Peds - Chapter 8, 12 & 13
Social Development
*Attachment* - Attachment begins prior to birth and continues as the caregiver/mother/father develops physical contact with the infant. Initially, the infant responds indiscriminately to anyone. Around 3-4 months, the infant begins to cry, smile and vocalize mostly to the mother/caregiver but will continue to respond in like to other. Around 6 months, the infant begins to show distinct preference to the mother and then about a month after this attachment is noticed, the attachment extends to other members such as the father or other caregiver. An insecure attachment is established when there is a lack of consistent and loving care. The components of cognitive development that are required to form attachment include... ability to discriminate mother from other individuals and the achievement of object permanence. *Separation Anxiety* - Around 4-8 months as the infant begins to develop object permanence and the ability to discriminate the mother from other individuals, the infant becomes aware that the parent is absent and significant separation anxiety can develop. This is exhibited by various activities such as crying and refraining from being separated from the parent. Around 6-8 months they may be distracted and not become aware of the absence and only protest later once they realize the parent is gone. By 11-12 months they become aware of activities going on around them in anticipation of the separation and begin to protest before being separated. *Stranger fear* - also develops during the later period of infancy as they begin to differentiate between the caregivers and others. Separation anxiety and stranger fear can be eleviated by: exposing the infant to others gradually in a safe environment, provide a transitional object for security (blanket, bottle, toy, etc...), get down on their eye level, speak softly, avoid sudden intrusive gestures such as smiling broadly and holding arms out. Help parents understand that clinging behavior is normal and the infant can be encouraged to develop health separation by being separated while providing reassurance that the parent is near by or will return. *Language Development* - Initially crying has a reflexive quality mostly related to physiologic needs. By the end of the first year, infants cry for attention, fear, frustration and in response to their developing yet inadequate motor skills. 2 months - begin making single vowel sounds...ah, uh 3-4 months - consonants are added...bah, nah, kah 6 months - imitate sounds and combine syllables...may hear dada but don't associate meaning to word until 10-11 months. 9-10 months - understand the meaning of "no" and can obey simple commands associated with gestures..."clap" 12 months - can say 3-5 words but have an understandings of up to 100 words. It is important to expose infants to expressive speech and delays in milestones should be carefully screened for potential hearing loss. *Social behavior * - includes the infants personal responses to the environment and is most influenced by external stimuli. 2 months - social smile is present in response to pleasurable stimuli. 4 months - laugh out loud and enjoy strange, novel stimuli. 6 months - infants are personable and interact when playing simple games...peek-a-boo 7 months - imitation develops with actions and noises. 8 months - imitation of sounds. 10 months - imitation of peek-a-boo. ** - Play during infancy coincides with the social development. Play is typically solitary.
Biological Development - *Vision*
*Birth* - pupillary and corneal reflexes present; able to fixate on object when held at 20-25 cm away; cannot integrate head and eye movement well (doll's eye reflex-eyes lag behind when head is rotated one side to another...abnormal if found at other times in childhood) *1 month* - range of following increases to 90 degrees; watches parent as speaks; tear glands begin functioning *1-3 month* - increased peripheral vision up to 180˚; binocular vision begins (integrating two images into one cerebral image); disappearance of doll's eyes *3-5 months* - recognizes feeding bottle; able to fixate on a block; looks at hand while sitting or lying; able to accommodate near objects *5-7 months* - adjusts posture to see an object; able to rescue dropped toy; develops color preference to yellow or red; develops eye hand coordination *7-11 months* - fixate on very small objects; depth perception begins to develop; lack of binocular vision indicative of strabismus *12 months* - normal visual acuity; follow rapidly moving objects; visual loss begins if strabismus is present **box 12-2 on page 466 in book**
Infant reflexes
*Stepping* - Elicited by holding upright with feet touching flat surface and makes stepping movements. Expected age - Birth - 1 month *Tonic neck (fencer position) - Elicited by turning head to one side and arm and leg on that side extend while opposing sides flexes. Expected age - Birth - 3-4 months *Sucking/rooting* - elicited by stroking cheek and infant turns toward the side that begins to suck. Expected age - Birth - 4 months *Moro (Startle) - Striking laying surface or allowing to fall backwards and arms and legs symmetrically abduct. Expected age - Birth - 4 months *Palmar grasp* - Elicited by placing an object in palm and infant grasps object. Expected age - Birth - 6 months *Plantar grasp* - Elicited by touching sole of foot and toes curl downward - Expected age - Birth - 8 months *Babinski* - Elicited by stroking outer edge of sole and foot and up toward toe and toes fan out. Expected age - Birth - 1 year
Integumentary System
All structures present but function is decreased. Epidermis and dermis is so thin that any friction can cause separation of these layers and blister formation, or loss of epidermis. Active sebaceous glands (due to high levels of maternal androgens) are the glands which produce vernix. Plugging of the glands causes milia which is a benign normal finding of infants and will self resolve. Eccrine glands (sweat glands) are active and produce sweat in response to heat and emotional stimuli. Useful in assessing pain. Apocrine glands (sweat glands attached to hair follicles) are small and nonfunctional during infancy. Melanin is low at birth and contributes to a lighter skin tone at birth then what will be seen during childhood.
