NLE Paediatric Nursing — Paediatric GI, Genitourinary & Neurologic DisordersRevision Notes

Exam Tips

• NLE questions on respiratory distress often test which sign is MOST concerning or requires IMMEDIATE action — always choose the late/ominous signs (bradycardia, apnea, cyanosis, lethargy).
• Questions about priority nursing diagnosis for any child in respiratory distress: Ineffective Airway Clearance or Impaired Gas Exchange come before all others (Maslow — physiological needs first).
• IMCI tachypnea cut-offs are commonly tested — remember them by age bracket.

Key Points

• Children decompensate rapidly — early recognition and intervention are essential nursing priorities.
• EARLY signs (compensating): restlessness, tachypnea, tachycardia, nasal flaring, mild subcostal retractions.
• WORSENING signs: intercostal, subcostal, and suprasternal retractions; grunting; head-bobbing; stridor; wheeze; use of accessory muscles.
• LATE/OMINOUS signs (pre-arrest): cyanosis, bradycardia, decreased or absent breath sounds, lethargy, and unresponsiveness — these signal impending respiratory failure.
• IMCI tachypnea thresholds: ≥60 breaths/min if <2 months; ≥50 if 2–12 months; ≥40 if 12 months–5 years.
• Bradycardia in a child in respiratory distress is a CRITICAL late sign — act immediately.
• Priority NANDA nursing diagnoses: Ineffective Airway Clearance; Impaired Gas Exchange; Ineffective Breathing Pattern.

Definitions

Section Title

Recognising Respiratory Distress in Children

Common Mistakes

• Confusing tachycardia (early compensatory sign) with bradycardia (late, ominous sign). On the NLE, bradycardia in a child with respiratory distress = EMERGENCY.
• Forgetting age-specific respiratory rate thresholds — memorise the IMCI values (60, 50, 40).
• Not recognising that cyanosis is a LATE sign — the child is already significantly hypoxic by the time cyanosis is visible.

Exam Tips

• TOF Tet spell priority = KNEE-CHEST (infant) or SQUATTING (older child). This increases systemic vascular resistance and reduces the right-to-left shunt. Always choose this FIRST before oxygen on priority questions.
• For digoxin: the apical pulse rule is the single most tested nursing action — count for a FULL MINUTE at the APEX.
• Boot-shaped heart on X-ray = TOF; Steeple sign = Croup; Thumb sign = Epiglottitis. Memorise these X-ray associations.
• Hypokalemia (from furosemide use) potentiates digoxin toxicity — monitor potassium levels and watch for toxicity signs (bradycardia, vomiting, anorexia, dysrhythmias).
• For feeding a CHF infant: the key principle is CONSERVING ENERGY — small feedings, soft nipple, limited feeding time, rest between feedings.

Key Points

• CHDs are classified as ACYANOTIC (left-to-right shunt → lungs overloaded, no cyanosis initially, risk of CHF) or CYANOTIC (right-to-left shunt → deoxygenated blood reaches systemic circulation → cyanosis unrelieved by oxygen alone).
• ACYANOTIC defects: VSD (most common CHD overall), ASD, PDA, Coarctation of the Aorta.
• CYANOTIC defects — the 5 T's: Tetralogy of Fallot (most common cyanotic CHD), Transposition of Great Arteries, Tricuspid Atresia, Truncus Arteriosus, Total Anomalous Pulmonary Venous Return.
• VSD: hole between ventricles; loud holosystolic murmur; small ones may close spontaneously.
• PDA: ductus arteriosus stays open after birth; machine-like continuous murmur, bounding pulses, widened pulse pressure. Indomethacin or ibuprofen closes it; prostaglandin E1 (PGE1) keeps it OPEN.
• Coarctation of Aorta: HIGHER BP and bounding pulses in ARMS; LOWER BP and weak or absent femoral pulses in LEGS.
• Tetralogy of Fallot (TOF): 4 defects — Pulmonary Stenosis, VSD, Overriding Aorta, Right Ventricular Hypertrophy. X-ray: boot-shaped heart.
• TOF Tet Spells: acute hypercyanotic episodes. PRIORITY INTERVENTION — place infant in KNEE-CHEST position (older child SQUATS), give oxygen, calm the child, administer morphine as ordered.
• Transposition of Great Arteries (TGA): survival depends on mixing — give PGE1 to KEEP the ductus open until surgical correction.
• Signs of CHF in infants: tachycardia, tachypnea, poor feeding, diaphoresis with feeds, poor weight gain, hepatomegaly, periorbital edema.
• Nursing care for CHF: small frequent feedings, soft/enlarged nipple, limit feed time to 20–30 minutes, cluster care, elevate head, daily weights, monitor I&O.

