Chapter 1:
1.Identify the Healthy People 2020 Leading Health Indicators. = Goal is to
increase length of healthy life and eliminate health disparities.
- Physical activity
- Overweight, obesity
- Tobacco use
- Substance use
- Responsible sexual behavior
- Mental health
- Injury and violence
- Environmental quality
- Immunization
- Access to healthcare
2. List the major themes of the Bright Futures. - Physical and mental health,
safety and injury prevention, family support, and community resources.
3. List the most Dramatic time when health promotion integrates
surveillance. Between birth and adolescence. Continuous screening for
physical, motor, cognitive, emotional , and social development occurs in infancy.
4. Identify the most essential component for healthy growth and
development. Proper nutrition. Oral health is an essential component for health
throughout infancy, childhood, and adolescence.
5. The most preventable Health problem identified for decades for children
must occur early in childhood. Dental caries.
6. The most common nutritional problem associated with American
children is associated with type 2 diabetes Childhood obesity.
7. Type of Injuries which are the leading cause of death in children older
than age 1 year. Motor vehicle accidents.
- Under age 1 is congenital abnormalities r/t short gestation, LBW, SIDs, or
maternal complications.
8. Identify direct preventive measures which can be determined by the
developmental stage and environment. Monitoring, teaching, child-locking, car
seats.
9. Identify symptoms of mental illness and resources available.
10. Identify infant morbidity statistics of specific illnesses of groups of
children. Measurement of specific illnesses in the population at a particular time.
That being, respiratory tract infections as the highest. Parasitic infections, then
common cold.
Infant mortality rate is the number of deaths during the first year of life per
1000 live births. Leading among the developed nations.
Chapter 2:
1.Define family, family structure, size, configuration, and positioning.
- Family is what an individual considers it to be.
- Structure can vary depending on the # and type of caregivers.
- Traditional nuclear - married couple and biologic children
- Nuclear - two parents and kids. Kids may be biologic/step/adopted/foster
- Blended - one stepparent, stepsibling, half sibling with a step parent and
biological parent.
- Extended family includes one parent and more members that are related or
not.
2. Identify parenting styles, their influences, lifestyles on the family.
3. List how culture influences the frame of the child’s life.
4. Define cultural competence and how nurses must understand the
influence.
5. Self-concept evolved from what roles.
6. Define Cultural Shock.
7. List types of subcultural influences on children.
8. Physical characteristics and health problems are related to ethnic and
cultural variations of hereditary and socioeconomic factors affecting
children in what manner?
9. Discuss culture and ethnicity in relation to child health.
10.Communication, verbal and nonverbal is also cultural.
11.Define Health beliefs as the integral part of the family’s cultural heritage.
12. Religion influences the lifestyles of most cultures.
13. Discuss the sources of violence and how exposure to violence affects
children.
14. Describe the impact of poverty and homelessness on the health of
children.
Chapter 3:
1.Genetic Disorders defined by genes which are segments of DNA are
caused by chromosome abnormalities, gene mutations or mtDNA
mutations.
2. List Genetic influences of child health.
3.Define congenital anomalies.
4. List Chromosome disorders which are alterations.
5. Types of chromosome breakage are translocation, triplet repeats,
penetrance, transmission of genes and variable expressivity.
6.List 3 reasons for prenatal testing.
7.Define why it is the nurse's responsibility to learn the basic genetic
principles.
8. Define the tool of family health history and its importance.
9. Identify ways that nurses assist children with special needs and their
families to obtain optimal functioning.
Chapter 4:
1. Establish the setting of the nurse interview with the client.
Allow for as much privacy as possible without distractions. Turn down the radio/TV. Children
should have toys they can play with. Notify them of the limits of confidentiality.
2. Identify the guidelines for telephone triage.
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Provides healthcare guidance on what actions to take in an emergency situation and if
the patient should be taken to a clinic or ER.
Guidelines include: Asking screening questions, determining when to immediately refer
to emergency medical services, when to refer to same-day appointments or 24-72hr out,
or home care.
Provider communication influences patient compliance.
3.Identify communication techniques for children at different
developmental stages.
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Address them by Mr/Mrs. Encourage parents to talk, address their problems, ask open
ended questions. Direct the focus. Listen for cultural awareness. Include the child in the
interactions by asking their name, age, and other information.
Anticipatory Guidance is focused on providing families with information on normal growth
and development. This will give parents knowledge for preventative measures.
Avoid info overload. If they begin to get anxious or overwhelmed then slow down.
Use an interpreter if they don’t speak english.
Communication with children at
● Infancy: non-verbally, meet physical needs, speak softly, and through touch.
Avoid loud sounds and sudden movement.
● Early childhood: Focus the communication on them due to their egocentrism.
Allow them to touch and examine articles. Ex- stethoscope bell feeling cold or
palpating a neck. Always speak directly and concrete, no analogies.
● School aged children: Rely on what they know. Want explanations and reasons
for everything. Interested in functional aspects of procedures. Ex- taking BP and
explaining what is happening.
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Adolescence: Fluctuation between child-like and adult behavior. Main focus is
confidentiality if within limits. Discuss perceptions and open and unbiased
atmosphere.
4. Identify 3 forms of nonverbal communication. Which are projective.
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Writing, drawing, play, and magic.
5. Play is the universal language of children.
- Social affective play - taking pleasure in relationships with people.
- Sense pleasure plays a nonsocial stimulating experience.
Light/color/tastes/odors.
- Skill play - ability to grasp and manipulate newly acquired abilities.
- Unoccupied behavior - anything can catch their attention
- Dramatic pretend play
- Onlooker play - watching older siblings bounce a ball
- Solitary play - play alone with toys different from the other children
- Parallel play is when they play with similar toys but neither is influencing
the other.
- Associative play is when they play together and engaged in a similar
activity but no organization
- Cooperative play is when they discuss and plan activities for the purpose
of a task.
6. Identify the 3 types of clues which can be found about children from play.
- Able to pick up on physical, intellectual, and social development progress. Can also
explore a child's fears or dynamics of family relationships.
7.Identify 6 Objectives of a health history.
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Chief complaint
History of present illness
Past medical history - birth, diet, illness, injury, allergies, medications, immunizations
,growth, sexual hc, psychoscial.
Review of systems - General, skin, HEENT, chest, respiratory, CV, GI, GYN/GU,
Musculoskeletal, neurological, endocrine.
8. General appearance of a child is defined by 8 components.
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Physical appearance - Growth measurement is a key element in health status. Includes
weight, height, skin fold thickness (measures fat %), arm circumference (measures
muscle %), and head circumference (up to 36 Months). BMI within the 10th and 75th
percentile is normal. Greater than 95% is overweight. Height/length is taken when
children are supine until 24 months. If able to stand, take off shoes and stand straight as
possible with the head in the midline. Can use a wall mounted stadiometer for accuracy.
State of nutrition - Assess growth, skeletal development, skin, hair, nails, eyes, mouth,
and teeth. Dietary Hx, 24 hour recall, food diary. Skinfold thickness and general growth.
Behavior
Personality
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Interactions with parents, siblings, and nurse
Posture
Development - Testing done at ages 2-6 for gross and fine motor movement, language,
and social skills. Denver developmental or ASQ.
9.Physologic assessment includes key elements of vital signs, and
assessment.
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Measure respirations first, then pulse, BP, and temperature last. Breathing is usually
diaphragmatic and regular. Apnea for 20 seconds is normal. Always count before
disturbing the child. Count for 1 whole minute.
If less than 2y/o take an apical pulse, this is more accurate than radial.
Temperature is usually taken Axillary and NEVER taken rectally for infants < 1mo.
For ages 2mo - 2 yrs. 2-5 years axillary, then tympanic, then oral. 5 years and older use
oral then axillary.
