s Stages Freud’s TheoryLanguage development in pediatrics, normal vs. abnormal. Toddler - At 1 year old, children use one-word sentences or holophrases; the word up can mean pick me up - By 2 years old, children use multiword sentences by stringing together two or three words such as the phrases “mama go bye bye” or “all gone” - By 3 years old, children put words together into simple sentences, begin to master grammatical rules, know their age and gender, and can count three objects correctly Preschooler - Children between 3 and 4 years old form sentences of about three or four words and include only the most essential words to convey a meaning - From 4-5 years old, preschoolers use longer sentences of four or five words and use more words to convey a message, such as prepositions, adjectives, and a variety of verbs Sexual development. Normal vs. abnormal. Development of breasts in girls Stage 2 (pubertal): Breast bud stage- Small area of elevation around papilla; enlargement of areolar diameter Stage 3: Further enlargement of breast and areola with no separation of their contours Stage 4: Projection of areola and papilla to form a secondary mound (may not occur in all girls) Stage 5: Mature configuration; Projection of papilla only caused by recession of areola into general contourGrowth of pubic hair in girls Stage 1: No pubic hair; essentially the same as during childhood; no distinction between hair on pubis and over the abdomen Stage 2: Sparse growth of long, straight, downy, and slightly pigmented hair extending along labia; between stages of 2 and 3 begins to appear on pubis Stage 3: Hair darker, coarser, and curly and spread sparsely over the entire pubis in the typical female triangle Stage 4: Pubic hair denser, curled, and in distribution but less abundant and restricted to the pubic area Stage 5: Hair adult in quantity, type, and pattern with spread to inner aspect of thighs Development stages of secondary sex characteristics and genital development in boys Stage 1: (Prepubertal) No pubic hair; essentially the same as during childhood; no distinction between hair on pubis and over the abdomen Stage 2: (Pubertal) Initial enlargement of scrotum and testes; reddening and textural changes of scrotal skin; sparce growth of long, straight, downy and slightly pigmented hair at base of penis Stage 3: Initial enlargement of penis, mainly in length; testes and scrotum further enlarged; hair darker, coarser, and curly and spread sparsely over entire pubis Stage 4: Increased size of penis with growth diameter and development of glans; glans larger and broader; scrotum darker; pubic hair more abundant with curling but restricted to pubic area Stage 5: Tested, scrotum, and penis adult in size and shape; hair adult in quantity and type with spread to inner surface of thighs Terms:  Puberty: development of secondary sex characteristics  Prepubescence: period of approximately 2 years before onset of puberty; preliminary physical changes occur  Postpubescence: period of 1-2 years after puberty; skeletal growth is complete; reproductive functions become well established Biologic Development:  Primary sex characteristics o External and internal organs necessary for reproduction  Secondary sex characteristics o Result of hormonal changes: voice change, hair growth, breast enlargement, fat deposits o Play no direct role in reproduction Hormonal Changes of Puberty:  Anterior pituitary gland and hypothalamus play a role  Hormones stimulate gonads  Gonads secrete sex-appropriate hormones o Secreted by ovaries, testes, and adrenal glands o Produced in varying amounts by both sexes throughout the lifespan o Maturation of gonads produces biologic changes of pubertySex Hormone:  Estrogen o “Feminizing hormone” o Low quantities during childhood o Increases during prepubescence o Boys: gradual production throughout maturation o Girls: increases until about 3 years after menarche o Girls: levels then remain at this maximum throughout reproductive life  Androgens o “Masculinizing hormones” o Secreted in small and gradually increasing amounts for up to 7-9 years o Then rapid increase in both sexes; in boys, rapid increase continues until age 15 years o Responsible for rapid growth in early teen years o Testosterone: secreted by testes; in boys, levels reach maximum at maturity o Early signs = very angry for no reason Sexual Maturation:  Tanner stages of sexual maturity o Stages of development of secondary sex characteristics and genital development o Defined as guide for estimating sexual maturity o Occur in an orderly sequence  Girls o Thelarche: appearance of breast buds; ages 9-13 years’ will typically have menarche in 2 years o Adrenarche: growth of pubic hair on mons pubis; 2-6 months after thelarche o Menarche: initial appearance of menstruation, approximately 2 years after first pubescent changes; average age, 12 years 4 months in North America  Boys o First pubescent changes: testicular enlargement, thinning, reddening, and increased looseness of scrotum; ages 9½-14 years o Penile enlargement, pubic hair growth, voice changes, facial hair growth o Temporary gynecomastia in one third of boys; disappears within 2 years Types of play. Appropriate toys for play.o Onlooker play-child watches other children but makes no movement to join. Example: younger sibling watching an older sibling bounce a ball o Solitary play- children play alone with different toys than other children in the same area o Parallel play- play with similar toys in a smaller space, but toys are used in the way the child sees them (toddler) o Associative play- kids play together with the same toys but no organization or leadership (beehive soccer) o Cooperative play- children play together in an organized groups- each person has a role (sports, house) Potty training readiness. Physical readiness - Voluntary control of anal and urethral sphincters, usually by 24-30 months old - Ability to stay dry for 2 ½ hours - Regular bowel