Peds Test 1 (Chapters 2, 3, 4, 5, 6, 9, 10, 11, 12, 13, 14, 15, 17, 18, 20)

LGBT Families

- 1/5 of all same sex couples raise children - When children are brought up in LGBT families, the relationships seem as natural to them as heterosexual parents do to their offspring

Syndrome

- A recognized pattern of congenital anomalies resulting from a single specific cause - Down syndrome, fetal alcohol syndrome

Family Structure

- Consists of individuals, each with a socially recognized status + position, who interact with one another on a regular, recurring basis in socially sanctioned ways - When members are gained or lost, the family composition is altered + roles must be redefined or redistributed

Telephone Triage Guidelines

- Date + time - Background: age, sex, contact info, chronic illnesses, allergies, current meds or treatments, recent immunizations - Chief complaint - General symptoms - Systems review - Steps taken

VACTERL

- Describes association congenital anomalies Vetebral defects Anal atresia Cardiac defect TracehoEsophageal fistual Renal defects Limb defects

Polygamous Family

- Not legally sanctioned in the US - The conjugal unit is sometimes extended by the addition of spouses in polygamous matings - Polygamy refers to multiple wives (polygyny) or rarely, multiple husbands (polyandry) - Many societies practice polygyny that is further designated as sororal, in which the wives are sisters or nonsororal in which the wives are unrelated - Sororal polygyny is widespread throughout the world

Permissive Parenting Style

- Parents exert little or no control over children's actions - Avoid imposing their own standards of conduct + allow their children to regulate their own activity as much as possible - Parents consider themselves to be resources for the children, not role models - If rules do exist, the parents explain the underlying reason, elicit the children's opinions + consult them in the decision making process - They employ lax, inconsistent discipline, do not set sensible limits + do not prevent the children from upsetting the home routine - Rarely punish children

Use of a Child as a Bilingual Interpreter

- Strongly discouraged - They are often not mature enough to understand health care questions, answers or messages - Some institutions prohibit the use of children as interpreters

Sequence

- When a single anomaly leads to a cascade of additional anomalies - Pierre Robin sequence begins with the abnormal development of the mandible, resulting in abnormal placement of the tongue during development. The normal developmental process for the palate is prevented because the tongue obstructs the migration of the palatal shelves toward the midline, and a cleft palate remains. Consequently, infants born with Pierre Robin sequence have a recessed mandible + an abnormally placed tongue + are at risk for obstructive apnea

How long to place children in time out?

1 minute per year of age

2 Blocks to Communication

1.) Those made by the nurse 2.) Information overload by the patient

Multifactorial Conditions

Cancer + neural tube defects

Sympathy

Having feelings or emotions similar to those of another person, rather than understanding those feelings

Female Genital Mutilation (Female Circumcision)

- Removal of or injury to any part of female genitalia - Practiced in Africa, the Middle East, Latin America, India, Asia, North America, Australia + Western Europe

4 Categories of Internal Assets

1.) Commitment to learning 2.) Positive values 3.) Social competencies 4.) Positive identity

Anthropometry

- An essential parameter of nutritional status - Measurement of height, weight, head circumference, proportions, skinfold thickness, arm circumference in children

Arm Circumference

- An indirect measure of muscle mass - Measured with a paper steel tape - Place tape vertically along the posterior aspect of the upper arm from the acromial process + to the olecranon process; half of the measured length is the midpoint - WHO growth curves are available

Encouraging Deep Breaths

- Ask the child to "blow out" the light on an otoscope or pocket flashlight; discreetly turn off the light on the last try so the child feels successful - Place a cotton ball in child's palm; ask child to blow the ball into the air + have parent catch it - Place a small tissue on the top of a pencil + ask the child to blow the tissue off - Have child blow a PINWHEEL, party horn or bubbles

Precaution

- Condition that MIGHT increase the risk for a serious adverse reaction or that might compromise the ability of the vaccine to produce immunity - If a precaution is present, the vaccine MIGHT be administered if the benefits outweigh the risks

Ear Canal in Infants

- Curves UPWARD - Pull pinna DOWN + back to the 6 to 9 o' clock

Advantages to Pulse Oximetry vs. TCM

- Does not require heating skin, thus reducing risk of burns - Eliminates delay period for transducer equilibration - Maintains an accurate measurement regardless of the patient's age or skin characteristics or the presence of lung disease

Determining Skin Turgor

- Done by grasping skin on the abdomen - One of the best estimates of adequate hydration + nutrition

Nursing Interventions for Rubella (German Measles)

- Droplet precautions - Reassure parents of benign nature of illness - Comfort measures - Avoid contact with pregnant women

Fluorosis

- Excessive flouride ingestion - Chalky white to yellow or brown areas on the enamel

Fluoroquinolones

- For treatment for bacterial conjunctivitis for those over 1 years old - Broad spectrum antibiotic - Drops during day + ointment at night - Moxifloxacin - Gatifloxacin - Besifloxacin

Encouraging Child's Acceptance of Oral Medication

- Give child a flavored ice pop or small ice cube to suck to numb the tongue before giving drug - Mix the drug with a small amount (1 tsp) of sweet tasting substance such as honey (except in infants), flavored syrups, jam, fruit purees, sherbet or ice cream; avoid essential food items because the child may later refuse them - Give a "chaser" of water, juice, soft drink or ice pop or frozen juice bar after drug - If nausea is a problem, give a carbonated beverage poured over finely crushed ice before or immediately after the med - When meds have an unpleasant taste, have child pinch nose + drink through straw. Much of what we taste is associated with smell - Flavorings, such as apple, banana + bubble gum (FLAVORx), can be added at many pharmacies at nominal additional cost. An alternative is to have the pharmacist prepare the drug in a flavored, chewable troche or lozenge.

Plastic Cups for Oral Meds

- Hard to measure med properly - Measures < 1 tsp are impossible to determine accurately with a measuring cup

Allergic Conjunctivitis Symptoms

- Itching - Watery to thick, stringy discharge - Inflamed conjunctiva - Swollen lids

Infant Head Control Development

- Newborns moemtariliy hold head in midline + turn head side to side when prone - 3 months hold head well beyond plane of their bodies - 4 months lift head + front portion of chest 90 degrees above table, bearing weight on forarms - 4-6 months, head control is well established

Poliomyelitis Complications

- Permanent paralysis - Respiratory distress - Hypertension - Kidney stones from demineralization of bone during prolonged immobility

Tylenol for Fever

- Preferred antipyretic for children - Given every 4 hours but no more than 5 times in 24 hours - Because body temperature decreases at night, 3-4 doses in 24 hours will control most fevers

Stadiometer

- Provides most ACCURATE height measurement - Wall mounted

Vision Testing

- Recommended for children 3-5 years old to detect the presence of amblyopia

Erythema Infectiosum (Fifth Disease) Complications

- Self limited arthritis + arthralgia (arthritis may become chronic, more common in adult women) - Anemia - Hydrops - Fetal death - Aplastic crisis in children with hemolytic disease or immunodeficiency - Myocarditis (rare)

Mumps Complications

- Sensorineural deafness - Postinfectious encephalitis - Myocarditis - Arthritis - Hepatitis - Epididymo-orchitis - Oophoritis - Pancreatitis - Sterility (rare in adult men) - Meningitis

Physical Exam of Toddler

- Sitting or standing on or by parent - Prone or supine in parent's lap - Inspect body area through play "count fingers", "wiggle toes" - Use minimal physical contact initially - Introduce equipment slowly - Perform traumatic procedures last (eyes, ears, mouth) - Have parent remove outer clothing - Remove underwear as body part examined - Allow toddler to inspect equipment, demonstrating use of equipment is usually ineffective - If uncooperative, preform exam quick - Use restraint when appropriate; request parent's assistance - Talk about exam if cooperative; use short phrases - Praise for cooperative behavior

Diptheria Complications

- Toxic cardiomyopathy (2nd - 3rd week) - Toxic neuropathy

How to do a Physical Assessment on a Child who is Fearful

- Use activities that can be presented as GAMES such as test for cranial nerves - Use approaches such as Simon Says to encourage child to make a face, squeeze a hand, stand on one foot, etc - Use Paper Doll Technique: 1.) Lay child supine on exam table or floor covered with large sheet of paper 2.) Trace around body outline 3.) Use body outline to demonstrate what will be examined, such as drawing heart + listening with a stethoscope before performing activity on the child

School Age Sleep

- Usually do not require naps - 5 years: 11.5 hours - 11 years: 9 hours

Superficial (First Degree) Burns

- Usually minor - Involves the epidermal layer only - Tissue damage is minimal + there is NO blistering - Latent period followed by erytehmia - Protective functions of skin remain intake - Heals in 5-10 days without scarring - Mild sunburn

Long Term Burn care

- When burn heals, rehavilitative phase of care beings - Scar formation becomes a major problem as burn heals - uiform pressure applied to scar DECREASES blood supply. When pressure removed, blood supply to scar is immediately increased; therefore periods WITOUT pressure should be beif to avoid nourishment of the hypertrophic tissue. Continus pressure to scars can be achieved by elastic bandages. Often worn for months - Scar tissue has no sweat glands + children with extensive scarring may experience difficulty during hot weather

7 Month Old Growth + Development

-Eruption of upper central incisors - When supine, spontaneously lifts head off surface - Sits, leaning forward on both hands - When prone, bears weight on one hand - Sits erect momentarily - Bears full weight on feet - When held in standing position, bounces actively - Transfers objects from one hand to the other - Has uni-dexterous approach + grasp - Holds 2 cubes longer - Bands cubes on table - Rakes at a small object - Can fixate on small objects - Responds to own name - Localizes sound by turning head in a curving arch - Beginning awareness of depth + space - Has taste preferences - Produces vowel sounds + chained syllables-baba, mama, dada, kaka - Vocalizes four distinct vowel sounds - "Talks" when others are talking - Increasing fear of strangers; shows signs of fretfulness when parent disappears - Imitates simple acts + noises - Tries to attract attention by coughing or snoring - Plays peek-a-boo - Demonstrates dislike of food by keeping lips closed - Exhibits oral aggressiveness in biting + mouthing - Demonstrates expectation in response to repetition of stimuli