Assessment - *Neuro*
As part of the neurologic assessment during infancy, care needs to be taken to assess the reflexes and fontanels making note of the normal and abnormal findings. Cranial nerves can be assessed along with reflexes... CN 1 (olfactory) - difficult to assess in infancy CN 2 (optic) - looks at face and tracks (see slide 16) pg. 466; pupils non-reactive to light at 1 month indicative of blindness CN 3 (oculomotor) - blinks in response to light, pupils reactive to light CN 4 (trochlear) - looks at face and tracks with eyes CN 5 (trigeminal) - has rooting and sucking reflexes; after reflex is gone, can attempt to have child imitate your activity by clenching teeth CN 6 (abducens) - looks at face and tracks with eyes CN 7 (facial) - has symmetric facial movements CN 8 (acoustic) - tracks a sound; blinks in response to a loud noise CN 9 (glossopharyngeal) - has a gag reflex CN 10 (vagus) - no difficulties swallowing CN 11 (spinal accessory) - moves shoulders symmetrically CN 12 (hypoglossal) - no difficulties swallowing, opens mouth when nares are occluded
Assessment - *Renal*
Assess for edema, urine output, frequency of feedings.
Assessing hearing
Assessing hearing involves inspection of external structures as well as internal... Observe the alignment of the external ear...draw a line from the outer orbit of the eye to the occiput - the top of the pinna should meet that line. Low set ears can be indicative of a chronic or congenital disorder. Newborn infants external ears are flat against the head and should gradually extend slightly outward from the skull. If flattened ears are observed beyond the first month, it could be indicative of frequent side-lying position and a need for education related to proper positioning and stimulation is needed. Inspect for skin tags or sinuses and make note of hygiene. Internal structures typically reserved for assessment by advanced practice nurse or physician but to perform inner ear exam, pull pinna down and back. Parents can be educated on holding techniques for exam...All infants and toddlers should be restrained for their protection and safety. Use the bear hug technique or laying down with head turned. All newborns undergo a hearing test at birth. Assessment of hearing loss in infancy is primarily noted through observation....lack of response to sudden, loud noises, absence of babble or inflections in voice by 7 months, response to loud noises as opposed to voice, failure to localize a source of sound by 6 months of age. Again, the key is to focus on what the infant should be doing at his/her developmental level to identify delays or delinquencies.
Assessing Vision
Assessing vision involves inspection of external structures as well as internal... Make note of the proper placement of the lid, conjunctiva, lining of the lids, sclera, cornea and pupil size, shape and movement. PERRLA-pupils equal, round, reactive to light, accommodation. Accommodation is tested by bringing a light from far to near and the pupil should constrict. Internal structures typically reserved for assessment by advanced practice nurse or physician. Can easily assess red reflex by shining a light about 16 inches away from eye. The light should fall symmetrically within each pupil - if off center in one eye, eyes are asymmetric. Use the cover test to test for strabismus (cover one eye and observe for misalignment in uncovered eye to confirm strabismus) Visual acuity testing in infants is limited to checking for light perception although you can check for strabismus in older infants. The key is to focus on what the infant should be doing at his/her developmental level. Move familiar object from side to side to check for peripheral vision and other abnormal eye movements or findings.
Musculokeletal System
At birth the skeletal system contains larger amounts of cartilage than ossified bone. Ossification is fairly rapid during the first year. Fontanels - skull bones are relatively soft and not yet fused.
Development of body image/gender identity
Body image development parallels cognitive development and evolves through their tactile experiences and development of movement. Achieving concept of object permanence is basic to development of self image and by the end of the first year infants recognize they are distinct and separate from the parents. As they develop more motor movement skills (ie. Use of hands, feet, etc...), they achievements transmit messages to them about themselves. Positive feedback transmit positive feelings about self. **think of all the goofy faces and exclamations parents do when tasks are accomplished** Gender identity begins and exploration of own body is common. Infants are capable of genital self-stimulation to orgasm; erections in male infants are common. Parent's response to actions influence child's evolving attitude regarding gender and sexuality.
Skin disorders - Seborrheic Dermatitis
Chronic recurrent inflammatory reaction of the skin that occurs most commonly on the scalp (cradle cap) but may also involve the eyelids, external ear canal, nasolabial folds, and inguinal area. Traditionally attributed to poor personal care and hygiene; cause is unknown. Lesions are characteristic for thick, adherent, yellowish, scaly, oily patches. *Diagnosis* made on appearance and location of lesions. *Nursing care* Treatment directed towards removal of lesions/crusts. Apply white petroleum to help with removal; can soak the scalp for several hours with vegetable oil and then remove the scales Educate parents on removal technique: after softening and soaking, gently comb loose crusts and repeat as needed.
Endocrine System
Developed but immature functions. Circulating maternal hormones may cause hypertrophied sex organs, and a sudden drop in progesterone and estrogen can cause pseudomenstration in females up to 2 months of age. Pituitary glands produces limited quantities of ADH which inhibits diuresis which causes greater fluid loss and predisposes baby to dehydration.
Skin Disorders - Diaper Dermatitis
Diaper dermatitis - common in infants and one of several acute inflammatory skin disorders caused either directly or indirectly by wearing diapers. Peak age is 9-12 months Caused by prolonged and repetitive skin contact with irritant, usually urine, feces, soaps, detergents, ointments and friction. Wetness enhances skin permeability to exogenous materials - maceration - increased susceptibility to friction damage - increased transepidermal permeability - increased microbial counts Typical diaper rash is reddened with well demarcated edges; candida albicans infection can develop and is notable for bright red lesions with raised borders and often with satellite lesions. Therapeutic management Primarily aimed at prevention; inflammation that does not respond to nursing care interventions may be treated with a low dose steroid cream; topical antifungals (nystatin) are used with candida infections. Nursing care Decrease wetness by frequent diaper changes and leaving skin open to air if possible; avoid frequent rubbing or washing of the macerated area-wipes often have alcohol which irritate and friction with washing exaccerbates the area; rinse soiled area with water and pat dry. Apply occlusive barrier creams to clean, dry skin; anything with zinc oxide, aquaphor, or white petroleum ointment.