Definitions

Section Title

Congenital Heart Defects (CHD)

Common Mistakes

• Confusing which drug closes vs. opens the ductus: INDOMETHACIN/IBUPROFEN = CLOSES (used for PDA); PGE1 = OPENS (used in duct-dependent cyanotic lesions like TGA).
• Forgetting that VSD is the MOST COMMON CHD overall, while TOF is the MOST COMMON CYANOTIC CHD — these are two separate 'most common' facts.
• Mixing up coarctation findings: HIGH BP in ARMS (above narrowing), LOW BP in LEGS (below narrowing).
• Giving digoxin without counting the apical pulse — this is a critical nursing safety step.
• Confusing the digoxin hold parameters: HOLD if apical HR <90–100 bpm in INFANTS; <70 bpm in OLDER CHILDREN.
• Repeating a digoxin dose if the child vomits — this is contraindicated and can cause toxicity.

Exam Tips

• Digoxin questions on the NLE almost always focus on ONE of three things: (1) where and how long to count pulse, (2) when to HOLD the dose, or (3) signs of toxicity. Memorise all three.
• If an NLE question asks what to do FIRST before giving digoxin — the answer is always: count the APICAL pulse for one FULL minute.

Key Points

• Count the APICAL pulse for a FULL ONE MINUTE before every single dose of digoxin.
• HOLD dose and NOTIFY the physician if: apical HR <90–100 bpm in an infant; <70 bpm in an older child.
• Signs of DIGOXIN TOXICITY: bradycardia, nausea, vomiting, anorexia, dysrhythmias. In older children: visual disturbances (yellow-green halos).
• NEVER double up or repeat a dose if the child vomits — vomiting itself is a sign of toxicity.
• Do NOT mix digoxin with food or formula — give alone with a proper oral syringe.
• Give at regular intervals spaced throughout the day.
• HYPOKALEMIA potentiates (worsens) digoxin toxicity — diuretics like furosemide cause potassium loss, so monitor serum potassium.
• Teach parents: exact dose with calibrated syringe, keep medication locked away from children, do not double dose if missed, call physician if child vomits after dose.

Definitions

Section Title

Digoxin Administration — Paediatric Safety (NLE High-Yield)

Common Mistakes

• Counting the radial rather than the APICAL pulse before digoxin — the apical site gives the most accurate count for infants.
• Forgetting the different hold parameters for infants (<90–100 bpm) versus older children (<70 bpm).
• Not connecting hypokalemia from diuretic use to increased digoxin toxicity risk.

Exam Tips

• NLE differentiates croup from epiglottitis very frequently. The key words: BARKING cough = croup; DROOLING + tripod position + toxic appearance = epiglottitis.
• The single most important nursing action for croup: KEEP THE CHILD CALM — anxiety and agitation worsen airway obstruction.
• Dexamethasone is the corticosteroid of choice in croup — it reduces subglottic edema.