Children playing with matches or fires

1 in 10 house fires

1 g wet diaper weight = ________ mL of urine

1 mL

2 Components of Cognitive Development Required for Infant Attachment

1.) Ability to discriminate the mother from other individuals 2.) Achievement of object permanence - These processes prepare infants for separation from the parent - Separation-individuation should occur as a harmonious, parallel process with emotional attachment

3 Classifications of Heart Murmurs

1.) INNOCENT: No anatomic or physiologic abnormailty 2.) FUNCTIONAL: No anatomic defect but a physiologic defect (such as anemia) 3.) ORGANIC: A cardiac defect with or without a physiologic abnormality exists

12 Communicable Diseases of Childhood

1.) Varicella 2.) Diptheria 3.) Erythema Infectiosum (5th disease) 4.) Exanthem Subitum (Roseola Infantum) 5.) Mumps 6.) Measles (Rubeola) 7.) Pertussis (Whooping Cough) 8.) Poliomyelitis 9.) Rubella (German Measles) 10.) Scarlet Fever 11.) Conjunctivits 12.) Stomatitis

4 Markers that Signal a Child is Ready for Toilet Training

1.) Waking up dry from a nap or overnight sleep 2.) Being aware of the urge to void or stool 3.) Communicating the need to go 4.) Being dry for AT LEAST 2 HOURS during the day

3 Ways to Define Failure to Thrive

1.) Weight that falls below 5th precentile 2.) Weight for age (height) z value less than -2.0 (a z value is a standard deviation value that represents anthropometric data normalizing for sex and age with greater precision than growth precentile curves 3.) Weight curve that crosses more than 2 percentile lines on a standardized growth chart after previous achievement of a stable growth pattern

NSAID Dosages for Pain

10 mg/kg every 6-8 hours Max dose: 40 mg/kg

Metabolic rate increases every ______ for every 1 C increase in temperature + 3-5 times during shivering, thus increasing oxygen, fluid + caloric requirements.

10%

Cognitive Impairment Severe IQ

20-25 to 35-40

Poliomyelitis Clinical Manifestations

3 Different Forms 1.) ABORTIVE or INAPPARENT: Fever, uneasiness, sore throat, headache, anorexia, vomiting, abdominal pain; lasts a few hours to days 2.) NONPARALYTIC: Same as inapparent but more severe with pain + stiffness in neck, back + legs 3.) PARALYTIC: Initial course similar to nonparalytic type, followed by recovery + then signs of CNS paralysis

When to assess for antipyretic effectiveness?

30 minutes after giving

Cognitive Impairment Moderate IQ

35-40 to 50-55

By ________ months old, most infants should be able to hold the head erect + midline

4

NSAID Dosages for Fever

5 mg/kg for temps < 102.6 F 10 mg/kg for temps > 102.6 F

Cognitive Impairment Mild IQ

50-55 to 70-75

Underweight BMI

< 5th percentile

Overweight BMI

> 85th percentile but < 95th percentile

Obese BMI

> 95th percentile

Primitive Reflexes

?

Toxoid

A MODIFIED BACTERIAL TOXIN THAT HAS BEEN MADE NONTOXIC BUT RETAINS THE ABILITY TO STIMULATE THE FORMATION OF ANTITOXIN

Conjugate Vaccine

A carrier protein with proven immunologic potential combined with a less antigenic polysacharide antigen to enhance the type + magnitude of the immune response

Forced Kneeling

A child discipline measure of some Caribbean groups in which a child is forced to kneel for a long time

General contraindication for all vaccines

A febrile illness

Response Burst

A phenomenon that occurs when the undesired behavior increases after ignoring is initiated because the child is "testing" the parents to see if they are serious about the plan

Burning

A practice of some Southeast Asian groups whereby small areas of skin are burned to treat enuresis + temper tantrums

Greif

A process, not an event, of experiencing physiologic, psychological, behavioral, social, and spiritual reactions to the loss of a child Anticipatory Guidance may assist grieving family members

Diptheria

AGENT: Corynebacterium diptheriae SOURCE: Discharges form mucous membranes of noes, skin + lesions TRANSMISSION: Contact, carrier or contaminated articles INCUBATION: 2-5 days PERIOD OF COMMUNICABILITY: Until virulent bacilli are no longer present; usually 2 weeks but as long as 4 weeks

Scarlet Fever

AGENT: Group A streptococci SOURCE: Nasopharyngeal secretions of infected persons TRANSMISSION: Direct contact or droplet INCUBATION: Usually 2-5 days with a range of 1-7 days PERIOD OF COMMUNICABILITY: During incubation period + clinical illness, approximately 10 days; during first 2 weeks of carrier phase, although may persist for months

Exanthem Subitum (Roseola Infantum)

AGENT: Human herpesvirus type 6 (HHV-6, rarely HHV-7) SOURCE: Possibly acquired from saliva of a healthy adult person; entry via nasal, buccal or conjunctival mucosa) TRANSMISSION: Year round, no contact with infected person in most cases. Mostly limited to children < 3 years old but peak age is 6-15 months INCUBATION: Usually 5-15 days PERIOD OF COMMUNICABILITY: Unknown

Craniosynostosis

Abnormal + may indicate premature closure of the sutures

Daptacel

Acellular pertussis vaccine

Transilluminator

Aids in finding + evaluating veins for access

Wheezes

Air passes through NARROW passages such as exudate, inflammation, spasm or tumor

Fever (Hyperprexia)

An elevation in set point such that the body temperature is regulated at a higher level; may be arbitrarily defined as a temp above 100.4 F

Doll's Eye Reflex

As head is moved slowly to the right or left, eyes lag behind + do not immediately adjust to new position of head Disappears as FIXATION develops; if persists, indicates neurologic damage

Auditory Acutiy

At adult levels during infants

Absolute Standard of Poverty

Attempts to delimit a basic set of resources needed for an adequate exstence

Recommended Temp Taking Sites for 2 - 5 Year Olds

Axillary Tympanic Oral Rectal (if definitive temp is needed)

Healthy BMI

Between 5th to < 80th percentile

Ambylopia

Blindness that results from disuse of eye when strabismus (cross eyes) is not corrected by 4-6 years old

Dermatome

Body area in a particular segement of spinal cord that can store viruses such as herpes zoster in the sacral + cervical dermatomes

Hyperthermia

Body temp exceeding the set point, which usually results from the body or external conditions creating more heat than the body can eliminate, such as in heat stroke, aspirin toxicity or hyperthyroidism.

S1 is synchronous with the _________________________

Carotid pulse To distinguish between S1 + S2, simultaenously palpate the carotid pulse with the index finger + middle fingers + listen to heart sounds

Vesicant or Sclerosing Agent

Causes varying degrees of cellular damage when even minute amounts escape into surrounding tissue

Most distressing sign of child's death for parents?

Change in respiratory pattern

Seesaw (Paradoxic) Respirations

Chest falls on inspiration + rises on expiration

Position for Lumbar Puncture

Children easiest to control in SIDE LYING position, with the head flexed + knees drawn towards the chest.

Organs that Can be Donated

Cornea Skin Bone Kidneys Heart Liver Pancreas

Strabismus

Cross Eyes

Normal Abdomen of Young Children

Cylindric + prominent

Binocularity

Develops at 6 weeks old + should be established by 4 months old

Increased BP

Excess sodium

Intestinal Parasites

Finish: pg 173

Respiratory Depression Caused by Benxodiazapines

Flumazenil (Romazicon) 0.1 mL/kg, if no or inadequate response after 1-2 minutes, administer same dose + repeat at 60 second intervals for a maximum dose of 1 mg (10mL)

When reprimanding children, why focus ONLY on the misbhavior?

Focus on the misbehavior, not the child. Use of "I" messages rather than "you" messages expresses personal feelings without accusation or ridicule. For example, an "I" message attacks the behavior ("I am upset when Johnny is punched; I don't like to see him hurt") NOT the child

Biochemical Tests for Nutrition

For UNDERNUTRITION: - Hemoblobin - RBCs - Serum albumin - Prealbumin For OBESITY: - Fasting serum glucose - Lipids - Liver function studies

Deltoid Injections

For children 18 months and older

Recommended Needle Length for Adolescents

For deltoid OR vastus lateralis: 25-51 mm (1 to 2 inches)

Normotensive

If BP < 90th percentile

Infiltration

Inadvertent administration of a non vesicant solution or med into surrounding tissue

Blinking or Corneal Reflex

Infant blinks at sudden appearance of a bright light or at approach of an object towards the cornea Persists THROUGHOUT life

FTT Formula

Infants: 24 kcal/oz formulas Older children (1-6) 30 kcal/oz formulas Toddlers: high caloric milk drink (PediaSure) - Monitor for signs of intolerance to formula - Give parents specific, step by step directions for formula preparation, as well as written schedule of feeding times - Restrict juice until weight gain has been achieved + then give no more than 4 oz/day of juice

Dermal Replacements

Integra = made of collagen + silicone rubber. silastic layer peeled off after dermis is formed AlloDerm = made of natural tissue that is processed to remove cells that can lead to tissue rejection. The resulting acellular tissue contains epithelia elements that provide a foundation for tissue regeneration

Physical Proverty

Lack of money or material resources, including poor nutrition, insufficient clothing, poor sanitation + deteriorating housing

Agonal

Last gaping breaths before DEATH

Normal Chest for Children

Lateral diameter increased in proportion to anteroposterior diameter

What is the more important component in effective communication?

Listening

Signs of Poison Ivy/Oak + Sumac Reaction

Localized, streaked or spotty, inflamed, oozing + painful impetiginous lesions that are often highly urticarial redness, swelling + itching at sight of contact

What can cause nutritional failure to thrive?

Low levels of zinc

Peristaltic Waves

May be visible through the abdominal wall in infants + thin children

Skinfold Thickness

Measurement of body's fat content because approximately HALF of the body's total fat stores are directly beneath skin

Flame Related Burns

More common in older children

Should a tape measure be used to measure length?