Gastrointestinal System
Digestion, absorption, and metabolism are adequate but limited to a certain point. Enzymes are present to break down and digest proteins and simple carbs but infants lack certain pancreatic enzymes (lipase, amylase) which limit ability to digest and absorb complex carbohydrates which are commonly found in cow's milk; human milk has a high fat content but also contains enzymes which help with digestion. Liver is most immature GI organ affects... 1. enzyme activity is reduced which affects conjugation of bilirubin which contributes to jaundice in the newborn period. 2. deficient in forming plasma proteins which contributes to edema after birth. 3. prothrombin and other coagulation factors are low 4. Stores less glycogen at birth - more prone to hypoglycemia; which may be prevented by early and effective feeding. Stool patterns... 1. Meconium - thick, black, tarry, no smell; should occur within 24-48 hours after birth. Composed of amniotic fluid, intestinal secretions, mucosal cells and possibly blood if ingested during birth. 2. Transitional stools - usually appear around DOL 3; greenish brown to yellow brown; thin, less sticky and may contain some milk curds. Typically coincides with transition from collustrum to milk 3. Milk stools - usually appear fully around DOL 4; breast fed infants are yellow to golden, pasty and an odor similar to sour milk; formula fed infants are pale yellow to light brown, firmer and more foul odor.
Maturation of Systems - *Thermoregulation*
During infancy the ability to shiver develops in response to cold. Capillaries begin to respond to heat and cold by dilating or constricting in order to control evaporative heat loss. Increased adipose tissue developed during first 6 months of life help insulate against heat loss.
Thermoregulation
Factors that predispose the newborn to excessive heat loss... 1. Large skin surface area related to weight facilitates heat loss - infants are predisposed towards flexion (fetal position) which decreases the amount of surface area exposed to the environment and conserves heat 2. Thin layer of subcutaneous fat. Core body temperature is 1 degree higher than surface temperature causing heat transfer from warm to cool. This is the reason we specify the route we are taking a temperature 3. no ability to shiver, but produces heat through nonshivering thermogenesis or chemical thermogenesis which is produced by stimulating cellular respiration, resulting in increased need for oxygen and glucose. A thermogenic source is brown adipose tissue or brown fat which has a gareater capacity for heat production through intensified metabolic activity than ordinary adipose tissue. Heat generated in brown fat is distributed to other parts of the body by the blood and warms as it flows through the layers. Superficial deposits of brown fat are located between the scapulae, around the neck, in the axillae and behind the sternum.
Maturation of Systems - *Immune System*
First 3 months immunity covered by maternally acquired IgG which protects from antigens that the mother was exposed to. After birth levels gradually drop as infant begins producing own IgG. Lowest level occurs between 2-4 months and remain until 6 months. Reach 40% of adult level of IgG by 12months. Adult levels of IgM reached by 9-12 months. IgA, IgD, and IgE development is more gradual and doesn't reach adult level until later in childhood. Function and quantity of T-lymphocytes, interleukins, interferon and complement factors are reduced in early infancy and prevent an optimum response to viral and bacterial infections. Human milk contains important prebiotic oligosaccharides which help produce important bacteria which can protect the gastrointestinal mucosa from certain pathogens and can prevent many illnesses such as necrotizing entercolitis, specifically in preterm infants.
Immune System
First line of defense in immunity is skin and mucous membranes which act as a barrier to invading organisms. Second line of defense in immunity include cellular elements such as neutrophils, monocytes, eosinophils, and lymphoctyes. Third line of defense in immunity include the formation of specific antibodies. Requires exposure to foreign objects, infants not capable of producing own immunoglobulins for first 2 months of life but receive significant passive immunity from maternal circulation and human milk. Infant is protected from many childhood diseases during first 3 months of life assuming the mother had developed antibodies.
Nutritional Disturbances - Food Sensitivity
General term that includes any type of adverse reaction to food or food additives. Approximately 6% of children may experience in first 3 years of life, 1.5% will have allergy to eggs and 0.6% to peanuts. Exposed to allergen (usually proteins) - induce IgE antibody formation which is called sensitization - subsequent exposures are stronger Oral allergy syndrome - food allergen commonly (fruits or vegetables) produce edema and pruritis involving lips, tongue, palate, and throat Immediate GI hypersensitivity-food allergen reaction include nausea, abdominal pain, cramping, diarrhea, vomiting, anaphylaxis or all the above Reaction can be caused by either ingesting, inhaling, or touching. *Cow's milk allergy* Approximately 2.5% of infants develop; 80% of those will outgrow by 4 years of age. Manifests within first 4 months and may appear within 45 minutes of ingestion or after several days. Diagnosis made based on history; several stool and blood tests can be done but most definitive is to eliminate cow's milk, observe for resolution of symptoms and then reintroduce to observe for return of symptoms. Management includes total elimination of cow's milk and using a formula which has the protein already broken down as in Pregestimil, Nutramigen or Alimentum. They are expensive and difficult to swallow...literally. Nursing care involves education and support to families. Just because the infant may spit up, have loose stools and seem fussy doesn't mean they have a cow's milk allergy. *Lactose intolerance* Involves a deficiency of the enzyme lactase-needed for digestion of lactose in the small intestines. 4 types: congenital, primary, secondary, and developmental. *Congenital* - occurs soon after birth when consuming cow's milk formula; is considered an inborn error of metabolism; complete absence or severely reduced presence of lactase and requires lifelong lactose free diet; rare. *Primary* - occurs around 4-5 years and is most common type; incidence tends to be higher in Asian, middle eastern, southern european and african-american populations. *Secondary* - occurs as a result of damage to the intestinal lumen which decreases or destroys the enzyme. *Developmental* - refers to a relative deficiency seen in preterm infants less than 34 weeks. Manifestations: abdominal pain, bloating, flatulence, diarrhea after ingestion of lactose; occurs within 30 minutes to several hours after ingestion Diagnosis made based on the resolution of symptoms with a lactose-free/reduced diet. Definitive diagnosis made with breath test-people with deficiency have a higher level of hydrogen in breath Treatment involves elimination of dairy products or significantly reducing; concern with children and adolescents is that totally cutting dairy products will contribute to reduced bone mineral density and osteoporosis; if able, encourage small intakes of dairy with each meal; dairy products taken with meals seems to be better tolerated than alone, pretreated milk with microbial-derived lactase seems to help with lactose absorption. Nursing care focuses on educating family on restrictions and management principles, sources of lactose, hidden sources that may be found in medications. identify alternative sources of calcium such as yogurt and calcium supplements.
