ATI Templates

The provision of therapeutic care in settings, by personnel, and through the use of interventions that eliminate or minimize the psychological and physical distress experienced by children and their families in the health care system.

Three principles:

1. Prevent or minimize separation from family
2. Promote a sense of control
3. Prevent or minimize bodily injury and pain

• Family-centered care is foundational
• Developmentally appropriate communication
• Honesty about procedures (children sense deception)
• Empowerment through choices when possible
• Pain prevention before procedures (proactive)
• Therapeutic play to process and rehearse
• Cluster care to minimize disruption

• Topical anesthetic (EMLA cream, LMX-4) 30–60 min before venipuncture or IM injection
• Use the smallest appropriate needle
• Avoid IM injections when possible
• Encourage parental presence during procedures
• Use comfort positioning (parent's lap) instead of restraint when possible
• Allow child to make choices: "Which arm?" "Stickers or band-aid?"
• Cover IV insertion site with self-adherent gauze
• Provide distraction (bubbles, music, tablet, breathing techniques)
• Treat pain with appropriate analgesics, not just non-pharmacologic methods
• Use child life specialists for procedural preparation
• Honor the child's "safe spaces" — perform painful procedures in treatment room, not bed

Pain is the 5th vital sign and must be assessed regularly in children. Pain assessment in children requires age-appropriate tools, recognition of developmental and verbal limitations, and use of physiological and behavioral cues for non-verbal children.

• Self-report is the gold standard when developmentally appropriate
• Match the tool to the child's age and cognitive ability
• Use the SAME scale consistently for one child
• Behavioral and physiological measures supplement (not replace) self-report
• Consider cultural, developmental, and individual differences
• Pain is what the child says it is

By age:

• NIPS — preterm and term neonates (facial expression, cry, breathing, arm/leg movement, arousal; 0–7)
• CRIES — neonate to 6 months postoperatively (Crying, Requires O₂, Increased VS, Expression, Sleeplessness; 0–10)
• FLACC — 2 months to 7 years OR any nonverbal child (Face, Legs, Activity, Cry, Consolability; 0–10)
• Wong-Baker FACES — 3 years and older (smiling to crying faces; 0–10)
• Numeric (0–10) — 5–7 years and older with understanding of numbers
• Visual analog scale — adolescents

Documentation: record score, location, quality, what relieves/aggravates, intervention given, and reassessment score (typically 30–60 min after intervention).

Family-centered care is the philosophy and practice that recognizes the family as the constant in a child's life and works to support and respect the family's role as the primary caregiver and decision-maker. It is a partnership between healthcare providers and the family.

Core elements:

• Respect, dignity, and inclusion of all family members
• Information sharing — accurate, timely, and unbiased
• Participation in care and decision-making
• Collaboration with families at all levels

• The family is the constant in the child's life; healthcare providers come and go
• Families are the experts on their child
• Cultural diversity must be acknowledged and respected
• Family strengths and individuality should be recognized
• Different methods of coping are recognized as valid
• Information needs vary by family and developmental stage
• Continuity of care and emotional support promote well-being
• Sibling needs must be addressed
• Empowerment and self-determination are essential
• Encourage family-to-family support

• Welcome family members to participate in all aspects of care
• Provide information in understandable language; use teach-back method
• Include family in care planning, rounds, and decision-making
• Encourage parents to remain with child during procedures when possible
• Respect cultural and religious beliefs (food, modesty, rituals)
• Provide written materials in family's preferred language
• Use interpreters when needed (not family members for medical translation)
• Address siblings' needs and questions
• Connect families to peer support groups
• Allow flexible visitation policies
• Provide private space for family discussions
• Involve family in discharge planning early
• Acknowledge family's expertise on their child
• Avoid judgmental statements about family choices
• Coordinate care across providers and settings

Erik Erikson's theory describes 8 stages of psychosocial development across the lifespan. Each stage has a developmental task (psychosocial crisis) that must be successfully resolved to develop the corresponding ego strength. Failure to resolve leads to difficulties in subsequent stages.