No it is inaccurate

Is breastfeeding contraindicated in vaccines?

No. The only vaccine found in human milk is Rubella + this is not harmful to infants

Sunscreens for infants under 6 months?

Not recommended. Instead, keep out of sun or physically shaded from it.

Recommended Temp Taking Sites for > 5 Years Old

Oral Axillary Tympanic

Rubella (German Measles) Clinical Manifestations

PRODROMAL: Absent in children, present in adults + adolescents; low fever, headache, malaise, anorexia, mild conjunctivitis, coryza, sore throat, cough + lymphadenopathy; lasts 1-5 days; subsides 1 day after appearance of rash RASH: First on face then rapidly spreads downward to neck, arms, trunk + legs; by end of 1st day, body is covered with discrete, pinkish-red maculopapular exanthema; disappears in same order as it began + usually gone by 3rd day

how much toothpast for a child 3-6 years?

Pea sized

Biot Resiration

Periods of hyperpnea alternating with apnea (similar to Cheyne Stokes but depth remains CONSTANT)

Informant

Person who supplies information

Most common gait problem in children

Pigeon toe (toeing in)

Position for Femoral Venipuncture

Places child SUPINE with legs in a FROG position to provide extensive exposure of groin area Infants legs can be controlled by nurses forearms + hands

Rapid Pulse

Potassium deficiency Excess thiamine

Neutropenic Precautions

Precautions that are aimed at protecting a patient who is immunocompromised

Rubella (German Measles) Complications

Rare, (arthritis, encephalitis or purpura)

Hard Palate

Roof of the mouth

SAFE PAD

S = suffocation, sleep position A = asphyxia F = fires E = electrical burns P = poison A = automobile safety D = drowning

SAFE PAD

S = suffocation, sleep position A = asphyxia, animal bites F = falls E = Electrical burns or burns P = poisoning, ingestions A = automobile safety D = drowning

Piaget's 4 Stages

Sensorimotor 0-2 years = object permanence Preoperational 2-7 years = symbolic thought Concrete Operational 7-11 years = operational thought Formal Operational 12+ years = abstract concepts

Tense Boardlike Abdomen

Serious sign of a paralytic ileus + intestinal obstruction

Normal Chest for Infants

Shape almost circular

Sheet Graft

Sheet of skin removed from donor site is place intact over recipient site + sutured in place. Used in areas where cosmetic results are most visible

Ashen Grey Tympanic Membrane

Signs of scarring from a previous perforation

Invisible Poverty

Social + cultural deprivation, such as limited employment opportunities, lack of or inferior health care services + absence of public services

When can urine be aspirated from diaper?

Specific gravity, ketones, glucose + protein

Black Areas in Tympanic Membrane

Suggests a perforation of the membrane that has NOT healed

Nontransparent Grayish Tympanic Membrane

Suggests serous otitis media

Safest Position to prevent Sudden Infant Death Syndrome

Supine No pillows should be placed in a young infants crib while sleeping.

Varicella

TRANSMISSION: Secretions of respiratory tract, skin lesions, CONTACT, DROPLET (airborne) INCUBATION: 2-3 weeks PERIOD OF COMMUNICABILITY: 1 day before eruption of lesions to 6 days after PRODROMAL: Slight fever, malaise, anorexeia for 24 hours, rash that is very itchy, begins as a macule then rapidly progresses to papule then vesicle with all three stages present at one time DISTRIBUTION: Centripetal, spreading to face + proximal extremities but sparse on distal limbs + less on areas not exposed to heat

Adacel

Tdap for 11-64 years old

TIG

Tetanus immunoglobulin Given for wound management to provide passive immunity

Family Function

The interactions of family members, especially the quality of those relationships + interactions

Set Point

The temp around which the body temp is regulated by a thermostat-like mechanism in the hypothalamus

Heart Palpitations

Thiamine deficiency

Decreased BP

Thiamine deficiency Excess Niacin

Rooting Reflex

Touching or stroking the CHEEK alongside of the mouth

Tympanic Membrane

Usually light pearly pink

Teeth defective enamel

Vitamin A, C, D, Calcium, Phosphorus deficiency

Gums that are spongy, friable, swollen, blush red or black, bleed easily

Vitamin C deficiency

What is rickets caused by?

Vitamin D deficiency

BMI Calculation

kg / height in meters squared

Reflex Chart

pg 203

Language Development of Infants

- First verbal communication is CRYING - In first weeks of life, crying has a reflexive quality + is mostly related to psychologic needs - Infants cry 1-1.5 hours a day up to 3 weeks old - By 6 weeks, it is 2-4 hours a day - Crying tends to decrease after 12 weeks old - It is thought that the increase in crying for no apparent reason during the first few months may be related to the discharge of energy + maturational changes in the central nervous system - At end of first year, crying is for attention, fear, frustration (usually in response to their developing but inadequate motor skills) - Vocalizations heard during crying eventually become syllables + words - Infants vocalize by as early as 5-6 weeks old - 2 months, VOWEL sounds ah, eh, uh - 2-4 months, CONSONANT sounds n, k, g, p, b + infants coo, gurgle + laugh - 6 months, imitate sounds + CONSONANTS t, d, w + combine syllables "mama" but do NOT acribe MEANING until 10-11 months - 9-10 months, comprehend meaning of the word "no" and obey simple commands - By 1 years old, they can say 3-5 words with meaning + may UNDERSTAND as may as 100 words

Alae Nasi

- Flaring may indicate respiratory difficulty

DEVELOPMENTAL FOCUS in Caring for Children Living with Chronic Diseases

- Focuses on child's developmental level rather than AGE or diagnosis emphasizes child's abilities + strengths rather than diabilities - Attention directed at normalizing experiences, adapting the environment, promoting coping skills - Also considers family development

Infanrix (Diptheria, tetanus toxoid, acellular pertussis conjugate)

- For children < 6 weeks old - Contains: Diptheria, tetanus toxoid + acellular pertussis conjugate

Urine Collection Bags

- For infants + toddlers who are not toilet trained - Special urine collection bags with self adhering material around opening at the point of attachemnt

Knock Knee

- Genu valgum - Opposite of bowleg - Knees are close together but feet are spread apart - Normally present in children from 2-7 years old

Bowleg

- Genu varum - Lateral bowing of tibia - Toddlers are usually bowlegged after beginning to walk until all their lower back + leg muscles are well developed - Unilateral or asymmetric bowlegs that are present beyond 2-3 years old, particularly in African American children may represent pathologic conditions

Bronchial Breath Sounds

- Heard only over trachea near suprasternal notch - Inspiratory phase is SHORT + the expiratory phase is LONG

Bronchovesicular Breath Sounds

- Heard over the manubrium + in the upper intrascapular regions where the trachea + bronchi bifurcate - Inspiration is louder + higher pitched than in vesicular breathing

Questionable Growth Charts

- Height + weight percentiles are widely disparate (height in 10th percentile + weight in 90th percentile, especially those with above average skinfold thickness) - Children who fail to follow expected growth velocity in height + weight, especially during rapid periods of growth such as infancy or adolescence - Children who show a sudden increase (except during puberty) or decrease in a previously steady growth pattern (crossing 2 major percentile lines after age 3) - Children who are short in absence of short parents

Galactogogues

- Herbs used to increase breast milk supply - Fenugreek - Blessed thistle - Fennel - Chaste tree - Debate on weather they are effective or not

Long Term Consequences of Untreated Pain in Infants

- Higher somatic complaints of unknown origin - Greater physiologic + behavioral responses to pain - Increased neurologic deficits - Psychosocial problems - Neurobehavioral disorders - Cognitive deficits - Learning disorders - Poor motor performance - Attention deficits - Poor adaptive behavior - Inability to cope with novel situations - Problems with impulsivity + social control - Accentuated hormonal stress responses in adult life

Attachment in Infants

- Importance of human physical contact to infants cannot be overemphasized - Attachment of parent + child, which often begins before birth + assumes even more importance at birth, continues during the first year - When infants are not provided a safe haven + consistent, loving care, an insecure attachment develops. Such infants do not feel they can trust the world in which they live. This insecure attachment can result in psychosocial difficulties as the child grows + may persist into adulthood. - During formation of attachment, the infant progresses through 4 distinct but overlapping stages: 1.) First few weeks, infants respond indiscriminately to anyone. 2.) 8-12 weeks old, they cry, smile + vocalize more to the mother than anyone else but continue to respond to others, weather familiar or not. 3.) 6 months, infants show a distinct preference for the mother. 4.) About 1 month after showing attachment to the mother, many infants begin attaching to other family members, most often the father

Extended Family

- Includes at least 1 parent, 1+ children + 1+ members (related or nonrelated) other than a parent or sibling - Parent-child + sibling relationships may be biologic, step, adoptive or foster - Within the extended family, grandparents often find themselves rearing their grandchildren - Young parents are often considered too young or too inexperienced to make decisions independently - Often, the older relative holds the authority + makes decisions in consultation with the young parents

School Age Erikson Stage

- Industry vs. Inferiority - Failure to develop a sense of accomplishment may result in a sense of inferiority - The danger inherent in this period of development is the occurrence of situations that might result in a sense of inadequacy or INFERIORITY. This may happen if the previous stages have not been successfully mastered or if a child is incapable or unprepared to assume responsibilities associated with developing a sense of accomplishment - Children achieve a sense of industry when they have access to tasks that need to be done + they are able to complete the tasks well despite individual differences in their innate capacities + emotional development

Amount of Formula for Infants

- Infants being fed on demand usually determine their own schedule - Some may need a more planned schedule to ensure adequate nutrients - Number of feedings decreases from six at 1 month to 4-5 in 6 months - The total amount of formula will usually level off at around 32 ounces a day

