Memory tricks for pediatric nursing

Epiglottitis (bacterial — historically Hib, now mainly strep and S. aureus): 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: dexamethasone (single-dose steroid) first-line, racemic epinephrine (aerosol) for stridor at rest, calm environment.

Unlike most adult medications, pediatric doses are calculated by weight (mg/kg or mcg/kg) rather than given as a flat dose — a critical safety difference nursing students must internalize early. The process: convert the child's weight to kilograms if given in pounds (divide by 2.2), calculate the ordered dose using the mg/kg/dose or mg/kg/day parameter from the order, then compare that calculated dose against the drug's established safe range from a reliable reference. Any calculated dose that falls outside the safe range must be questioned and clarified with the provider before administration — never given as ordered on the assumption the prescriber already checked. Many high-alert pediatric medications also require an independent double-check by a second nurse before administration.

Type 1 diabetes results from autoimmune destruction of pancreatic beta cells, causing an absolute insulin deficiency, and is typically diagnosed in childhood. Classic presentation: the 3 Ps — polyuria (excessive urination, sometimes new bedwetting in a previously dry child), polydipsia (excessive thirst), polyphagia (excessive hunger) — plus unexplained weight loss. If undiagnosed, children can present in diabetic ketoacidosis (DKA): fruity/acetone-smelling breath, Kussmaul respirations (deep, rapid breathing compensating for metabolic acidosis), abdominal pain, dehydration, and altered level of consciousness. Core family teaching: insulin is lifelong and must never be stopped or skipped — including on sick days, when insulin needs often increase due to stress hyperglycemia rather than decrease. Additional teaching: blood glucose monitoring, recognizing hypo- vs. hyperglycemia, carbohydrate counting, and rotating injection sites.

Newborn: HR 120–160, RR 30–60, BP 60–90/30–60. Infant (1–12 mo): HR 100–160, RR 25–50. Toddler (1–3): HR 90–150, RR 20–30. Preschool (3–6): HR 80–140, RR 20–25. School-age (6–12): HR 70–120, RR 14–22. Adolescent (12–18): HR 60–100, RR 12–20 (adult range). Key NCLEX point: children compensate for shock by increasing HR — tachycardia is the EARLY sign. BP drops LATE in children (they have excellent compensatory mechanisms). Hypotension in a child = decompensated shock = emergency. Pain scale for children: FACES scale (3+), FLACC (nonverbal/infant).

Gross motor: 2 months — social smile, holds head up. 4 months — rolls front to back. 6 months — sits with support. 9 months — crawls, pulls to stand. 12 months — walks holding on, may take first steps; walks alone by about 15–18 months. 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. 9 months — babbles mama/dada (stranger anxiety, a social milestone, also appears). 12 months — 1–3 words (mama, dada), waves bye-bye. 18 months — 10+ words. 2 years — 2-word phrases. 3 years — 3-word sentences. 4–5 years — sentences, strangers understand speech. Red flags — refer immediately: no babbling by 12 months, no words by 16 months, or any loss of previously acquired skills at any age. Validated tools such as the ASQ-3 are now used for screening (the Denver II is older).

A fast-recall companion to the Developmental Milestones lesson. Gross and fine motor skills move in rough parallel. The 9-month pincer grasp is the single highest-yield checkpoint.

Acute vasculitis, usually under age 5. Diagnosis requires the fever PLUS at least 4 of the 5 CRASH features. Most serious complication: coronary artery aneurysm (20-25% untreated, down to 3-5% with treatment). Treatment: IVIG + HIGH-DOSE ASPIRIN — the deliberate exception to avoiding aspirin in children, since the anti-inflammatory/antiplatelet benefit outweighs Reye's syndrome risk here. Treat within 10 days of fever onset. Delay live vaccines ~11 months after IVIG.

CFTR gene defect → thick, sticky secretions everywhere. Sweat chloride test is the gold-standard diagnostic. Pancreatic enzymes given WITH every meal and snack (not on a fixed schedule) — they only work while food is present. Fat-soluble vitamins A, D, E, K supplemented. Bronchodilator BEFORE chest physiotherapy — opens airways so mucus clears more effectively. Meconium ileus in a newborn (no first stool in 24h) can be an early sign.