Key Points

• CAUSE: viral, most commonly parainfluenza virus. Affects children ~6 months to 3 years. Usually worse at night.
• CLASSIC TRIAD: barking ('seal-like') cough + inspiratory stridor + hoarseness.
• X-ray finding: STEEPLE SIGN (narrowing of the subglottic area resembling a church steeple).
• Most cases are MILD and managed at HOME with cool humidified air and increased fluid intake.
• Hospital management for moderate-severe cases: keep child CALM (agitation worsens obstruction), cool humidified oxygen, nebulised racemic epinephrine for stridor at rest, dexamethasone (corticosteroid) to reduce airway edema.
• Racemic epinephrine effect is SHORT-ACTING — observe for REBOUND EFFECT (worsening symptoms after 2–4 hours) — do NOT discharge immediately after treatment.
• Priority NANDA: Ineffective Airway Clearance related to subglottic edema.

Definitions

Section Title

Croup (Laryngotracheobronchitis)

Common Mistakes

• Confusing croup (viral, barking cough, steeple sign) with epiglottitis (bacterial, 4 D's, thumb sign). These are completely different in cause, presentation, and management.
• Discharging a child too early after racemic epinephrine without observing for the rebound effect.
• Using a warm mist humidifier instead of COOL mist — cool humidified air is recommended for croup.

Exam Tips

• On the NLE, if a question describes a child who is drooling, sitting forward, looks very sick, and has a high fever — the PRIORITY action is NEVER to examine the throat. Prepare for intubation.
• Epiglottitis is an airway emergency — in ABCDE prioritisation, airway comes first. The nurse's role is to keep the child calm while preparing for advanced airway management.
• Hib vaccine prevention is a key public health point — children who are fully immunised per EPI (Expanded Programme on Immunisation) in the Philippines are protected.

Key Points

• CAUSE: BACTERIAL — classically Haemophilus influenzae type b (Hib). Now RARE in countries with widespread Hib vaccination. Rapid onset — a TRUE airway emergency.
• CLASSIC '4 D's': DROOLING, DYSPHAGIA (difficulty swallowing), DYSPHONIA (muffled/hoarse voice), DISTRESS.
• Child appears TOXIC: high fever (>39°C), sits in TRIPOD/SNIFFING POSITION (leaning forward on hands, neck extended), refuses to lie down.
• X-ray: THUMB SIGN (swollen epiglottis resembling a thumb on lateral neck X-ray).
• ABSOLUTE CONTRAINDICATION: DO NOT examine the throat with a tongue depressor or attempt a throat swab/culture — this can trigger complete laryngospasm and TOTAL airway obstruction.
• PRIORITY NURSING ACTIONS: Keep child CALM and UPRIGHT, allow parent to stay, give humidified oxygen, prepare for IMMEDIATE intubation or emergency tracheostomy, have emergency airway equipment at the bedside, administer IV antibiotics as ordered.
• Priority NANDA: Risk for Suffocation; Ineffective Airway Clearance.

Definitions

Section Title

Epiglottitis — Airway Emergency

Common Mistakes

• Attempting to inspect the throat with a tongue depressor in suspected epiglottitis — this is the MOST DANGEROUS nursing error and a frequently tested 'what NOT to do' question.
• Laying the child down — never place a child with epiglottitis in a supine position as this worsens obstruction.
• Confusing epiglottitis (bacterial, rapid onset, toxic child, no barking cough) with croup (viral, gradual onset, barking cough, not toxic-looking).

Exam Tips

• NLE key fact: Bronchiolitis = RSV = infants < 2 years = CONTACT precautions = SUPPORTIVE care + suctioning.
• Palivizumab questions: always test whether students know it is PROPHYLAXIS not treatment. If the infant already has RSV, palivizumab will NOT help.
• The priority nursing action for an infant with bronchiolitis and copious secretions = SUCTIONING to maintain airway patency.