10. Discuss important concepts related to the health assessment of
children.
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Malnutrition
Abuse
Neglect
Developmental delays
Infection
11. Describe the appropriate sequence of the physical examination in the
context of the child’s developmental stage.
- Infant: If quiet, auscultate heart, lungs, and abdomen. Record HR and RR.
Palpate and percuss the same areas. Proceed in the head-to-toe exam.
Elicit reflex as the body part is examined. Test moro reflex last. Use
distraction for cooperation with bright objects or rattles.
- Toddler: Inspect body areas through play like counting fingers and tickling
toes. Use minimum physical contact initially. Introduce physical equipment
slowly. Auscultate, percuss, palpate whenever quiet. Perform traumatic
procedures last. Allow them to inspect the equipment and demonstrate its
use. If uncooperative, perform quickly and use short phrases through the
exam.
- Preschool: If cooperative, perform head to toe. If uncooperative proceed as
with a toddler. Request self-undressing. Offer equipment for inspection.
Make up story about procedure. Use paper-doll technique. Teach about
body function.
- Adolescent: Same as an older school age child. May exam genitalia last.
Allow to undress in private. Give a gown. Exposure only area to be
examined. Explain findings during the exam. Matter of fact common about
sexual development.
12. Distinguish normal variations in the physical examination from
differences that may indicate serious alterations in health care.
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Physical exam per body system
Skin - Assess for color, texture, temperature, moisture, turgor, lesions, acne, and
rashes. Look at hair and nails as well. Issues include: cyanosis, Pallor, Erythema,
Ecchymosis, Petechiae, Jaundice.
Head and Neck - Head is large and neck is short (grows over 3-4 years). Anterior
fontanels close between 12-18 months. Posterior fontanelle closes at 2 months. Head
lag longer than 6 months indicates injury. Observe symmetry and movement.
Opisthotonos is hyperextension of the head with pain on flexion indicated meningeal
irritation. Report masses. Craniostenosis is premature closure of the sutures.
Eyes: Inspect lids for proper placement (upper lid should fall near the upper iris). When
the eye is closed, it should completely cover the cornea and sclera. Determine a normal
PERRLA. Permanent eye color is est. by 6-12 months old. Check red reflex (if negative
and no red color is present, more tests are warranted). The Snellen chart is used at age
3. Visual fixation and following should be present by 3 months, otherwise there is an
issue. Check peripheral vision for the visual field of each eye. Check for color blindness.
Cover test, one eye is covered and the other must focus on an object further away. If the
covered eye moves, it's misaligned.
Ears: Inspect external structures like the pinna, pits/openings, and hygiene. Assess the
tympanic canal. View ear canal for an infant by pulling the pinna down and back.
View it for kids older than 3 by pulling up and back. Visualize the external ear, then
introduce speculum into the meatus between 3 and 9 o'clock positions in a downward
and forward position. Note signs of irritation, foreign bodies, and infection.
Nose: Check placement and alignment. Look at mucosal lining should be redder than
normal oral membranes. No discharge from the nose. Test for smell.
Mouth and Throat: To check the throat, instruct kids to tilt their head back slightly,
breathe deep, and bold breath. Use the tongue of the blade to depress the tongue.
Check for caries, ulcers, tonsil size. Newborn’s tongue is ⅓ of their mouth which is why
they can’t eat right away.
Chest: Inspect chest size and symmetry. Movement, breast development, and the bony
landmarks. Watch diaphragm breathing which is normal in children. Listen for rate,
rhythm, depth, and quality.
Lungs: Assess respiratory effort, rate, rhythm, depth, and quality. Can evaluate
this by placing a hand on their back with thumbs at the midline. Absent or
diminished breath sounds are abnormal.
Abdominal: Auscultation and then palpation. Listen for peristalsis
Genitalia and anus : Enhance privacy by using the same sex nurse. Assess anal
reflex for good sphincter control.
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Spine and extremities: Note the curvature and symmetry. Scoliosis is lateral
curvature of the spine. Test by bending over at the waist and feeling the back’s
symmetry. Inspect each extremity for symmetry of length and size. Polydactyly is
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an extra finger/toe. Syndactyly is the fusion of digits. Check grasp strength if it is
equal.
Neurologic: Drift test to determine if there are issues. Ex- both arms go up but
one slowly lowers on its own if they are focused on something else.
Reflexes: Babinski older than 1 year is bad. Head drop older than 6 months
is bad.
Chapter 5:
1.Identify the major physiologic events associated with the perception of
pain.
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Increased HR, respirations, sweating, grimacing, withdrawal, wringing of hands. HR and
respirations may actually reduce in infants with pain.
2. Discuss the factors that influence the pain response.
- Age
- Development level
- Cause and nature of the pain
- Ability to express pain
- Chronic pain lasts longer than 3 months or beyond the expected period of
healing.
- Recurrent pain is defined as episodes of pain that recur every 3 months or
more. Ex- In children this may be migraine headache, episodic sickle cell
pain, abdominal pain, and recurrent limb pain.
3. Identify the developmental considerations of the effects and
management of pain in the infant, toddler, preschooler, school-age, and
adolescent.
- Newborn and young infants: Uses crying. Reveals facial appearance of
pain. Exhibits body response of rigidity or thrashing. No relationship
between what is causing the pain and subsequent response.
- Older Infant: Uses crying, shows localized body response with deliberate
withdrawal from source, reveals expression of pain or anger, demonstrates
a physical struggle to get away.
- Young child: Crying and screaming, “ow, ouch, it hurts.” Thrashing arms
and legs, lack of cooperation, begs to end, worries about the painful
procedure.
- School age: Demonstrates behaviors of a young child. Time-wasting
behavior, “I’m not ready, wait.” Displays muscular rigidity and clenched
fists.
- Adolescents will be less vocal and show less resistance. More verbal in
“you are hurting me.” Increased muscle tension and body control.
4. List the principles of pain assessment as they relate to children.
- Intensity
- Assessment
- Pain in neonates may look like: Increased HR & BP, rapid shallow
breathing, decreased O2sat, Pallor or flushing, sweating, increased
muscle tone, dilated pupils, hyperglycemia, crying, whimpering, limb
withdrawal, thrashing, flaccidity, changes in activity level. Eye squeeze,
brow bulge, open mouth, taut tongue.
- Can respond to pain by lying with their eyes closed.
5. List the use of various pain rating scales and physiologic monitoring for
children.
- Children can identify facial expressions at age 3.
- Pain charts or drawings for the location of pain can be used at age 8+.
- FLACC - Face, legs, activity, crying, consolability. Uses a behavioral
approach that monitors these things.
- Wong-Baker faces pain rating scale - uses cute faces in 6 different ranges
to help the child determine their score. Used for children less than 3 y/o.
- COMFORT - Score of 17-26 is adequate control. Above 26 needs
assistance. Only used for unconscious and ventilated infants, children, and
adolescents. Observe for 2 minutes and add the scores of each indicator.
Score each between 1-5: Alert, calm, RR^v, physical movement, BP, HR,
muscle tone, facial tension.
- CHIPS - postoperative pain scale
- CRIES - neonatal pain scale. Crying, Requiring more O2, Increased
VS, Expression, and Sleeplessness. Scored 2 pt per thing, total of 10
points for the worst pain.
- PIPP - Premature Infant Pain Profile developed for premature infants.
Pain score will be higher for earlier gestations due to inability to express
pain. Used for 25-40 week old infants from procedural and postoperative
pain.
- NPASS - Neonatal pain, agitation, and sedation scale. Used on
neonates from 23 to 40 weeks and on to 100 days of age.
