Peds notes #1 Pediatric Nursing Anticipatory guidance: given when nurses understand the developmental stage of the child and teach parents how to assist the child to meet expected milestones by providing a safe, stimulating environment - done when a parent brings in their child in for a checkup - assess where the child should be with their milestones - provides education to parents on how to achieve these milestones and safety precautions Pediatric nursing: specializes in caring for pediatric pts across the 5 growth and development stages - understanding the differences in the pediatric body across the 5 growth and development stages and how they differ from the adult - safety comes first especially in children, and they need guidance and teaching about protection and monitoring to remain safe at all times - implementation of safe practices and educating parents on how to keep their children safe as well Speaking with pediatric patients - speak to the child on their educational level (until they are an adolescent, then you can speak to them like an adult) and use a non-threatening tone - do not argue with the child - use words and explain procedures to the child so that they understand - build a therapeutic relationship with the child by letting them participate, making them feel helpful and in return, making the child more compliant with their care Family centered nursing care - involves the whole family not only the pt - Families are groups that should remain constant in children’s lives and is defined as what an individual considers it to be - Include the parents, who are the head of the family and can make decisions and siblings (that should be included in the recreational parts of care like snack and play time) - Does not involve research Positive family relationships: characterized by parent-child interactions that show mutual warmth and respect Includes: - Agreed upon partnerships between the family, children, and health professional providing care that are beneficial to both the family and children - Respecting and incorporating cultural diversity and practices - Understanding growth and developmental needs of children and families - Allowing families to serve as experts regarding their child’s health conditions, usual behaviors and routine needs Comprehensive family assessment: done to assess and identify strengths and weaknesses - Nurses should pay close attention when a family member says that a child isn’t “acting right” or has other concerns - Children’s opinions should be considered when providing care Characteristics of a healthy family: - Members communicate well and listen and support each other - There is a clear set of family rules, beliefs, and values - Respect for others is taught - Interaction with one another - Shared sense of responsibility - Adaptability and flexibility in roles - Members seek help for their problems Peds notes #1 Family theories 1- Family systems: the family is viewed as a whole system, instead of an individual family member - A change in one family member affects the entire system - The system can both initiate and react to change - Too much or too little change can lead to dysfunction 2- Family stress - Stressors that are expected or unexpecting both affect the family - Explains the reaction of a family to stressful events - Offers guidance for adapting to stress 3- Developmental: views the family as small groups that interact with the larger social system - Emphasizes similarities and consistencies in how families develop and change - Duvall’s family life cycle stages to describe the changes a family goes through over time - How a family functions in one stage has a direct effect on how the family will function in the next stage Family compositions Traditional nuclear family: married couple and their biological children (full siblings only) Nuclear family: two parents and their children (biological, adoptive, step or foster) Single- parent family: one parent and one or more children Blended family/reconstituted: at least one stepparent, stepsibling, or half sibling - Health assessment standards/techniques for all pediatrics pts Always document findings on the growth chart so that it can be compared for later visits Assess infants on the caregiver’s lap Auscultate first, while the child is quiet and/or sleeping so you can hear everything Perform the most invasive procedures last – if they start crying it’s hard to listen Explain everything to caregivers during the assessment Gather information through play Be flexible during the assessment and get information in whatever way works with that child Provide distractions Allow child to touch safe medical equipment- medical play Do not ask permission from the child, it gives them the option to say no Use positive reinforcements and praises Explain procedures in simple, concrete, and positive terms Give them choices throughout the examination Allow them to play with the medical equipment Peds notes #1 CH15: Care of the Newborn and Infant Doctors’ visits - Appointments conducted at- newborn, 1, 2, 4, 6, 9 and 12 months because they grow the fastest and go through a lot of changes - the earlier you establish there is a problem, the easier it is to fix it - Involve the parents and caregivers Growth & Patterns (newborn -12 months) - Document all physical growth data points on growth charts to assess trends and averages and compare Growth: increase in size Development: attainment of different physical, psychosocial, and cognitive skills - The development of these skills take place in a sequential order: one skill must be attained before a more complex skill is developed Cephalocaudal pattern: attainment of skills from head to toe - Large muscle group growth - Being able to hold its own head up is seen before crawling - Gross motor skills: large muscles (head, arms, trunk, legs) Proximodistal pattern: attainment of skills from trunk (center) out to extremities - Fine motor skills (fingers, hands) 1- Length - Grow 1.5-2.5cm per month for the first 6 months - Grow 1cm per month from months 6-12 - Measure from the head to the heel, make sure to extend the babies legs 2- Weight - Lose 10% of their body weight in the first week of life, but regain it by the end of the 2 nd week - Gain 20-30 grams per day for the first 3 months - An average 6-month-old weighs around 16 lbs - Weight doubles by 4-6 months – should be double birth weight by 5 months - Weight triples by 12 months 3- Head circumference - Increases rapidly the first 6 months, then slows down until 12 months - Tape measure is placed above the middle of the eyebrows and wrapped around - The baby’s head circumference and the closing of the fontanelles tell us if the head is forming properly Peds notes #1 Developmental patterns 1- Piaget- sensorimotor stage – cognitive - Infants progress from reflexive to simple repetitive to imitative activities Tasks: - Separation- learn to separate themselves from other objects in the environment - Object permanence- learn that an object still exists even when it is out of view (9-10 months) - Mental representation- ability to recognize and use symbols 2- Erickson- trust vs mistrust – psychosocial - Achieving this is based on the relationship between the caregiver and the child - The infant begins to learn delayed gratification- failure to learn this, leads to mistrust - Mistrust develops if needs are inadequately or insufficiently met before being vocalized by the infant 3- Social development - Initially influenced by the infants’ reflexive behaviors, and includes attachment, separation, recognition/anxiety, and stranger fear Attachment- seen when infants begin to bond with their parents - Seen within the first month but started before birth - The process is enhanced when the infant and parent are in good health, have positive feeding experiences, and receive adequate rest Separation- occurs within the first year as infants begin to distinguish themselves as and their parents as different people that are not part of them - Occurs around the same time as object permanence is developed - Separation anxiety begins around 4-8 months of age, protesting leaving their parents. By 11 months infants are able to anticipate their mothers departer by watching their behaviors - Stranger fear develops at around 6-8 months, when infants have the ability to discriminate between familiar and unfamiliar people - Reactive attachment disorder: is a result from maladaptive or absent attachment between the infant and the caregiver and continues throughout life Sensory developments of newborns and infants 1- Vision - 20/400 vision at birth - No color vision until 7 months 2- Hearing - Prefer high pitched voices 3- Taste - Prefer sweet tastes over sour tastes 4- Touch - Prefer soft, gentle touches Peds notes #1 Physical variants in newborns and infants 1- Head Fontanelles: soft spots in the skill where the cranial bones have not yet fused together and ossified - This is soft because the baby needs to be squeezed out of a small opening in order to be born, if the cranial bones are ossified, the head won’t fit through - Upon assessment the fontanelles should be soft and flat - If the baby is dehydrated, the fontanel will sink down - If the baby is crying or in distress, the fontanel will bulge a little bit - The brain also grows very fast in the first year, so the fontanelles give the brain room to grow can indicate neurological abnormalities or an alteration in fluid balance - Posterior: smaller, closes between 2 & 3 months - Anterior/soft spot: larger, closes between 12 & 18 months 2- Eyes Strabismus: eyes not aligning to look at the object (cross eyed) - They don’t have good control of the eye muscles - This is normal until 6 months Questions to ask: - Does the parent notice the baby recognizing faces? 3- Ears - When inspecting the pinna of the ear, pull it back and down - The top of the pinna (top of the ear) should align along an imaginary line with the outer cantus of the eye - A pinna that sits below the imaginary line between the outer canthus of the eye could indicate chromosomal abnormalities Questions to ask: - Does the baby turn its head when he/she hears a voice or sounds? 