Key Points

• CAUSE: Respiratory Syncytial Virus (RSV) — most common cause. Affects infants <2 years, peak incidence at 2–6 months.
• SIGNS AND SYMPTOMS: wheezing (low-pitched), tachypnea, retractions, nasal flaring, copious nasal secretions, cough, poor feeding, low-grade or no fever.
• RSV is HIGHLY CONTAGIOUS — transmitted by DROPLET and CONTACT. Virus survives on surfaces for hours.
• NURSING PRIORITY: strict CONTACT PRECAUTIONS + hand hygiene; cohort or private room; gown and gloves when within 3 feet.
• MANAGEMENT IS SUPPORTIVE: bulb/nasal SUCTIONING to clear airway (PRIORITY nursing action), humidified oxygen, adequate hydration (IV or oral), small frequent feeds, head-of-bed elevation.
• PALIVIZUMAB (Synagis): a monoclonal antibody given as MONTHLY PROPHYLAXIS to HIGH-RISK infants (preterm, congenital heart disease, chronic lung disease) during RSV season. It is NOT a treatment — it does NOT cure active RSV infection.
• Priority NANDA: Ineffective Airway Clearance; Impaired Gas Exchange; Deficient Fluid Volume.

Definitions

Section Title

Bronchiolitis (RSV)

Common Mistakes

• Saying palivizumab TREATS RSV — it is strictly PROPHYLAXIS (prevention) for HIGH-RISK infants.
• Forgetting that RSV requires CONTACT precautions (not just droplet) — it survives on surfaces and spreads by touch.
• Not prioritising SUCTIONING before feeding an infant with bronchiolitis — clear the airway first.

Exam Tips

• SILENT CHEST is the single most important clinical finding to recognise in asthma — it means the child is in severe/near-fatal status asthmaticus.
• Drug classification questions: salbutamol = SABA = RESCUE/RELIEVER; budesonide/fluticasone = ICS = CONTROLLER/PREVENTER.
• NLE health teaching questions about asthma commonly test: (1) spacer use, (2) mouth rinsing after ICS, (3) trigger avoidance, and (4) distinguishing reliever from controller medications.

Key Points

• Asthma is a CHRONIC REVERSIBLE inflammatory airway disease characterised by bronchospasm, mucosal edema, and excess mucus secretion.
• CLASSIC SIGNS: wheezing (primarily EXPIRATORY), dry cough, chest tightness, prolonged expiration, use of accessory muscles.
• SILENT CHEST (no audible wheeze in a child with severe respiratory distress) is an OMINOUS sign indicating near-complete obstruction — a life-threatening emergency.
• RELIEVER/RESCUE DRUG: Short-Acting Beta-2 Agonist (SABA) — SALBUTAMOL (albuterol). Causes bronchodilation. Side effects: tachycardia, tremor, jitteriness.
• CONTROLLER/PREVENTER DRUG: Inhaled Corticosteroids (ICS) — e.g., budesonide, fluticasone. Reduce airway inflammation. IMPORTANT: RINSE THE MOUTH with water and spit after every use to prevent ORAL THRUSH (candidiasis).
• For acute exacerbations: oral or IV corticosteroids, ipratropium bromide as adjunct, oxygen.
• Always use a SPACER (holding chamber) with a metered-dose inhaler (MDI) in children — improves drug delivery to the lungs.
• Teach TRIGGER AVOIDANCE: cigarette smoke, dust mites, pet dander, cold air, strong odours, exercise-induced (use pre-exercise salbutamol as ordered).
• Provide a written ASTHMA ACTION PLAN (green/yellow/red zones).
• Priority NANDA: Ineffective Airway Clearance; Impaired Gas Exchange; Deficient Knowledge.

Definitions

Section Title

Asthma in Children

Common Mistakes

• Forgetting to teach parents/child to RINSE THE MOUTH after inhaled corticosteroid use — oral thrush is a preventable complication.
• Confusing salbutamol (reliever — PRN for acute symptoms) with inhaled corticosteroids (controller — taken DAILY even when feeling well).
• Thinking that wheezing loudly means the child is getting worse — the SILENT chest (NO wheeze) is actually the most dangerous sign.
• Not using a spacer with MDI in young children — they cannot coordinate breath and puff effectively.