- PPQ - Assess pt and parental perception of pain. Cognitive development
considerations. Pain history, language, colors assoc. w/ pain, emotions,
worst experiences, coping, positive aspects, location of current pain. Child
and parent fill out a form separately.
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APPT - Assesses pain location, intensity, and quality. Body outlines for
pain assessment. Pt color in areas on the drawings to show where they
have pain.
- NCCPC - For children who cannot communicate with cognitive
impairments.
- PICIC - communicatively impaired children
- Oucher pain scale - For 3-13 y/o, for AA and white kids.
6. Define the different types of pain and different techniques for
interventions.
- Neuropathic
- Nociceptive
- Acute
- Chronic - Recurrent - PCA pump (only be used at lockdown schedules, after the
admin of a bolus, the continuous basal rate of infusion delivers a constant
amount of meds)
- Post-op/cancer pain - scheduled pain medication.
- Ketamine - used during procedural sedation. Subanesthetic doses with
high opioids for cancer pain.
7.Describe the difference between coanalgesics or adjuvant analgesics and
antiepileptics and tricyclic antidepressants which assist in relieving pain
on two different systems.
- Two step ladder system. Older than 3 mo 1st is NSAIDs then a strong
opioid for severe pain - morphine is the best. If it doesn’t work, then
dilaudid or fentanyl is used.
- NSAIDs - acetaminophen, trilisate, ibuprofen (>6mo), naproxen (>2 yr),
indomethacin, diclofenac. Issue is the ceiling effect.
- Morphine, fentanyl, hydromorphone, methadone, oxycodone.
- Coanalgesics include: sedatives like valium and versed for sleeping,
Amitriptyline, pimiramine (TCA’s), gabapentin, carbamazepine,
clonazepam (antiepileptics) for neuro pain. These are supposed to
increase the pain relief and effects of analgesics.
- Stool softeners and laxatives
- Antiemetics
- Diphenhydramine for itching
- Steroids for inflammation and bone pain
8. Identify 2 serious side effects of opioids.
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Low RR. Develops slowly, after 6-8 hours. Always check them and have
Narcan available. If at <12 respirations then turn off PCA and use narcan?
- Low heart rate
- Sedation level - assess, reduce infusion, stimulate the patient, administer
O2. Suction, ambu bag/mask, and IV access should be present.
- Decreased peristalsis
- N/V
- Pruritus
- Tolerance - dose must be increased to achieve the same effect. May
develop after 10-21 days. Increase dose or decrease duration between
doses.
- Physical dependence is the normal natural physiological adaptation.
Withdrawal symptoms occur with in hr of abrupt stopping. Use a weaning
method. When treating this, taper down by reducing one half dose q 6hr for
the first 2 days. Then reduce by 25% q2d until 0.6mg/kg/day then stop.
9.Identify the alterations of surgery and traumatic injuries on children and
how these changes generate a catabolic state.
- Consequences of unrelieved pain = increased ICP, HR, RR, BP, and
decreased SaO2.
- Catabolic hormones alter blood flow, coagulation, fibrinolysis, substrate
metabolism, and water/electrolytes.
- Chest/abdominal surgery may lead to lung complications due to decreased
breathing rate/deep breathing
- Preemptive analgesia prevents these catabolic states.
- Burn pain: IV Ketamine .
- Headaches in children are caused by many things. Key thing is
prevention and modifying behaviors that lead to them. Teach parents
to deal with the pain in a matter of fact way, find moderate ways to deal
with it, avoid giving excessive attention to it.
- Recurrent abdominal pain is defined by occurring once a month for 3
months. It can interfere with ADLs. Has some pain free periods. Highly
individualized approach. Goal is to minimize the impact of pain on the
child’s life.
- Sickle Cell disease - Opioid is the major therapy. Tolerance is common.
Ask their normal pain management routine and medications. Attempt non
pharmaceutical measures.
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Cancer pain - CBT, guided imagery, relaxation, music therapy, and
conscious sedation are effective in decreasing pain during a procedure.
10. Establish a nursing care plan for children related to management of
pain, including pharmacologic, and nonpharmacological techniques and
strategies.
- Prevention is always better!
- Non Pharmacological strategies include: forming a trusting relationship,
expressing concern regarding reports of pain and intervene appropriately,
avoid planting the idea of pain, say “This will push, stick, or pinch. Tell me
what it feels for you.” Avoid painful descriptors when possible, ex- burning
vs. heat. Stay with the child and educate them and the parents.
- Pain diaries can help identify triggers and interventions that work.
- Distraction, guided relaxation/imagery, and cutaneous stimulation may
help. Thought stopping. Behavioral contracting w/ tokens.
- Breast feeding, pacifier use, hypnosis, CBT, and breathing focused
interventions help needle pain.
- Kangaroo, breast feeding, swaddling, or tucking helps with heel punctures
in preterm and newborns.
- Children metabolize opioids faster than adults meaning they need a
stronger dosage.
- Evaluate q15-30 minutes after pain management and providing
medication.
- PCA pumps allow for continuous pain management that is patient
controlled. Issues with nurse or parent controlled PCA’s.
- Epidurals are used with fentanyl, hydromorphone, and preservative free
morphine. Always monitor for respirations.
- Windup phenomenon is when children have a decreased pain threshold
and chronic pain, they perceive non-noxious stimuli as painful.
Chapter 6:
1.Identify anatomic and physiologic differences in children
Versus adults in relation to the infectious process.
- Avoid dorsogluteal sites for vaccines due to high innervation and risk for
damage. Deltoid is recommended for 12 months and older. Ventrogluteal
and anterolateral thigh is a safe site.
2. Identify common infectious disorders during early childhood such as
communicable diseases, intestinal parasitic infections, conjunctivitis, and
stomatitis.
- Diphtheria, direct contact with droplet precautions, upper respiratory
symptoms with progression. Cutaneous symptoms include a “bulls neck, or
swollen neck”, cutaneous lesions. Treatment is abx, rest, and support.
- Pertussis (whooping cough), droplet precautions, Catarrhal stage upper
respiratory symptoms for 1-2 weeks, then paroxysmal stage with short,
rapid coughing followed by gasing with cyanosis. Support during
hospitalization, suction, humidify, careful oral feeding, hydration.
- Measles (Rubeola) is viral, direct contact with airborne precautions until
day 5 of the rash. S/s include fever, malaise, coryza, cough, Koplick spots
(rash appearing 3-4 days after illness)
- Rubella (German Measles) is dangerous for pregnant women.
- Varicella (Chicken pox) droplet, slight fever with malaise, then rash with
vesicle erupts, rash on face and extremities. Contagious a day before rash
appears and until vesicles are crusted. Prevent a secondary skin infection.
- Streptococcus pneumoniae high risk for infection under 2 years, otitis
media, pneumonia, sinusitis. High problem in day care facilities. Droplet
precautions.
- Influenza varies yearly, droplet, abrupt fever, upper respiratory symptoms,
malaise, anorexia.
- Meningococcal disease has the highest rate of morbidity in children in the
US. Those younger than 1 year and those living in college dorms are at
high risk.
- Erythema Infectiosum (Fifth disease) is herpesvirus type 6. Droplet.
Persistent fever 3-7 days, slapped cheek appearance, URI.
- Scarlet Fever is a droplet contact infection, abrupt high fever, halitosis,
tonsil enlargement, edematous, exudate, strawberry tongue,
sandpaper-like pink rash. Tx is penicillin and supportive care.
- Conjunctivitis - contact precaution, ophthalmic medications, comfort and
support care, educate caregivers, prevent spread.
- Viral skin infections - warts, herpes 1&2, varicella, molluscum
- Fungal skin infections - Tinea capitis, corporis, cruris, pedis, thrush
(oral), and candidiasis.
- Scabies - mites with eggs, intense itching, excoriation, inflammation, treat
with permethrin cream 5%, clean clothes on high heat.