movements - Gross motor skills of sitting, walking, and squatting - Fine motor skills to remove clothing Mental readiness - Recognizes urge to defecate or urinate - Verbal or nonverbal communication skills to indicate when wet or has the urge to defecate or urinate - Cognitive skills to imitate appropriate behavior and follow directions Psychologic readiness - Expresses willingness to please parent - Able to sit on toilet for 5-8 minutes without fussing or getting off - Curiosity about adults’ or older siblings’ toilet habits - Impatience with soiled or wet diapers Types of families. Family Structure and Function:  Traditional nuclear family  Nuclear family  Blended family  Extended family  Single parent family  Binuclear  Polygamous  Communal  LBGT families Cultural norms for families of varying cultures. What you can do for children of varying cultures Health promotion topics for different age groups.  Adolescents- Substance abuse  Infants- Sleep safety  Toddlers- Car safety Fine motor vs. gross motor skills and development. Age-appropriate activities to support each.  Infants and toddlers Pain scales  How can we assess pain in children?? o Behavior- crying, irritability, quiet o Physiologic s/s- inc HR, inc RR, inc BP, sweating o Self-report  Behavioral pain measures o Facial expression, Leg movement, Activity, Cry, Consolability (FLACC) o COMFORT scale o Children’s and Infants Postoperative Pain Scale (CHIPPS) o Premature Infant Pain Profile (PIPP)  Self-report pain-rating scales o Older than 4 years o Simple, concrete words o Faces pain scale—revised (FPS-R) o Wong-Baker FACES pain-rating scale  4-17 wong  Numeric >7 ideally o Visual Analog Scale (VAS) o Numeric Rating Scale (NRS) FLACC Scale:Pain Scales: Hospitalization stressors for children. Stressors of Hospitalization:  Separation anxiety o Protest phase  Crying and screaming, clinging to parent o Despair phase  Cessation of crying; evidence of depressiono Detachment phase  Denial; resignation but not contentment  Possible serious effects on attachment to parent after separation Separation Anxiety:  Early childhood o If separation can be avoided, children can withstand many other stressors  Late childhood and adolescence o Family does not play as important a role as peers Loss of Control: Infants:  Needs: o Trust o Consistent loving caregivers o Daily routine Loss of Control: Toddlers:  Needs: o Autonomy o Daily routines and rituals; Do not ask them if they want to take their medicine (give them a choice of how to take it) o Loss of control may contribute to-  Regression  Negativity  Temper tantrums Loss of Control: Preschoolers:  Needs: o Egocentric and magical thinking o May view illness/hospitalization as punishment o Preoperational thought Loss of Control: School age:  Needs: o Striving for independence and productivity o Boredom o Fears-  Death  Abandonment  Permanent injury Loss of Control: Adolescents:  Struggle for independence and freedom  Separation from peer group  May respond with anger &/or frustration  Need for information about illness Individual Risk Factors:  “Difficult” temperament- Arguing, fighting, Lack of fit between child and parent  Age (especially between 6 months and 5 years)  Male gender  Below-average intelligence  Multiple and continuing stresses (e.g., frequent hospitalizations) Changes in the Pediatric Population:  More serious and complex problems  Fragility of newborns  Severe injuries in children  Children with disabilities who have survived because of increased technological advances  More invasive and traumatic procedures  Increasing length of hospitalization Beneficial Effects of Hospitalization:  Recovery from illness  Competence in abilities to cope  Mastery of stress  New socialization experiences  Appropriate nursing strategies Stressors and Reaction of the Family:  Parental reactions o Overall sense of helplessness o Questioning the skills of staff o Accepting the reality of hospitalization o Dealing with fear o Coping with uncertainty o Seeking reassurance  Sibling reactions o Experiencing many changes and being too young to understand them o Being cared for by nonrelatives or outside of the home o Receiving little information about the ill brother or sister o Perceiving that parents will treat the sick child differently Preparation for Hospitalization:  Preparing child for admission  Preventing or minimizing separation  Preventing or minimizing parental absence  Minimizing loss of control o Promoting freedom of movement o Maintaining child’s routine o Encouraging independence and industry  Preventing or minimizing fear of bodily injury  Providing developmentally appropriate activities o Diversional activities o Expressive activities o Toys  Role of the child life specialistNursing Care of the Family:  Supporting family members  Providing information  Encouraging parent participation  Preparing for discharge and home care Special Hospital Situations:  Ambulatory or outpatient setting o Helps minimize stress of hospitalization o Reduces chance of infection o Increases cost savings o Is most frequently used for surgical or diagnostic procedures  Emergency admission o Most traumatic of hospitalizations o Little time for preparation because of sudden onset o Overuse of emergency departments o Participation of child and family as appropriate to the situation  Intensive care unit o Child’s and parents’ stress is increased o Emotional needs of the family must be met o Parents need information o Critically ill children become the focus of their parents’ lives Pediatric morbidity and mortality  Based on ppts  Firearms are leading cause of death  Second is car accidents Drug Dosage  Grams to kg  Lbs/oz to grams; 16 oz in 1 lb  14 lbs 12 oz = 6,700 grams Daily Maintenance fluid therapy with calculations  Medication administration to pediatric patients.  How are you going to give meds to kids  Where are you going to put an IV  Where would you give an IM injection; Baby vs. adolescent