Maturation of Systems - *Renal System*
Gradual decrease of extracellular fluid seen during first months of life attributed to enhanced renal tubular function, increased glomerular filtration and ECF compartment contraction. Full maturity of kidney function is established later in childhood but filtration improves during first 12 months.
Maturation of Systems - *Cardiovascular System*
Heart rate slows and may see sinus arrhythmia as it coincides with respirations. Blood pressure changes-systolic rises during first 2 months related to increased ability to pump blood systemically. Diastolic pressure initially decreases during first 3 months then gradually increases to values close to birth. Fluctuations noted with activity and emotion. (important to note when assessing vital signs)
Maturation of Systems - *Hematopoietic*
Hematopoietic Fetal hemoglobin present during first 5 months of life with gradual increase in adult hemoglobin. Fetal Hgb results in a shortened life of RBC and depress the production of erythropoietin. May see physiologic anemia at 2-3 months as a result of changes from fetal Hgb to adult Hgb. Maternal derived stores of iron gradually are depleted up to 5-6 months of age and will contribute to physiologic anemia. Iron stores are needed in order to help with formation of adequate Hgb. This is why all infant formula is iron fortified.
Maturation of Systems - *Digestive System*
Immature at birth and human milk has properties that help compensate for decreased digestive enzymatic activity. Gastric digestion aided by action of hydrochloric acid and rennin (enzyme) which react to casein in milk which causes curds which causes milk to stay in stomach longer and allow digestion to occur. Digestion also takes place in duodenum where pancreatic enzymes (lipase and amylase) help break down fats and protein. Levels and secretion of enzymes are limited until about 4-6 months. Stomach grows and accomodates larger amounts of food as the infant grows. By 12 months three meals a day with a night time bottle is tolerated. Any gastric irritation predisposes infant to diarrhea, vomiting and dehydration. Liver is most immature of all GI organs during infancy. Gluconeogenesis, formation of plasma proteins (think clotting factors), ketone formation, storage of vitamins, and the break down of amino acids remains immature for first 12 months. Suck and swallow are both reflexes present at birth and work together for efficient intake of fluids. As the infant grows, the tongue becomes smaller proportionally to the mouth and the swallow becomes more efficient at swallowing solids. Swallow reflex that is present during infancy when a puff of air is directed to the face is helpful when administering small amounts of medication or liquid (Santmyer swallow).
Growth Failure - Failure to Thrive
Inadequate growth resulting from inability to obtain or use calories required for growth. Generally referred to infants who's weight falls below the 5th percentile for age. *Inadequate caloric intake* - incorrect formula preparation, neglect, food fads, excessive juice consumption, poverty, behavioral problems affecting eating, CNS problems affecting intake *Inadequate absorption* - cystic fibrosis, celiac disease, vitamin or mineral deficiencies, biliary atresia, hepatic disease *Increased metabolism* - hyperthyroidism, congenital heart defects, chronic immunodeficiency *Defective utilization* - genetic anomaly, such as trisomy 21 or 18, congenital infection, or metabolic storage diseases Diagnosis made from evidence of growth failure; if FTT is acute, weight will be below but not height; if FTT is longstanding, weight and height are both low and indicate chronic malnutrition. Management primarily is aimed at reversing the cause. Goal is to provide sufficient calories to "catch-up" growth. May also receive multivitamin supplements and dietary supplement with high-calorie foods and drinks. Approach is multidisciplinary with focus on behavior modification, stress relief, temporary placement in foster care if indicated in the presence of neglect. Hospital admission necessary with evidence of severe malnutrition, abuse or neglect, dehydration, caretaker substance abuse, outpatient management not sufficient, serious intercurrent infection. Nursing management focuses on the child and the parents. Accurate weights initially and daily, assessment of child and parental interactions, document feeding patterns and behaviors. The FTT child are watchful, may dislike being touched or held yet protest when being placed down for a short time then become apathetic; patterns during feedings such as crying, vomiting, hoarding food in mouth, displaying aversion behaviors can become attention seeking behaviors surrounding mealtime. The FTT parent can display a lack of education, physical and mental health problems, immaturity, lack of commitment to parenting. Developing trust between the nurse and child is important and creating an environment which offers encouragement for eating rather than negative feeding patterns is important. Nutritional management primary goals include: correct nutritional deficiencies and achieve ideal weight for height, allow for catch-up growth, restore optimum body composition, educate parents regarding requirements.