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Lice (Pediculosis capitis) - remove nits, use permethrin cream.
Rickettsial infection - transmitted via ticks, fleas, or mites.
Lyme disease - tick bite. Stage 1 is bulls eye, fever, milase. Stage 2 is
rash on hands and feet, then systemic involvement. Tx is doxycycline for >
8r, then Amox < 8 years.
- Rocky Mountain Spotted fever - transmitted via tick, dog, rodent. Treated
w/ abx tetracycline./
- Cat scratch disease - Via cat. Don’t need abx
3.Identify recommended routine childhood immunizations and appropriate
information regarding vaccine safety, benefits, and risks.
- Begin at 2 weeks after birth
- HepB before discharge after birth, if the mother is HBsAg negative. If mom
is HBsAg positive, the baby should receive the HepB and HBIG within 12
hours of birth at 2 different injection sites.
- HAV vaccine is recommended at 1 year, with the second dose following at
6 months.
- Diphtheria vaccine admin with tetanus (Dtap) starting at 2 months, 4mo,
6mo, then 15mo.
- Tetanus vaccine Tdap is recommended for 11-12 years. Usually 4 rounds
starting at age 4?
- Pertussis - vaccinate at 2 months. Tdap recommended for 11-12 years.
- Polio - 4 doses, 2 months, 4 months, 6-18 months, and 4-6 years.
Pediatrix is a combo vaccine with DTap, hepB, and IPV which can be
given at 2 months
- Measles (rubeola) is given at 12-15 months and 2nd dose given at 4 years.
During an outbreak it can be given at 6 months with a second inoculation
at 12 months. If vaccinated after 12 months, 2 additional doses are
needed, 4 weeks apart. MMRV is a live virus which can be given at 12
months or at 4 years. Can’t give it to a pregnant woman.
- Mumps vaccine is given at 12-15 months with measles and rubella (MMR).
- Rubella (German measles) given at 12-15 months and at 4-6 years.
- Varicella (Chicken Pox) Given at 12-15 months and again at 4-6 years.
Administer simultaneously with MMR.
- Streptococcus Pneumoniae vaccine PCV13 vaccine at 2,4,6 months of
age, with the 4th dose at 12 months. Recommended for kids with sickle
cell disease, asplenia, nephrotic syndrome, immunosuppression.
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Influenza vaccine given at 6mo to 18 years. Administered in the fall before
flu season and repeated yearly. Given in two separate doses within 4
weeks for first timers younger than 9 y/o.
- Meningitis vaccine for children at risk will receive 2 doses given at least 2
months apart. Traveling, or at age 11-12 is a normal time to receive it. A
booster is given at 16-18 years.
- HPV given at 11-12 years, 2nd given 1-2mo, then 3rd given at 6mo.
4.Identify the most common types of parasitic diseases and how they
spread, method of prevention, and treatment.
- Giardiasis - protozoan infection, most common parasitic pathogen in the
US. Common in areas with untreated water. Common due to cysts living
for months. S/s are vomiting, diarrhea, anorexia, and failure to thrive.
Found via stool samples. Duodenal specimens. Treatment is Flagyl,
Tindamax, Alinia. Prevention includes education for parents, child care
center staff, and other caregivers.
- Enterobiasis (Pinworms) - common helminthic infection in the US.
Occurs normally in crowded areas, classrooms, or daycares. Eggs persist
inside for 2-3 weeks. Dx made from tape test. Drugs like pyrantel,
pamoate, and albendazole. Mebendazole not for <2 yr. Dosage should
be repeated in 2 weeks to ensure clearance of the organism. Treat family
members.
5.Describe the most essential prophylactic measure in caring for infants
and children to prevent the spread of infection.
- Assess for recent exposure to a known cause
- Assess for prodromal symptoms ex- malaise or fatigue. Assess for
constitutional symptoms ex- fever or rash.
- Immunization hx and hx of having the disease
- Primary prevention is immunization, handwashing, cover face when
coughing/sneezing
6. Identify appropriate nursing assessments and interventions related to
medications and treatments for childhood infections and communicable
disorders.
- Pertussis can be treated with azithromycin and erythromycin.
- Vitamin A reduces morbidity in measles.
- Wear lightweight, loose, nonirritating clothing and keep out of the sun to
reduce itching. Benadryl or atarax is used for severe itching.
- Fever is reduced with antipyretics
- Sore throat reduced with lozenges and saline rinses.
7. Devise an individualized nursing care plan for the child with an infection
or communicable disorder.
- Conjunctivitis could lead to blindness in children if not treated. s/s redness,
swelling, eyelid edema, and discharge. Viral is self-limited but bacteria is
treated with abx polymyxin and bacitracin. Infants require systemic
anbx. Drops used in the day and ointment at night. Keep the eye clean and
administer ophthalmic medication. Remove secretions by wiping the inner
canthus downward and away from the opposite eye. Warm, moist
compresses remove crusts. Take it off though to prevent growth.
- Stomatitis is inflammation of the oral mucosa which includes the cheek, lip,
tongue, gingiva, and other areas. Focus on treating the pain with tylenol
or NSAIDs. Topical anesthetics. Also prevent the spread of herpes virus.
Hydrate, eat bland foods, liquids, encourage mouth care with a soft tb.
● Aphthous Stomatitis is a canker sore. Benign but painful. Onset with
mild injury in the mouth, lasting 4-12 days.
● Herpetic gingivostomatitis (HGS) - Type 1 herpes is a cold sore.
● Recurrent herpes labialis - begins with a fever and painful lip blister
with a foul odor.
Chapter 7.
1. Identify normal developmental changes occurring in the newborn and
infant.
- Respiratory: Amniotic fluid leaves the lungs via squeezed through the birth
canal and the rest of the fluid is absorbed via capillaries. Chemical stimulus
of low O2, high CO2 and low pH initiates it. Thermal stimulus starts it via
sudden change from hot to cold environment. Tactile stimulation such as
tapping or flicking the soles of the feet may initiate breathing as well. Don’t
slap the butt or perform prolonged tactile stimulation.
- Circulatory changes occur as the lungs are being used, the surface tension
goes down and blood goes in. PVR decreases as SVR increases. Increase
in pulmonary blood flow reduces resistance and shunts blood away from
the ductus arteriosus, allowing it to close. Left atrial pressure increases
above the right which closes the foramen ovale soon after birth. Ductus
arteriosus closes 4 days after birth.
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Thermoregulation is done by the heart, liver, and brain with increased O2
metabolism due to inability to shiver (Nonshivering thermogenesis).
Quickly dry the infant and place them skin-to-skin with mom to warm them.
- Blood of the NB depends on blood transfer from the placenta before
clamping. Full term should have 80-85 ml/kg of body weight. TBV is usually
300mL.
- Fluid balance, babies are nearly 73% water with a metabolism 2x an adult.
Acidosis can occur more rapidly. Risk for dehydration and
overhydration.Immature kidneys cannot concentrate urine to conserve
body fluid. Total urine volume per 24 hours is about 200-300mL by the
end of the first week. Voiding 10-20 times per day.
- The GI system is lacking the ability to break down fat and complex carbs.
Lacking enzyme glucuronyl transferase which conjugates bilirubin,
resulting in a build up and jaundice.Meconium should appear within
24-48 hr after birth. Transitional stool 3rd day of life. Milk stools appear by
4th day. Small volume colon leading to more stools.
- Skin is immature. Active sebaceous glands which produce vernix.
Apocrine glands are non-functional until puberty. Hair follicles are
present but they may be over/under active.
- Musculoskeletal system is full present, muscles hypertrophy with growth.
Rapid ossification in the first year.