Conjunctivitis

- Inflammation of the conjunctiva - In newborns, it can occur from infection during birth, most often from Chalmydia trachomatis (includsion conjunctivitis) or Neisseria gonorrhoeae. Can cause serious ocular damage. - In infants, recurrent conjunctivitis may be a sign of nasolacrimal (tear) duct obstruction - A chemical conjunctivitis may occur within 24 hours of instillation of neonatal opthalamic prophylaxis; the clinical features include mild lid edema + a sterile, nonpurulent eye discharge

Stomatitis

- Inflammation of the oral mucosa - May be infectious or noninfectious - Aphthous stomatitis + herpetic stomatitis are common in children - More common in those with immunocompromised - May occur as a manifestation of hand-foot-and-mouth disease (HFMD) + herpangia; both manifest with scattered vesicles on the uccal mucosa and are commonly caused by nonpolio enteroviruses (coxackieviruses)

Social Development in Infants

- Initially influenced by their reflexive behavior such as the grasp + depends primarily on the interaction between them + their principal caregivers - Crying + reflexive behavior are methods to meet one's needs in early infancy - The social smile is an early step in social connection - By 4 months, infants laugh - Play is an important socializing agent + provides stimulation needed to learn from + interact with the environment - By 6 months, they play peek a boo + signal the desire to be picked up by extending their arms + show displeasure when a toy is removed or their faces are washed 3 Important Components of Social Development: 1.) Attachment 2.) Play 3.) Language

Child presents to hospital with undiagnosed EXANTHEMIA

- Institute strict Transmission Based Precautions (contact, airborn + droplet) + Standard Precautions until a diagnosis is confirmed - Could be: Diptheria, varicella zoster, measles, tuberculosis, adenovirs, Haemophilus influenzae, mumps, Neisseria meningitis, Mycoplasma pneumoniae infection, Pertussis, Plague, Rhinovirus, Group A streptococcal pharyngitis, SARS, Pneumonia or Scarlet Fever

Introducing Solid Foods

- Introduction of solid food in an infant's diet is primarily for taste + chewing experience, not growth - One food item is introduced at intravals of 4-7 days to allow for identificiation of food allergies - As amount of solid food increases, quantity of milk decreases to less than 1 L/day to prevent overfeeding - Foods should NOT be mixed in with milk or formula + fed through a bottle

Infant Locomotion Development

- Involves acquiring the ability to bear weight, propel forward on all four extremites, stand upright, cruise by holding onto furniture + walk alone - Following a cephalocaudal pattern,, infants who are 4-6 months old have increasing coordination in their arms - Initial locomotion results in infants propelling themselves BACKWARD by pushing with their arms - 6-7 months they are able to bear ALL of their weight on the legs with assistance - 9 months crawling progresses to creeping - 11 months can walk while holding onto furniture or with assistance - 1 year can walk with one hand held - Some attempt their first steps by first birthday - An infant who does not pull to a standing postion by 11-12 months should be further evaluated for possible developmental dysplasia of the hip

Treating Sunburn

- Involves stopping the burning process, decreasing the inflammatory response + rehydrating the skin - Local application of cool tap water soaks or immersion in a tepid water bath (slighly below 98 F) for 20 minutes or until skin is cool limits tissue destruction + relieves the discomfort. After cool applications, a bland oil in water moisturizing lotion can be applied - Tylenol for discomfort - Partial thickness burns are treated the same as those from any heat source

Color Vision

- Ishihara Test - Hardy-Rand-Rittler Test - Each test consists of a series of cards (psuedoisochromatic) containing a color field composed of spots of a certain "confusion" of color - Against the field is a number or symbol similarly printed in dots but of a color likely to be confused with the field color by a person with a COLOR VISION DEFICIT - As a result, the figure or letter is invisible to an affected individual but is clearly seen by a person with normal vision

Nursing Interventions for Mumps

- Isolation during period of communicability - Droplet + contact precautions - Encourage rest + decreased activity during prodromal phase until swelling subsides - Encourage fluids + soft, bland foods - Avoid foods requiring chewing - Apply hot or cold compresses to neck, whichever is more comforting - To relieve orchitis, provide warmth + local support with tight fitting underpants

Nursing Interventions for Erythema Infectiosum (Fifth Disease)

- Isolation of child is NOT necessary except when hospitalized, suspected parovirus infection - Droplet + standard precautions - Pregnant women need not be excluded from workplace where parovirus infection is present though they should NOT care for patients with aplastic crises

Measles (Rubeola) Nursing Care

- Isolation until 5th day of rash - Airborne precautions - Rest during prodromal stage - Antipyretics - Dim lights if photophobia present - Clean eyelids with warm saline - Keep child from rubbing eyes - Coryza, cough: use cool mist vaporizer; protect skin around nares with layer of petrolatum - Encourage fluids + bland foods - Keep skin clean - Tepid baths

Nursing Care of Conjunctivitis

- Keep eye clean - Remove secretions from wiping inner to outward, away from opposite eye - Warm, moist compresses to remove crusts - Compresses are NOT kept on eye as that promotes bacterial growth - Instill meds immediately after cleaning eyes - Keep child's washcloth + towel separate from those used by others - Discard tissues used to clean eye - Instruct child not to rub eyes + to wash hands often

Factors that INCREASE Iron Absorption

- LOW pH - Administer iron BETWEEN meals - Administer iron WITH Vitamin C to enhance absorption - Vitamin A - Tissue (cellular) need - Meat, poultry, fish - Cooking in cast iron pots

Adolescent Response to Pain

- Less vocal with less physical resistance - More in verbal expressions such as "it hurts" or "you're hurting me" - Increased muscle tension + body control

Preschool Preconventional or Premoral Level (Kohlberg)

- Little, if any, concern about WHY something is wrong - Children judge weather an action is good or bad based on wheather it results in a reward or punishment - If punished, the act is bad - If not punished, the act is good - NAIVE INSTRUMENTAL ORIENTATION from 4-7 years old. Actions are directed toward satisfying their needs + less frequently, the needs of others. Have a concrete sense of justice + fairness - Development of conscience is strongly linked to spiritual development

Physical Signs of Approaching Death

- Loss of sensation + movement in the lower extremities, progressing towards upper body - Sensation of heat, although the body feels cool - Loss of senses - Tactile sensation decreasing - Sensitivity to light - Hearing is last sense to fail - Confusion, loss of consciousness, slurred speech - Muscle weakness - Loss of bowel + bladder control - Decreased appetite + thirst - Difficulty swallowing - Change in respiratory pattern - Cheyne-Stokes respirations (waxing + waning of depth of breathing with regular periods of apnea) - "Death rattle" (noisy chest sounds from accumulation of pulmonary + pharyngeal secretions) - Weak, slow pulse - Decreased BP

Serious Conjunctivitis Signs

- Loss of vision - Ocular pain - Photophobia - Exophthalmos (bulging eyeball) - Decreased ocular mobility - Corneal ulceration - Unusual patterns of inflammation (perilimbal flush)

Rectal Administration

- Lubricate suppository with warm water (water soluble jelly may affect absorptio) - Apex foremost - Using a gloved finger, quickly but gently insert the suppository into the rectum beyond both of the renal sphincters - Hold buttocks together firmly to relieve pressure on anal sphincter until urge to expel the suppository has passed, within 5-10 minutes

Nursing Interventions for Varicella

- Maintain standard, airborne + contact precautions until ALL lesions are crusted - For immunized child with mild breakthrough varicella, isolate until no new lesions are seen - Keep child away from susceptible individuals until vesicles have dried (usually 1 week from start) - Isolate high risk children from infected children - Skin care: give bath, change clothes + linen daily, administer topical calamine lotion - Apply mittens if child scratches - Keep child cool (may decrease number of lesions) - Remove loose crusts that rub + irritate skin - Teach child to apply PRESSURE to pruritic area instead of itching it - Avoid aspirin (possible association with Reye syndrome)

Reducing Distress form Otoscopy in Young Children

- Make examining the ear a game by explaining that you are looking for a "big elephant" in the ear. This kind of make believe is an absorbing distraction + usually elicits cooperation - After examining the ear, clarify that "looking for elephants" was only pretend + thank child for letting you look in their ear - Another great distraction is asking the child to put a finger on the opposite ear to keep the light form getting out - As you insert eh speculum into the meatus, move it around the outer rim to accoustom the child to the feel of something entering the ear 0 If examining a painful ear, examine the unaffected ear first, then return to the painful ear + touch a nonpainful part of the affected ear first. By this time, the child is usually less fearful of anything causing discomfort to the ear + will cooperate more.

Adolescent Understanding of Death

- Mature - Influenced by remnants of magical thinking + are subject to guilt + shame - Likely to see deviations from accepted behavior as reasons for their illness - Most difficulty coping with death - Least likely to accept cessation of life, particularly if it is their own - Concern for present much more than past or future - Adolescents orientation to the present compels them to worry about physical changes even more than the prognosis - Because of their idealistic view of the world, they may criticize funeral rites as barbaric, money making + unnecessary

Weight

- Measured with an electronic or appropriately sized balance beam scale, which measures to nearest 10 g (0.35 oz) for infants + 100 g (0.22 lb) for children - Before weighing, set scale to 0 - Infant scales are more accurate than adult platform scales - Newer scales tend to be more accurate than older ones - When precise measurements are necessary, 2 nurses should take weight independently; if there is a discrepancy, take a 3rd reading + use the MEAN of the measurements - Birth - 2 years or birth - 36 month charts, they should be weighted nude - If the child needs to wear a special device when weighing, note this when recording the weight - When weighing an infant, place your hand slightly ABOVE the infant to prevent them from accidentally falling off scale - Cover scale with clean sheet of paper between each child's measurement

Length

- Measurements taken when child is SUPINE - Also referred to as recumbent length - Taken until children are 2 years old + able to stand alone(36 months old if using a chart for birth to 36 months), measure recumbent length using a length board + 2 measures - Because of the normally FLEXED position during infancy, fully extend body by 1.) holding head at midline 2.) Grasping knees together gently 3.) pushing down on knees until legs fully extended + flat - Place head touching the headboard + footboard firmly against the heels of the feet - A tape measure should NOT be used to measure the length of infants + children due to inaccuracy + unrelability - Measure to nearest 1 mm or 1/16th inch - Two measurers are required to accomplish correct positioning; one measurer can be a parent to assist - Position head in Frankfort vertical plane (imaginary line from the lower order of the orbit through the highest point of the auditory meatus; the line is parallel to the headboard + perpendicular to the length board) - Reposition child + repeat procedure at least 2 times (ideally 3 times). Average measurements for final value