4- Nose - Only nose breathers due to breast feeding, if they breathed through their mouth, they wouldn’t be able to breathe - At around 4-6 months when they learn to control their tongue reflex (extrusion reflex) when they start to breathe through their mouth as well, it’s also when you start feeding them through their mouths - Any congestion in the nose can affect their breathing 5- Diaphragm/chest - Barrel check with a 1:1 anteroposterior transverse diameter is normal (look round) - Diaphragmatic breathing - Irregular breathing with occasional pauses (they are learning to control their breathing) – assess for a full minute 6- Respiratory system - Airways are smaller - Lungs have fewer alveoli - Chest wall is more compliant - Have poor hypoxic drive and decreased surface area for gas exchange - All leaving the infant at a higher risk for respiratory distress even with mild respiratory illnesses 7- Heart - Irregular heart rate - Presence of S3 may be audible (in utero they didn’t use the heart as much as they do when they are outside of the womb, the mother did a majority of the work) - Asymptomatic murmurs are often present due to the shunts being closed - Best place to listen/feel to the pulse for maximal impulse (PMI) is in the fourth intercostal space and slightly right of the midclavicular line - BP is not normally checked till a child is 3y/o unless diagnosed with a cardiac defect Questions to ask: - Does the baby ever turn blue? - Does the baby tire easily or become diaphoretic when feeding – both can indicate congenital heart defects Peds notes #1 8- Skin - Skin variants including salmon patches (red marks), and Mongolian spots (bruise like marks) Acrocyanosis: blue discoloration, cyanotic discoloration of extremities - Trying to regulate their circulation may be present in newborns 9- Bones - Assess for hip dysplasia until 3 months of age (they are laid down and the hips are rotated, listening for cracks, there should be an even number of folds in their legs, legs should be even) - Incomplete bone ossification – due to needing to squeeze out of the birth canal - Benign metatarsus adducts: feet curving inwards 10- Communication and speech of newborns and infants - Communicate through crying - Different pitches of cries based on their needs - Begin cooing at 2 months old - Babbles by 6 months - Copies sounds at 9 months - Says a few words, gesture and follow simple directions by 12 months Delayed verbal skills: - If an infant is not imitating sounds or babbling by 7 months, the infant has a delay in language development and further investigation is needed - Problems with hearing are often the cause of speech delay - Infants who have had reoccurring ear infections often have speech delay due to fluid in the middle ear 11- Lab values/ immune system - Have passive immunity until 6 months – from the blood and breast milk from mom. This begins to fade at around 6 months - Born with high levels of fetal hemoglobin (HgbF) and physiological anemia as the iron starts to deplete as the child grows (no longer getting it directly from moms’ blood). This is the reason why iron fortified milk and food is given at around 4 months 12- Reflexes - Myelination of the spinal cord begins from newborn to 24 months Primitive reflexes: born with and go away - Sucking, rooting, Babinski (lasts until 24 months), Moro (startle- lay them down and they think they are falling), stepping, palmar grasp (use whole hand to pick something up), plantar grasp, and tonic neck (fencer) - Typically disappear over the first year of life Protective reflexes: - Develop after the disappearance of the primitive reflexes - Not present until 12 months of age - Assessed in toddlers and older children 13- Stool - Differs from baby to babe Meconium: newborns first stool - Thick and green If breast fed: - Thinner in consistency - Seedy and yellow If formula fed: - Pastier in consistency - Darker in color Constipation: - One stool a day or every other day is normal and up to 10 stools daily - Focus on the consistency and not quantity of the stool - Grunting is not a sign of constipation - If they are bottle fed, water is added to the formula and if breast fed, a bottle with water is given in addition to relieve the constipation Peds notes #1 14- Pain - Assess pain through observation of behaviors and consolability - Incorporate the caregiver in the pain assessment FLACC scale: main assessment tool used for newborns - Face, legs, activity, cry, consolability - Each domain is scored from 0-2 - Scores 0-10- the higher the score, the more pain they are in Neonatal infant pain scale (NIPS): - Facial expression, cry, breathing patter, arm, legs, and state of arousal score - Scale of 0-1 for all EXCEPT crying, which is scored from 0-2 - Maximum score of 7, the higher the score indicates more pain 15- Oral health - First tooth at 4-7 months Signs of teething: - Fussy and irritable - Increased salivation - Low grade fevers - Difficulty sleeping Interventions: - Frozen teething rings - topical analgesics - wash gums with soft washcloth or infant toothbrush until tooth eruption - avoid refined sugars and propping bottles (no bottles in bed because if they fall asleep while drinking their bottle because the sugars stay on their teeth and tooth decay develops) 16- Attachment and bonding - Look at the way the parent and child interact - Does the parent respond the babies’ cues? - Does the parent seem interested in the child’s development and health? Growth and development social determinants of health 1- Risks - Tobacco exposure – linked to the development of asthma - Food and housing insecurity – can cause the baby to be diagnosed with failure to thrive - Parental substance abuse – if the parent is breast feeding and taking drugs/alcohol the child is at risk 2- Protective factors - Support network - Positive family relationships - Adequate childcare 3- Infant behavior - Parent infant relationships and daily routines – are they bonding? Peds notes #1 Nutrition 1- Feeding choices - Neither one is right or wrong, it’s what works for the baby and mother - Breast feeding: provides a complete diet for infants during the first 6 months, provides all the antibodies from the mother giving the child more protection – infant should cover all of the areola - Formula feeding - Iron fortified formula: given to infants because at around 4 months, the mother breast milk no longer supplies the baby with enough iron - Cows milk is not recommended - Vit D supplements should be given within the first few days of life to prevent rickets (improper calcification of bone leading to bowlegs) and vitamin D deficiency - Alternate sources of fluids (juice and water) are not needed during the first 4 months. Excessive water intake could result in hyponatremia or water intoxication - 100% fruit juice should be limited to 4-6oz per day 2- Hunger Cues - Rooting: automatically looks for the breast - suckling - Crying and opening the mouth - Moving hands to the mouth 3- Satiety cues - child is no longer hungry - Stops sucking - Pulling off the breast - Pushing away - Closing the mouth 4- Solid foods - Starting at 6 months - Disappearance of the tongue extrusion reflex and ability to sit in a highchair with good head control (46 Months), interest in solid foods - Start with iron- fortified cereal, then add other pureed foods slowly - All new foods should be added in slowly one at a time over 5-7 days to observe signs of allergies/intolerance (fussiness, rash, vomiting, diarrhea, and constipation) - Vegetables and fruits can be started first between 6-8 months. After both have been introduced, meats can be added - Citrus fruits, meats, and eggs are not introduced until after 6 months - Breast milk/formula should be decreased as intake of solid food increases, but should still be the primary source of nutrition for the first year Starting table foods: - Parental knowledge of choking hazards - Self-feeding - Feedings should be done by itself without distractions to avoid choking - Should be well cooked, chopped, and unseasoned up to 1 years old - Appropriate finger foods- ripe bananas, toast strips, graham crackers, cheese cubes, noodles, firmly cooked vegetables, raw pieces of fruit except whole grapes Weaning from the breast to the bottle: - Infant readiness Parental readiness Transition to a cup Gradually replace one bottle or breastfeeding at a time with breast milk or formula in a cup with handles Bedtime feedings are the last to be stopped Peds notes #1 Common conditions Colic: abdominal pain due to intestinal gas or obstruction in the intestines - self-limiting condition of increased fussiness and inconsolable crying - Peaks of 6 weeks and resolves by 3-6 months - Is often worse in the evening - No treatment, but caregivers require psychological and emotional support (lack of sleep, feeling like they are a bad parent) - Encourage caregivers to lay the infant in the crib when frustrated to avoid over shaking them (shaken baby system) Diaper dermatitis: any skin breakdown in the diaper region - Skin is erythematous and excoriated - Skin folds are not affected - Painful for infants - Clean with a mild soap, rinse them thoroughly and pat dry - Treated by leaving diapers off and allowing the skin to dry - Commercial skin barriers can be used, chemical barriers so that wet substances can touch the skin - Notify healthcare provider if odor, fever, or purulent drainage is present – indicates the need for an antibiotic or fungal ointment Nystatin is used for a fungal infection: - Given PO or topical (usually done first) - Finds to the fungal cell membrane changing the cell wall permeability Seborrhea/cradle cap: dry spots on the scalp (dandruff) - Scales and erythema, usually only found on the scalp - Not painful or itchy - Resolves by 12 months of age - Remove scales with soft brush - Hydrocortisone cream can be put on if seborrhea extends beyond the scalp Fever: a temperature over 100.4 F and 38 C - Indicates illness and a sign of infection - Do not place infants in a cool bath, this makes them very uncomfortable - Monitor for poor perfusion, hyperventilation, or hypoventilation - Babies cannot regulate their temperature properly, if they are over dressed, they will develop a fever S&S: - Tachypnea - Irritability - Tachycardia Treatment: - Only administer antipyretic if symptomatic and irritable - Acetaminophen/ Tylenol - Ibuprofen/Motrin Peds notes #1 Anticipatory guidance/ parental teachings 1- Use a bulb syringe to clear nasal passageways - Suctions an infant’s nostrils - Infants are nose breathers and if they are congested their breathing is affected - Squeeze the bulb syringe prior to insertion. Gently insert the tip of the syringe into the nostril and release the bulb. Empty the syringe into a tissue and wash the syringe after each use 2- Over the next 2 months you can expect the child to begin to: - Recognize his or her name - Enjoy playing, especially with parents - String consonant sounds together while babbling - Indicate joy and displeasure - Eat pureed foods - Reach for objects - Roll both ways - Sit in a tripod position without support - Have teeth 3- As the child becomes more mobile, you will need to increase safety measures including: - Either lock low cabinet doors or keep all breakable items and cleaning solutions in high cabinets - Cover electrical outlets and electrical cords are out of reach - Never leave a child unattended on a high surface or on the floor - Make sure all foods are pureed, as your child will not be able to chew yet even if they have teeth 4- For 6-month old’s (when they come in for their 4-month checkup) Over the next 3 months you can expect your child to: - Become more mobile, either scooting or crawling - Pick up small objects with the whole hand - Begin to eat more table foods - Begin to pull themselves up to a standing position while holding onto a table or chair 5- Falls - Never leave an infant alone on an elevated surface - Make sure infants