- Skin and mucous membranes are the first line of defense. Second line is
neutrophils, eosinophils, and lymphocytes. 3rd is IgG from mom for 3
months.
- Endocrine is fully developed but immature. Residual effects from mom's
hormones like enlarged breasts are common for the first 2 months.
- Neurology is not totally integrated. ANS is crucial because it regulates
temp, hr, and rr. Myelination goes head to toe in development.
- Vision is not fully complete. Pupils react to light, blinking occurs, and
corneal reflexes. Tear glands have no function until 2-4 weeks.
- Hearing is possible and indicated with the Moro Reflex (startle). Ex- infants
younger than 3 days old can discriminate the mother’s voice from that of
other women.
Newborn Assessment:
- Apgar - based on HR, RR effort, muscle tone, reflex, irritability, and color.
Each given a score of 0-2, for a total of 10 points being the most healthy.
Perform immediately after birth and 5 minutes later. 0-3 is severe distress,
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4-6 is moderate difficulty, and 7-10 absence of difficulty. Depends on low
tone, reduced reflex irritability, degree of physiologic immaturity, infection,
congenital malformations, and maternal sedation. Any score below 8
requires intervention.
Transitional: Periods of reactivity. First is 30-60 minutes after delivery. The
baby is interested in the environment and a full-term baby may breast feed.
Second period is 2-4 hours and they will be sleepy and calm. Then last 2-5
hour alert and responsive.
Crying should be strong, lusty at birth. Enduring 5 minutes to 2 hours.
Feeding helps stop it. Holding, skin-to-skin contact helps, swadling,
wrapping in a blanket. Variations may indicate problems with respirations
(weak cry), absent (patho.), or high-pitched shrill (ICP).
Attachment between infant-parent bonding. Feeding time is a good time for
attachment.
Assessing for gestational age is the New Ballard Scale and Dubowitz
scale which assesses six external and neuromuscular signs.
Birth weight related to GA is a poor indicator of fetal maturity. Growth
between the 10th-90th percentile is good. LGA is above 90th and SGA is
below 10th.
Term is 36-42 weeks, preterm is <36, and postterm is >42.
Average head circumference is 33-35.5cm. By the 3rd day head size is
normal. Measure abdominal cir. Just above the umbilical. Head to heel
length is measured with an average of 48-53cm. Body weight is measured
quickly due to high metabolism. They lose 10% of birth weight by day 3-4.
Temperature is taken axillary with an average of 36.5-37.6 C
(97.7-99.7 F). HR apical 120-140 bpm WNL, RR 30-60 b/m with a
20s pause, BP baseline of cardiac problems. HR and RR should
be counted for a full 60 seconds.Check vs q 30min for 2 hours then
once every 8hr until discharge. Listen to the HR between the point of
maximum intensity between the 4th-5th intercostal space at the left
midclavicular line.
Dextrocardia is when the heart is on the right side of the body and
opposite organs.
Most newborns are born in a flexion position with the head flexed and chin
resting on the upper chest. ASsess behavior for alertness, drowsiness,
irritability.
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Head shape may be pointed immediately after birth then move to an oval
shape 1-2 days after. Palpate for patent sutures and fontanelles by using
the tip of fingers across the head. Head Lag is normal but in a sitting
position they should attempt to control the head in a straight line.
When on the abdomen, they should try to move the head side to side.
Marked head lag indicates down syndrome, prematurity, hypoxia, and
neuromuscular compromise.
- Trauma like physiologic craniotabes is the phenomenon that when
pressure is put on the margin of the parietal and occipital bones, a
snapping sensation may occur like an indentation of a ping pong ball - soft
skull.
- Cephalhematoma - can be seen as bruising or swelling on the sides
of the head - the parietal lobes due to forceps.
- Caput succedaneum =
- Eyes will be tightly closed. Eyelids are puffy. Slight drainage of tears is ok
but purulent is not. Light skin babies may have grey eyes and red reflex
should be present - prob if not.
- Nose is usually flattened at birth but will grow out. Report nasal
obstructions. Sneezing white mucus is common after birth.
- Mouth and throat - inspect internal structures carefully. Epstein pearls are
small white epithelial cysts and are normal. Neonatal teeth are not normally
found, they are associated with abnormalities.
- Short neck is normal
- Occasionally a milky substance is found.
- Umbilical cord will initially be white then turn yellowish brown while
shriveling in size. Will fall off in 10-14 days.
2. Identify the gross and fine motor milestones of the newborn and infant.
- Moro reflex - startle with fanning of the hands and feet.
- Tonic neck reflex - turning head side/side
- Dance reflex - when holding the baby up they should attempt to move
their legs. Ends around 3-4 weeks.
- Crawl reflex - when on their abdomen they can slightly bend their arms
and legs similar to a crawl but can’t quite do it yet.
- Babinski - touching the heel to the toes and watching the toes flare out.
Ends around 1 year.
- Perez reflex - stroke the back when prone, the child should flex
extremities, elevating the head and pelvis. Ends around 4-6 months.
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Skin should be smooth and puffy around the eyes, legs, and dorsal hands
and feet. White infants may be pink, AA will be yellow brown, hispanic may
be olive or yellow. Vernix and lanugo are present.
- Spine is assessed in a supine position with a rounded shape. S curve
appears later in life.
- Check extremities for ROM, reflexes polydactyly (extra digits) or
Syndactyly (fused digits), muscle tone. Sudden asynchronous jerking
movements are normal.
3. Describe the language development in the first year of life.
- First means of communication is crying. Crying for 1hr-1.5hr for the first
3 weeks, then 2-4hr by 6wk, decreasing by 12wk.
- Vocalizing noises by 5-6wk.
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Vowel sounds 2mo
Consonants by 3mo
Imitate sounds 6mo - Mama, Dada
Ascribe meaning to the word - 10 mo
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Can comprehend the meaning of simple commands at 9-10mo.
Saying 3-5 words at 1yr and may understand roughly 100
4. Develop a nutritional plan for the first of life. Breast milk is ok.
- Human milk - best for infants up to 1y/o. Micronutrients are bioavailable.
Immunologic properties. Protects infants against infections. Casin
improves iron absorption. Contains lipids, triglycerides, and cholesterol
(brain growth). Lactose is the main carb. Contains protein’s whey and curd.
Whey plays a part in preventing allergies. It has a laxative effect. Vitamin D
varies depending on the mothers intake. It is related to decreased type 2
diabetes, obesity, fewer infections, higher test scores, and decreased pain.
DO NOT MICROWAVE HUMAN MILK! It destroys the nutritive
properties and can have hot spots that burn the baby.
- Colostrum is high in immog/ vit. K, and protein, but lower fat. Transitional
milk replaces this when milk production increases.
- Contraindications for breastfeeding:
● Maternal chemotherapy
● Active TB infection
● HIV infection
● Galactosemia in infant
● Maternal Herpes lesion on breast
● Cytomegalovirus in LBW infants
● Maternal drug use
● Tuman T-cell
● Radioactive isotopes for testing.
● Placing prone after feeding
- Commercialized whole cow’s milk infant formula. Comes in liquid
concentrate, powder, or ready to feed liquid. Can be based on cow’s milk,
soy-based, casein/whey based, or amino acid based. Recommends soy
protein formulas for lactose intolerance.
- Preparing formula: Always wash hands and equipment with soap and
water. Can also boil to sterilize. DO NOT ALTER DILUTION. Could result
in malnutrition.
- DO NOT USE goats milk, condensed milk, or raw milk.
- No cows milk before 1 y/o. High protein, low fat and lipid and iron deficient.
May cause allergies if implemented too early.
- Don’t assume parents know how to bottle feed. Teach them! Hold the
baby while rocking them or cuddling helps ensure the emotional
component. Hold the baby at alternating sides for stimulus. Don’t rush the
feeding. Actively feed the baby for 20 minutes at an angle and hold the
bottle.