Diagnosis requires a bulging, immobile tympanic membrane — not redness alone. Pulling the pinna/tragus worsens pain in otitis externa, not true AOM (infection is behind an intact eardrum). High-dose amoxicillin is first-line; switch to amoxicillin-clavulanate if no improvement in 48-72 hours. Watchful waiting (no antibiotics) is an option for nonsevere AOM: unilateral at 6–23 months, any at 2+ years, with follow-up. Pain control is a priority regardless. Tympanostomy tubes for recurrent cases fall out spontaneously in about 6-18 months.

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. PCV15/PCV20: 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 (egg allergy is NOT a contraindication to 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 (fever ≥38.0°C/100.4°F, often higher). 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.

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 as long as possible, to the seat's rear-facing limit (usually past age 2). 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: firearms (#1 cause of teen death since 2020), motor vehicle crashes (#2), alcohol/drugs, suicide. 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.

Children have excellent compensatory mechanisms — they maintain blood pressure until they've lost 25-30% of their blood volume. By then, they can crash rapidly. The FIRST sign of shock in a child is TACHYCARDIA, not hypotension. Other early signs: prolonged capillary refill above 2 seconds, mottled skin, decreased urine output, irritability. Treat aggressively before hypotension develops.

SIDS (Sudden Infant Death Syndrome) is the leading cause of death in infants 1-12 months. The AAP Safe Sleep guidelines: Alone (no co-sleeping), Back (supine every sleep), Crib (firm flat surface, no soft bedding, bumpers, or toys). Room-sharing WITHOUT bed-sharing is recommended for at least 6 months. Pacifier use at sleep time is protective. Overheating is a risk factor — dress lightly.

Nurses are mandatory reporters in all 50 states — suspicion alone is enough to report; you do not need proof. Classic red flags: spiral fracture in a non-ambulatory infant (cannot happen from a fall), circular burns (cigarette), bruising on buttocks or back in a non-walking child, delay in seeking care, inconsistent stories between caregivers. Document objectively — exact quotes, exact injury descriptions.

Epiglottitis is a life-threatening airway emergency. The child appears toxic, leans forward in the "tripod position" (sniffing position), drools, cannot swallow, and has a muffled voice. CRITICAL: Do NOT examine the throat, do NOT use a tongue blade, do NOT lay the child down — any stimulation can cause complete airway obstruction. Call anesthesia and ENT immediately. Treat in OR with controlled airway.

Mild (under 5%): dry mouth, slightly decreased tears. Moderate (5-10%): sunken fontanelle, sunken eyes, decreased skin turgor (tenting), tachycardia, decreased urine output. Severe (above 10%): all of the above plus lethargy, mottling, hypotension — immediate IV fluid bolus. Best indicator of rehydration: improved urine output and weight gain. Oral rehydration solution (ORS) preferred for mild to moderate dehydration.

Acyanotic defects (left-to-right shunts) cause extra blood to lungs — heart failure symptoms, not initially blue. VSD is the most common CHD overall. Cyanotic defects (right-to-left shunts) cause deoxygenated blood to bypass lungs — child is blue. Tetralogy of Fallot is the most common cyanotic CHD. "Tet spells" = sudden cyanosis during crying — place child in knee-chest position to increase SVR.

FLACC (Face, Legs, Activity, Cry, Consolability) = infants and preverbal children, each scored 0-2, max 10. FACES scale (Wong-Baker) = ages 3-7 who can point but not quantify — 6 faces from smiling to crying. Numeric 0-10 scale = children 7+ who can abstract numbers. Never skip pain assessment because the child is quiet — some children go quiet when in severe pain. Pain is the 5th vital sign.

Sickle cell vaso-occlusive (pain) crisis is the most common type. Sickling is triggered by: hypoxia, dehydration, cold, infection, stress, high altitude. Priority treatment: IV fluids (hydration prevents sickling), warmth (cold causes vasoconstriction and sickling), oxygen if hypoxic, and aggressive pain management with opioids — do NOT withhold opioids. Aplastic crisis = parvovirus B19 infection + severe anemia.

Children show respiratory distress differently from adults — they use accessory muscles visibly and grunt to maintain PEEP (positive end-expiratory pressure). GRIN: Grunting (expiratory — child is trying to keep alveoli open), Retractions (subcostal, intercostal, suprasternal — all indicate effort), Increased RR, Nasal flaring. A child who has been working hard and suddenly becomes quiet and limp is deteriorating — immediate intervention needed.