are buckled in swings and bouncy seats - Once an infant is mobile, use safety gates at the top and bottom of the stairs - Do not allow infants to use a baby walker 6- Medication administration - Talk with the PCP before administering medications to infants - Ensure that the medication is safe to give to infants - Use the infants most current weight to determine the correct dose - Most medications are given in Mg/Kg - Double check that the medication is the right dose before giving it - Measure out the dose exactly using a medication syringe or dropper - Give medications as prescribed - Place liquid medications in the side of infants mouth - Topical medications are quickly absorbed into the skin, so use them sparingly 7- Play - Infants engage in solitary play: playing alone while surrounded by other babies not interacting - Playtime includes reading, singing, and playing with age-appropriate toys - Younger infants- toys can be kicked or batted, unbreakable mirrors, and contrasting patterns - Older infants- toys that make noise or light up, soft dolls, teething toys, board books (thicker pages so they chew on it and choke), and large blocks Peds notes #1 8- Sleep - Room sharing in own bed until 6 months of age is recommended - Newborns sleep about 16 hours per day Sudden infant death syndrome (SIDS) prevention techniques: - Skin to skin contact should be made within the first hour of birth - nothing in the crib with them- no blankets, pillows, or toys - use a tightly fitted crib sheet - parents should practice room sharing but not bed sharing for the first 6 months - avoid exposing infants to secondhand smoke - offer a pacifier to the infant at naptime and bedtime - Babies should always sleep on their backs 9- Immunizations - Protects against communicable diseases - For the first 3-6 months infants rely on passive immunity received through the placenta (maternal immunoglobulin G is passed down from the mother) - Provide vaccine information sheets and administration record Types of vaccine: Live attenuated: weak version of the virus, pathogen is killed but the virus is active but modified. The immune system forms antibodies (ex: measles, mumps, rubella, varicella) - Have to ask if anyone in the household has a weakened immune system because the child will be able to spread the live vaccine to other people Inactivated: virus is killed, but the vaccine is still capable of producing an immune response (ex: inactivated polio vaccine) Toxoid: protects against bacteria that cause toxins. uses a weakened form of the toxin/harmful product made by the germ that causes the disease. Helping the person create immunity (diphtheria, tetanus) Conjugate: combines a weak antigen with a strong antigen as a carrier so that the immune system has a stronger response to the weak antigen by using a polysaccharide coating that allows the immune system to recognize the bacteria and react (ex: haemophilius influenza type B) Barriers to vaccine compliance: - Lack of transportation to get the baby their vaccines - Financial concerns - Safety concerns- normal and abnormal side effects CDC recommended Immunizations for infants less than 12 months - Birth- hepatitis B - 2 months- Diphtheria, tetanus toxoids, pertussis (DTaP), retrovirus (RV), inactivated poliovirus (IPV), haemophiles influenza type B (Hib), pneumococcal vaccine (PCV), and Hep B - 4 months- DTaP, RV, IPV, Hib, PCV - 6 months- DTaP, IPV (6 -18 months), PCV, and Hep B (6-18 months), RV, Hib - 6-12 months- seasonal influenza vaccines yearly Common side effects: - Fever of up to or around 102°F - Have redness or a small amount of swelling at the injection site - Be fussier and sleep more in the first 24h after the shot When to call the doctor: - Child has a fever of 105°F or higher If the child has a seizure If the child has uncontrollable crying for 3hrs or longer If the child has an anaphylactic reaction (SOB, closed airway, itching, rash) Uncontrollable crying for 3hrs or longer Peds notes #1 - CH 16: Care of the Toddler (1-3 years old) Appointments conducted at – 15 months, 18 months, 2 years, 2.5 years and 3 years Developmental growth patterns - Standing weight and height is taken when they can stand on their own - document all physical growth so that it can be compared to growth charts and for the next visits 1- Weight - Usually weighed sitting on the scale until they are around 3 years old - Gain 5 pounds per year 2- Height - Grow 5 inches from 12 months to 2 years - Grow 2-3 inches from 2 to 3 years 3- Head circumference - Increases by 2cm from 12-24 months Developmental patterns 1- Erikson- autonomy vs shame and doubt - psychological - Independence is important for toddlers who are attempting to do everything for themselves - Often use negativism or negative responses as they begin to express their independence - Having a ritual gives them a sense of comfort as they begin to explore the environment 2- Piaget- transition from sensorimotor to preoperational - Cognitive - sensorimotor -continues till age 2 - preoperational- begins at age 2 (doesn’t allow the toddler to understand other people’s points of view, but does allow them to copy people and activities they do) - object permanence is fully developed - toddlers manipulate objects to learn - begin to imitate others and play “house” - Animis: belief that inanimate objects have consciousness and other life like properties 3- Moral development - Closely associated with cognitive development - Egocentric- toddlers are unable to see things from the perspective of others. Can only view things from their point - Punishment and obedience orientation begins with a sense that good behavior is rewarded and bad behavior is punished – don’t know the difference between right and wrong 4- Freud- psychosexual - Anal stage - The toddler is focused on learning about when and where to defecate - Stool holding can be common during toilet training 5- Kohlberg- morals - Preconventional - Learning obedience 6- Self-concept - Toddlers progressively see themselves as separate from their parents and increase their explorations away from them 7- Body image changes - Learn to appreciate the usefulness of various body parts - Develop gender identity by age 3 Peds notes #1 Physical variants and finding on assessment 1- Head - Myelination of the brain is completed at 1 year 2- Ears - To inspect the pinna, pull it back and down 3- Teeth - All 20 baby teeth should be present by 3 4- Breathing - Start to breathe with their diaphragm instead of their stomach 5- Heart - Point of maximal impulse (PMI) is at the fourth intercostal space midclavicular line – used to hear the heart the best 6- Stomach - Protrudes out because they haven’t developed stomach muscles 7- Stool - Decrease in stool frequency (usually once a day) 8- Reflexes and coordination - Hand preference is established by 2-3 years old - Have a wide gait and flat feet - Bowed legged - Lordosis: back sways towards the front 9- Vital signs - BP increases and HR decreases as toddler grows and develops 10- Immunity - Immature adaptive immunity – building their own immunity - Haven’t been exposed to many germs yet so their immunity is still weekend 11- Lab values - Normal hemoglobin ratio at 1 year 12- Pain assessment - Use pain screening tools that are age appropriate (FLACC, pictures) - Incorporate the parents’ input - Toddlers react to painless procedures the same way as they do for painful procedures because they are scared - Encourage toddlers to use words for pain 13- Communication and speech - Receptive language (understanding what people are saying) develops quicker than expressive language - Can understand directions before giving directions - Encourage parents to read to their children Echolali: repetition of words and phrases without understanding them Telegraphic speech: two-to-three-word sentences that contain enough words to get the point across Peds notes #1 Nutrition - Eating habits established during childhood can be followed for the rest of their life - Change from formula or breastmilk cow’s milk at 1 year (24-28oz/day) - To prevent anemia limit milk consumption because the child will fill up on milk and not eat other foods - Use nonflavored whole milk and can switch to low fat milk at 2 - Have the toddler drink from a cup instead of the bottle - Do not allow a bottle at naptime or bedtime - Can develop physiological anorexia from decreased caloric needs – seems like they aren’t eating but their body doesn’t require - Food jags: times where a toddler will only eat certain foods then suddenly refuse to eat them anymore (common at around 3) - Picky eaters – begin to develop taste preferences - Offer a variety of health foods and do not force a child to eat - Healthy food choices -Quality over quantity - Consistent mealtimes Daily consumption guidelines: - Juice consumption should be limited to 4-6oz/day - Trans and saturated fats should be avoided - Diet should include 1 cup of fruit - Food serving size should be 1 tbsp for each year of age, or ¼ - 1/3 of an adult portion - Snacks or desserts high in sugar, fat, or sodium should be avoided Choking hazards: - Adult supervision to be provided during snack and mealtime - Toddlers should not be allowed to engage in eating or drinking during play time or when distracted - Cut food into small bite sized pieces Foods to avoid: - Nuts - Whole grapes - Peanut butter - Raw carrots - Dried beans - Tough meats - Popcorn - Hot dogs - Marshmallows Peds notes #1 Common conditions 1- Atopic/acute Dermatitis- eczema - Most common chronic skill condition in children - Linked to children being more likely to have allergies and asthma S&S: - Severely dry skin - Erythematous (red bumpy) patches - Extreme pruritus - Thickening of the skin Treatment: - Avoid flair ups by determining and avoiding triggers - Keep hydrated - Use topical corticosteroids if environmental changes are not effective - With corticosteroids educate the parents that before application clean the area and then pat it dry 2- Acute Otitis media (AOM)- ear infection - Inflammation of the middle ear and middle ear effusion (fluid behind the ear drum) - The toddler is at risk for speech delay if frequent or untreated – fluid keeps the ear bones from wiggling and sounds aren’t transmitted to the brain Risk factors: - Exposure to tobacco smoke - Exposure to other children - Congenital abnormalities Protective factors: - Breast feeding - Pneumococcal vaccination Treatment: - Antibiotics - Comfort measures (elevate the head of the bed with a pillow under the mattress) relieves the pressure - Myringotomy (ear tubes to facilitate the drainage of the fluid equalizing the pressure) for recurrent ear infections Peds notes #1 Anticipatory guidance/ parental teachings 1- Brushing teeth - With the development of teeth, parents should assist children in brushing their teeth to insure that the teeth are cleaned and healthy so they can least till the second set comes in 2- Discipline - They don’t fully understand rules - Approach as a teaching experience rather than a punishment - Reward positive behaviors