- Promote feeding on demand and schedule. They will be hungry every
2-3 hours. Place supine after feeding. If they are hungrier, feed them
more often.
- Supplemental water isn’t necessary.
- Feeding behavior: crying or fussing in prefeeding, approach behavior
which is sucking or rooting reflex, attachment is receiving the nipple and
sucking. Consummatory is coordinated sucking and swallowing, then
satiety is when the infant is done, usually falling asleep.
5. Describe the nutritional requirements of the newborn and infant.
- Fed every 2-3 hours.
- Feed on demand
- Breast fed is better but there are good supplements.
- Vitamin D and iron can be supplemented.
6.Identify common issues related to growth and development in infancy.
- Provide stimuli for the baby. Take them with you. Talk to them. Hold them.
Use black and white geometric objects to entertain them.
7. List appropriate anticipatory guidance for common developmental
issues.
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Encourage the father to show emotions
Excessive drooling is bad.
Nystagmus, slight vaginal reddish discharge, and dark green stool is
normal.
- Flaring of nares indicates respiratory distress.
- If discharged early, return for follow up in 48 hr. Void every 4-6 hours.
Spitting up after feeding is normal.
- Jaundice in 1st 24 hr must be eval.
8. Identify discharge teaching for the newborn’s safe care in transportation,
elimination, sleep patterns, jaundice, and follow-up care with physician.
- If early discharge: # of Wet diapers = # day of life, then at 14 days it
settles at 6-10 per day. Breast feeding 2-3 hr. Formula 3-4 hr.
Circumcision wash only w/ warm water. Stools q2-3 days w/ bottle or
2-3/day breast. Activity will have 4-5 wakeful periods per day. Call pcp if
jaundice appears in 24 hr (hemolytic jaundice). Umbilical cord kept
above diaper line, VS HR 120-140, RR 30-55 (w/o grunt or faire), and temp
97-98. Sleep on their back.
- Sleep patterns include: After the initial awake period, the infant may sleep
for 2-3 days to recover from the birth process. Typically sleep 16-18 hours.
Stages include: deep sleep, light sleep, drowsy, quiet alert (best to talk to
them), active alert, crying. Supine position during sleep. Sleeping prone
is associated with SIDs. Encourage alternate positions when awake.
- When clearing the nose, clear the mouth first! This prevents aspiration.
- Eye care with Erythromycin to prevent Neisseria gonorrhoeae
infection is postponed for 1 hour for maternal/infant bonding.
- Vitamin K is administered to prevent hemorrhagic disease b/c the gut
isn’t fully formed to make it.
- Bathing is bonding time for mom and dad. It also allows the RN to assess
for behavior, state of arousal, alertness, and muscular activity. The 1st bath
is given 24 hours postpartum. Also allows the nurse to teach the parents
the proper way to give a bath. Don’t rub off vernix b/c its used to
stabilize the baby’s skin pH. Only bathe with water for 2 weeks, then
use a mild pH balanced soap. No more than 2-3 baths a week for the first 4
weeks. Clean head to toes.
- Cord care - clamp removed at 24 hours, clean and dry, alcohol wipes if
soiled, keep diaper fold below the cord, monitor for odor, edema, or
discharge.
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Circumcision is common in the US. Apply petroleum jelly on the penis and
clean after each void with water. Monitor for excessive bleeding. Record
1st void after. And Eval the site every 30 minutes for 2 hours, then 2 hours
after that. 2nd day a yellow/white exudate forms which is normal.
Chapter 8:
1. Identify the different types of birth injuries during delivery.
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Dystocia is the uterus not contracting and expanding uniformly. Due to fetal
macrosomia, multiple fetuses, abnormal presentation, or congenital anomalies.
Can attribute to soft tissue injuries. Forceps can bruise or abrase. Petechiae or
bruising after a breech. Petechiae will be further eval for potential blood disorder.
Maintain asepsis, provide explanation and reassurance to parents, record
accurate descriptions of injuries.
Caput Succedaneum - scalp lesion with vaguely outlined area of edema on
the head due to vertex delivery. Petechiae and ecchymosis may also be
present outside. No treatment needed, will reduce naturally.
Cephalhematoma - formed when blood vessels rupture during labor which
bleeds between bone and periosteum. More likely with forceps. Affects parietal
bones. No treatment needed. Fractures require eval.
Subgaleal hemorrhage - bleeding in the subgaleal compartment which is
loosely arranged connective tissue. Risk w/ vacuum or forceps. Early detection
is vital, measuring head circumference and inspecting the back of the neck
for increasing edema. S/S swelling, pallor, hypotonia, and increasing HC.
Complications: Hypoxic-ischemic brain injury, due to hypoxia. Germinal Matrix
hemorrhage. Intracranial hemorrhage.
Fractures: Most common fracture is the clavicle/collarbone due to shoulder
dystocia, vertex, breech delivery, macrosomic, or extended arm breech. S/s crepitus upon palpation, edema, reluctant to move arm, asymmetric Moro
reflex. Rn interventions include supporting the affected bone. Pick the baby up
by the upper/lower back rather than the arms. DO NOT place the baby on the
affected side. Long bone fractures are difficult to detect. Skull fractures are
uncommon.
Craniotabes which the cranial bones can move freely on palpation - if persisting
this needs eval.
Facial paralysis - pressure on cranial nerve VII. Ex- loss of movement of 1 side,
noticeable when they cry. Will go away within a couple weeks/months. RN
assistance with breast feeding to promote nutrition and prevent aspiration.
Monitor for respiratory distress as well.
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Brachial Palsy - plexus injury (Erbs palsy) due to damage to upper plexus from
stretching or pulling away of the shoulder from the head. Full recovery is
expected in 3-6 months.
Phrenic nerve paralysis - seen via paradoxic chest movement and elevated
diaphragm. Respiratory distress is the most common sign - the lung of the
affected side doesn’t move. Monitor for pneumonia, cyanosis, tachypnea.
Mechanical ventilation. Hold their chest on either side to feel movement. If not
symmetrical, indicates damage.
2. List the different types of infections during delivery the newborn is
exposed to via the skin, eye, mouth, lungs, and CNS.
- Erythema Toxicum Neonatorum - Aka flea bite dermatitis or newborn
rash. Usually appears within 2 days of life. Lesions are firm, 1-3mm, pale,
yellow, or white papules/pustules. Can be located anywhere except for
palms and soles. Usually lasts 5-7 days.
- Candidiasis in oral or diaper regions seen as small white or yellow pebbly
pustules. Oral candidiasis makes it difficult for babies to drink milk and it
can take as long as 2 months to stop. Antifungal meds like Nystatin,
fungizone, lotrimin, mycelex, fluconazole, or miconazole are given
until 2 days after the infection disappears.
- RN management - keep diaper area clean, apply meds, administer nystatin
after feedings or oral thrush, rinse infant’s mouth with plain water and boil
bottles/nipples 20 minutes.
- Herpes simplex virus - seen via skin, eye, mouth disease, CNS disease,
or organ disease. Carefully eval for s/s.
- Birthmarks: discolorations of the skin is common
● Mongolian spots - dark blue spot in sacral area
● Telangiectatic nevi - cluster of red nerves
● Cafe-au-lait spots are multiple light brown spots assco. w/ albright
syndrome.
● Port-wine stains are pint, red, or purple stains of skin that thicken
and darken as the child grows.
● Strawberry hemangiomas are benign, bright red, rubbery nodules.
● Laser therapy can be the treatment for these.
● Bullous impetigo is a skin infection treated with abx. S/s -large
blisters, on arms and chest.
