Module 1
Why should infants NOT watch TV?
Because they are more positively stimulated and learn language best when interacting with another person, listening to parents' or caregivers' voices and looking at a face that responds to them.
What is the first step for feeding an infant?
Bringing the infant slowly to an awake state for feeding
When should most infants demonstrate a social smile?
By 3 months old, infants demonstrate a social smile and will smile in response to parent's voice
At what age can an infant sleep through the night without a feeding?
By 4-5 months of age, infants begin sleeping through the night without feeding
Piaget (7-12yrs)
Concrete Operational Stage o Children use symbols to represent concrete objects and to preform mental tasks o Requires cognitive skill to organize experiences and classify increasingly complex info o Schoolwork requires functioning at this level o Stage is characterized by flexibility of thought, declining egocentrism, logical reasoning and greater social cognition
Describe the elimination patterns of the infant from 0 to 3 months of age.
Elimination patterns become more regular No longer defecating with each feeding o Formulafed Range from 1 or 2 bowel movements daily or every other day o Breastfed Range from1 or 2 daily to every 3-5 days Wet diapers typically occur after each feeding
When should anticipatory guidance regarding purple crying be given
0-3 months because this usually is worst around 2 months and gets better from 3-5 months
How many hours does newborn usually sleep?
16 out of 24 hrs
Usual length of feeding for a NB?
20-30 min If longer than 40 min or shorter than 20 min-evaulate!
When does the infant experience a growth spurt and fuss to eat more frequently? Why may this be discouraging to a breast feeding mother?
At about age 6-8 weeks, the infant may experience a growth spurt and fuss to eat more frequently. Mothers who are breastfeeding need extra encouragement during this time because they may believe they are not making enough milk for their baby. Encourage mothers to follow infant's cues; extra suckling will increase milk production to meet the needs of the growing infant.
What changes occur in the social/emotional development of a 4-5 month old?
Babies are now more engaging and entertaining Spontaneous smiling, turn head 180 degrees, they notice things They recognize the parent responding to their needs Parents can often distract them from demanding instant gratification Enjoy playing with parents Crying takes on new meaning-TIRED AND LONELY not just hungry
Weight gain after the initial loss averages ounce per day, or about 2 pounds per month. Nutritional needs to promote growth are approximately kcal/kg/day.
0.5-1 oz 110
Crying
infants in this state have bursts of crying that last at least 15 seconds. Hunger, cold, fatigue, and other noxious stimuli make this phase more pronounced. Infants typically transition from crying to sleep or alert and active phases.
When should developmental screening with a standardized, valid, and reliable instrument be performed?
Screenings should be conducted at 2-, 4-, 6-, 9-, and 12-month well child visits or when parent or provider has concerns.
Piaget Stage (Birth- 2yrs)
Sensorimotor stage o Children learn about the world through their actions and sensory and motor movements o Key concepts include Object permanence Spatial relationships Causality Use of instruments combination of of objects o Little cognitive connection to objects outside of self
Describe the motor skills development of the 6-8 month old.
Sit for longer periods May scoot Crawling begins with pushing up to the hands and knees rocking in place; may stand fully supporting their weight Rake objects on table then able to hold small cube Can transfer toys between hands Can introduce solids
Describe the cognitive development of the 9-12 month old.
Stacking and container play Master object permanence Hold crayon with whole hand Mark dots on paper Play becomes more spontaneous and self-directed
Describe the motor skills development of the 9-12 month old.
Entrtain themselves Fine pincher grasp Love to put all in their mouths Can stack blocks one on top of the other (11-12 months) Hold cup with 2 hands (difficulty sealing lips around cup) Sit for long periods and crawl Begin to "cruise" Let themselves down from furniture Take a few steps if someone hold their hands Some may take a few steps
Piaget (13-adulthood)
Formal Operational Stage o Being to think abstractly o Imagine solutions to problems o Increased awareness of health and illness o Recognize how behaviors can impact health o Appreciation of differences between differences in judgment in themselves and others
What is the purpose of the Family Genogram?