End Title Carbon Dioxide (ETCO2) Monitoring

- Measures EXHALED CO2 noninvasively - Capnometroy provides a numeric display + capnography provides a graph over time - Continuous capnometry is available + differs from pulse oximetry in that it is more sensitive to the mechanics of ventilation rather than oxygenation - Hypoxic episodes can be prevented through the early detection of hypoventilation, apnea or airway obstruction - NORMAL ETCO2 = 30-43 mm Hg, which is lightly lower than normal PCO2 values of 35-45 mm Hg - Values consistently < 15 mm Hg indicate ineffective compressions or excessive ventilation - Changes in waveform + numeric display follows changes in ventilaition by a few seconds + precede changes in respiratory rate, skin color + pulse ox values

MCV4

- Meningococcal Vaccine - Menactra: For children 9 months up - Menveo: For children 2 years up - IM injection (0.5 mL) - May be administered with other vaccines in a separate syringe and at a separate site - Contraindicated in those with hypersensitivity to diphtheria toxoid + rubber latex

School Age Biologic Development

- Middle years begin with shedding of first tooth + end at puberty - 6-12 years: grow 2 inches a year, gaining 1-2 feet in height + almost DOUBLE their weight, increasing 4.4-6.6 lbs per year - 6 years: 46 inches, 46 lbs - 12 years: 59 inches, 88 lbs - Decreased head circumfereence in relation to standing height - Increased leg length in relation to height - Heart is smaller in relation to the rest of the body than at any other period in life - Preadolescence = period begins toward end of middle childhood + ends at 13 - Prepubescense = 2 year period that precedes puberty - 2 years between girls + boys in age of onset of pubescence - Puberty = 10 in girls + 12 in boys, though it can be normal for either after 8 years

Rubella Vaccine

- Mild infection in children - In pregnant women, the infection presents serious risks to the developing fetus - The aim of rubella shots is the protection of the unborn child rather than the recipient of the shot - All children at 12-15 months old + age of school entry (4-6 years old) - Emphasis on all unimmuized, especially woman of childbearing age - The live attenuated virus may CROSS the placenta so it is NOT recommended for pregnant women - Women should not become pregnant for 28 days AFTER receiving the vaccine - MMR, MMRV vaccines

Birth History

- Mother's health during pregnancy - Labor + delivery - Infant's condition immediately after birth - Prenatal influences have significant effects on a child's physical + emotional development - Emotional factors also affect outcome of pregnancy - Investigate concurrent crises during pregnancy + prenatal attitudes toward the fetus - Approach the topic of parental acceptance of pregnancy through indirect questioning

NPASS

- Neonatal Pain, Agitation + Sedation Scale - Developed to measure pain or sedation in preterm infants after surgery - Measures 5 criteria in 2 dimensions (pain + sedation) - Used in neonates as young as 23 weeks up to infants 10 days old - Extra points are added in the pain scale dimension for preterm infants based on gestational age - Variables: Cry/irritability, behavior/state, facial expression, extremities/tone, vital signs (HR, RR, BP, SaO2) - Sedation score: 10 = deep sedation, 0 = no sedation - Pain score: 10 = intense pain, 0 = no pain

Infants Rolling Over Development

- Newborns roll over accidently - 5 moths turn from abdomen to back - 6 months turn from back to abdomen - Infants put to sleep on sides may easily roll over to prone (face-down) position, thus placing them at higher risk of sudden infant death syndrome. Therefore it is important to place infants in SUPINE position for sleep

Rubella (German Measles) Therapeutic Management

- No treatment other than antipyuretics + analgesics for comfort

NCCPC-PV

- Non-Communicating Children's Pain Checklist-Postoperative Version - Pain measurement tool specifically designed for children with cognitive impairments. - Discriminates between periods of pain + calm + predict behavior during subsequent episodes of pain. - Consists of 6 subscales (vocal, social, facial, activity, body limbs, physiologic signs), which are scored based on the number of TIMES the items are observed over a 10 minute period. (0 = none, 3 = very often). - Used for children ages 3-18 years old, who are unable to speak because of cognitive (mental/intellectual) impairments or disabilities - Can be used WEATHER OR NOT a child has physical impairments or not - Intended for use for pain after surgery or due to other procedures - If pain is suspected for a child at home the NCCPC should be used - Based off observations for 10 minutes - NOT necessary to watch the child continuously for this period but it is recommended that the observer be in the presence of the child for the majority of the time - N/A scores as 0 Pg. 122

Exanthem Subitum (Roseola Infantum) Therapeutic Management

- Nonspecific - Antipyretics

Special Considerations when Taking Height

- Normally height is LESS when taken in afternoon - Normally height is MORE when taken in morning - Time of day should be recorded when measurements are taken - For children in whom there are concerns about growth, serial measurements should be taken at SAME time of day to establish an accurate growth velocity

Ocular Alignment

- Normally, between 3-4 months old, children are able to fixate on one visual field with both eyes simultaneously (binocularity) - IN STRABISMUS or cross eye, one eye deviates from the point of fixation. The brain eventually suppresses the image produced by that eye. If not detected + corrected by 4-6 years old, blindness from disuse, known as AMBLYOPIA may result

Head + Neck Assessment

- Observe for general shape + symmetry - A flattening of one part of the head, such as the occiput, may indicate that the child continually lies in this position - Palpate the skull for patent sutures fontanels, fractures + swelling - Normally, the posterior fontanel closes by 2 months old. The anterior fontanel fuses between 12 - 18 months old. Early or late closure is noted - Hyperextention of the head (opistootonos) with pain on flexion is a serious indication of meningeal irritation + should be reported to provider immediately

Febrile Seizures

- Occur in 3-4% of all children - Do not use antipyretics or anticonvulsants to prevent a second febrile seizure; nursing intervention should focus on ways to provide comfort and care during febrile illness - Simple febrile seizures lasting less than 10 minutes do NOT cause brain damage or other debilitating effects

Exanthem Subitum (Roseola Infantum) Clinical Manifestations

- Persistent high fever > 103 degrees for 3-7 days in a child who appears well - Precipitous DROP in fever to normal with appearance of rash - Bulging fontanel - RASH: discrete rose-pink macules or maculopapules appearing first on trunk, then spreading neck, face + estremities; nonpruritic; fades on pressure; lasts 1-2 days - Associated with cervical + postauricular lympahdenopathy, inflamed pharynx, cough, coryza

Pertussis (Whooping Cough) Complications

- Pneumonia (usual cause of death in younger children) - Atelectasis - Otitis media - Seizures - Hemorrhage (secleral, conjunctival, epistaxis, pumonary hemorrhage in neonate) - Weight loss - Dehydration - Hernias (umbilical + inguinal) - Prolapsed rectum - Syncope - Sleep disturbance - Rib fractures - Incontinence - Pneumonia

Infant Maturation of Systems

- Respiratory rate slows + is stable - Respiratory movements are abdominal - Close proximity of trachea to the bronchi RAPIDLY transmits infectious agents from one location to another, making them more vulnerable to respiratory problems - Straight eustachian tube allows infection to spread from the pharynx to the middle ear - Heart rate slows, called Sinus Arrhythmia (rate increases with inspiration + slows with expiration) - Liver is most IMMATURE of all GI organs. Ability to conjugae bilirubin + secret bile within first few weeks. However geluconeogenesis, plasma protien formation, ketones, storage of vitamins + deaminization of amino acitds remain immature for first year of life - Immaturity of renal structures predisposes the infant to dehydration + electrolyte imbalance. - Complete maturity of kidenys occurs during latter half of the 2nd year, which si when the cuboidal epithelium of the glomeruli becomes flattened - Urine is voided frequently has a low specific gravity (1.008-1.012) - Most infants secrete 15-40mL/kg/24 hours - An output < 0.5 mL/kg/hour after 48 hours of age is considered oliguira - Auditory acutiy is at adult levels AT BIRTH

Growth Charts

- Series of percentile curves to demonstrate the distribution of body measurements in children - CDC + WHO have recommends that standards be used to monitor growth between ages 0-2 - Because breastfeeding is the recommended standard for infant feeding, the WHO growth charts reflect growth patterns of children who are still breastfeeding at 12 months old - CDC growth charts are used for children age 2+ - Normal growth patterns vary among children of same age

Blood Pressure

- Should be measured annually in children > 3 years - Ascultation remains the gold standard method of BP measurement in children - In infants, automated devices are acceptable because auscultation is difficult - Oscillometric devices measure mean arterial BP + then calculate systolic + diastolic values - Dinamap is generally HIGHER (10 mm Hg higher) than measurements using auscultation

Nutrition During Infancy

- Should begin prenatally with maternal intake - Solid foods should not be introduced until 4-6 months old - Childhood obesity is decreased when breastfeeding is continued + solid food introduced after 4 months old

Chief Complaint

- Specific reason for the child's visit to the clinic, office or hospital - Elicit the chief complaint by asking open ended, neutral questions: "what seems to be the matter?" - Avoid labeling type questions: "how are you sick?" or "what is the problem?" as it is possible that the reason for the visit is not an illness or problem

Nursing Interventions for Diptheria

- Standard + droplet precautions until 2 cultures are negative for C. diptheriae - Administer antibiotics - Maintain bed rest - Use suctioning as needed - Observe respiration for signs of obstruction - Administer humidified oxygen as prescribed

Nonpharmacologic Strategies for Pain Management in Preterm + Newborn Infants

- Surcrose is a safe + effective in reducing pain during needle stocks in neonates - Facilitated tucking - Kangaroo care

Aphthous Stomatitis

- Type of stomatitis - Canker sore - Benign but PAINFUL whose cause is UNKNOWN - Onset associated with mild traumatic injury such as: biting cheek, hitting with toothbrush, allergy or emotional stress - Painful, small, whitish ulcerations surrounded by a red border - Distinguished from other types of stomatitis by HEALTHY adjacent tissues, absence of vesicles + no systemic illness - Ulcers persist for 4-12 days + heal uneventfully

Growth + Development Assessment

- Weight, length + head circumference at birth - Patterns of growth on the growth chart + any significant deviations from previous percentiles - Concerns about growth from the family or child - Developmental milestones

Early Childhood Caries

- tooth decay from 18 months - 3 years - considered an INFECTIOUS DISEASE as caused by Streptococcus mutans

How far to advance the Otoscop in children?