3.Describe the different craniofacial abnormalities and the specialized
nursing care involved to assist the full recovery of health.
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Normal suture/fontanelle closure: PF closes 8wk, fibrous union of
sutures at 6mo, anterior fontanelle closes 18 mo, sutures are fully set
at 12yr.
- Microcephaly - occurs 6-8 wks of utero, no upper brain, small lower brain,
don’t live long.
- Craniostenosis is the closure of a suture before expected time. Results in
low blood flow to the brain and inhibits perpendicular growth, and small
brain.
- Nursing care is supporting infants and family. Early ID of cranial molding,
monitor for redness, draining, or swelling, and temp >101.
- Cleft lip and palate occurs during embryonic developmental stages 4th
and 10th weeks. CP is less obvious than CL. CP is a continuous opening
from the mouth to the nose. Support lip seal when feeding, chin and cheek.
Surgical treatment for CL at 2-3 months. Cp repair <12mo to enhance
normal speech. Interferes with feeding and anterior lip seal. Pre Op prep
the baby to drink from open cup/sippy. Post op add jelly to the lip and
elbow immobilizers. For 7-10 days. Upright seated position immediately
post op for secretion drainage. DO NOT put anything into the mouth.
- Pierre Robin sequence is an underdeveloped jaw.
4. List the Nursing care required for electrolyte imbalance in the newborn.
- pH at birth 7.11-7.36, 1 day 7.29-7.45, child 7.35-7.45.
- Co2 at birth 27-40, infant 27-41
- HCO2 at birth 21-28, infant 22-26
5. Identify the specialized care the preterm infants require to maintain
homeostasis.
- Parenteral fluids to supply additional calories, electrolytes and water.
Careful regulation and checked hourly for extravasation, fluid
overload, or dehydration.
- Monitor weights from insensible fluid loss due to the warmer.
- Monitor for vasospasms due to catheters
Hyperbilirubinemia - excessive level of bilirubin in the blood seen via jaundice
or icterus. Usually benign. S/S - yellow skin, sclera, nails, mouth. C/b reduced
enzyme glucuronyl transferase due to developmental factors, breastmilk,
dehydration. Dx depends on the level of bir. 0.2-1.4mg/dl is normal, >12.9
abnormal. Timing of jaundice.
● Physiologic jaundice is due to immature hepatic function and increased
bilirubin load. C/b shunting where conjugated becomes unconjugated. Due
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to reabsorption. Starts 1st day until 7th day. Increase feedings, evaluate
stool pattern, risk assessment, phototherapy.
Breast-feeding assoc. Jaundice - decreased milk intake, seen at 2nd-4th
day and has a variable duration. Treat by feeding more or using light
therapy. Late onset may begin on the 4th-8th day and last 3-12 weeks.
Hemolytic disease is a blood antigen incompatibility causing a large
breakdown of RBCs. Begins first 24 hours and lasts depending on the
severity. Treatment is IV immunoglobulin therapy, blood transfusion,
use bottle feed milk, and monitor TcB or TSB levels.
Monitor via: TcB test screening tool, requires multiple readings at a
consistent site. After phototherapy is initiated, TcB is no longer useful.
RF: younger <38 wk, maternal diabetes, delayed bowel movement, weight
loss, cutaneous bruising.
Follow up: TcB within 3 days of discharge if d/c <24 hours
Complications: highly toxic to neurons and may cause encephalopathy.
Kernicterus is the yellow staining of brain cells. S/s are CNS excitability or
depression.
Treatment: monitor levels, prevent enceph., reverse blood incompatibility,
and hemolytic process. Light therapy with specter 420-460 for 4-6 hours.
Shielding the infant's eyes with the propersize. Monitor for
hypo/hyperthermia. Document time started and stopped, shielding of eyes,
and type of light source, used with incubator or bassinet, measurement of
light intensity, feeding/elimination pattern, body temp, and bilirubin levels.
S/e phototherapy: green stool, skin rash, hyperthermia, increased
metabolic rate, dehydration,
● Prognosis is good with early recognition.
● Teaching: recommend breastfeeding q2hr, avoid glucose water, supplemental
water, and formula. Monitor for early stooling. Advise to call if not feeling well,
difficult to around, or not voiding/stool.
● Requires informed consent.
Hemolytic Disease: Hyperbilirubinemia can result in HDFN which is a rapid rate
of RBC destruction. C/b isoimmunization and ABO incompatability. Issues when
mother is Rh negative and baby is Rh positive. Antepartum admin of Rh
immunoglobulins to prevent issues.
● S/s: Jaundice in 24hr, amenia, increased bilirubin, marked pallor, and
hypovolemic shock.
● Dx: indirect Coombs test for a maternal antibody titer at the first prenatal
visit to determine maternal/fetal blood type and provide isoimmunization
early on.
● Therapy: photolight or transfusion for the baby. RhIg given to mom in 72hr
postpartum or 26-28wk antepartum. Exchange transfusion is NPO,
peripheral infusion of dextrose and electrolytes is est. Vs monitored and
correlated with blood infusion. Thermoregulation is necessary b/c risk for
hyperthermia.
● Complications: Watch for blood transfusion reaction w/
tachy/bradycardia, respiratory distress, dramatic change in BP, temp.
Instability, and rash.
Hemorrhagic - Give phytonadione (vit K) to prevent this.
Hypoglycemia: <80mg/dl. Larger infants are at risk for this due to
hyperinsulinemia. Increased metabolic demands, or enzymatic endocrine
problems. ID those at risk and provide calcium and vit D.
● S/s: jitteriness, tremors, twitching, weak or high-pitched cry.
● Screen bs at bedside
● Treatment = early feeding w/ 1 hr in normoglycemic and symptomatic. IV
admin glucose if breastfeeding isn’t tolerated.
Hyperglycemia (transient): >120 preterm and >150 full term. Frequently
monitor bs and UO. Support parents.
Hypocalcemia: <7.8-8mg/dl for serum calcium or <4.4mg/dl ionized calcium.
● Early onset first 48hr infants who experienced perinatal hypoxia. Late
onset cows milk induced after 3-4 days.
● S/S: Jitteriness, apnea, cyanotic, edema, high-pitched cry, abdominal
distension, twitching, tremors, seizure.
● Treat with calcium supplements or infant formula. For late onset, admin
calcium gluconate orally or IV & vit. D.
Respiratory distress syndrome: developmental delay in lung maturity seen
exclusively in prematures. Alveoli are not uniformly present until 36 wks.
- Non-pulmonary origin c/b sepsis, airway obstruction, hemorrhage,
hypoglycemia, metabolic acidosis, acute blood loss, and drugs.
- c/b deficient surfactant and unequal inflation of alveoli. Increased effort
to expand lungs results in exhaustion and reduced RR. This eventually
leads to acidosis
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Dx: X-ray of diffuse granular pattern over both lung fields, dark red streaks,
bronchograms. Pulse ox and CO2 monitoring. Grading of chest movement,
synchronization of upper and lower chest, intercostal visibility, xiphoid
retraction,nare dilation, and grunting.
- Treatment: Provide O2, ensure room air 88% SaO2. RR < 60bpm and
pH >7.30. Prevent hypotension. Nutrition is parenteral to reduce effort.
Exogenous surfactant made from bovine or porcine. Removal of
transudate of fluid impairing the lungs. Ventilator may be necessary.
Suction if needed. Auscultates the chest. Maximum airway expansion
position for newborns - side with head supported by pillow or on their back
in a position with their nose tilted upwards.
- Prognosis: 48 deterioration without surfactant use. If they survive the first
72 hr then they will have a reasonable chance of recovery. If resuscitation
is required, only use room air for the first minute, then use O2 if
unsuccessful.