and ignore negative ones - Use developmentally appropriate approaches - Be consistent with the consequences and rewards - Emphasize that the behavior is bad not the child - Use a nonphysical method of punishment like “time out” Temper Tantrums: - Result of receptive language development versus expressive language development - May begin at 1 year - Do not interact with the child, just make sure they are safe - Reward good behavior and ignore the bad - Biting and hitting should be addressed with time outs - Disruptions in routine and inconsistent expectations increase temper tantrums 3- Potty training - Usually begins at 2 y/o - Positive reinforcement is the most effective way to potty train - Provide stickers and “big kid” underwear - Do not punish them if they have accidents - Toddlers feel more comfortable using a potty chair rather than the toilet - Toddlers can forget they know how to use the toilet when they are going through difficult times or changes in their life (new sibling, sexual abuse, hospitalization) Signs of readiness: - Have an interest in using the toilet - Remaining dry for 2hrs at a time - Having words for urine and stool - Bringing a clean diaper to their parents so they can be changed - Take their diaper or clothes off because they don’t like the be soiled - Tell the parent when they want to go to the bathroom 4- Safety - As they learn to walk more, they can get into new places and open more things - Increased falls - They have a big head and small body, so they are unstable and fall a lot Falls: - Do not allow children to climb on furniture - Supervise when on stairs and playground equipment - Use gates at the top and bottom of the stairs Motor vehicle safety: - Ride forward facing in the back seat in a five-point harness from ages 2-4 5- Foster independence - Encourage the parents to give the child choices Peds notes #1 6- Playing - Toddlers’ patriciate in parallel play - They have short attention spans - Do not understand the concept of sharing - Use toys that help develop gross and fine motor skills, and social skills (push and pull toys, tunnels, stackable blocks, puzzles with large pieces, large crayons and chalk- easier for them to hold) - Musical instruments and active play outside are liked Age-appropriate toys: - Toys that can be pushed and pulled - Tunnels to crawl through - Household items such as wooden spoons and plastic containers - Stackable blocks - Large crayons or chalk - Puzzles with large pieces - Musical instruments - Toys that can be manipulated, like putting the appropriate shapes in the right holes - Dolls that have clothes with Velcro and large buttons that they can manipulate - Bath toys 7- Sleep considerations - Sleep is required for growth, development, and cognitive functioning - Require 11-13hrs of sleep in a 24hr period - 9hrs at night and 2 naps until 18 months - 9hrs at night and 1 longer nap after 18 months - Incorporate a consistent bedtime routine Negative consequences from lack of sleep: - Mood disturbances and irritability - Poor behavior and hyperactivity 8- Medication Administration - Usually come in liquid forms because they are unable to swallow pills - Parents need to measure the correct amount of medication, so they don’t overdose or underdose their child - Household items should not be used for measurement of medications, only the medication cup or syringe Peds notes #1 CH17: Preschoolers (3 - 6 years) Development 1- Motor skills - Gross motor skills become more coordinated - Fine motor skills develop exponentially (get really good) 2- Psychosocial - Take imitative to try new things - Wants to please parents - Plans and initiates activities Erickson- initiative vs guilt - Become energetic learners, despite not having all the physical abilities necessary to be successful at everything - Guilt can occur when preschoolers think they have misbehaved or when they are unable to accomplish a task - Guide preschoolers to attempt activities within their capacities while still settling appropriate limits Kohlberg- moral development/preconventional stage - Early preschoolers- continue in the good-bad orientation of the toddler years and actions are taken based off whether or not it will result in a reward or punishment - Older preschoolers- take actions based on satisfying personal needs, yet are able to understand the concepts of justice and fairness 3- Cognitive development Piaget- preoperational phase - Thought transition between preconceptual thought intuitive thought at around age 4 and lasts till 7 - Transition from totally egocentric thoughts (still egocentric) social awareness and the ability to consider other viewpoints - Develops logic Make judgments based on a person’s visual appearance: - Magical thinking- thoughts are all powerful and can cause events to occur - Animism- giving intimate objects human quality - Centration- focus on one aspect instead of considering all the possible alternatives - Time- start to understand the sequence of daily events. Time is best explained to them in the relation to events. By the end of the preschool age, children have a better comprehension of time-oriented words - Transudative reasoning- connecting unrelated events- trying to put things together - Irresponsibility- unable to reverse a sequence of events (put things in order going forward but not back) - Imagination and creativity are key 4- Language development - Vocabulary increases to more than 2,000 words by the end of the fifth year - Speak in sentences of three to five words at the age of 3 & 4 and four to five words by the age of 4 & 5 - They enjoy talking and it becomes the main form of communication 5- Self-concept development - Start to feel good about themselves based on mastering a skill that allows them to be independent (dressing, brushing their teeth, feeding) - During stress, insecurity or illness, preschoolers can regress to previous immature behaviors or develop habits (nose picking, bed wetting) Peds notes #1 6- Body- image changes - Begin to recognize differences in appearance and identify what is considered acceptable - By the age of 5, preschoolers begin comparing themselves to others - Poor understanding of anatomy makes intrusive experiences (injections or cuts) frightening to preschoolers. They feel like they believe it is important to use a band aid after any injury 7- Psychosexual - Phallic stage- 3rd stage where a child develops a desire to learn more about their genitals - Genitals become an area of interest - Identifies more with parents of the same sex 8- Social development - Generally, do not exhibit stranger anxiety and have less separation anxiety - Changes in daily routine are tolerated, but they can develop more imaginary fears - Prolonged separation can provoke anxiety. The use of a favorite toys and appropriate play is useful - Pretend play is healthy and allows them to determine the difference between reality and fantasy 9- Communication and speech - Rapid language acquisition (receive and comprehend language) – vocabulary increases fast - Children living in poverty are at an increased risk of language delay - Language is learned through exposure to words - Screen for language delays at each well child visit Causes of language delays: - Autism - Cognitive impairment - Emotional delay - Low socioeconomic status or neglect - Underlying neurological disorders – were not yet developed to fully assess Physical growth of preschoolers 1- Height - Grow 2.5- 3in per year - The average 4-year-old is around 3.3ft 2- Weight - Gain 5lbs per year from ages 3-6 - Average 4-year-old weights 40lbs 3- Head circumference - Brain growth slows - Only 1.9-2.4-inch increase from 3-18 years old Peds notes #1 Health assessment findings and techniques - Begin to involve the child in health history – you can ask the child questions directly - Allow the child to have a choice of sitting on the examination table or on the parent’s lap - Implement visual acuity testing (Snellen chart) at age 4 – done with shapes and symbols - Assess hearing with optoacoustic emission test - To inspect the pinna pull it up and back – starting at age 3 because their ear canal is more strait - Can incorporate more formal assessments and screenings – the child is more cooperative and understand more - Can use radial pulses for heart rate assessments - Ask the parents if the child is in preschool so that they are predisposed to the environment and stimulated with social skills and learning. If they don’t go to school, they will be at a disadvantage when they enter kindergarten 1- Physical Variants - Visual acuity reaches 20/20 at 4 -5 years - Thoracic breathing begins at 5 - May experience stool holding during toilet training - Full daytime bladder control around 3 - Nighttime bladder control over 4-5 - Genu valgum (knock- knees) in early preschool period is normal and a change from being bow legged - Body is more slender and abdominal muscles are stronger – losing their potbelly shape 2- Pain assessment - Are able to point to location of pain - Not able to describe the quality of pain - Are able to use developmentally- appropriate self-report tools - Take the observations of the parents and caregivers too - 3 y/o children cannot distinguish pain from no pain even with the use of a simple pain scale, the FLACC tool is best used for that age group Ocher scale: - Has six points with corresponding photos of children faces depicting different levels of pain - Scale from 0-100, the higher number indicating more pain FACES scale: - Most common - six cartoon faces with different expressions - scale of 0-10 the higher the number the more pain - Children in the 4-year-old group can distinguish pain from no pain more clearly when using this tool Peds notes #1 Anticipatory guidance/ parental teachings 1- Safety - Like new experiences - Don’t comprehend risks - Role model safe behaviors because they copy the people around them - Stranger safety and street are most important - Teach home address and phone numbers incase they get lost Natural curiosity can create harmful situations such as: - Improper handling of firearms - Poisoning - Choking 2- School readiness - Reading- use picture books with a few words per page to stimulate reading and understanding - Carry a conversation- ask open ended questions so that they can reply - Encourage social interactions with peers - Provide structured environments with choices - If the child isn’t in preschool implement a head start or other preschool services for low-income families 3- Play - Encourage imaginary and creative play - Allow them to work through frustrations and anxiety Use arts: - Modeling clay - Crayons - Pain Sharing/taking terms: - Teach them how to share - Simple board games can demonstrate turn taking Outdoor activities: - Playgrounds, bicycles, tricycles - Unstructured physical activity Toys to avoid: - Toys with small parts - Small magnets – acid burns them from the inside out - Lead paints - Excessive electronics – causes them to have and decrease in physical activity that can lead to obesity 4- Sleep - No more naps, sleep