Genograms provide graphic representations of complex family data; they allow providers to map the family structure and roles, life cycle transitions, family functioning, and social networks. They provide efficient clinical summary, making it easier for providers to keep in mind the family members, patterns, and events that may have recurring significance in a family's ongoing care. The purpose is to understand the family's structure and function - not the family's genetic risk factors.
Describe the social/emotional development of a 6-8 month old.
Greatly enjoy social play May express frustrations during feeding (reject spoon while mom is trying to feed them and prefer to feed themselves) Pointing gestures, reaching with arms, tugging, vocalizing, and throw things Stranger danger and separation anxiety may occur
What is the usual weight gain pattern of a 4-5 month old?
Growth slows to about 5 ounces per week. (birth weight usually doubled between 4 and 6 months)
The ASQ-3 is used with what age child?
Infants and young children o Ages and stages questionnaire o Screening and surveillane of developmental milestones o Measures Communication Gross motor Fine motor Problem solving Personal-social Overall development o Use in 1 month to 5.5 years old o Report on 30 items + overall concerns
Describe the oral-motor development that usually begins at 6 months of age that are essential for speech production.
Learns to chew by moving the jaw up and down while flattening and spreading the tongue, and to control biting by using rotary jaw movements with lateralization of tongue placement. These motor skills, essential for the production of speech, are among the most complex movements the child must master.
In a 3 week old who takes 15 minutes to feed, what should be done?
Less than 20 minutes should be evaluated.
Describe the physical development of the 9-12 month old.
May follow a different growth curve than used to If significant decrease in growth you must assess their caloric intake (may be caused from increased activity or decreased intake due to painful teething. Also illness) Regular bowel and bladder patterns Sleep issues tend to resolve They gain 1 pound per month 3 meals a day with two snacks is sufficient
Describe the regulation and sleep-wake patterns from birth to 1 month.
Normal neonates require 16 hours of sleep every 24 hours Breastfed infants may need to eat more often so may wake more Use a consistent daily routine to help infant establish a good wake sleep cycle Place infant in crib or basinet for daytime naps Infants need a rhythmic voice and movement for transition for sleep to wake Swaddling can help them adjust and so can music
Why is the prenatal visit important for the provider?
Opportunity to form a relationship assess parents' knowledge and receptiveness to anticipatory guidance provide a foundation for later visits Discuss breastfeeding, immunizations wishes about circumcision, sleep safety, car seats
By what age should a parent have begun to read to an infant?
Parents should begin daily reading to their infants by 6 months old if they have not already started.
Describe the motor skills development of the 4-5 months old
Play with their hands and reach and pull for clothing Grasp toys start to place their hands on the breast or the bottle in attempt to hold it • Rolling • No head lag when pulled to sit • Infant learns to sit in tripod stance • Lift legs and bring feet to mouth • Bear full weight when standing and enjoy bouncing up and down • All movements should be symmetric
What are the components of the prenatal and perinatal history?
Prenatal o Planned Pregnancy? When did prenatal care begin? What was the mother's health during pregnancy? Drug, alcohol, or tobacco use? Illnesses and medications? Weight gain? Accidents? Perinatal o Where was the baby born and who delivered the infant? Duration and process of labor? Vaginal or cesarean delivery and process? Infant response to labor and delivery (breathing, crying)? Resuscitation needed? Apgar scores? Birth weight, length, and head circumference? Gestational age? Neonatal course: infections or other problems, physiologic stabilization, feeding, responsiveness? Jaundice? Weight at discharge? Hospital duration? Neonatal follow-up over the first few weeks?
What are the basic components of the pediatric health history?
Prenatal and birth history Developmental history Social history of family - environmental risks Immunization history
Piaget (2-7yrs)
Preoperational o Egocentric o Only able to reason when there are connections to concrete objects o Learn cause and effect o Reasoning often flawed o Being to use semiotic functioning, or the use of one thing to represent another o Intuitive reasoning emerges toward end of stage o Reasoning remains connected to concrete reality of the here and now
Describe the communication and language development of the 9-12 month old.