0.23 to 0.5 inches

Most Restrictive Child Restraints

- 1-4 limbs - Mummy restraint - Papoose board - Seclusion - Chemical

Infants Sitting Development

- 2-3 months back is uniformly rounded - 3-4 moths convex cervical curve forms - 4 months convex lumbar curve when child begins to sit - 7 months can sit alone - 8 months sit while unsupported - 10 months can maneuver from a prone to sitting position

Preschooler Physical Development

- 3 years, 32 lbs + 37.5 inches - 4 years, 36.8 lbs + 40.5 inches - 5 years, 41.5 + 43.5 inches - Yearly weight increase of 4.5-6.5 lbs - Yearly height increase of 2.5-3.5 inches - Can ride a tricycle, walk on tiptoe, balance on one foot for a few seconds + do broad jumps - 4 years, catch a ball reliably - 5 years, skip on alternate feet + jump rope + begin to skate + swim

Restraints for Children

- < 9 years = reordered every 1 hour - 9-17 years = reordered every 2 hours - 18+ = reordered every 4 hours - Children in behavioral restraints must be observed + assessed according to facility policy, typically continuously, every 15 minutes, or every 2 hours.

Ages + Stages

- A term used to broadly outline key periods in the human development timeline - During each stage, growth + development occur in the primary developmental domains, including physical, intellectual, language + socio-emotional - Ages + Stages Questionares (ASQ) are high quality screening tools that include 19 age specific surveys that ask parents about developmental skills common in daily life for children 1 month to 5 1/2 years old - Parentsl

Teaspoon for Oral Meds

- An inaccurate measuring device

Mumps Therapeutic Management

- Analgesics for pain - Antipyretics for fever - IV fluid for child who refuses to drink or vomits because of meningoencephalitis

Influenza Vaccine

- Annually for children 6 months - 18 years - IIV )inactivated influenza vaccine) - May be given to any healthy children age 6 months + older - Administered in early Fall before flu season begins - IM shot in 2 separate doses 4 weeks apart in first time recipients younger than 9 years old - Dose is 0.25 mL for children 6-35 months old - Dose is 0.5 mL for children 3 years and up - Intradermal form of IIV for persons 18-64 years old - May be given simultaneously with other vaccines but in a separate syringe + at a separate site - Administered yearly as different strains of flu are used each year - An assessment of the egg allergenic reaction (mild to severe) should be given prior for those who have a history of egg allergy - LAIV (live attenuated influenza vaccine) is an alternative to the IM trivalent vaccine. Given as 2 doses at least 28 days apart in healthy persons 2-49 years old. NOT recommended for children 2-4 years old with weezing in the previous 12 months, those with asthma or those with underlying medical conditions that predispose them to complications - Yearly flu vaccine given for children 6-59 months old with medical conditions: asthma, cardiac disease, diabetes, HIV, sickle cell

Immunobiologic

- Antigenic substances or antibody containing preparations from human or animal donors for active or passive immunization or therapy - Vaccines + toxoids

Developmental Disability

- Any significant lag or delay in a child's physical, cognitive, behavioral, emotional or social development when compared against developmental norms - In absence of clear cut evidence of a cognitive impairment, it is more appropriate to use diagnosis of developmental disability

Dyslalia

- Articulation problems with speech - Revert to using infantile speech - Occurs when children are pressured into producing sounds ahead of their developmental level

Congenital Anomalies

- Birth defects, occur in 2-4% of births - Classified as deformations, disruptions, dysplaisas or malformations - Insults during development or abnormalities in differentiation or in the proper timing of organogenesis may result in a variety of congenital anomalies

Facies

- Child's facial expression + appearance - Give clues to when they are in pain, have difficulty breathing, feel frightened, discontended or unhappy, mentally delayed or acutely ill

Sibling Grief

- Children grieve differently than adults - Children of all ages grieve the loss of a loved one + depend on their developmental level - Children grieve for a LONGER duration, revisiting their grief as they grow + develop new understandings of death - They do not grieve 100% of the time - Express their grief through play + behavior - Can be exquisitely attuned to their parent's grief + will try to protect them by not asking questions or by trying not to upset them

Umbilical Hernias

- Common in infants, especially in African American children

Kinrix

- DTaP + IPV - May be used as the 5th doe of DTap + the 4th does of IPV series in children

Toddler Psycosocial Development

- Differentiation of self from others, particularly the mother - Toleration of separation from parent - Ability to withstand delayed gratification - Control over bodily functions - Acquisition of socially acceptable behavior - Verbal means of communication - Ability to interact with others in a less egocentric manner

Diptheria Treatments

- Equine antitoxin preceded by skin or conjunctival test to rule out sensitivity to horse serum - Antibiotics (Penicillin G or erythomycin) in addition to equine antitoxin - Bed rest - Tracheostomy for airway obstruction

3 Types of Transmission Precautions

1.) Airborne 2.) Droplet 3.) Contact

2 Type of Coping Mechanisms in Caring for Children with Chronic Conditions

1.) Approach Behaviors 2.) Avoidance Behaviors

3 Components of an Intellectual Disability

1.) Intellectual functioning: determined by IQ score of 70 and below or as high as 75 2.) Functional strengths + weaknesses: such as communication, self care, home living, social skills, leisure, health + safety, self direction, academics, community use + work 3.) Younger than age 18 at time of diagnosis

Poliomyelitis

AGENT: 3 enteroviruses: Type 1 (most frequent cause of paralysis) Type 2 + Type 3 SOURCE: Feces + oropharyngeal secretions TRANSMISSION: Direct contact with infected person; spread fecal oral + pharyngeal-oropharyngeal routes, VACCINE-AQUIRED is no longer issue in US INCUBATION: Usually 7-14 days with range of 5-35 days PERIOD OF COMMUNICABILITY: Not known, virus present in throat + feces shortly after infection + persists for 1 week in throat + for 4-6 weeks in feces

Recommended Temp Taking Sites in Birth to 2 Years Old

Axillary Rectal (if definitive temp is needed for infants older than 1 month)

Infant Stranger Fear

Develops between 6-8 months

Mature Minor

Exception to consent laws is recognized in a few states for children 14 years and older who can understand all elements of informed consent + make a choice based on the information; legal action may be required for designation as a mature minor.

Teeth with Caries

Excess carbohydrates

Teeth brown mottling, pits, fissures

Excess flouride

Polydactyly

Extra digit

Droppers for Oral Meds

Inaccruate

Hot Water Scalds

Most frequent in toddlers

Allen Test

Procedure that assesses the circulation of the radial, ulnar or brachial arteries

Calcified Tympanic Membrane (hearing loss)

Related to EXCESS vitamin D

Boostrix

Tdap for children 10-18 years old

Macrominerals

Those with daily requirements above 100mg calcium, phosphorus, magnesium, sodium, potassium, chloride, sulfer

Micronutrients

Those with daily requirements under 100mg trace elements

When do children FAIL hearing test?

When they cannot hear the tones at 20 dB

Cognitive Impairment Profound IQ

below 20-25

How to treat rash

on ppt

How much toothpaste for a toddler < 3?

smear or rice sized place along NARROW width of toothbrush rather than its length

Avoid using the term ______________ when measuring the vital signs of young children

"take" as they may think that it will be literally taken away

Upper Arm Circumference

- Correlated with measurements of total muscle mass - Muscle serves as the body's major protein reserve, this measurement is considered an index of the body's protein stores

Assessment of Pain in Children with Communication + Cognitive Impairment

- Crying, being less active, seeking comfort, not cooperating, being stiff, irritability, agitated, fidgety, flinching, moving body part away, moaning, inconsistent patterns of play + sleep, changes in facial expression + other physical problems that may mask expression of pain + be difficult to interpret - FLACC observational pain scale uses a behavioral approach that observes the child's face, legs, activity, cry + consoability + is supported for use in clinical practice for children with cognitive impairment - NCCPC is a pain measurement tool specifically designed for children with cognitive impairments. Discriminates between periods of pain + calm + predict behavior during subsequent episodes of pain. Consists of 6 subscales (vocal, social, facial, activity, body limbs, physiologic signs), which are scored based on the number of TIMES the items are observed over a 10 minute period. (0 = none, 3 = very often). Pg. 122

FTT Diagnostic Evaluation

- Diagnosis made from evidence of growth failure - If FTT is recent, the weight, not the height is below accepted standards; if FTT is longstanding, both weight + height are low, indicating chronic malnutrition - Complete health + diet history, physical exam for organic causes, developmental assessment, family assessment - 24 food intake history for 3-5 days - To avoid stigma during early phase, some use the term Growth Delay until diagnosis is established

Chest Exam

- During infancy, the chest is almost circular, with the anteroposterior (front to back) diameter EQUALING the transverse direction, causing the anteroposterior diameter to be LESS than the lateral diameter - Note the angle made by the lower costal margin + the sternum + palpate the junction of the ribs with the costal cartilage (costochondral junction) + sternum, which should be fairly smooth

Emergency Management of Anaphylaxis

- Epinephrine 0.001 mg/kg up to MAX of 0.3 mg - EpiPen Jr (0.15 mg) IM for child weighing 8-25 kg (17.5-55 lbs) - EpiPen (0.3 mg) IM for child weighing 25 mg (55 lbs) or more - Observe for adverse reactions such as tachycardia, hypertension, irritability, headaches, nausea + tremors