longer at night – naps typically end around 4 - Require 10-13 hours of sleep/day - maintain a bedtime routine and remain consistent with it Nightmares: child wakes up scared and wants the comfort of their parents - Are able to recall the nightmare - Assist them back to sleep Night terrors: episodes of screaming, intense fear, and flailing while asleep - child is not awake and will not remember the dream or anything that happened when they wake up - do not try to wake the child up, just make sure that they are safe Peds notes #1 5- Discipline - They behave better if given opportunities for independence with set limits - Incorporate daily routines for consistency - Explain consequences for rule breaking - Avoid yelling and spanking- This leads to aggression and physical struggles Time- outs: - Used to remove child from their environment - 1 min per year of age - If you leave them there for too long they won’t remember why they were there in the first place 6- Nutrition - Implement a healthy well-rounded diet - Incorporate fruits, vegetables, whole grains, and lean proteins - Require 1,200-1,400 calories per day - Avoid foods that are high in fats and sugar - Three meals a day with one or two snacks - Need to have an adequate intake of calcium, iron, folate, and vitamin A and C - Involve the child in meal preparation and choices - Do not fix separate meals for different children- this encourages picky eating - Finicky eating usually stops by age 5 - Do not force the child to eat if they are not hungry - Screen for obesity and educate about prevention Healthy food options: - Protein -13-14g (3-5oz) of protein a day - Vegetables- 1-5-2.5 cups/day - Fruits- 1-2 cups/day - Dairy- 2.5 cups - Grains- 4-6oz - Limit white grains (white flower and pasta) 7- Lying - Stems from overactive imaginations or to avoid punishment - Reasons for lying change as preschoolers get older - Teach children that lying is never okay - Role model positive behaviors - Punishment should be based on severity of the transgression and lie - Praise them for telling the truth Peds notes #1 Common conditions 1- Fifth disease/erythema infectious - Caused by parvovirus B19 - Peaks in late winter and spring - Viral infection - Benign and self-limiting - Offer supportive treatment in symptoms are prodromal (have an incubation period between infection and showing S&S) - Avoid pregnant women because the virus can harm the fetus S&S - Bright red cheeks with a “slapped” appearance - Lacy rash on trunk and upper extremities 2- Hand- foot-and- mouth disease - Caused by coxsackie virus - Spread through the fecal- oral route - Can be prevented with proper hand washing – preschoolers don’t wash their hands that often after the bathroom - Self-limiting condition that usually resolves after 1 week - Monitor for dehydration S&S: - Vesicular and/or pustular lesions occur on the oropharynx - palms of hands and soles of feet - may have a mild fever with moderate pain 3- Conjunctivitis/ pink eye - Inflammation of the conjunctiva - Bacterial, viral, or an allergic reaction - Very contagious - Bacterial conjunctivitis can spread from one eye to the other by the child not sleeping on the effective side, the drainage rolls across the face to the other eye- sleep on effective side S&S: - Bacterial- purulent drainage (white, yellow, or brown), water drainage, crusting, pruritus (itching) may or may not occur, unilateral or bilateral appearance - Viral- redness of the conjunctiva, watery drainage, pruritus (itching) may or may not occur- mostly not, only occurs in one eye (unilateral) - Allergy- redness of the conjunctiva, edematous (swelling) of the conjunctiva, pruritus is almost always present, usually bilateral Treatment: - Antibiotics - bacterial infection – go into the eye, clean the eye and dry it first - Symptomatic management - Mast cell stabilizers- calm down the inflammation while they are exposed to the allergen - Antihistamines - allergic reactions - Viral is self-limiting and resolves on its own - Avoid contact with the barrel tip of the dropper to the eye Peds notes #1 CH: 18 The school aged child (6-12 years) - Doctors’ visits every year from 6-12 Development 1- Physical - Coordination, balance, and strength improve Weight: - gain about 4.4-6.6lbs/year - weight varies based on diet, physical activity levels, and home environment - begin plotting body mass index to determine risk for obesity Height: grow an average of 2inch/year - Intermittent growth spurts - Girls are taller than boys at age 12 Prepubescence: - Onset of physiological changes at around age 9 (particularly girls) - Rapid growth in heigh and weight - Difference in maturation between girls and boys become noticeable - Visible sexual maturation is minimal in boys - Permanent teeth grow in - Bladder capacity differs but girls have a larger bladder capacity then boys - Immune system improves - Bones continue to ossify 2- Cognitive Piaget- concrete operation - Transition from perceptual conceptual thinking - Master the concept of conservation – that the volume stays the same even if the container it is in changes. Mass is understood first, followed by weight and volume - Learns to tell time - Classifies more complex information - Able to see the perspective of others - Understands cause and effects - Abe to solve problems - Logical thinking develops – consequences of decisions and actions 3- Psychosocial Erikson- industry vs inferiority - Industry – achieved through the development if skills and knowledge that allows the child to provide meaningful contributions to society - A sense of accomplishment is gained through the ability to cooperate and compete with others - Children should be challenged with tasks that need to be accomplished - Should be allowed to work through individual differences in order to complete a task - Creation of a reward system for the successful completion or mastery of a task can create a sense of inferiority in children that haven’t acquired the skill – set realistic, achievable goals - Children should be taught that not everyone will master every skill - Learns productivity and perseverance Peds notes #1 4- Moral development - Conventional stage- “good boy”, “good girl” and “society” Early school age years: - Do not understand the reasoning behind rules and expectations for behaviors - Believe what they think is wrong and what others tell them is right - Judgment is guided by rewards and punishment - Sometimes interpret accidents as punishments - Follow rules Later school age years: - Able to judge the intentions of an act rather than just its consequences - Understand different point of views instead of just whether or not an action is right or wrong - Starts to understand to treat others like they would want to be treated 5- Psychosexual - Latent stage - Focuses more on relationships with same sex peers 6- Self- concept development - Develop awareness of themselves in relation to others - Start to understand personal values, abilities, and physical characteristics - Confidence is gained through establishing a positive self- concept, which leads to feelings of worthiness and the ability to provide significant contributions- focus on the positive rather than the negative - Parents continue to influence their child’s self-ideas, by middle childhood the opinions of peers and teachers become more valuable 7- Body image change - Solidification of body image occurs - Curiosity about sexuality should be addressed with education regarding sexual development and the reproductive process - Become more modest with an emphasis on privacy 8- Social Development - Peer group associations are important for social development - Peer pressure begins to take affect - Being a part of clubs and having best friends are important for them - Bullying is intended to cause harm or to control someone. Sometimes attribute to poor relationships with peers and difficulty identifying with a group - Often prefer the company of the same sex - Begin to develop an interest in the other sex toward the end of the school age years - Most relationships come from school 9- Motor skill Gross motor: - Muscle coordination, rhythm, and balance improve - Can ride a bike by age 7-8 - Growth spurts may decrease coordination - Organized sports, dance, and gymnastics are popular activities help development of skills Fine motor: - Improved hand- eye coordination and finger dexterity - Playing an instrument, braiding strings for bracelets, building models are popular activities and help development of skills - May be frustrated as skills develop Peds notes #1 10- Communication and speech - Ability to think about language and how it is used (metalinguistic awareness) - Increase use of jokes and humor – didn’t understand this before - Reading skills increase - Ability to think about and talk through feelings 11- Social and emotional development - Separate from parents and develop peer relationships - Develop positive or negative self-esteem through interactions with others - Children identify a best friend by age 7 - Want to be accepted by peers and are subject to peer pressure - Children with negative self-esteem are more likely to give into peer pressure - Peer groups tend to be the same sex - Children with low self-esteem often feel like they are not capable of completing tasks, developing talents, or having friends. Signs of low- self-esteem: - Gives up on tasks easily, fearing failure - Cheats or lies to avoid failure - Often says things like “I’m stupid” or “I can’t” - Places blame on external forces - Strongly affected by negative peer comments - Withdraws society Gender dysphoria: identifying with a gender different from their biological sex - First seen in children ages 9-10 - May be short or long term - Encourage parents to support their children - Assist families in adjusting - Remain nonjudgmental - Watch for signs of bullying, depression, anxiety, and low self esteem 12- Safety - Sports- Water protective gear, prevent dehydration - Water- Teach children how to swim - Bicycles- Always wear a helmet that fits securely - Look both ways before crossing the street Health assessment techniques and variations - Direct questions to child but verify the answers with parents - Assess development through questions about life (what they do after school, what grade they are in, are they part of clubs) - Make the child sit on the examination table during the assessment - Preform in a head-toe- manner (no longer have to do the most important things first because they won’t scream) - Parents should remain in the examination room during assessment - Use the regular Snellen eye chart for eye assessments - Begin hyperlipemia screenings at 11 y/o- for early screening of diabetes Peds notes #1 1- Physical variants - Frontal sinuses are fully developed by 7 years old - Tonsil’s hypertrophy (get enlarged) - Facial structures become elongated – losing the baby fat and building muscle - Oriented to person, place, and time - Fully developed respiratory system at 10 y/o - Bowel movements affected by diet and physical activity - Acne may