Receptive language improves Participate in games They may stop when told no BUT DO NOT UNDERSTAND Enjoy songs and nursery rhymes THREE-FOUR WORDS (by 12 months) Name a picture in book (By 12 months) Visually look for objects when named (By 12 months) Follow simple one-step requests (By 12 months)
Describe the progression of cognitive development from 5 months to 8 months of age.
SIGNIFICANT COGNITIVE GROWTH Cause and effect like ringing a bell or dropping a toy out of crib Visually follow a toy Object permanence is evident for some with peek a boo and looking for partially hidden objects Resistance to bedtime, feeding and parental separation occurs
Describe the social and emotional development of a 9-12 month old.
Stranger anxiety persists Fear new experiences Look to parents for reassurance Emotions more evident Enjoy initiating interactive games They try to engage the parents a lot Little understanding of the things that can cause them harm Pride in mastering new skills They are in love with the world at age 11 months May help with getting dressed
When does teething usually occur?
Teething begins about 6 months as the central incisors emerge 8 months the lateral incisors emerge.
What is anticipatory guidance?
Telling parents what to expect at certain ages and stages of development so they are prepared and can better deal with these changes.
When should a primary care follow up be scheduled for a newborn discharged from the nursery? Why?
The follow-up visit should be in the office 48-72 hours after discharge to screen for feeding problems and jaundice.
What is the usual weight loss of NB? How long does it take to usually regain this loss?
The infant may initially lose up to 5%-8% of birth weight Should regain it within 10-14 days (2 weeks) Weight loss of 10% or more requires further investigation
What are the leading causes of infant mortality in the U.S.?
The leading causes of infant mortality are congenital malformations, low birth weight, prematurity, maternal delivery complications, multiple gestation, SIDS, and unintentional injuries.
Who completes the ASQ & PEDS?
These should be completed by the parents while waiting to see the provider
What is the Dubowitz/Ballard examination?
This examination is used to determine gestational age.
Describe Tummy Time and its purpose.
Tummy time consists of supervised time spend playing with the baby in a prone position. It is best to start with sessions less than 4 minutes, two or three times a day, but should increase up to 1 hour daily while prone. Time spent prone allows infants to develop strong neck muscles and decrease the likelihood of positional plagiocephaly.
Describe the communication/language of the 6-8 month old
Variety of pitch and sounds, initially single sound units, then double-consonant sounds. Use mama and dada nonspecifically. Imitate sounds such as cough or "raspberry". Listen to and respond to parents' talking, distinguish expressions and gestures, may still or quiet to "no".
What changes occur in the cognitive development of a 4-5 month old?
Visual exploration increases bc they seek out objects in the environment Prefer to look at parents faces Chewing and mouthing allow them to assess their surroundings Can bring a toy to their mouth (first when lying down and then while sitting up)
Describe the cognitive development of a 4 to 8 week old.
Visually track faces or toys past midline vertically and horizontally Demonstrate facial expressions, respond to sounds, and attempt to imitate mouthing mvmts By 3months they can enjoy toys and may wave arms when toy brought into sight
What is included in The Classic Health History?
1. Patient identifiers (name, dob, sex, address, record number, name of historian, relationship to patient) 2. CC 3. HPI 4. PMH (prenatal, natal, postnatal, past illnesses, allergies, accidents, hospitalizations, immunization history, nutrition history, growth, and development 5. ROS (physical (body systems), psych - colic, breath holding, thumb sucking, head banging, hair pulling, masturbation, adjusting to home, school, neighborhood, temperament - activity level, predictability, moods, intensity of reactions, adaptability, initial responses, sleep - amount, habits, problem 6. Family history 7. Socioeconomic (occupations of parents, time spent with child, finances, persons in home, house living arrangements, general relationship with family members, community support, safety precautions)
Erickson 12-36mo
Autonomy vs shame ex. To hold on; to let go
What are considered the NBs signals of distress?
