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. - - 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. - - 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. ● 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. - 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. - 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. - - 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 - 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. - - 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. - 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. - - - - - - - - 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. - 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 - 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. - 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. - 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. - 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. - 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. - 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. - 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. - 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, - - - - - - 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. - 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. - 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. - Vowel sounds 2mo Consonants by 3mo Imitate sounds 6mo - Mama, Dada Ascribe meaning to the word - 10 mo - 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. - 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. - 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. - - - - - - 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. - - 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. - 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 ● ● ● ● ● ● ● ● 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 - 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.