Diastasis Recti

- Failure of the rectus abdominis muscles to join in utero - A midline protrusion from the xiphoid to the umbilicus or symphysis pubis

Infant Hematopoietic Changes

- Fetal hemoglobin present for 1st 5 months, then replaced with adult hemoglobin - Fetal hemoglobin results in a shortened survival of RBCs + thus a decreased number of RBCs and physiologic anemia commonly results at 3-6 months old. A time when maternally derived iron stores also gradually diminish

Clinical Manifestations of Failure to Thrive

- Growth failure - Developmental delays: social, motor, adaptive, language - Undrenutrition - Apathy - Withdrawn behavior - Feeding or eating disorders: vomiting, feeding resistance, anorexia, pica, rumination - No fear of strangers (at age when stranger anxiety is normal) - Avoidance of eye contact - Wide eyed gaze + continual scan of the environment ("radar gaze") - Stiff + unyielding or flaccid + unresponsive - Minimal smiling

Total Body Surface Area (TBSA)

- How burns are assessed based off a percentage of body burned - Estimated by using specially designed age-related charts - 10% TBSA can be life threatening if not treated correctly

Palpable Liver

- If the liver is palpable 1.2 inches BELOW the right costal margin or the spleen is palpable more than 0.8 inch below the left costal margin, it is ENLARGED - Must be reported to provider immediately

Core Temperature

- Most closely reflects the temp of the blood flow through the carotid arteries to the hypothalamus - Relatively constant despite wide fluctuations in the external environment - Pulmonary artery is closest to the hypothalamus + best reflects core temp

Measles (Rubeola) Complications

- Otitis media - Bacterial pneumonia - Obstructive laryngitis - Laryngotracheitis - Encephalitis (rare but high mortality)

School Age Play

- Rules + rituals - Team play - Quiet games + activities - Ego mastery

School Age Understanding of Death

- Still associate misdeeds or bad thoughts with causing death + feel intense guilt + responsibility - Respond well to logical explanations + comprehend the figurative meaning of words - Fear the mutilation + punishment they associate with death - Personify death as the devil, a monster or bogeyman - Naturalistic or physiologic explanations of death - By 9-10 years old, they have an adult concept of death, realizing that it is inevitable, universal + irreversible - Fear of unknown is greater than fear of known - Interested in post death services - Because children's fear of the unknown, anticipatory preparation is important - Because the developmental task of this age is INDUSTRY, help children maintain control over their bodies + increase understanding to allow them independence, self worth + self esteem + aboid a sense of inferiority

Erythema Infectiosum (Fifth Disease) Therapeutic Management

- Symptomatic + supportive - Antipyretics, analgesics, antiinflammatorys - Blood transfusion for aplastic anemia

Windup Phenomenon

- attributed to a decreased pain threshold + chronic pain - Central + peripheral mechanisms that occur in response to noxious tissue injury have been studied in an attempt to explain a prolonged neonatal response to pain characteristic of the windup phenomenon - After exposeure to noxious stimuli, multiple levels of the spinal cord experience an altered exitability. This altered excitability may cause non-noxious stimuli, such as routine nursing care + handling, to be PRECEIVED as noxious stimuli

4 Types of Conjunctivitis

1.) Bacterial ("pink eye") 2.) Viral 3.) Allergic 4.) Caused by a foreign body

2 Components of Prevention

1.) Preventing disease 2.) Control its spread to others

Pertussis (Whooping Cough)

AGENT: Bordetella pertussis SOURCE: Discharge form respiratory tract TRANSMISSION: Direct contact or droplets INCUBATION: 6-20 days, usually 7-10 days PERIOD OF COMMUNICABILITY: Greatest during prodromal (Catarrhal) stage before onset of paroxysms

Feeding During 1st Year

Before 6 months = breastfeed 4-12 months = solid food 4-6 months = cereal 6-8 months = fruits + vegetables 8-10 months = meat 12 months = eggs + cheese

Normal Abdomen of Older Children

Flat

ProQuad

MMRV 12 months - 12 years

Tongue Glossitis

Niacin, riboflavin, folic acid deficiency

What is an unsuitable way to administer oral meds?

Paper cups

Crackes

Passage of air through fluid or moisture

Attenuate

Reduce the virulence of a pathogenic microbe by such measures as treating it with heat or chemicals or cultivating it on a certain medium

After 6 months old, significant head lag strongly indicates _______________________________.

cerebral injury

Greenish black teeth

may be stained temporarily from ingestion of supplemental iron

4 Components of Present Illness

- "Illness" is used in broadest sense to denote ANY problem of a physical, emotional or psychosocial nature 1.) Onset 2.) Complete interval history 3.) Present status 4.) Reason for seeking help now

Early Intervention

- Any sustained + systemic effort to assist develpmentally vulnerable or disabled children from birth to 3 years old - Assisted with passage of Education for Handicaped Children Acts

Empathy

- Capacity to understand what another person is experiencing from within that person's frame of reference - Put oneself in another's shoes - Accurately understanding another person's feelings

Teething

- Erupion of the deciduous (primary, baby) teeth - First teeth to erupt are the lower central incisors between 6-10 months - Next teeth are the upper central incisiors - Age of child in months - 6 = number of teeth - ex. 8 months = 2 teeth - Teething is a psysiologic process - Some discomfort is common as the crown of the tooth breaks through the periodontal membrane - Some shoe minimum evidence of teething, such as drooling, increased finger sucking or biting on hard objects. Others are irritable, have trouble sleeping, ear rubbing and decreased interest in solid foods - Fever, vomiting or diarrhea are NOT symptoms of teething - Because teething pain is a result of inflammation, cold is soothing - A frozen teething ring helps relieve inflammation - Benzocaine is a topical anesthetic but may case a RARE serious disorder called methemoglobinemia - Analgeicis (tylenol, aspirin) can be given for no more than 3 days

Pseudostrabismus

- False impression of misalighment during CORNEAL LIGHT REFLEX - May be caused by EPCANTHAL FOLDS

Pediarix

- For use in children as young as 6 weeks old - Combination vaccine - Contains: DTap (contains acellular pertussis), Hep B + IPV

Fourth-Degree Burns

- Full thickness burns that involve underlying structures, such as muscle, fascia + bone - Wound appears dull + dry + ligaments, tendons + bone may be exposed

Gingiva

- Gums - Color is coral pink with a STIPPLED texture, similar to an orange peel - In dark skinned children, the gums are more DEEPLY colored + a brownish area is often observed along the gum line

Vesticular Breath Sounds

- Heard over the entire surface of the lungs with the exception of the upper intrascapular area + area beneath the manubrium - Inspiration is louder, longer + higher pitched than expiration - Sound is SOFT, swishing noise

Second 6 Months Nutrition

- Human milk or formula shoudl be the primary source of nutrition - If breastfeeding is discontinued, a iron fortified formula should be substituted - Solid food may be introduced after 4-6 months as their GI tract has matured + teeth begin to erupt + the extrusion reflex has disappeared

Listening

- Most important component in effective communication - Purpose is to understand the person being interviewed - It is an active process that requires concentration + attention to all aspects of the conversation(verbal, nonverbal + abstract) - Major blocks are distraction + premature judgment

CRIES Tool

- Pain assessment tool for neonates - Valid for use in infants between the ages 32 weeks gestation up to 20 weeks postterm - Each is scored 0-2, with a total possible pain score of worst pain at 10 Crying Requiring increased oxygen Increased vital signs Expression Sleeplessness FOR POSTOPERATIVE PAIN: C = +1: high pitched crying +2: inconsolable crying R = +1: < 30% Ox +2: > 30% Ox I = +1: HR + BP increase < 20% of preoperative state +2: HR + BP increase > 20% of preoperative state E = +1: Grimace +2: Grimace, grunt S = +1: Wakes at frequent intervals +2: Constantly awake

Adequate Intake (AI)

- Part of Dietary Reference Intake (DRIs) - Based on estimates of nutrient intake by healthy individuals

Cremasteric Reflex

- Pulls the testes higher into the pelvic cavity - Stimulated by cold, touch, emotional excitement or exercise - Having the child sit indian style to prevent - It may also be prevented by placing the thumb + index finger over the upper part of the scrotal sac along the inguinal canal

Binuclear Family

- Refers to parents continuing the parenting role while terminating the spousal unit - The degree of cooperation between households + the time the child spends with each can vary - In joint custody, the court assigns divorcing parents EQUAL rights + responsibilities regarding the child - These alternate family forms are efforts to view divorce as a process of reorganization + redefinition of a family rather than as a family dissolution

Nursing Interventions for Scarlet Fever

- Standard + droplet precautions until 24 hours after initiation of treatment - Rest during febrile phase - Quiet activity during convalescent period - Relieve discomfort of sore throat with analgesics, gargles, lozenges, antiseptic throat sprays + inhalation of cool mist - Encourage fluids - Avoid irritating fluids such as citrus juices or rough foods (chips); when child is able to eat, begin with soft diet - Discard toothbrush; avoid sharing drinking + eating utensils

Nursing Interventions Exanthem Subitum (Roseola Infantum)

- Standard precautions - Administer antipyretics - Seizure precautions if prone to seizures

Depth Perception

- Steropsis - Begins to develop 7-9 months old but may not mature until 2-3 years old

Ear Canal in Children > 3 years

- The canal curves DOWNWARD + FORWARD - Pull pinna UP + back toward 10 o' clock

Viral Conjunctivitis Symptoms

- Usually occurs WITH an upper respiratory tract infection - Serous (watery) drainage - Infamed conjunctiva - Swollen Lids

Pentacel

- for infants 4 weeks old - Contains acellular pertussis, diptheria, tetanus, inactivated poliovirus + Hib conjugate

Toddler's 2 Piaget Phases

1.) Sensorimotor (12-24 months) 2.) Preoperational (2-7 years)

Measles (Rubeola)

AGENT: Virus SOURCE: Respiratory tract secretions, blood + urine TRANSMISSION: Direct contact with droplets, primarily in winter INCUBATION: 10-20 days PERIOD OF COMMUNICABILITY: 4 days before + 5 days after rash appears but mainly during the prodromal (catarrhal) stage

Recommended Needle Length for Toddlers and Older

DELTOID: 16 to 25 mm (5/8 to 1 inch) VASTUS LATERALIS: 25-32 mm (1 to 1 1/4 inches)

Tongue diminished taste sensation

Defiecnecy of zinc

Syndactyly

Fusion of digits

Arrhythmias

Magnesium + Potassium deficiency Excess Niacin + Potassium

Do genetics contribute to diseases?