Crying, arching or gagging
How often should the NB breast feed during the day? Night?
Encourage breastfeeding every 2-3 hours during the day and may stretch to every 4 hours at night
Erickson 12-17 y/o
Identity vs role confusion ex. To be oneself; to share being oneself or not being oneself
Erickson 6-11 y/o
Industry vs inferiority ex. To make things; to complete
alert and active
Infants in this state keep their eyes open but are likely to fuss if hungry, soiled, tired, or overstimulated. They may wiggle and make faces during this time. When consoled by caregivers, they can calm and either fall asleep or go into quiet but alert state.
Erickson 3-6 y/o
Initiative vs guilt ex. To make things; to play
Erickson 17-30 y/o
Intimacy vs isolation ex. To lose and find oneself in another
What sense is the most acute in the NB?
Sense of smell
What are usually the infant's first toy?
The hands
Erickson 0-12 mo
Trust vs mistrust ex: To get; to give in return
Describe the vision of the NB
Vision is limited Have the ability to focus briefly on a face or bright object when it is brought into visual range (8-12 inches from the face) Usually track objects to the midline.
What is the normal weight gain of a 6-8 month old?
Weight gain slows to 3-4 ounces per week or about 1 pound per month.
Screening:
done at 9 months, 18 months, and 24-30 months o Can use a parent self -reporting tool completed in waiting room, scored by RN and then reviewed by APRN o Review findings with family o If the APRN does not assess developmental screening self reports, the subtle variations of normal behavior or abnormal behaviors can be overlooked o First level of contact to ID potential and actual developmental concerns o Allos the APRN to document a child's progress over time and objectively ID and reinforce a child's developmental strengths o Language, motor, social-emotional, and cognitive skills assessed o Regulation and sensory systems need to be screened • Sleep wake cycles • Receive process and respond to internal and external stimuli o Parent and child interaction is crucial
When does the capacity for an infant to self-soothe normally develop?
first three months of life
How is the infant's autonomic nervous system stability evaluated
heart rate, respiratory rate, temperature control, and color changes.
Drowsy awake state
infants in this state are quiet and appear sleepy but can become fussy and active if stimulated. The respond to stimuli slower than those in an alert state. Blinking and yawning are common.
quiet but alert awake state
infants in this state frequently look around and quietly observe their environment; they brighten with stimulation from caregivers or other sources. It is common for infants to transition from quiet but alert to sleep states or the alert and active state.
Assessment
o A developmental assessment is conducted when a definitive diagnosis and a more individualized approach to guide the plan of care and manage the child's problems are required o Areas for developmental assessment • 1) physical development (physical stability, growth, and sexuality) • 2) regulatory skills (state control and modulation) • 3) adaptive skills and fine motor skills (feeding, bathing, brushing teeth) • 4) motor skills (locomotion) • 5) communication/language (verbal and nonverbal gestures) • 6) social emotional development and parent-child interactions • 7) cognitive and intellectual development (problem solving and decision making skills) o Assessment tools require special training and such to administer accurately o Only use assessment tools when concerns require more in depth developmental or diagnostic eval
Monitoring:
o Developmental monitoring should be a part of EACH WELL CHILD VISIT per the AAP o Focus is to build parental competence and competence o Emphasis on monitoring development over time within child's overall wellbeing o Focus on: eliciting and attending to parents concerns; obtain a relevant developmental hx; making accurate observations of the child
Describe the sleep states of normal newborns.
oquiet sleep Quiet sleep occurs when the infant is in deep sleep, shows little movement, and is difficult to arouse even when touched or stimulated by sound. oactive sleep Active sleep, the most common type of sleep, involves rapid eye movement, smiling, sucking and briefs fussing or crying
What is "family functioning"?