Assessment - *Cardiovascular*
Inspect for chest wall symmetry, peripheral cyanosis, edema. In infancy, high predominance for skin color change related to emotional state or temperature. Palpate peripheral pulses making note of brachial pulses in infants, capillary refill (use central location such as forehead if able). Auscultate heart sounds - note quality (distinct, clear, muffled), intensity (weak vs. pounding), rate (regular, even), rhythm - remember review of functional closure of fetal circulation can effect heart sounds, sinus arrhythmia (rate increases with inspiration and decreases with expiration) is a normal variant during infancy
Assessment - *Digestive/GI*
Inspect for contour (infants tend to by cylindrical), skin character, movement (infants may exhibit peristaltic waves), umbilical site (for newborns, should appear dried and healed within 4-6 weeks); common areas for hernias in infancy include umbilical, inguinal or femoral Auscultate bowel sounds Palpate superficial by placing hand against skin in all four quadrants noting any tenderness or superficial lesions; palpate deeply noting again tenderness, firmness, muscle tone. In infants helpful to bend knees and raise to chest to relax abdominal wall muscles. Also includes quality of nutritional intake and any problems related to feeding.
Maturation of Systems - *Neuro*
Many reflexes present at birth and need to be assessed as well as knowing when they should not be present in order to be aware of abnormalities. Neurologic changes coincide with fine motor and gross motor development and can be assessed accordingly.
Fluid and Electrolytes
Newborn weight is approximately 73% fluid (adults 58%), extracellular fluid volume exceeds intracellular. Significantly shifts during postnatal period most likely due to rapid cellular growth. Due to the higher extracellular volume, an infant also has a higher level of total body sodium and chloride, and a lower level of potassium, magnesium and phosphate. Factors that make the infant more prone to dehydration and overhydration.... 1. Infant has a higher rate of fluid exchange (up to 7 times greater than an adult), 2. rate of metabolism is twice as great related to total body weight 3. immature kidneys cannon sufficiently concentrate urine to conserve body water. As a result twice as much acid is formed, leading to more rapid development of acidemia
Assessment - *Vital Signs*
Newborns: temperature typically taken rectally at birth to facilitate assessment of patency of anus but taken axillary after to avoid trauma to rectal mucosa (best method for obtaining temperature is controversial and is usually determined by the institution) - make noted of site, environment when taken (radiant warmer, open crib, incubator, etc...), instrument used and any concerns related to purpose (fever, septic workup, etc...) Heart rate and respiratory rate taken for full minute using a stethescope to account for normal irregularities; brachial or femoral pulses noted for equality of strength or fullness. Blood pressure can be taken on calf as is comparable to brachial pressures. Infants: temperature generally taken axillary although rectal is recommended for definitive reading; skin temperature can fluctuate in response to external stimuli. Heart rate and pulse can be satisfactorily achieved through peripheral palpation but the apical impulse is most reliable. Count for full minute. Respiratory rate can easily be assessed through auscultation or inspection due to predominant abdominal movement with respirations. Count for a full minute. Blood pressure can be measured on calf. **make note of normal vital signs for newborn and during infancy**
Assessment - *Respiratory*
Nose: inspect symmetry, patency of nares, internal structures Mouth/throat: note buccal mucosa, tongue, hard palate, gums; note color, moisture, any ulcerations or white patches...tissue should be pink, moist, smooth, glistening and uniform Chest: inspect chest size, shape, symmetry, movement (note rate, rhythm, depth and quality) and bony landmarks - Chest circumference can be measured by using measuring tape around rib cage at the nipple line (one during inspiration and one during expiration). More circular in infancy. Movement should be symmetric although abdominal or diaphragmatic in nature during infancy. Auscultate lung sounds - note character (noisy, grunting, wheeze (narrowed passageways - airway edema, spasm, exudate), crackles (passage of air through fluid or moisture)) Make noted of process of listening - start at top, go to opposing side, go down, go to opposing side, etc...in order to compare sides for adventitious sounds
Skin Disorders - Atopic Dermatitis
Otherwise known as eczema, chronic inflammatory skin condition that is associated with allergy with a hereditary tendency. Diagnosis based on combination of history and skin findings. Majority of infants with AD have a family history of eczema, asthma, food allergies or allergic rhinitis. Cause is unknown. Clinical manifestations include dry skin, evidence of increased transepidermal water loss, a defect in cells which help retain water and provide skin barrier functions, and increased colonization of staph aureus. Worse during winter with dry hot air and better controlled in humid climates; as a whole, is controlled by not cured. Therapeutic management includes 1.Hydrate skin 2.Relieve pruritus 3.Reduce flare-ups or inflammation by avoiding triggers 4.Prevent and control infection 5.And live as normal a childhood as possible Tepid bath with mild soap (or no soap) followed by application of an emollient within 3 minutesàtraps moisture and prevents loss Avoid irritants in the form of harsh soaps or bubble baths. Treat pruritis with oral antihistamines. Topical corticosteroids are first line treatment; degree of potency may be prescribed depending on severity of flare-up. Acute flare-ups may require wet wraps - apply light coat of corticosteroids - wrap child is cool, wet towels for 10 minutes - remove towels and reapply steroid cream - apply moisterizer Nursing care management includes... Intervening to control pruritis (socks or mitts for hands, keep fingernails trimmed) Eliminate conditions that aggrevate pruritis (clothings, blankets, stuffed animals, etc...) Prevent infection (maintain personal hygiene, room humidifier, routine assessment of skin and questionable areas of lesions) Apply interventions as ordered and needed (wet wraps, compresses) Family support