Necrotizing enterocolitis - requires prompt intervention within 24 hr. Monitor
vs for bowel perforation, septicemia, or cv shock. S/S - Distended abdomen,
gastric residuals, and blood in stools, lethargy, poor feeding, hypotension, apnea,
vomiting, v urinary output.
Hypoxic-Ischemic brain injury: Common cause of neurologic impairment. Brain
damage from asphyxia before, during, or after delivery. This leads to
encephalopathy. Can occur w/ intravascular hemorrhage.
External hazard exposure: Infants may exhibit drug withdrawal effects exheroin 12-24 hr and methadone 2-3 weeks.
● S/s of withdrawal is irritability, seizures, hyperactivity, high-pitched cry,
tremors, hypertonicity of muscles, poor feeding, diarrhea, dehydration,
vomiting, sweating, fever, mottled skin, disrupted sleep, >60 HR. Degree
of withdrawal is closely related to the amount of drug taken, the
length of time, and drug level at delivery.
● Drug testing urine, hair, or meconium
● Poor brain/body growth. Breastfeeding is ok if not on drugs, don’t have
HIV, and methadone compliant.
● Interventions: frequent weighing, I/O measures, and additional calories.
Monitor activity level and compare to feedings.
PKU: Deficiency in the enzyme needed to metabolize the amino acid
phenylalanine. The inability to convert pheny. To tyrosine, so it builds up. S/s if
untreated are growth failure, frequent vomiting, irritability, hyperactivity, and
erratic behavior.
● Tested with the Guthrie blood test to check for phenylalanine in the blood.
Values >4 indicate a problem
● Treatment is restricting phenylalanine and managing the child’s nutritional
need for optimum growth. Maintain phenylalanine in a safe range.
● Requires a phenylalanine free formula
● Avoid aspartame.
Galactosemia - Rare autosomal recessive disorder without galactose. Can’t
drink milk - results in v/d/weight loss. If untreated, results in hepatic dysfunction,
cirrhosis, cataracts, and cerebral damage.
● Treatment is to eliminate all milk and lactose, including breast milk. Need
a soy based formula
Chapter 9:
1.Define high- risk neonates. Newborn regardless of age and weight with
increased morbidity or mortality because of conditions. Variability is the
gestational age at which survival outside the uterine environment is
possible. Classified by birthweight, gestational age, pathophysiologic
problems, congenital abnormalities.
- Late Preterm is 34-36 wks
- LBW - <2500g
- VLWB - <1500g
- ELBW - <1000g
2. Identify Respiratory Distress Syndrome (RDS) and define the parameters.
- Lack of O2 due to decreased surfactant from immature lungs. Can’t
breathe in enough, due to high surface tension. Seen with intercostal
bones, diaphragm, and nare expansion.
3. List three factors which play an important role in necrotizing
enterocolitis INEC).
- Formula feeding
- Intestinal ischemia
- Colonization of the bowel by a pathogen
4. Define hypoxic-ischemic encephalopathy (HIE) and 3 long term sequelae.
- Brain damage from hypoxia
- Intravascular hemorrhaging
- Encephalopathy
5. Identify the 3 types of apnea of prematurity (AOP).
6. List the side effects of maternal conditions which affect the neonatal
period.
7. Define the neonatal abstinence syndrome (NAS) and how it affects the
nursing care of the neonatal infant.
Chapter 10:
1. Identify the Biologic development of the infant: proportional changes;
sensory changes; including binocularity; depth perception, and visual
preference; maturation of biologic systems; fine motor development; and
gross motor development’
2. Describe the psychosocial development of trust identified by Erickson’s
theory.
- When crying, the mother will always come to the baby. This begins the
trusting relationship. The baby eventually learns that the mother will come
back and feed him/her.
3. List Piaget’s theory of cognitive development for the infant.
- Focus is a sensorimotor which covers reflexes, primary circular reactions,
secondary reactions, coordination, and new schemata for situations. Major
accomplishment is object permanence.
4. Define Object permanence. - Understanding that an object does not
disappear when it isn’t in view anymore.
5. Describe the four main components which guide social development.
- Crying, smiling, grasping…..
6. Delineate the traits of Shaken baby syndrome presentation, factors
which may lead to the syndrome, and steps which can be taken to prevent.
- Parent frustration, teach them the normal child development. Infants cry
because needs are not being met, not to intentionally irritate the adult.
Fussy babies may be victims of shaken baby syndrome.
- Colic babies may be at risk.
7. Identify the nutritional components of breast milk, contrast with the
formula for infants.
- Breast is the best for the 1st 6 months. It has a lot more fat, good for brain
growth. It has been associated with better brain growth but smaller bodies.
-
Commercial iron-fortified is an alternative
After 4-6 mo a gradual intro of solid food like cereal is ok. Only introduce 1
solid good every 4-7 days to prevent allergic reactions.
- Whole milk is not recommended until 12mo.
- NO HONEY!!! Botulism.
8. List the steps to introduce food to the infants and the justification for the
slow introduction.
- Non-allergenic cereal around 4-6mo due to not fully developed gut
bacteria. Start fruit/veg at 6-7mo. Chopped food/commercially prepared at
12mo. Mean/fish/poultry 8-10mo. Egg and cheese 12 mo.
9. Describe safety steps for infants to prevent injury
- Use a federally approved rear facing car seat. Keep small objects out of
reach, many things out of reach.
- Monitor for foreign objects, suffocation, falls accidental poisoning, burns.
- Focus on prevention to make the area safer.
Test 1 Study Guide Words
Breath Sounds
Head Lag
Conjunctivitis
Respiratory Distress Syndrome
Safety
Moro Reflex
Infant Behaviors
Babinski
Symptoms of Respiratory distress
Opisthotonos - spasm of the muscles causing backward arching of the head, neck, and spine, as
in severe tetanus, some kinds of meningitis, and strychnine poisoning.
Scarlet Fever - strawberry tongue
Vitamin K
Child Abuse - bad, report
Vitamin A
Car Seat
Vitamin E
Common Food Allergies - Milk, eggs, peanuts, tree nuts, fish, shellfish, wheat,
soy. Most common is peanuts, then milk, then shellfish.
● Have epipen ready for anaphylaxis. Use when: itching sensation occurs,
tightness in throat, hoarseness, difficulty swallowing, barky cough,
wheezing, dyspnea, cyanosis, mild cardiac dysrhythmia, severe
bradycardia, LOC.
● Monitor for residual effects and late reactions 24-48hr later
● Benadryl and Zyrtec are ok for cutaneous and nasal manifestations but not
airway.
Food intolerance - elicits a reaction but no immune response. Ex- lactose
intolerance.
Hydrocephalus - Water on the brain causing extra pressure and brain damage.
Seen as head enlargement. May experience headache, impaired vision, loss of
coordination and incontinence.
Ages of Child response to shots or immunizations
Subdural Hematoma - blood collecting between the brain and skull, cause by a
head injury. Can be seen as a headache that keeps getting worse.
Developmental level
Cephalhematoma
Physical Health
Caput Succedaneum
Testicular self exam
Medical History
Breast self exam
Family History
Heredity
Growth and development
SIDS
Obesity
Shaken Baby Syndrome
NSAIDS
Morphine, Codeine
Thrush
Surfactant
Hypothyroidism - Due to genetics or lack of iodine. Give synthetic levothyroxine
asap to prevent growth and cognitive delays. Test for T4 and TSH in utero. s/s poor feeding, lethargy, respiratory difficulties.
Diaper Dermatitis c/b Prolonged exposure to irritants (urine, feces, soap, detergents,
ointments) and interventions are altering wetness, pH, and fecal irritants. Treatment is to
hydrate the skin, relieve itching, reduce flairups, and prevent secondary infection. Ex- Changing
the diaper asap.