• "the good enough family" allows for the less than perfect family to feel successful and empowered • Family resilience is the ability of the family to rebound from adversity stronger and more resourceful than before • Family resistance is key to healthy family functioning • Family beliefs • Family organization and resources • communication • Resilient families are flexible, connected to one another, and support by social and economic resources • Open communication, mutual respect, differentiation, shared problem solving and and decision making, flexibility, sense of play, shared value of service, enhancing personal growth
What information should be included in the management plan?
• ALWAYS INCLUDE A RECOMMENDATION FOR THE NEXT VISIT AND WHAT IS TO BE DONE AT THAT VISIT IN AN ATTEMPT TO MOVE THE CHILD INTO A HEALTH MAINTENANCE PATTERN RATHER THAN FOR ACUTE ISSUES ONLY • Need to have shared decision making with the child and family that works with the APRN and family to find a health care decision that is acceptable to both parties • Both pt and providers participate • Info is shared between both parties • Expressed tx preference is shared • Agreement is reached
Parent Development Theory
• Asserts that the parenting role begins in childhood, evolves over time, and is influenced by personal experiences, social norms, the health of the parent-child relationship, family dynamics, and the child's own characteristics • The parent is the individual who assumes the responsibility of caring for and raising a child • Six characteristics: bonding, discipline, education, general welfare, responsibility, sensitivity
Describe the strength/motor coordination of the 4-5 month old. Should walkers be used? How long should this age remain in a nonmobile, sitting/reclining device?
• Become more mobile • Child proof home • Walkers should not be used • Floor-time play encourages motor strength and coordination • Infants should remain in non-mobile sitting devices for briefs periods of 10-15 minutes at a time. • Must ensure a safe environment for infant
What is Bright Futures
• Bright Futures is a national health promotion initiative dedicated to the principle that "every child deserves to be healthy and that optimal health involves a trusting relationship between the health professional, the child, the family, and the community as partners in health practice." Bright Futures helps providers deliver prevention-based, developmentally oriented care in a family-focused manner and fosters the aforementioned relationships
What is the purpose of CPT codes?
• Current Procedural Terminology (CPT) codes provide therapeutic intervention codes.
Explain what is meant by "competent developmental care requires 3 strategies: Monitoring (surveillance), screening, and assessment.
• Ensuring the child is progressing appropriately takes a collective approach of these three components. • Gaining the parent's and child's trust and engagement is in the interview process is are critical to obtaining accurate info
What is "family social network"?
• Individuals, activities, agencies, and institutions that have the potential to support harm or drain energy from the family • Positive social support exists when the family feels emotional support and has help and is informed
What is the first thing that you do when you go into a room (after you wash your hands
• Introduce yourself to family and child
Why does the 4-5 month old usually drool?
• It can be due to teething • mostly occurs because of salivary gland maturation and decreased ability to coordinate swallowing of excess saliva.
Why is the use of a pacifier a good thing for an infant during sleep time?
• It may reduce the incidence of SIDS.
What anticipatory guidance (related to social/emotional growth of 4-5 month olds) be given to parents?
• Need nonnutritive sucking as a means to self-regulate • Start talking about discipline versus punishment • Explain developmental milestones • Parents need to ID roles in family • Reinforce that parents need alone time • Counsel on finding safe and appropriate child care
Describe the regulation and sleep-wake patterns of the 4-5 month old.
• Need to be allowed to self soothe in middle of night • Rituals at night are key • Need varied approached to infants of varying temperament
How can communication/language be fostered in a 4-5 month old?
• Parents need to use reciprocal talking with their infant with various intonation • Talk to infant during diaper changes and meal prep etc • Reading to infant daily starting a min of 6 months of age
What can a parent do to foster the infant's auditory eterm-87xperience and prevent overstimulation?
• Placing mobiles to the side of the bassinet or crib can prevent overstimulation. • Playing soft music enriches the infant's auditory experience.
What can be done to foster the social/emotional growth of the 1-3 month old?
• Respond to infant cries asap to reassure them that their needs will be met • Parents perception of their infant's temperament plays an important role in how they respond to their infant • Have an increased social need and desire to play with the caregiver • Fussing/crying is misinterpreted as hunger • Have short attention span (10-15 minutes at a play station for a total of 1 hour will = tired happy baby) • Parents need alone time as a couple
How should cereal be administered to the 4-5 month old?