Psychosocial Development
Phase 1 entails birth to 1 year and concerned with development of trust while overcoming a sense of mistrust. Trust of self, of others and of the world. Crucial element for achievement is the quality of the relationship between caregiver and child and the care the infant receives. Established through the delivery of food, warmth, and shelter. Failure to meet these needs results in the development of mistrust. Failure to learn delayed gratification also leads to mistrust. If needs are met before infant signals their readiness, they never learn their ability to control their environment. Conversely, if the delay is prolonged, infants will experience increasing frustration and development of mistrust. Consistency of care is essential. Development of trust is the foundation of the remaining succeeding phases and gives them a feeling of physical comfort and security - enables them to experience unfamiliar environments with minimal fear. Primary narcissism is at its height during the first 3-4 months but is replaced with more advanced behaviors such as grasping and nonverbal cues as their other bodily processes develop (such as vision, movement, vocalization). The quality of the relationship (not necessarily degree of mothering, quantity of food, or length of sucking) between the infant and caregiver has the most influence on the successful development of trust. **think of the bottle propping**
Cognitive Development - *Sensorimotor Phase: Piaget*
Phase to explain cognition extends from birth to 24 months. During this phase, three crucial events take place... 1. Separation - Learning to separate themselves from objects in their environment; others besides themselves control the environment; adjustments must be made for mutual satisfaction. Coincides with Erikson's concept of the formation of trust and mutual regulation of frustration 2. Object Permanence - Learning that objects which are removed from field of vision still exist; typically begins to develop at 9-10 months of age - corresponds with development of locomotion. 3. Mental representation - Learning the use of symbols to think of an object or situation without actually experiencing it (ex. Sad face, happy face, heart means I love you, etc...) Infants progress from use of reflexes (sucking, rooting, crying) to voluntary actions (begin to associate parents vocal response to crying to receiving nipple...cry, hear voice, stop crying, then receive nipple) to voluntary actions with added dimension of time and deliberate intention to eventual beginning knowledge of intellectual reasoning (as evidenced by development of object permanence).
Biological Development - *Hearing*
Progressive myelination of auditory pathway causes a development of generalized response to specific response of locating sound *Birth* - responds to loud noise by startle reflex; quieting effect from low-pitched sounds *2-3 months* - turns head toward sound made at ear level *3-4 months* - locates sound by turning head to side and looking in direction of sound *4-6 months* - locates sound by turning head up and down and looking in direction of sound *6-8 months* - responds to own name; turns head in an arch to locate sound *8-10 months* - locates sound by turning head diagonally and directly towards sound *10-12 months* - knows several words and their meaning **box 12-3 on page 466 in book**
Feeding Issues
Proper feeding techniques include holding the bottle properly to ensure liquid is swallowed and not air; responding to infants cues for burping and satiation (education needs to be given concerning an infants need for non-nutritive suck), holding during feeding as opposed to laying down (issues with propped bottles at night). Issues arise often related to feeding too much or too little, feeding too often (snacking), poor food selection for developmental level, incorrectly preparing formula. Tends to occur with first time parents but can also be seen with experienced parents who are not familiar with the new infants cues and responses. Nursing care focuses on reassurance, guidance, and demonstration. Early assessment is essential to preventing more serious problems. *Regurgitation* - is the return of undigested food from the stomach, usually after burpring. *Spitting up* - is dribbling of unswallowed formula from the infant's mouth immediately after feeding. Common problem during infancy and nursing care is focused on educating parents on measures that can be taken to reduce occurance Frequent burping during feedings, minimize handling of infant during and after a feeding, position on right side with head slightly elevated after feeding. *Recommended feedings guidelines:* *First 6 months:* Human milk most desirable for first 6 months. Iron fortified formula if not receiving breast milk. Avoid fruit juices until after 6 months. No honey for first year due to risk of botulism. No solid foods prior to 4-6 months due to inability of the digestive tract to handle complex nature. *Second 6 months:* Human milk or formula continue to be main source of nutrition with iron supplementation may be necessary with exclusively breast fed infants. Introduction of solid foods begins after 6 months and start with rice cereal, barley, oatmeal or high-proteain cereal. Introduce one solid at a time to be mindful of allergies. Can begin to give fruit juices in small quantities - avoid apple, pear, prune, peach or grape juice due to high amounts of fructose and sorbital which may cause GI upset...chose white grape juice.