develop - Point of maximal impulses moves to the 5th intercostal space, midclavicular line - Legs and arms grow faster than the rest of the body – have a short body, long legs, and arms - 20 primary teeth and 32 secondary (permanent) teeth 2- Puberty - Monitor for precocious (early) puberty- needs more investigation - Girls hit puberty before the males Males: - Secondary sex characteristics develop in boys between 9 and 14 years old - First sign of development is testicular enlargement - Growth spurts occur in males later in puberty Females: - Secondary sex characteristics develop in girls between 8 and 13 years old - First sign of puberty is breast bud development (thelarche) - Earlier growth spurts in girls - Menstrual cycle (menarche) usually occurs 2 years after bud development 3- Pain - Use the Oucher or FACES pain scales for children under 7 - Ask questions to determine pain quality - Nonpharmacological pain methods - Use distractions for those with chronic pain - Use cultural considerations Numerical Rating Scale/visual analog scale: - Used for children over the age of 7 - Line that shows the pain on a scale from 1-10 - The higher the number the more pain they are in Peds notes #1 Anticipatory guidance/ parental teachings 1- Sleep considerations - Require 9-12 hours of sleep per night - Daily physical activity improve quality of sleep Adequate sleep is associated with: - Healthy immune system - Improved academic performance - Overall better mood - Improved behavior Encourage a healthy bedtime routine such as: - Consistent bedtimes - Only use bed for sleep - No electronic devices 2- Discipline - Clear set of rules and consequences - Teach societal rules - Role model desired behaviors - Teach to express emotions in a calm manner - Remain consistent 3- Nutrition - Teach children about specific caloric needs - Allow children to assist with meal planning and cooking - Encourage families to eat together - Explain the benefits of a healthy breakfast - Monitor calcium and vitamin D intake- for growth - Avoid sugary drinks and snacks - Energy drinks are dangerous and should be avoided – throws off electrolytes water works best - Assist families with food insecurity or limited resources – food hoarding is a signs of insecurity 4- School refusal - Unwillingness to attend school – why do they not want to go to school? - Multiple short absences or one prolonged absence - Common in children ages 5-7 and 12-14 - Refuse to board the bus, remain in bed, and/or throw temper tantrums - Vague somatic symptoms - May be associated with recent life stressors Multidisciplinary approach to treatment 5- Bullying - Common experience for children - Verbal and social bullying are most common - Associated with many negative consequences like depression, anxiety, and academic struggle - Rates of cyberbullying are increased - Report bullying behavior to the school and collaboratively develop an action plan (how to avoid this) 6- Cheating and stealing - May be the result of peer pressure - Competitiveness may be the reason for cheating - Children with siblings are more likely to cheat - Understand the concepts of property and ownership at 7years - Implement consequences for cheating and stealing Peds notes #1 - Further assessment if child shows no remorse for behaviors- something else can be triggering them 7- Safety - Motor vehicles- always wear a seatbelt, avoid distracted drivers, follow speed limit - Fire safety- learn campfire safety, safely use matches, escape plan, practice escape routes - Sun safety- use of sunscreen outdoors, wear hats, do not use tanning beds 8- Risk reduction Pregnancy and sexually transmitted diseases (STI’s): - Maintain open and honest conversation and remain nonjudgmental - Encourage HPV vaccinations - Offer resources on obtaining protection and provide education - Teach about the danger of STI’s Substance abuse: - Cognitive task deficits - Discuss danger of substance use and abuse - Educate about dangers of vaping and tobacco use - Determine the risk of substance use disorder with validated screening and tools 9- Sleep considerations - require 7-8 hours of sleep per night - sleep deficits are common - sleep extra on weekends to compensate Change in circadian rhythm: - go to bed at 11 pm and wake up around 9am - start school at 9am Effects of sleep deficits: - negative mood and increased emotional reactivity - mood disorders - substance abuse – they need to stay awake and then go to sleep at night - obesity 10- Violence - Can be victim of, or are the ones electing violence - Violence can be physical, verbal, sexual, bullying, and cyber bullying - Exposure to violence leads to increased risk to perpetrate acts of violence - Educate parents about violence associated with the media and online Risk factors that increase violent behaviors: - Exposure to firearms - Single parent homes - Low socioeconomic status - Poor family function 11- Depression - Daily disruptions of mood and loss of pleasure in activates - Lasts longer than 2 weeks - Incidence rates increase after the onset of puberty - Risk doubles if the parents are depressed - Could also manifest as anger, aggression, and substance abuse - Treat with psychotherapy and antidepressants (SSRI’s are most common) if no signs of improvement - Increased risk of suicide Peds notes #1 Nutrition - teach children about specific caloric needs - healthy food choices – eat out with peers a lot - discussion about fad dieting - emphasize danger of energy drinks- electrolyte imbalances - peers have greater influence on diet than parents and family - explain benefits of high-quality diets and physical activities Screen for eating disorders: - include anorexia nervosa, bulimia, and binge eating disorders - can’t deal with it on their own - try different approaches - family based therapy has positive treatment outcomes - notice signs of an eating disorder (eroded teeth, wearing big clothes, seeing ribs) Common illnesses 1- Tinea infection - Fungal infections classified by location - Increase risk if the child is immunocompromised - Highly contagious - Tinea corporis- scaly rash on the torso - Tinea pedis- scaly rash between the toes - Tinea capitis- infection on the head often leading to alopecia S&S: - Pruritis (itchy skin) - Scaling Treatment: - Antifungals (topical first than oral) - Griseofulvin- oral antifungal for tinea capitis- with a fatty meal to increase absorption for PO – may increase risk of infection- monitor CBC and LFT- hepatotoxic - Terbinafine- topical antifungal for tinea pedis and tinea corporis- clean and dry the area before applying 2- Pharyngitis and tonsilitis - Can be viral or bacterial - Tonsilitis is most likely viral - A culture is done to determine if infection is viral or bacterial S&S: - Sore throat – most common - Streptococcal pharyngitis- may also present with a sandpaper- like rash - Tonsil hypertrophy- may lead to partial airway obstruction and/or sleep apnea Treatment: - Antibiotics-for streptococcal pharyngitis and tonsilitis 3- Infectious mononucleosis/ mano - Viral infection cause by Epstein bar virus - Spread though oral secretions - Avoid contact sports for 2-3 weeks to avoid splenic rupture - Acute symptoms last 2-4 weeks - Full recovery may take 6 months S&S: - Fever - Pharyngitis - Enlarged tonsils - Hepatomegaly – liver and spleen enlargement - Splenomegaly Treatment: - Supportive treatment (fluids, antipyretics, analgesics, and rest) Peds notes #1 4- Dysmenorrhea - Painful uterine cramps before the onset of menses - Symptoms last 1-3 days - Primary- no underlying cause and is most common - Secondary- underlying cause Treatment: - Motrin - decrease prostaglandin production with nonsteroidal anti-inflammatory medications - If ineffective start hormonal therapy with oral contraceptives - Implement alternative pain relief forms 5- Acne vulgaris - Open comedones- black heads - Popular acne - Cystic acne Treatment: - Wash face regular and pat dry - Salicylic acid or benzoyl peroxide to wash face - Do not scrub face too hard or try to pop pimples - Stop the use of cosmetic or hair products that may plug follicles on forehead - The first line of treatment is topical retinoid - For inflammatory acne use topical antibiotics - For acne that doesn’t respond to topical treatment, systemic antibiotics can be used - Severe acne with the potential of scarring is treated with isotretinoin- has serious side effects and must be used with caution - Educate adolescence and their parents about protentional side effects Peds notes #1 CH19: Care of the adolescent (10-21 years old) Health assessment techniques - Privacy is more important - Preform health history without a parent present to ensure a therapeutic relationship with your pt and get more information out of them - If there is a opposite sex PCP and pt a nurse must be present to insure nothing happens - Allow the parent the opportunity to ask question - Preform in a sequential head to toe manner - Keep body covered as much as possible during examination - Annual health visits - Children transition to adult - Ongoing identity formation - Increase in risky behavior Development 1- Physical - Wisdom teeth develop - Prefrontal cortex is Stage of Female Male underdeveloped until adolescent late adolescence - Tanner stages 1-2 - Tanner stags 1-2 Early (10-13y) - Onset of puberty - Breast buds - Testicular enlargement - Growth plates close - Public and axillary hair - Start of penile growth in middle to late - Growth spurt - Period arrives adolescence- bone - Tanner stages 3-5 - Tanner stages 3-5 Middle (14growth - Peak growth velocity - Growth spurt 17y) - Muscle development - Nocturnal emissions is greater in males - Body and facial hair - Active sebaceous Tanner stage 5 - Tanner stage 5 Late (18-21y) glands lead to acne - Increased muscle mass - Increased lean muscle - Apocrine sweat glands increase – hygiene teaching - Skeletal growth occurs before muscle growth Height: - Growth spurts vary based on age and gender - Females grow 3-3.5 inches per year during growth spurts - Males grow 3.5-4 inches per year during growth spurts Weight: - Healthy body mass index between the 5th and 85th percentile - Body fat increases in females - Muscle mass increases in males 2- Divided into three stages - Early- 10-13 y/o - Middle- 14-17 - Late- 18-21 3- Cognitive development Piaget- formal operations - Able to think through more than two categories of variables at the same time (abstract thinking without manipulating concrete objects) Peds notes #1 - Capable of evaluating the quality of their own thinking - Able to maintain attention for longer periods of time - Highly imaginative and idealistic - Increasingly capable of using formal logic to make decisions - Think beyond current circumstances and think about the future - Understand how actions influence others - Abstract possibilities and hypothetical situational thinking - Logic and reasoning develop - Egocentric 4- Psychosocial Erickson- identity vs role confusion - Swing and variations in moods with outward expression is normal - Introspection (evaluation of