• Spoon-feeding helps the infant develop new oral-motor skills. • Cereal should not be put in a bottle or cup.
What is SSHADESS and when is it used?
• Strengths • School • Home • Activities • Drugs • Emotions • Sexuality • Safety • Psychosocial screening test
Describe the regulation and sleep-wake patterns of the 1-3 month old.
• Structure the infants day to help meet the infant's ongoing need for external routines and helps the infant transition • Immature nervous system creates a need for swaddling • Place on back to sleep • Sleep location and position and establishment of set naps all influence later sleep habits • Can self soothe within first three months of life • Parents work schedule, day care, breastfeeding, etc influence family decisions
What can you do to avoid diagnostic errors?
• Test-retest: ask the questions again later, take BP again later, assess for same symptom later • Interrater reliability: ask someone if they get/find the same thing as you on their additional assessment • Internal consistency: Look for logical consistency if the findings obtained. If something is out of sync question it. • To assess validity: • Make sure the cumulative data fit and support a given diagnosis • Was diagnosis make on a cluster or isolated event • Were cues missed • Provider expectations • Were all data reviewed promptly?
What is the AAP?
• The AAP American Academy of Pediatrics publishes the Recommendations for Preventive Pediatric Health Care annually. These recommendations aim to improve the efficacy and effectiveness of health promotion and preventive pediatric care and have placed greater emphasis on behavioral and developmental issues in recent years. • Part of the revision includes basing well child and family development rather that the periodicity of required immunizations
What is the purpose of the ICD-10-CM?
• The ICD-10-CM is designed to represent the primary phenomena of concern to physicians and NPs. The listings are recognized by many insurance carriers for billing purposes and, as such, have become the "currency" for much health care delivery in the US. • Represents physiologic p roblems extremely well but includes few labels or rubrics for the behavioral, social, and developmental problems that NP's also manage. • ICD-10-CM provides the lists of reimbursable diagnoses
How should adolescents/teens be interviewed?
• The hx can be started with the parents and teen together but then they need to be separate and interviewed separate • Must have patience with teens
What is considered objective data?
• The physical examination • Labs and xrays • Hearing and vision tests • Social worker reports, PT/OT/ST reports • The problem list based on the analysis of subjective and objective data
What is meant by children are learning a "script" at the office visits
• The visit should help them learn a script that is understandable and not too stressful. When the script is too varied alert them to the change with cues and explanations for the new experiences of this visit and the likelihood that the new script will be repeated at future visits
Why is it important to incorporate the physical as well as psychosocial developmental stages for every child on every visits into the assessment and management plan?
• Understanding development incorporating the physical as well as psycho social development stages for every child on every visit into the assessment and mgmt plan, and evaluating developmental outcomes as a measure of health are the core concepts of pediatric health care. Kids are not little adults!! B/c children change so quickly developmentally one cannot be lax about including developmental as a core domain for assessment Ex: the 6 month old infant functioning as a 3 month old level is 50% behind!
What all should be evaluated to assess if a 1 month old has adequate nutrition?
• Urinary output • weight again • feeding type (breast of bottle) • frequency and duration of feeding • frequency of spit ups • infant activity level must be evaluated to determine adequate nutrition
What cognitive/environmental stimulation can be used for a 4-5 month old?
• Varities of toys like soft toys, rattles, pots • Mirrors • Take to store and on walks
What is the danger of propped bottles?
• risk of aspiration
Describe the toys that should be used in infants 1-3 months of age.
• semi-rigid • unpainted • varying textures • Pieces should be no smaller than the child's first to avoid choking hazard • Rattles and things that make noise are entertaining and encouraging
What is the purpose of the Ecomap?
•The ecomap is a similar tool that is used to construct a picture of the family structure and relationships within the family and in the community that are supportive or harmful