Colic
Reported to occur in 15-40% of all infants with no affinity to any particular race or gender. Described as abdominal pain or cramping that is manifested by loud crying and drawing the legs up to abdomen; reports that episodes tend to occur in late afternoon/early evening. Lots of different theories as to etiology: too rapid feeding, overeating, swallowing excessive air, improper feeding techniques, emotional stress and tension between parent and child, parental smoking, lactase deficiency, difficult infant temperament, overstimulation, immature nervous symptom, neurochemical dysregulation-nothing scientifically proven; agree that it is multifactorial and no single treatment works for all. Management involves looking for an organic cause. Can try changing formulas. Some medications are used such as sedative, antispasmodics, antihistamines, antiflatulents-studies have shown that none take away symptoms completely. One study supported massage, herbal tea, sucrose solution and hydrolyzed formula use. Interestingly, study comparing recommended interventions between physicians and PNP showed PNP recommended behavioral or environmental modification strategies and MD recommended pharmacologic interventions or formula changes. Nursing care starts with taking a thorough detailed history of usual daily events: infant diet, diet of breast feeding mother, time of day when crying occurs, relationship of crying to feeding time, presence of specific family members during crying and habits of family members (smoking), activity of mother or usual caregiver before, during and after crying, characteristics of the cry, measures used to relieve crying and their effectiveness, infant's stooling, voiding and sleeping pattern. Strong emphasis is made with reassuring parents...you're not doing anything wrong, feelings of frustration are normal, etc... Colicky infants are at risk for traumatic brain injury associated with shaken baby. See table on pg. 535
Maturation of systems - *Respiratory*
Respiratory rate decreases although the movements continue to be abdominal. Predisposed to severe and acute respiratory problems given the proximity of the trachea to the bronchi, short, straight eustachian tubes which communicates more directly with the ear allowing infectious agents to readily populate middle ear from the pharynx, respiratory tract ability to produce mucus is diminished which affects ability to humidify the air. Lumen of airways remains small proportionally to the size of the lungsàsmall airways are easily blocked with mucus, edema or foreign object. More pliant rib cage causes less chest wall recoil and in respiratory distress the work of breathing is increased. Volume of dead space is large and requires the infant to breathe approximately twice as fast as an adult to provide needed amount of oxygen.
Respiratory System
Stimuli that help initiate respiration are primarily chemical and thermal. Chemical factors in the blood are low oxygen, high CO2, and low pH. The abrupt temperature change from the mothers warm environment to a cool atmosphere excites sensory impulses in the skin that are transmitted to the respiratory center. Tactile stimulation includes slapping or flicking the soles of the newborns feet or gently rubbing the back. Fetal fluid in the lungs are squeezed out through the nose and mouth as the infant passes through the birth canal; once the chest is delivered it recoils and draws air into the lungs to replace the fluid. In cesarean births the chest is not compressed and the newborn may need additional respiratory support such as suctioning or oxygen to help with initiation
Cardiovascular system
Transistion from fetal circulation to postnatal circulation involves the functional closure of the fetal shunts - the foramen ovale, the ductus arteriosus and eventually the ductus venosus. Once the lungs are expanded the inspired oxygen dilates the pulmonary vessels, which decreases pulmonary vascular resistance and consequently increases pulmonary blood flow. As the lungs receive blood the pressure in the right atrium, right ventricle and pulmonary arteries decreases. Dramatic decrease in pulmonary vascular resistance leads to closures of ductus arteriosus. Clamping the cord leads to gradual increase in systemic vacular resistance and increases the pressure in the left side of the heart (pressure higher in LA then RA, because blood flows from an area of high pressure to low pressure), causes closure of the foramen ovale. Most important factor controlling ductal closure is the increased oxygen concentration of the blood. Secondary factors are the fall in endogenous prostaglandins and acidosis. Foramen ovale - functional closure soon after birth from compression of the two portions of the atrial septum Ductus arteriosus - functional closure approximately 4 days after birth; anatomic closure much longer Failed closure takes blood away from pulmonary circulation
Nutritional Disturbances - Vitamins
Vitamin disturbances are rare in the developed countries, namely the United States. *Vitamin D deficiency rickets* - populations at risk include children exclusively breast-fed by mothers with inadequate vitamin D intake, children with darker pigmented skin exposed to minimal sunlight because of socioeconomic, religious or cultural beliefs or in urban housing areas with high levels of pollution, children with diets low in vit D and calcium and children who use products not supplemented as their primary source of milk. Children as risk secondary to another disorder: children with malabsorption issues, high doses of salicylates (difficulty storing vit C), one study sickle cell disease (poor intake resulted in suboptimal intake of vit E&D, folate, calcium, and fiber Excessive dose of vitamin can lead to hypervitaminosis; typically a result of excessive supplementation
Malnutrition
When talking about malnutrition, lack of food is not always the primary cause. In developed and underdeveloped countries diarrhea or gastroenteritis is a major factor. Also includes bottle feeding in poor sanitary conditions, inadequate knowledge of proper child care practices, parental illiteracy, economic and political factors, climate conditions, cultural and religious food preferences, and lack of adequate food. Occurs primarily in children 6monts to 2 years. Kwashiorkor-a deficiency of protein with an adequate supply of calories Clinical manifestations include... 1.thin, wasted extremities 2.Prominent abdomen from ascites 3.Edema masks severe muscular atrophy 4.Scaly, dry depigmented skin 5.Mineral and vitamin deficiencies with corresponding clinical states - ex - deficiency in zinc results in rkin rashes, loss of hair, impaired immune response and susceptibility to infections, digestive problems, night blindness, affective behavior changes, defective wound healing, and impaired growth. 6.Diarrhea (due to lowered resistence to infection) - complicates electrolyte imbalance Marasmus-general malnutrition of both calories and protein (common in underdeveloped countries during drought, adults eat first) Clinical manifestations include... 1.Physical and emotional depravity 2.Gradual wasting and atrophy of body tissues (especially subcut fat) 3.Appears old with loose wrinkled skin 4.Fat metabolism is less impaired than kwashiorkor so deficiency of fat-soluable vitamins is minimal or absent 5.No edema Therapeutic management includes... 1.Provide a diet with high quality proteins, carbs, vitamins and minerals 2.Rehydrate with oral rehydration solution to replace electrolyte losses 3.Administer meds (antibiotics, antidiarrheals) Nursing care includes... 1.Focus on prevention during high risk time Education (feeding practices during crucial time, administration of immunizations, promote health and nutrition of lactating mothers, encourage well-child visits)
Nutritional Disturbances - Minerals
When we talk about minerals we talk about macrominerals: daily requirement greater than 100mg include calcium, phosphorus, magnesium, sodium, potassium, chloride and sulfer; microminerals (trace elements): daily requirement less than 100mg and exact role still unclear. Most concern with deficiencies; can be secondary to mineral-mineral interaction - excess in one will cause a deficiency in another therefore mega dosing in one is not recommended; some substances interact with minerals and for insoluble complexes; certain illnesses and treatements lead to deficiencies such as s/p chemotherapy or radiation, HIV, sickle cell disease, cystic fibrosis, GI malabsorption and very low birth weight preterm infants.