Pediatric stages (birth to ~20):

Infant — promote trust:

• Respond promptly and consistently to needs
• Hold during feeds
• Keep parent present during hospitalization
• Maintain consistent caregivers

Toddler — promote autonomy:

• Offer choices ("red cup or blue cup?")
• Allow self-feeding, dressing within reason
• Use minimal restraints; comfort positioning
• Don't shame negativism or tantrums
• Respect rituals and routines

Preschool — promote initiative:

• Use therapeutic play; medical play with dolls
• Praise efforts
• Allow safe exploration
• Provide simple, concrete explanations
• Reassure that illness/procedures are NOT punishment

School-age — promote industry:

• Allow involvement in care
• Provide collections, projects, schoolwork
• Praise effort and accomplishment
• Respect privacy and modesty
• Use accurate medical terminology

Adolescent — promote identity:

• Respect privacy and confidentiality
• Allow control in decisions
• Encourage peer contact
• Provide accurate information about body changes
• Help maintain school connections, social roles
• Respect emerging independence

Jean Piaget's theory describes how children construct understanding through interaction with the environment. Four stages from infancy through adulthood, each marked by qualitatively different ways of thinking. Knowing the stages helps nurses tailor education and explanations to children at developmental level.

Sensorimotor (infant/toddler):

• Provide sensory stimulation
• Use objects to demonstrate (toys, dolls)
• Allow exploration with all senses
• Don't expect understanding of cause-effect in young infant
• Use simple language
• Parent presence essential

Preoperational (toddler/preschool):

• Use simple, concrete language
• Use therapeutic play, dolls, toys to explain procedures
• Show equipment before using
• Avoid abstract terms ("take your appendix" — child thinks it will be carried away)
• Magical thinking: reassure that illness is NOT punishment for thoughts or actions
• Use simple analogies (IV = "straw for medicine")
• Expect egocentric responses
• Don't lie about painful procedures

Concrete Operations (school-age):

• Provide concrete, factual explanations
• Use simple diagrams, models
• Anatomy textbook diagrams appropriate
• Allow questions; answer honestly
• Involve in decisions when possible
• Reassure that illness has cause and treatment

Formal Operations (adolescent):

• Provide abstract explanations
• Use medical terminology with explanation
• Discuss "why" — pathophysiology
• Engage in decision-making
• Discuss consequences and future implications
• Respect emerging autonomy
• Provide written materials, internet resources (with guidance)

Therapeutic play uses play activities as a means to help children cope with illness, hospitalization, procedures, and emotional concerns. Play is considered the "work of childhood" and a critical part of atraumatic care. Specialized child life specialists provide structured therapeutic play, but nurses also incorporate it throughout care.

Functions of play:

• Promotes normal development (cognitive, motor, social, emotional)
• Provides outlet for emotions (anger, fear, anxiety)
• Allows mastery and control in unfamiliar environment
• Increases sense of self-confidence and self-worth
• Provides distraction during procedures
• Develops trust with healthcare providers
• Allows assessment of child's understanding and concerns
• Maintains familiar routines

Types of play:

• Energy-release play: physical activity, releases pent-up emotions (punching bags, running, throwing balls)
• Dramatic (medical) play: child role-plays with medical equipment, dolls — preparation for procedures and processing experience
• Creative expression: art, music, writing — emotional outlet
• Diversional play: helps pass time, provides enjoyment (video games, books, crafts)

Play by developmental stage:

• Infant: solitary play, sensorimotor (rattles, mobiles, mirrors)
• Toddler: parallel play (alongside others without true interaction)
• Preschool: associative play (similar activities with others)
• School-age: cooperative play (group activities with goals, rules)
• Adolescent: socialized play (sports, music, screens)

General principles:

• Provide a safe, welcoming play environment
• Include age-appropriate toys, games, art supplies
• Involve child life specialist when available
• Offer toys/activities child can handle physically
• Allow child to choose activities
• Don't force participation
• Allow child to direct play
• Avoid using restraint as punishment

Preparation for procedures:

• Use dolls with simulated equipment (IVs, casts, NG tube, dressings)
• Demonstrate procedure on doll first
• Let child handle equipment when safe
• Use medical play with stethoscope, BP cuff, syringes (no needles)
• Read pediatric medical books
• Show pictures/videos of procedures

During procedures:

• Distraction tools: bubbles, pinwheels, music, tablets, virtual reality
• Allow child to hold favorite toy
• Comfort positioning (with parent)
• Sing songs, count, deep breathing

Post-procedure:

• Allow child to play through experience
• "Doctor play" — child becomes the doctor/nurse to gain mastery
• Drawing about hospital experience
• Praise courage

Environmental:

• Playroom (sanctuary — no procedures done here)
• Bring familiar items from home (favorite blanket, toy)
• Decorations age-appropriate
• Window for outside view
• Allow sibling visits when possible

For infants/toddlers:

• Familiar sounds (music, parent's voice)
• Cuddling, rocking
• Comfort objects (blanket, pacifier)
• Skin-to-skin (especially infants)
• Mobiles, rattles, books

For school-age/adolescents:

• Schoolwork to maintain continuity
• Tablets, video games
• Crafts, art, music
• Access to peers (in-person or virtual)

Primitive (involuntary) neonatal reflexes are present at birth and disappear at predictable ages. Their presence indicates intact neurologic function; persistence beyond expected age may indicate neurologic problems (e.g., cerebral palsy). Absence at birth may indicate dysfunction.

Assessment:

• Assess reflexes in routine newborn exam
• Document presence, symmetry
• Note timing of disappearance at follow-up exams
• Asymmetric Moro → may indicate brachial plexus injury, fracture, or hemiparesis
• Absent Moro at birth → CNS depression, sedation

Education for parents:

• Reflexes are normal and expected — not voluntary actions yet
• Different ages of disappearance — track at well-child visits
• Some reflexes (sucking, rooting) help with feeding
• Moro may surprise parents (looks like startle) — comfort by holding
• Stepping reflex looks like walking but is reflexive, not voluntary
• Babinski response NORMAL in infants but ABNORMAL in older children/adults (would indicate upper motor neuron problem)
• Persistence of primitive reflexes past expected age may need evaluation (CP, ID)
• Don't test for "walking" reflex to encourage early walking — has no developmental benefit
• Voluntary motor skills (purposeful grasp, sitting, walking) emerge as primitive reflexes integrate

Clinical implications:

• Absent reflexes → CNS dysfunction, prematurity, sedation, sepsis
• Asymmetric reflexes → focal lesion or injury (brachial plexus, fracture)
• Persistent reflexes → neurodevelopmental concern
• Brisk Moro → neurologic excitability (drug withdrawal, hypocalcemia)

Immunization is one of the most cost-effective public health interventions. Active immunization (vaccines) stimulates immune system to produce antibodies and memory cells. Passive immunization (immunoglobulins) provides immediate, temporary protection. Pediatric schedule is established by ACIP (Advisory Committee on Immunization Practices), CDC, AAP, and AAFP.

Types of vaccines:

• Live attenuated: weakened pathogen; produces strong, lasting immunity (MMR, varicella, rotavirus, LAIV nasal flu, BCG)
• Inactivated (killed): killed pathogen; may need boosters (IPV, hepatitis A, inactivated flu)
• Subunit/Recombinant/Conjugate: pieces of pathogen (HepB, HPV, Hib, PCV, MCV)
• Toxoid: inactivated toxin (DTaP, Tdap)
• mRNA: contains genetic instructions (COVID-19)

Pediatric schedule highlights (CDC):

Contraindications and precautions:

• Anaphylactic reaction to vaccine component: contraindication to that vaccine
• Immunocompromised: avoid LIVE vaccines (MMR, varicella, rotavirus, LAIV) — including chemo, high-dose steroids (≥ 2 mg/kg/day prednisone × ≥ 14 days), HIV with low CD4
• Pregnancy: avoid live vaccines (MMR, varicella)
• Moderate-severe illness: defer (mild illness OK)
• History of GBS within 6 weeks of prior flu vaccine — caution
• Egg allergy: typically NOT a contraindication to flu vaccine (newer guidelines)

NOT contraindications (common misconceptions):

• Mild illness, low-grade fever
• Antibiotic use
• Mild reaction to prior vaccine (soreness, low fever)
• Premature birth (give per chronological age)
• Breastfeeding
• Recent exposure to disease
• Family history of vaccine reactions

Common side effects:

• Local: pain, redness, swelling at injection site
• Systemic: low-grade fever, fussiness, sleepiness
• Rash with MMR (5–10 days), varicella (10–14 days) — mild
• Severe reactions are RARE
• Anaphylaxis: extremely rare (~1 per million)

Pre-vaccination:

• Review immunization history (paper records, registry)
• Screen for contraindications, precautions
• Provide Vaccine Information Statement (VIS) — required by law
• Address parent concerns (don't dismiss)
• Use evidence-based communication
• Verify correct vaccine, dose, route per protocol
• Atraumatic care preparation

Administration:

• 5 rights of medication
• Correct route, site (IM, SQ, oral, intranasal)
• Correct needle size
• Most pediatric IM vaccines: vastus lateralis (infants), deltoid (older)
• Comfort measures: position with parent, breastfeeding, sucrose, distraction, EMLA cream
• Give in opposite limbs if multiple
• 2-finger separation if multiple in same limb
• Some can be given simultaneously (most can be given same day)
• Aspiration NOT routinely required
• Apply bandage

Post-vaccination:

• Observe 15 minutes (some 30) for immediate reactions
• Document in chart and immunization registry
• Provide aftercare instructions
• Discuss expected side effects
• Acetaminophen or ibuprofen for fever/soreness (NOT before for prophylaxis — may decrease antibody response)

Catch-up immunizations:

• Children behind on schedule — catch-up per ACIP guidelines
• Minimum intervals must be followed
• Don't restart series — pick up where left off
• Can give multiple vaccines same day

Special populations:

• Premature: give per chronological age (not corrected)
• Travel: additional vaccines may be needed
• Immunocompromised: modified schedule
• Pregnant adolescents: avoid live
• Breastfeeding moms: most vaccines safe

Addressing hesitancy:

• Listen to concerns without judgment
• Share science-based information
• Acknowledge importance of vaccines for community immunity
• Discuss diseases vaccines prevent (some parents have never seen)
• Address specific concerns (autism debunked, vaccine ingredients explained)
• Strong recommendation from trusted provider effective
• Document refusal if persistent

Storage and handling:

• Cold chain critical (most refrigerated 35–46°F)
• Some frozen (varicella, MMRV)
• Monitor temperatures
• Reconstitute properly
• Use within specified time after reconstitution
• Discard expired vaccines

Reporting:

• VAERS (Vaccine Adverse Event Reporting System) — report adverse events
• VICP (Vaccine Injury Compensation Program) — federal program for compensation

Pediatric death is uniquely devastating and developmentally complex. Children's understanding of death evolves with cognitive development. Family-centered, developmentally-appropriate care includes palliative care, pain management, communication, and bereavement support. Pediatric palliative care can be integrated alongside curative treatment, not just at end of life.

Child's concept of death by developmental age:

Family/Sibling responses:

• Anticipatory grief
• Each family member grieves differently
• Siblings often "forgotten mourners" — may feel guilty, jealous, displaced
• Parents may neglect their own needs
• Marital strain common
• Cultural and religious factors influence grief
• Bereaved siblings at risk for psychological problems

Kübler-Ross stages of grief (not linear): denial, anger, bargaining, depression, acceptance

Pediatric palliative care principles:

• Begins at DIAGNOSIS of life-threatening illness (not just end of life)
• Concurrent with curative treatment
• Multidisciplinary
• Goal: quality of life
• Aggressive symptom management
• Family-centered
• Decision support, advance care planning
• Bereavement support

Hospice eligibility (typically):

• Life expectancy ≤ 6 months if disease follows usual course
• Patient/family decision to focus on comfort
• Can include some disease-directed therapies in pediatric hospice

Symptom management:

• Pain: opioids, adjuvants; don't under-treat for fear of "addiction" in dying child
• Dyspnea: opioids, oxygen, position
• Nausea/vomiting: antiemetics
• Anxiety: benzodiazepines, environmental measures
• Constipation
• Secretions: anticholinergics (atropine, scopolamine)
• Seizures

Communication with child:

• Be honest — children sense when something is wrong; lies erode trust
• Use developmentally appropriate language
• Use the words "death" and "dying" (not "passed away," "went to sleep" — which scares them about bedtime)
• Allow questions, answer truthfully
• Listen for the question behind the question
• Acknowledge emotions
• Use stories, books, art
• Allow child to express fears, wishes
• Don't force conversation if child not ready
• Some children want to plan their funeral, write letters, make memories
• Reassure child not at fault
• Address pain, comfort, who will be with them

Communication with family:

• Honest, compassionate communication
• Use clear language (not jargon)
• Family meetings for major decisions
• Involve interpreters when needed
• Respect cultural and religious beliefs
• Address concerns about pain, suffering
• Goals-of-care discussions
• Advance directives, MOLST/POLST
• Code status decisions
• Location of death (home, hospital, hospice)

Siblings:

• Include in discussions appropriately
• Allow visits
• Acknowledge their experience
• Provide age-appropriate explanations
• Don't exclude — they imagine worse than reality
• Watch for changes in behavior, school, appetite
• School coordination, counselor
• Maintain routines when possible
• Allow them to participate in caregiving if they want (within reason)

Spiritual/cultural:

• Spiritual care/chaplaincy
• Religious rituals, prayer, sacraments
• Cultural practices around death
• Memory-making: photos, hand/foot prints, hair, art, recordings

At time of death:

• Allow family time with child
• Don't rush
• Help family bathe, hold, dress child if desired
• Provide privacy
• Cultural and religious practices honored
• Allow siblings, friends to say goodbye if family wishes
• Discuss autopsy, organ donation if appropriate

Bereavement:

• Follow-up contact (cards, calls, anniversary)
• Bereavement support groups
• Refer to community resources
• Mental health referral if complicated grief
• Sibling-specific bereavement programs
• Acknowledge anniversaries

Staff:

• Self-care, supervision
• Debriefing
• Peer support
• Recognize moral distress
• Avoid burnout
• Honor each child cared for

Pediatric vital signs are age-specific — adult parameters do NOT apply. Critical to know normal ranges by age to recognize deviations indicating illness. Includes heart rate, respiratory rate, blood pressure, temperature, oxygen saturation, and pain level. Vital signs change significantly during childhood, particularly in infancy and early childhood.

Normal vital sign ranges by age (awake):

Temperature (normal): 36.5-37.5°C (97.7-99.5°F)

• Rectal most accurate (newborns, severely ill)
• Axillary (least accurate; for screening)
• Oral (≥ 4 years, cooperative)
• Tympanic (≥ 3 months; varies by technique)
• Temporal artery (newer; good for screening)
• Fever: >38°C (100.4°F) — concerning in infants < 3 months (sepsis workup), tolerable in older

Oxygen Saturation: Normal ≥ 95% on room air (most healthy children). Newborns may transiently be lower.

Estimating BP (SBP) by formula:

• SBP = 90 + (2 × age in years) — older approximation
• SBP 5th percentile = 70 + (2 × age in years) — minimum acceptable
• For accurate BP, use age- and height-specific tables (e.g., AAP HTN guidelines)
• BP cuff: width should cover 40% of upper arm circumference

Influences on Vital Signs:

• ↑ during fever, crying, agitation, activity, pain, fear
• ↓ during sleep, sedation
• Always assess in context
• Trends are more important than single readings

Red flag vital signs (general):

• Sustained tachycardia (compensated shock)
• Tachypnea (respiratory distress, fever, acidosis, shock)
• Bradycardia in pediatrics → impending arrest (especially with hypoxia)
• Hypotension is a LATE sign in pediatric shock (children compensate well, then crash)
• Apnea
• Hypothermia in infants (sepsis)
• SpO₂ < 92% on room air

Pediatric Early Warning Score (PEWS):

• Scoring system for behavior, cardiovascular, respiratory
• Triggers escalation of care

Best practices for measurement:

Heart rate:

• Apical for full minute in children < 2 years (irregular rhythms common, accuracy)
• Brachial or radial pulse for older children
• Femoral useful in shock states
• Auscultate over 4th-5th ICS, midclavicular line
• Count for 1 full minute in infants and young children

Respiratory rate:

• Count BEFORE disturbing child (when calm or sleeping if possible)
• Observe abdominal movement in infants (diaphragmatic breathing)
• Count for 1 full minute (irregularity common in infants — periodic breathing)
• Assess effort: retractions, nasal flaring, grunting, head bobbing, accessory muscle use

Blood pressure:

• Use age-/height-appropriate cuff size
• Cuff bladder covers 40% of arm circumference
• Manual BP more accurate in young children/sick infants
• Compare to age/height/sex norms
• 4-extremity BP if cardiac concerns (coarctation)
• Routine in children ≥ 3 years at well visits; younger if indicated

Temperature:

• Rectal: most accurate; standard for newborns, sick infants; insert 1 inch
• Axillary: least accurate (lower than core); safe for newborns
• Oral: only in cooperative children ≥ 4 years
• Tympanic: > 3 months; technique-dependent
• Temporal: non-invasive, accurate for screening

Pulse oximetry:

• Probe on finger, toe, or foot
• Verify good waveform/signal
• Adjust for movement, cold extremities
• Pre-ductal (right hand) vs post-ductal (foot) — newborns with cyanosis to assess for cardiac issue

Pain:

• Use age-appropriate scale (covered in separate template)

Documentation:

• Document all vital signs
• Note position (sleeping, calm, agitated)
• Note any interventions
• Recognize abnormal values for age
• Trends matter more than single readings

Recognize shock states:

• Compensated shock: tachycardia + delayed cap refill + cool extremities + altered mental status WITH normal BP
• Hypotension is LATE — when it occurs, decompensation is severe
• Quick recognition saves lives

Special considerations:

• Newborn: assess immediately after birth (Apgar at 1, 5 min)
• Infants: cluster care to avoid waking
• Toddler/preschool: minimize fear; use parent for security
• School-age: explain
• Adolescent: privacy, normal adult-like

Includes physical abuse, sexual abuse, emotional/psychological abuse, and neglect (physical, emotional, medical, educational). Munchausen syndrome by proxy / Factitious Disorder Imposed on Another is a form of medical child abuse. Nurses are mandated reporters by law in all 50 states. Reporting protects the child; the legal system investigates and determines outcomes.

Types of maltreatment:

• Physical abuse: non-accidental injury (bruises, burns, fractures, head trauma, abdominal injury)
• Sexual abuse: any sexual contact with a child; sexually transmitted infections; pregnancy in young adolescent
• Emotional/psychological: rejection, terrorizing, isolating, exploiting, witnessing domestic violence
• Neglect: failure to provide basic needs (food, shelter, clothing, medical care, supervision, education); most common type
• Medical neglect: failure to provide necessary medical care
• Munchausen syndrome by proxy: caregiver fabricates or causes illness in child to gain attention
• Bullying: peer-to-peer maltreatment

Red flags for physical abuse:

• Story doesn't match injury (developmentally, anatomically, or by mechanism)
• Inconsistent explanations
• Delay in seeking care
• Suspicious injuries:
• "TEN-4 FACES" bruising in < 4 years — Torso, Ear, Neck, < 4 years; Frenulum, Auricular area, Cheek, Eye, Sclera
• Bruises in non-walking infants ("those who don't cruise rarely bruise")
• Patterned bruises (belt, cord, hand, bite)
• Burns: stocking-glove (immersion), cigarette, branded shape
• Multiple injuries different healing stages
• Spiral fractures in non-ambulatory child
• Posterior rib fractures (from squeezing/shaking)
• Metaphyseal corner/bucket-handle fractures (long bone in infants — pathognomonic)
• Subdural hematoma in infant ("shaken baby") — often with retinal hemorrhages
• Abdominal trauma without obvious cause
• Genital injuries
• STIs in pre-pubertal children
• Pregnancy in young adolescent

Behavioral red flags in child:

• Regression in development
• Behavior changes (withdrawal, aggression, fear)
• Hypervigilance, startles easily
• Sexualized behavior inappropriate for age
• Knowledge of sexual matters beyond age
• Sleep disturbances, nightmares
• School problems, declining grades
• Avoiding home or specific person
• Eating disorders
• Self-harm, suicidality
• Substance abuse
• Running away
• Reports abuse (often the child tells someone)

Behavioral red flags in caregiver:

• Inappropriate response (overly calm or overly emotional)
• Story changes or is implausible
• Blaming child or sibling
• Hostility, defensiveness
• Frequent ED visits, doctor shopping
• Refusing to leave child alone with provider
• Substance abuse, mental illness
• Domestic violence in home
• Caregiver was abused as a child
• Social isolation, lack of support

Risk factors for maltreatment:

• Child: prematurity, disability, chronic illness, behavioral problems, infants (highest risk for abuse)
• Caregiver: young parent, single parent, substance abuse, mental illness, history of abuse, poverty, stress, lack of support, unrealistic expectations
• Environment: poverty, social isolation, domestic violence, unsafe housing