one’s mental health) is increased - By the later adolescent years, stability of emotions and anger management are developed - View themselves as invincible and that nothing can hurt them - Self-consciousness about their body changing and concerns with attractiveness - Body image stabilizes and identity forms 5- Sexual identity - Begins with close, same sex friendships that sometimes include sexual experimentation and curiosity - Self-exploration and masturbation occur - In late adolescence, sexual identity usually integrated through sexual experiences, feeling, and knowledge 6- Moral – postconvention stage - Solve moral dilemmas using internalized moral principles, establish their own morals - Understand what is morally right and legally right are not always the same - Question the relevance of existing morals values to society and individuals - Individual morals may be different than family morals 7- Psychosexual - Genital stage – educate about sex and body changing - Experiments sexually – support them - Settle into relationships 8- Religion and spirituality - Views are more personalized with decreased focus on religious tradition - Influenced primarily by peers and can influence self-identity 9- Self-concept development - View themselves in relation to similarities with peers during early adolescence - View themselves in their own terms 10- Body image changes - Compare themselves to peers - The image established during adolescence follow them throughout life 11- Social development - Peer relationships develop and these relationships serve as a support system - Best friend relationships are more stable and long lasting - Parent child relationships change to allow a greater sense of independence Peds notes #1 12- Motor development Gross motor: - Speed, coordination, and endurance improve - Teenagers narrow focus of interest and extracurricular activates - Focus on skill and muscle movement Fine motor movement: - Dexterity continues to improve - Improve hand- eye coordination - Advanced fine motor skills 13- Communication and speech - Vocabulary and language increase - Abstract though improves – think things out - Use of slang and “text speak” - Language use is at the adult level by the end of adolescence 14- Social and emotional development - Peers become more important - Separate from parents - Body image and self-esteem affected by relationships - Strive for independence - Caregivers should maintain open and positive behaviors and relationships - Opposite sex relationship emerges - Self-concept and body influence are closely related - Body image is influenced by development of secondary sex characteristics - Gender identity and sexual orientation develops - Females focus on social relationships - Males focus on sports and other activates 15- Pain assessment - Use a numerical rating scale - Visual analog scale (VAS) – “no pain” to “worst pain imaginable” - Use cognitive interventions and deep breathing - Assess developmental level- if they don’t have the mentally capacity to do so use other pain scale and document Peds notes #1 Safety considerations for pediatric pts - Do parents know what dangers their children are in? - Develop a safety plan in case of emergencies (what happens when theirs a fire, where to meet up, what to bring) - Have a fire escape plan Suffocation/strangulation: - Make sure the infant’s bed is free of any loose items - Keep the crib away from pull cords on curtains and blinds - Crib stats must not be more than 6cm apart - Keep plastic bags away from infants Electrocution: - Mobile infants may stick objects in outlets - Cover electrical outlets - Keep infants away from electrical cords Choking: - Keep small objects away from infants - Make sure floors are clean once an infant is mobile - Cut foods into small pieces - Foods with a high choking risk- carrots, popcorn, hard candy, grapes, marshmallows, hot dogs Burns: - Do not carry hot liquids while carrying an infant - Make sure the hot water heater is set no higher than 120 °F - Never leave a hot beverage on the coffee table - Keep hot objects out of reach and use back burners when possible Poisoning: - Keep all cleaning products out of reach or in a locked cabinet - Keep all medications out of reach - Keep houseplants out of reach - Have poison control number ready and easily displayed - Keep plants off the floor - Keep any alcohol or tobacco products out of reach Drowning: - Never leave an infant unattended in the bath - Do not leave any standing water like in a bucket and toilets - Keep safety locks on toilets Motor vehicles: - Never leave an infant alone in a car for any amount of time - Infants up to 12 months older and 20lbs should ride in a rear-facing car seat with a 5-point harness - Do not place an infant in the front seat due to the airbag - Children less than 4ft 9in should be in a booster seat with a regular seatbelt - Children may use the seatbelt only when they lap of the belt fits on the hips and the shoulder belt is across the shoulder rather than the neck - Children under the age of 12 should sit in the back seat Firearms: - Remove firearms from areas where children play and sleep - Lock them in a closet - Keep them unloaded Peds notes #1 CH20: Alterations in respiratory function Airway components Upper airway: - Nasopharynx and oropharynx - Epiglottis - Pathway for gas exchange - Allows for ventilating - Larynx separates the upper and lower airways Pediatric variations: - Shorter and narrower upper airway - Small oral cavities and larger tongues - Long, floppy epiglottis - Larynx and glottis are found higher in the neck - Cartilage in the neck is more flexible - Increased airway resistance because their airway is small Lower airway: - Allows for oxygenation and gas exchange - Bronchi and bronchioles - Alveoli - Lungs - Trachea Structures that put babies at risk for alterations in breathing: - An infant’s tongue is larger in proportion to the mouth than the adult – increasing the risk for obstructions with narrowing of the airway - Trachea is cartaginous and the neck is shorter- increasing the risk for airway obstruction Respiratory abnormalities Respiratory distress: difficulty in breathing Respiratory failure: the body can no longer maintain effective gas exchange often when oxygen demand far outweigh the oxygen supply – becomes severely hypoxic - Caron dioxide levels can rise as a result of hypoventilation to the point where the child becomes apneic Peds notes #1 Assessment Respiratory rate Color Breath sounds Respiratory effort Neurological state/behavior Cardiovascular 02 sat Respiratory distress - rate - Pink - Pale - Wheezing - Able to auscultate air - Nasal flaring Retractions Grunting Irritability Increased restlessness Confusion Headache Tachycardia Diaphoresis Hypertension - May be normal or slightly lower May require oxygen to maintain a level greater than 93 Mild hypoxia - - Blood gas analysis - - Ph may be normal or alkalotic, mild acidosis may be present PaO2: >60 mm Hg PaCO2: <50 mm Hg Respiratory failure - rate, progressing to - Cyanotic - Gray - Diminished breath sounds - Adventitious sounds - Minimal chest expansion - Severe retractions - Apnea - Difficult to arouse - Limp - Stupor - Coma - Extreme tachycardia - Bradycardia when hypoxia is present - Hypotension - Unable to maintain level even with oxygen - Hypoxia worsens, oxygen deficient is beyond spontaneous recovery - Cerebral oxygenation is severely affected - Ph acidotic - PaO2: <50 mm Hg PaCO2: >50 mm Hg Croup disorders 1- Laryngotracheobronchitis (LTB) - Most common croup disorder occurring in 3 months -8 y/o - Virtual infection of the upper airways - Gradual onset and slow progression S&S: - Brassy cough - Dyspnea - Stridor - Low grade fever Treatments: - If treatment has to be given the child is most likely admitted to the hospital for it - Steroids - Fluids - Racemic epinephrine Peds notes #1 2- Spasmodic laryngitis - Occurs in children 3 months to 3 years - Occurs suddenly – often overnight - Unknow cause – possibly a viral infection S&S: - Barking cough - Afebrile - Mild respiratory distress Treatment: - Cool mist - Treatment is usually done at home 3- Epiglottitis: the epiglottis that covers the trachea is inflamed and infected partially blocking to trachea - Medical emergency due to airways constriction - “Nothing in mouth” should be written on the door to inform everyone that the pt cannot put anything in their mouths for the risk of infection. Including thermometers, liquid, tongue depressors and step culture - Sit the child up in bed to better ventilate - Drooling in the tripod position is a sign of epiglottitis and not strep - Increased drooling means its getting worse and their airway is even more compromised - By the bedside, oxygen, move the crash cart closer to the pt but not directly in their room because that would take away from the other pts - IV inserted for meds and fluids S&S: - Drooling in the tripod position - Strider or croaking sounds - High fever with a cherry red epiglottis - Steeple sign of x ray Treatment: - Keep calm and avoid anxiety and crying, keep them calm and quite to not compromise their airway and breathing - Start with a broad-spectrum antibiotic and if it hasn’t gotten better in a few days, the pcp might order a throat culture - An endotracheal tube may be inserted if airway is increasingly compromised and not getting better 4- Pneumonia - Infection or inflammation in lower airways - Bacterial or viral – community or hospital acquired (after surgery because they are doing the incentive spirometer) S&S: - Fever - Tachypnea - Cough - Nausea and vomiting - Irritable, restless and lethargic Treatment: - Monitor for respiratory distress - Encourage coughing and deep breathing to open up the airways - Antibiotics- bacterial infection Peds notes #1 5- Bronchiolitis - Respiratory syncytial virus (RSV) - Cells in the bronchioles die and accumulate and obstruct - Worsening symptoms after 2 days S&S: - Mild cough - Rhinorrhea - Congestion 6- Bronchitis: inflammation of the trachea, bronchi, or bronchioles - Usually, viral S&S: - Course barking cough - Chest pain - Thick sputum Treatment: - Humification- loosens up the mucus so that they can cough it up (may vomit) 7- Tuberculosis: lung infection with acid- fast bacilli - Risk factors can be environmental or immune related - Spread by airborne droplets - Primary and secondary forms S&S: - Persistent cough - Night sweats - Fevers Diagnostic testing: - TB skin test - Chest x ray - QuantiFERON gold test 8- Foreign body aspiration - inhalation of objects into the respiratory tract S&S: - Cough - Dyspnea - Stridor - Hoarseness - Severe respiratory distress Prevention: - Avoid foods that are a choking hazards (nuts, seeds, popcorn, hot dogs) - Avoid leaving around household items (coins, safety pins, buttons, beads, batteries) - Avoid and monitor usage with toys with parts that can fall off (marbles, pens, wheels, screws) 9- Asthma - The bronchioles swell and mucus forms causing wheezing upon expiration due to resistance, the worse it gets the more the airway is compromised