Renal System
all structures are present but kidneys have a functional deficiency in its ability to concentrate urine and to cope with fluid and electrolyte fluctuations such as dehydration or a concentrated solute overload. Total volume of urinary output per 24 hours is 200-300 mL by then end of the first week. Bladder involuntarily empties when stretched by a volume of 15 mL, resulting in as many as 20 voids per day. First void should occur within 24 hours, and should be colorless, and odorless and have a specific gravity of about 1.020
Biologic Development - *Sensory Changes*
binocularity - fixation of 2 ocular images into one cerebral picture begins to develop by 6 weeks of age and is well established by 4 months... lack of binocular vision can result in strabismus and must be detected early to prevent permanent blindness. Depth perception (stereopsis) begins by 7-9 months. By 6 months infants respond to facial expressions and can distinguish between familiar and strange faces.
Biologic Development - *Proportional Changes*
birth *weight* doubled by 6 months, typically around 1.5lb per month. Weight gain decreases during the second 6 months and weight has tripled by 1 year (typically around 20lb). *Height* increases by 1 inch per month for the first 6 months - occurs in spurts rather than slow and steady. At 12 months typically gained up to 50% of birth length ... mostly occurs in the trunk rather than the legs. *Head circumference increases approximately 2 cm per month from birth to 3 months, 1 cm from 4-6 months and 0.5 cm per month during the second 6 months. Average head size is 46cm (18in) at 12 months. By 1 year head size has increased almost 33%. Closure of the cranial sutures occurs with the posterior fontanel fusing by 6-8 weeks of age and the anterior fontanel closing by 12-18 months of age. Brain growth increases 2.5 times replacing primitive reflexes with voluntary, purposeful movement. All children from birth - 36 months should be weighed nude. Length should be assessed laying down (recumbent) up to 24 months Head circumference should be done up to 36 months; measure at the greatest circumference - usually slightly above eyebrows and pinna of ear then around occipital prominence at the back of the skull.
Hematopoietic System
blood volume of newborn is directly related to the amount of blood transferred from the placenta after birth and before clamping the cord. Blood volume of a full term infant before birth is approximately 80-85mL/kg. Immediately after birth the total blood volumes average 300mL but can be increased by as much as 100mL depending on how much the infant remains attached to the placenta before clamping the umbilical cord.
Biologic Development - *Gross Motor Development*
includes developmental maturation in posture, head balance, sitting, creeping, standing and walking. Neck righting reflex turns the body to the same side as the head, and enables the child to roll from supine to prone. *Head Control* 3 months - infants can hold their head beyond the plane of the body 4 months - infants can lift head and front portion of chest 5 months - can turn from abdomen to back 6 months - can turn from back to abdomen *Sitting and Posture* - follows progressive development of head control 1-3 months - back is rounded and inability to sit up 4 months - convex lumbar curve appears in infant able to sit upright with assistance 7 months - can sit alone with support of own arms 8 months - can sit well while unsupported and begin to explore environment 10 months - can maneuver from a prone to a sitting position 11-12 months - should be able to pull to a standing position and walking while holding onto furniture. Consider hip dysplasia if milestone is not met *Locomotion/standing/walking* - acquired ability to bear weight, propel forward, stand upright with support then walk alone 6-7 months - Crawling - propelling forward with belly off floor 9 months - creeping - on hands and knees with belly off floor; begins pulling up to standing with assistance of objects 11 months - walks while holding onto furniture 12 months - steps while holding onto hands Motor quotient = Motor age/chronologic age * 100 Ex - 12 month old begins to creep....9/12 *100 = 75; values above 85 are within normal limits, values below 70 are abnormal, and values between 70-85 are borderline.
Biologic Development - *Fine Motor Development*
includes the use of hands and fingers in the grasp of object. Grasping occurs at 2-3 months as a reflex and then gradually becomes voluntary. 1 month the hands are closed, by 3 months they are mostly open. 3 months begin demonstrating an interest in grasping an object (more with eyes than with hands). If object is placed in hands, will actively hold onto it. At 5 months - able to voluntarily grasp an object At 6 months - infants can hold their bottle, and grasp their feet, feed themselves a cracker. At 7 months they can transfer objects from one hand to the other. At 8-9 months - crude pincer grasp replaces palmer grasp... sufficiently established by 10 months. At 10 months - they can deliberately let go At 11 months - they put objects into a container and remove them. 1 year - they try to build a tower of 2 blocks but fail.
Neurologic System
nervous system is formed but poorly integrated. Adequate to sustain life outside of the uterus, although most functions are primitive. Rapidly develop and change during first year of life. Autonomic nervous system (uncontrollable centers - breathing, HR, digestion) is crucial for survival and transition from uterine life....Stimulates respiration, helps maintain acid-base balance and partially regulates temperature control. Myelin is necessary for efficient and rapid transmission of nerve impulses. Myellination develops in a cephalocaudal-proximodistal (head to toe, center to periphery) manner and largely dictates developmental milestones.