Exam Tips

• NLE prevention question: the single most important action to PREVENT rheumatic fever = COMPLETE the full antibiotic course for strep throat. Partial treatment leads to recurrence and cardiac damage.
• JONES mnemonic for major criteria: J-O-N-E-S (Joints/polyarthritis, cOrditis, Nodules subcutaneous, Erythema marginatum, Sydenham's chorea).
• The most dangerous complication tested on the NLE = carditis → mitral valve damage → rheumatic heart disease.

Key Points

• Rheumatic fever (RF) is an AUTOIMMUNE inflammatory disease that follows UNTREATED or INADEQUATELY TREATED Group A Beta-Hemolytic Streptococcal (GABHS) pharyngitis (strep throat) — typically 1–5 weeks after infection.
• Most common in SCHOOL-AGE children.
• Diagnosed using the JONES CRITERIA — Major and Minor manifestations plus evidence of preceding strep infection.
• MAJOR manifestations (JONES): (J) Joints — migratory polyarthritis; (O) Carditis — most DANGEROUS, can cause permanent valve damage; (N) Nodules — subcutaneous nodules; (E) Erythema marginatum — ring-shaped rash; (S) Sydenham's chorea — involuntary, jerky movements.
• CARDITIS is the most serious complication — leads to RHEUMATIC HEART DISEASE (most commonly MITRAL VALVE damage/stenosis).
• MANAGEMENT: Penicillin to eradicate strep + anti-inflammatories (aspirin is intentionally used for arthritis/carditis under medical supervision in RF — an exception) + bed rest during acute phase.
• LONG-TERM PROPHYLACTIC PENICILLIN to prevent recurrent strep infections and further cardiac damage.
• PREVENTION: Treat all strep throat infections promptly and COMPLETELY with the full antibiotic course — the MOST IMPORTANT prevention strategy.
• Priority NANDA: Decreased Cardiac Output; Activity Intolerance; Acute Pain (joints).

Definitions

Section Title

Acquired Heart Disease: Rheumatic Fever

Common Mistakes

• Forgetting that aspirin USE IN RHEUMATIC FEVER is a deliberate medical choice for anti-inflammatory purposes — this is a specific exception to the general caution about aspirin in children (Reye's syndrome risk).
• Not emphasising long-term penicillin prophylaxis — this is the cornerstone of preventing recurrence and further cardiac damage.
• Confusing the MOST DANGEROUS manifestation (carditis/mitral valve damage) with the most PAINFUL (migratory polyarthritis).

Exam Tips

• If the NLE describes a child under 5 with high fever for >5 days, strawberry tongue, red/cracked lips, conjunctivitis, and peeling hands — think KAWASAKI DISEASE.
• The most feared complication = CORONARY ARTERY ANEURYSM. Treatment = IVIG + aspirin.
• Both rheumatic fever AND Kawasaki disease use aspirin intentionally — note this as exceptions to the aspirin-in-children rule.

Key Points

• An acute systemic VASCULITIS (inflammation of blood vessels) of UNKNOWN CAUSE affecting predominantly children UNDER 5 YEARS of age.
• Leading cause of ACQUIRED HEART DISEASE in children in developed countries.
• DIAGNOSTIC CRITERIA: High fever >5 days (unresponsive to antipyretics) PLUS at least 4 of the following — CRABSS mnemonic: Conjunctivitis (bilateral, non-purulent); Rash (polymorphous); Adenopathy (cervical lymphadenopathy ≥1.5 cm); Bulging/peeling skin of hands and feet (redness, swelling, then desquamation); Strawberry tongue + cracked, red lips.
• DREADED COMPLICATION: CORONARY ARTERY ANEURYSM — can lead to myocardial infarction, even in young children.
• TREATMENT: IV IMMUNOGLOBULIN (IVIG) — given as a SINGLE high dose within the first 10 days to reduce inflammation and risk of coronary aneurysm; HIGH-DOSE ASPIRIN (anti-inflammatory phase), then LOW-DOSE ASPIRIN (antiplatelet/anticoagulation phase to prevent clotting in aneurysm).
• KEY nursing teaching: explain the peeling skin (parents are often alarmed), monitor for irritability (very common), teach about long-term cardiac follow-up.
• Priority NANDA: Hyperthermia; Decreased Cardiac Output (risk for coronary aneurysm); Acute Pain; Deficient Knowledge.