Legal framework:

• CAPTA (Child Abuse Prevention and Treatment Act)
• State-specific laws — every state has Mandated Reporter laws
• Mandated reporters: nurses, doctors, teachers, social workers, mental health professionals, law enforcement, daycare workers, others (varies by state)
• Required to report SUSPICION (not proof) of abuse/neglect
• Failure to report can result in criminal/civil penalty
• Good faith reports protected from liability
• Reports may be made anonymously (in some states)

Assessment:

• Thorough history and physical (private setting)
• Interview child alone when possible (age-appropriate; without caregiver present for suspicious cases)
• Document EXACT statements ("quotes")
• Document all physical findings with precise location, size, color, shape
• Photograph injuries (with consent and per facility policy)
• Skeletal survey for children < 2 years if suspected physical abuse
• Head CT/MRI if head injury or unexplained neurologic findings
• Retinal exam (shaken baby syndrome)
• Sexual abuse exam: forensic exam by trained provider (SANE — Sexual Assault Nurse Examiner) within 72-96 hours of acute event
• STI testing (sexual abuse)
• Toxicology if substance exposure suspected
• Don't lead, suggest, or interrogate child — open-ended questions

Reporting:

• Report SUSPICION — you don't need proof
• Report to: Child Protective Services (CPS), local law enforcement, or both (varies by state)
• Most states have hotline numbers (e.g., 1-800-4-A-CHILD national)
• Report ASAP — typically within 24 hours, immediately verbally then written
• Document the report (date, time, person spoken to)
• Follow institutional policy
• You DON'T need permission of supervisor (but inform them)
• Continue to provide medical care regardless of reporting
• Don't confront caregiver before reporting (may endanger child or compromise investigation)
• Tell parent that report has been made (after reporting)

Nursing interventions:

• Ensure child's safety first — admit to hospital if needed for protection during investigation
• Treat physical injuries
• Provide emotional support — believe the child, validate
• Build trust; allow child to talk at own pace
• Don't promise confidentiality you can't keep
• Don't pressure for details
• Use multidisciplinary team (child abuse pediatrics, social work, mental health)
• Provide developmentally appropriate explanations
• Coordinate with CPS, law enforcement, legal
• Refer to mental health services
• Document objectively (just facts, no opinions)
• Photograph injuries per protocol
• Preserve evidence (clothing, etc.) for sexual abuse
• Support to non-offending caregiver
• Educate family on positive parenting strategies (prevention)
• Identify and report repeat injuries
• Follow-up planning

Prevention efforts (community level):

• Parent education programs
• Home visiting programs (Nurse-Family Partnership)
• Anticipatory guidance at well-child visits
• Stress management resources
• Substance abuse treatment
• Mental health services
• Domestic violence interventions
• Safe Haven laws (allow surrender of newborns without prosecution)
• Mandatory reporting
• Public awareness campaigns
• Crib distribution programs
• Shaken baby education for new parents
• Period of PURPLE Crying education

Caring for the nurse:

• Vicarious trauma is real — debriefing, supervision, self-care
• Be informed about resources

Sequence of life-saving measures during cardiac/respiratory arrest in infants and children. Pediatric arrest is typically respiratory in origin (vs. cardiac in adults) — leads to asphyxial arrest. Early high-quality CPR and rapid intervention improve outcomes. Includes recognition, activating emergency response, CPR, and AED use.

Age categories:

• Infant: < 1 year (excluding newborns immediately at birth — separate NRP protocol)
• Child: 1 year to puberty (signs of puberty)
• Adult: puberty and older

BLS Sequence (lone rescuer; AHA C-A-B):

1. Scene safety
2. Check responsiveness: tap and shout (infant: tap foot)
3. If unresponsive: shout for help; have someone call 911 + get AED
4. If alone with unresponsive child: if witnessed sudden collapse → call 911 first (likely cardiac); if unwitnessed/asphyxial → start CPR for 2 min then call 911
5. Check pulse (≤ 10 seconds):
   • Infant: brachial artery (inner upper arm)
   • Child: carotid or femoral
6. If no pulse OR pulse < 60 with poor perfusion: begin compressions

Compressions:

Compression principles:

• Push hard, push fast
• Allow full chest recoil (between compressions)
• Minimize interruptions (< 10 sec)
• Switch compressors every 2 min to avoid fatigue
• Hard, flat surface preferred

Compression-to-ventilation ratio:

• Lone rescuer (infant or child): 30:2
• 2 rescuers (infant or child): 15:2
• Advanced airway in place: continuous compressions 100-120/min + 1 breath every 2-3 sec (20-30/min)

Ventilations:

• Each breath over 1 second
• Just enough volume to make chest rise
• Avoid excessive ventilation (↑ intrathoracic pressure → ↓ venous return)
• Mouth-to-mouth-and-nose for infants; mouth-to-mouth for children with nose pinched
• BVM with appropriate-sized mask

AED use:

• Use AS SOON AS available
• Pediatric pads/dose attenuator preferred for < 8 years or < 25 kg
• If only adult pads available — use them rather than nothing
• Infant: anterior-posterior placement
• Child: standard anterior-lateral or AP
• Follow AED prompts
• Resume compressions immediately after shock
• Continue 5 cycles (~2 min) before reassessing

Pediatric-specific considerations:

• Respiratory cause MOST COMMON — adequate ventilation crucial
• Pulse rate < 60 bpm with poor perfusion in child = start CPR (different from adult criteria)
• Foreign body airway obstruction more common
• Better outcomes with rapid recognition
• Hypothermia: continue CPR longer; "not dead until warm and dead"

Choking management (FBAO):

• Infant: 5 back blows + 5 chest thrusts (NO abdominal thrusts — liver injury)
• Child: Abdominal thrusts (Heimlich)
• If unresponsive: CPR (look in mouth before breaths)

Special situations:

• Drowning: prioritize ventilation; start with rescue breaths (5 initial)
• Trauma: c-spine precautions, jaw thrust (don't use head-tilt/chin-lift)
• Asphyxial arrest: start with compressions but prompt ventilation important

Recognition:

• Identify cardiac/respiratory arrest quickly
• Look for: unresponsiveness, no normal breathing (only gasping is NOT normal), no pulse
• Differentiate from sleep, seizure, syncope

Quality CPR:

• Push hard, push fast (rate 100-120/min, depth 1/3 AP chest)
• Allow complete chest recoil
• Minimize interruptions (< 10 seconds)
• Avoid excessive ventilation
• Switch rescuers every 2 min
• Pulse and rhythm check every 2 min (≤ 10 sec)

Equipment for in-hospital BLS:

• BVM with appropriately-sized pediatric masks
• Oral and nasal airways (sized to patient)
• Suction
• AED or defibrillator with pediatric pads
• Crash cart with appropriate-sized supplies
• Broselow tape (length-based emergency reference for weight, drug doses, equipment sizes)

Team roles (in-hospital):

• Code leader
• Compressor(s)
• Airway/ventilations
• Medication/IV access
• Recorder/timer
• Family support person
• Communication

Documentation:

• Time of arrest
• Time CPR started, who initiated
• Time of each intervention (drugs, shocks, intubation)
• Pulse and rhythm checks
• Resuscitation team members
• End-of-event status (ROSC, transferred, deceased)
• Family notification and presence

Post-cardiac arrest care:

• Optimize ventilation (don't hyperventilate)
• Optimize hemodynamics
• Targeted temperature management (consider)
• Manage seizures
• Monitor for re-arrest
• Investigate cause

Family presence:

• AHA supports family presence during resuscitation with support person
• Allows family to witness efforts, ask questions, say goodbye if needed
• Designated support person to explain

Prevention strategies:

• Address common causes: SIDS prevention, immunizations, safe sleep, drowning prevention, choking hazards, car safety, helmet use, recognize and treat respiratory illness early
• Caregiver CPR training
• Asthma action plans, anaphylaxis epinephrine training
• Sports cardiac screening
• Lay rescuer training programs

Education for families:

• Teach BLS/CPR to caregivers
• Emphasize calling 911
• Emphasize chest compressions (even if not comfortable with breaths)
• Post emergency numbers
• Have AED accessibility in schools, public spaces

Survival outcomes:

• In-hospital arrest: ~30-40% survival to discharge with good neurologic outcome
• Out-of-hospital arrest: lower (~10%)
• Bystander CPR doubles or triples survival
• Early recognition + early high-quality CPR + early advanced care = best outcome