and results in decreased wheezing - Most common chronic condition Peds notes #1 - Diagnosed by pulmonary function test Albuterol is prescribed A spacer is given for the right amount of medication is administered 02 should be 95 or above – in a peds pt because their brain is still growing, and lack of oxygen may cause disabilities down the line 2LPM for a pt that you deem is in distress – max flow in scope of practice Use a step – wise approach for management and treatment Create asthma action plan used with peak flow meter (green, yellow, red) to prevent from getting to the red zone, blow into it and take the average of the three 10- Cystic fibrosis: excessive amounts of mucus is produced that block organ functions - Autosomal recessive genetic disorder cause abnormalities in the body’s salt, water, and mucus making cells Mucus builds up in the lungs, sinuses, liver, pancreas, intestines, and reproductive organs Both parents have to carry the gene in order to pass it down to their child People can be asymptomatic, or they can carry the symptoms of the genes After a blood test is done and it doesn’t show any abnormalities a sweat chloride test is done – measures the salt and chloride in sweat Almost always test positive for a lung infection because it’s a great place for bacteria – meaning they are on antibiotics Peds notes #1 - Fluids are given to thin the mucus which makes it easier for them to get it up Do not feed them before chest PT, fluid should be given 30-45 min before chest PT to make it effective and loosen the mucus Administer pancreatic enzymes before meals and snacks because they don’t have the digestive enzymes to digest the foods leaving them malnourished S&S: - Steatorrhea – increased fat in stool making it look greasy Failure to thrive Treatment: - Pancreatic enzymes replacement Percussion and drainage (chest PT) Mucolytics- break up the mucus so it’s easier to expel A diet high in protein, calories, and fat Cardiac class notes 1- Decreased pulmonary blood flow kids with squat down to increase their blood flow, if not then then you put their knees to their chest Increased pulmonary blood flow 2- Very pink baby 3- Crackles 4- Extra blood a increased blood flow in the lungs cause fluid accumulation that are at risk for upper respiratory tract infection (multiple) 5- If not treated can lead to pneumonia, decreased or absent lung sounds 6- Antibiotic teachings Decreased pulmonary blood flow Kowasaki disease: disease of the heart - IGIG- builds up immune system and high dose aspirin (igig is too thick causing aneurysms around the heart) - When giving aspirin the risk of reyes syndrome, the benifts out weight the risk - Worried about bleeding in the GI tract - Can lead to heart failure S&S: Peds notes #1 - Strawberry tongue (bright red with little seeds) - Rash - increased fever over a long period of time - The smaller the child the faster they get dehydrated - Red sclera with watery eyes - Hands and feet itching and peeling - lips are very very dry Treatment: - IV immunoglobulin (IGIV) so that the body attacks the IGIV instead of the blood vessels - No live vaccines for 11 months (no MMR, Vericella, and influenza) – body has decreases ability to provide antibodies - Aspirin to prevent inflammation and used as an antiplatelet to thin the blood Rhematic fever: can result after not treating strep throat or scarlet fever correctly causing total body inflammation - Affects the blood vessels, joints, skin, blood vessels, and brain - Damages the heart valves- heart murmur – pneumatic heart disease - In pt history, ask for recent fever or sore throat, means strep wasn’t treated properly - Once the strep gets the heart it pumps out more infection to everywhere in the body S&S: - Sore throat – usually in the past 2-6 weeks - Fever - Joint pain Treatment: - Come back after the antibiotics are finished for another culture to avoid rheumatic fever - NSAIDS for inflammation and pain Peds notes #1 Growth and Developmental milestones 2 Age MONTHS - 4 MONTHS - 9 MONTHS - rolls from FRONT to BACK reaches for things supports themselves on elbows and wrists - Rolls from BACK to FRONT Sits in the tripod position Locomotion: the baby can now move back and forth This means that the baby will soon learn how to crawl, and things need to be childproofed sits without support pulls to stand - - 6 MONTHS Gross motor Holds head up when held Lifts head & chest when on stomach - - Fine motor Open and closes hands Brings hands together puts hands in their mouth grasps objects when put in their hands but doesn’t grab it themselves Bangs objects on surface Raking grasps: putting their hands out to grab something and pull it towards them Transfers objects from one hand to the other - bangs objects together Feeding Hunger Cues Rooting: turning the head to look for the mother’s breast, regardless of if the person holding them is able to do so Suckling: if a child is sucking on an object that cannot give them food. Indicating that they are hungry Hands in mouth Crying the baby now needs iron because the mother can no longer provide the adequate amount leading to anemia Fortified formula is given to supplement Feeding reediness for bottle feeding: Disappearance of tongue extrusion reflex (tongue outside their mouth) Increase need to feed Ability to sit in a highchair Eats iron fortified cereal from spoon rather than the bottle eats pureed fruits and veggies from a spoon - feeds self with fingers Language Different cries for different needs Coos: sounds that come from interacting with the baby. The child is trying to repeat what’s been said to them - - - - - Babbles (if this is not done it can be because the parents aren’t talking to the baby enough, the baby has multiple inner ear infections and the bones can no longer conduct sound properly due to fluid buildup, or the baby can’t hear - copies sound - “mamma” & “dada” with no meaning - Social social smile Recognizes people Laughs out loud - knows familiar faces notices strangers - Waves bye Plays peek-a-boo Has favorite Peds notes #1 12 MONTHS - crawls on hands and knees Stands independently Takes 1st step - let’s go on purpose Uses pincer grasps: grabbing thins with two fingers Holds with whole hands - - 15 months - 18 months - Squats to pick up objects Crawls up steps Drinks from a cup - Walks independently Pushes and pulls toys when walking - - - - Feeds self with “sippy” cup and spoon - Marks things with a crayon Puts objects in and out of cups Scribbles Rolls ball Eats with a spoon Helps undress - Drinks from a cup Eats with a spoon and most of the food goes into their mouth - - 2 years - Top heavy - Pot belly - Legs are a little bowlegged - Have a wide stance - - - 3 years - - Runs – fall a lot because they are top heavy and unstable Kicks a ball back Jumps with two feet (in place, doesn’t go anywhere) Climbs on furniture - Pedals a tricycle Jumps forward Walks up and down the stairs with one foot on each step Jumps forward - - - - - Copies straight lines and circles Stacks objects Turns pages Throws objects with an overhand motion - - - Finger foods Have a lot more choking hazard Finger foods (should not be given when the child is preoccupied Toddler stage begins Turns door - eats handle independently Screws lids on and off Builds tower of 6 or more blocks Copies a circle Undresses and dress themselves - - - - - Understands “no” Uses “mamma” & “dada” specifically Understands 1 word Follow 1-word directions - Follows simple commands Names familiar objects Uses jargan - Uses Jargan: baby talk that the parents will eventually understand the meaning for Says single words Names 2 body parts Names 5 objects Form 2-word sentences Follows simple directions Names 5 body parts Has a 50-word vocabulary Points to objects - 3-word sentences Repeats a story from a book Understands over and under, in and out Strangers start to understand 75% of speech Says their name and age Uses plurals - - Imitates caregivers Cries when parents leave Hugs parents Points at things they want May have a security item (blanket) Plays simple pretend games Parallel play: play next to others but not with them Temper tantrums Toilet training ready Imitates others Shows defiance Shows independence - Cooperative play: begin to play with other children and start sharing Separates easily from parents Shows affection Copies adults Understands “yours” and “mine” Peds notes #1 - - - 4 years - Climbs and hops Can stands on one foot Can catch a bouncing ball - - - 5 years - Swings Climbs Stands on one foot for 10s Somersaults - - - School Age (6-12 years) - - Learn how to ride a 2 wheel bike Increased coordination Runs, jumps, skips, and hops - Does 3–4piece puzzles draws person with head and 1 body part turns pages one by one hold a pencil with one hand - Draws a person with three body parts Draws a cross Buttons and unbuttons large buttons Grasps a pencil with the thumb and finger Uses a pair of scissors Draws a person with at least six body parts Prints some letters and numbers Copies shapes Uses a fork and spoon - Throws more accurately and with increased distance – the bigger they get the more the distance increases - - - - - - Can name a friend Follows instructions with 2-3 steps - Uses “he” and “she “correctly Sings songs Tells stories Strangers can understand 100% of the child’s language Uses fourworded sentences Knows some colors and numbers - Counts to 10 Names at least four colors Uses full sentences Knows name and address Understands and uses the future tense - - - - - Food allergies become an issue - Talks through thoughts and feelings - Goes to the bathroom by themselves Shows concern Likes to do new things Engages in creative and imaginative plays Likes to play with other children Talks about interests Follows simple rules May not be able to differentiate between “real” and “makebelieve” Follows simple directions Wants to please friends Understands gender Differentiates between “real” and “make believe” Is likely to follow rules Develops hobbies Thinks about the future Shows an increased concern for others (moving from its all about them to thinking about others) Peds notes #1 - Adolescents (1220 years) - - Developing adult coordination and endurance Play sports Drive cars Dexterity (skills in performing tasks) improves to an adult level - - At risk for obesity Eat more junk and sugary foods Need healthy nutrition teaching - Use slangs By the end of adolescence communication at adult level - Vital Signs Age New born (birth2 days) Infant (2 days- 1 y/o) Toddler (1-3 years) Preschoolers (35 y/o) School aged (612 y/o) Adolescence (1318 y/o) Temperature Friendships become important Peers are most important to them Become more independent Develop body image concerns struggle with gender identity BP Pulse Respirations Female Male 99.5F 110 to 160/min 30-60/min 99.9F 90-160/min 25-30/min 65-78/41-52 99.0F 80-140/min 25-30/min 98.6F 70-120/min 20-25/min 98.2F – 98.1F 60-110/min 20-25/min 97.9F 50-100/min 50-100/min 83-114/38-67 80-114/3466 86-117/47-76 86-120/4475 91-122/54-83 91-125-5384 108-138/64- 111-145/6393 94