Definitions

Section Title

Acquired Heart Disease: Kawasaki Disease

Common Mistakes

• Forgetting that aspirin in Kawasaki disease is a DELIBERATE THERAPEUTIC EXCEPTION — it is used specifically for its anti-inflammatory and antiplatelet effects despite the general Reye's syndrome caution.
• Confusing rheumatic fever (follows strep throat, damages mitral valve) with Kawasaki disease (unknown cause, coronary artery aneurysm) — both are acquired heart diseases in children but very different.
• Missing the fever duration criterion — the fever in Kawasaki is >5 DAYS and does NOT respond to antipyretics (ibuprofen, paracetamol).

Exam Tips

• NLE questions about cleft lip/palate often test: (1) Rule of 10s timing, (2) post-operative positioning (never prone for lip repair), (3) elbow restraints, and (4) nothing hard in the mouth after palate repair.
• The priority problem for ANY child with cleft lip/palate = FEEDING DIFFICULTY and ASPIRATION RISK — this addresses Maslow's most basic physiological need.
• Remember: cleft palate repair is at 6–12 months because it needs to be done BEFORE the child develops significant speech patterns.

Key Points

• Congenital facial malformations resulting from failure of embryonic facial processes to fuse during the first trimester. Can occur independently or together.
• PRIORITY PROBLEMS: Feeding difficulty and aspiration risk (impaired suction), plus later problems with speech and recurrent otitis media (middle ear infections due to eustachian tube dysfunction).
• PRE-OPERATIVE FEEDING: hold infant UPRIGHT, use SPECIAL DEVICES (wide-base soft nipple, cross-cut nipple, squeezable bottles like Haberman feeder or Mead Johnson bottle), feed SLOWLY, burp FREQUENTLY (they swallow excess air). Breastfeeding may still be possible.
• TIMING OF REPAIR — RULE OF 10s for CLEFT LIP: repair at approximately 10 WEEKS of age, weight ~10 POUNDS (~4.5 kg), haemoglobin ~10 g/dL.
• CLEFT PALATE repair: usually at ~6–12 MONTHS of age — before significant speech development begins.
• POST-OPERATIVE CLEFT LIP CARE: position SUPINE or on SIDE (NEVER PRONE — avoids rubbing the suture line on mattress); apply ELBOW RESTRAINTS (no-no restraints) to prevent infant from touching suture line; keep suture line CLEAN; avoid tension/crying; AVOID HARD OBJECTS in the mouth.
• POST-OPERATIVE CLEFT PALATE CARE: NOTHING HARD IN THE MOUTH — no straws, no pacifiers, no spoons, no oral suction catheters near the suture line; feed with a cup or the side of a spoon; soft/liquid diet; ELBOW RESTRAINTS.
• Monitor for AIRWAY OBSTRUCTION and BLEEDING post-operatively.
• Priority NANDA: Imbalanced Nutrition: Less Than Body Requirements; Risk for Aspiration; Impaired Verbal Communication (palate); Deficient Knowledge (parents).

Definitions

Section Title

Cleft Lip and Cleft Palate

Common Mistakes

• Positioning infant PRONE after cleft lip repair — this rubs the suture line on the mattress and can disrupt wound healing. NEVER prone post-lip repair.
• Allowing straws, pacifiers, or spoons near the mouth after cleft PALATE repair — any rigid object can disrupt the palate suture line.
• Confusing the timing: CLEFT LIP = 10 weeks (Rule of 10s); CLEFT PALATE = 6–12 months. Do not mix these up.
• Using a regular nipple and bottle — special feeding devices are required pre-operatively.