Many if not most diseases are caused by a genetic predisposition that can be ACTIVATED by an environmental trigger. ex. PKU (phenylketonuria) is a disorder resulting from the (genetically determined) absence of an enzyme that metabolizes the amino acid phenylalanine. However, the deleterious effects in the infant are expressed ONLY after ingestion of phenylalanine containing substances such as milk (environmental trigger)

Analgesia of choice in Major Burns

Morphine sulfate IV Extensive distribution + is metabolized rapidly

Nonaccidental Burns Indicating Maltreatment

Most often seen < 3 years old

Mucous membranes stomatitis

Niacin deficiency

Emancipated Minor

One who is legally under the age of majority but is recognized as having the legal capacity of an adult under circumstances prescribed by state law, such as pregnancy, marriage, high school graduation, independent living or military service

What religion does not allow organ donation?

Orthodox Judaism

Inability to conserve

part of piaget's preoperational thought Inability to understand the idea that a mass can be changed in size, shape, volume, or length without adding to the original mass ex. give med in small cup as child will imagine that the larger vessel contains more med or give a large, flat cookie rather than a small one

TRANSDUCTIVE REASONING

part of piaget's preoperational thought Reasoning from the particular to the particular Child refuses to eat a food because something previously eaten did not taste good accept reasoning; offer refused food at a different time

Global Organization

part of piaget's preoperational thought Reasoning that changing any one part of the whole changes the entire whole Child refuses to sleep in their room because location of bed has changed accept child's reasoning; use same bed position or introduce change slowly

Centration

part of piaget's preoperational thought focuses on one aspect rather than considering all possible alternatives child refuses to eat a food because of its color even though its smell and taste are acceptable accept child's reasoning

Irreversibility

part of piaget's preoperational thought inability to undo or reverse the actions initated physically when told to stop dong something (such as talking) unable to think of a positive activity state requests or instructions POSITIVELY (such as "be quiet")

Magical Thinking

part of piaget's preoperational thought thinking thoughts are all powerful + can cause events child wishes someone died; then if the person dies, child feels at fault clarify that thoughts do not make something happen + the child is not responsible

If vital signs cannot be taken without disturbing the child, ________________________________, along with the measurement

record the child's behavior (ex. crying)

Plastic Hood Oxygen Administration

- 7 L/min necessary to maintain oxygen concentrations + remove CO2 - Oxygen delivery to infants - The humidified oxygen should NOT be blown into face

Contraindication

- A condition that INCREASES the risk for a serious adverse reaction - If a contraindication is present, the vaccine would NOT be administered

Respiration

- Count in same manner as adults - In infants, observe abdominal movements, as respirations are primarily diaphragmatic - Because the movements are irregular, count them for 1 full minute

Factors that DECREASE Iron Absorption

- High pH - Antacids - Phopsphates: milk should NOT be used for iron administration - Phytates (found in cereals) - Oxalates (found in many fruits + vegetables; spinach, sweet potatos, tomatoes, plums, currants + green beans) - Tannins (coffee, tea) - Tissue (cellular) saturation - Malabsorptive disorders - Distrubances that cause diarrhea or steatorrhea - Infection

24 Hour Recall

- Most common + easiest method of assessing dietary daily intake - The child or parent recalls every item eaten in last 24 hours + approximate amounts - Most beneficial when it represents a typical day's intake

Scarlet Fever Complications

- Peritonsillar + retropharyngeal abscess - Sinustitis - Otitis media - Acute glumerulonephritis - Acute rheumatic fever - Polyarthritis (uncommon)

Nursing Interventions Poliomyelitis

- Position to maintain alignment, prevent contractures or skin breakdown; use footboard to prevent footdrop + pressure mattress for prolonged immobility - Encourage child to preform ADLs - Promote early ambulation with assistive devices - Analgesics for maximum comfort during physical activity - High protein diet - Bowel management for prolonged immobility - Observe for respiratory paralysis (difficulty talking, inability to hold breath, shallow + rapid respirations) + REPORT TO PROVIDER

Bacterial Conjunctivitis "Pink Eye" Symptoms

- Purulent drainage - Crusting of eyelids, especially on awakening - Inflamed conjunctiva - Swollen lids

Food Diary

- Record of every food + liquid consumed for a certain number of days - Improves reliability of dietary recall - A 3 day record consisting of 2 weekdays + 1 weekend day is representative for most people - Providing specific charts can improve compliance

Somatitis Nursing Care

- Relief of pain - Prevention of spread - Drink bland fluids through a straw - Mouth care with a SOFT bristle toothbrush - Infection is autoinocuable, children should keep fingers out of the mouth - Very young children may require elbow restraints to keep fingers out of mough

Varicella Complications

- Secondary bacterial infections (abscesses, cellulitis, necrotizing fasciitis, pneumonia, sepsis) - Encephalitis - Varicella pneumonia - Hemorrhagic varicella - Thrombocytopenia

Taking Vital Signs on Infants

- Take respirations first (before the infant is disturbed) - Take pulse next - Measure temp last

Transpalmar Crease

- The two distal horizontal creases may be fused to form a single horizontal crease - Often seen in down syndrome

Red Reflex

- When the FUNDUS is immediately apparent - Intensity of the color increases in darkly pigmented individuals - A brilliant, uniform red reflex is am important sign as it rules out many serious defects of the cornea, aqueous chamber, lens + vitreous chamber - Any dark shadows or opacities are recorded as they indicate abnormality

Phases of Adjustment of Child's Chronic Disease Diagnosis

1.) Shock + denial 2.) Adjustment: overprotection, rejection, denial, gradual acceptance 3.) Reintegration + Acknowledgment

3 Leading Causes of Accidental Death in Infants

1.) Suffocation 2.) Motor vehicle injuries 3.) Drowning

Rubella (German Measles)

AGENT: Rubella virus SOURCE: Nasopharyngeal secretions, blood, stool + urine INCUBATION: 14-21 days PERIOD OF COMMUNICABILTY: 7 days before to 5 days after rash CONTITUTIONAL SIGNS + SYMPTOMS: Low fever, headache, malaise, lymphadenopathy

Alternative Temperature Taking Sites

Distal esophagus Urinary bladder Nasopharynx Skin Pulmonary Artery

Herbs Known to have Adverse Effects in Children

Ephedra Comfrey Pennyroyal

Sign of Phlebitis

Erythemia (redness) at insertion site. Pain may or may not be present.

Signs of Contact Dermatitis

Faint, transient erythemia ot massive bullae on an erythematous swollen base. Itching a constant symptom

Latency Period

Freud described middle childhood as the latency period, a time of tranquilty between the oedipal phase of early childhood + eroticism of adolescence

How long should a child use a car booster seat?

From 7-8 years old

Cheyne Stokes Respiration

Gradually increasing rate + depth with periods of apnea

Animism

part of piaget's preoperational thought Attributing lifelike qualities to inanimate objects child scolds stairs for making child fall down join child in scolding; keep frightening objects out of view

Toddler Language Development

- 1 year: 4 words - 2 years: 300 words - Ability to UNDERSTAND speech is much greater than number of words child can say - 1 year: one word sentences or holophrases. "Up" can mean "pick me up" or "look up here". 25% speech is understandable. - 2 years: multiword sentences by stringing 2-3 words together, "mama go bye bye" or "all gone". 60% speech is understandable - 3 years: put words together in simple sentences, begin to master grammatical rules, know their age + can count 3 objects correctly - Reading books together can further language development - Gestures precede or accompany each of the language milestones up to 30 months of age - After sufficient language development, gestures phase out + the pace of word learning increases

Preschool Language

- 2 years: 300 words - 5 years: 2100 words - 3-4 years old form sentences of about 3-4 words and include only the most essential words to convey a meaning - Speech is often termed TELEGRAPHIC for its brevity - 3 years: ask many questions + use plurals, correct pronouns + past tense for verbs - From 4-5 years, use longer sentences of 4-5 words + use more words to convey a message, such as prepositions, adjectives + a variety of verbs

Separation Anxiety of Infant

- 4-8 months old, infants progress through the first stage of separation individuation + begin to have some awareness of themselves + their mothers as separate beings - At the same time, object permanence is developing + infants are aware that their parents can be absent. Therefore, separation anxiety develops + is manifested through a predictable sequence of behaviors - During the early second half of the first year, infants protest when placed in cribs, and a short time later, object to when their mothers leave the room. Infants may not notice the mother's absence if they are absorbed in an activity. When they realize their absence, they protest. From this point, they are alert to her wherabouts. By 11-12 months old they are able to anticipate her departure by watching her behaviors + begin to protest BEFORE she leaves

1 Month Old Growth + Development

- 5-7 oz weight gain a week, 1st 6 months - 1 inch height gain a month, 1st 6 months - 0.5 inch head circumference gain a month, 1st 6 months - Primitive reflexes present + strong - Doll's eye reflex + dance reflex fading - Obligatory nose breathing - Assumes flexed position with pelvis high but knees not under abdomen when prone (at birth, knees flexed under abdomen) - Can turn head from side to side when prone; lifts head momentarily - Marked head lag, especially when pulled from lying to sitting - Holds head momentarily parallel + in midline when suspended in prone position - Assumes asymmetric tonic neck flex position when supine - When held in standing position, body is limp at knees + hips - In sitting position, back is uniformly rounded, with absence of head control - Hands predominently colosed - Grasp reflex strong - Hand clenches on contact with rattle - Able to fixate on a moving object of 45 degrees - 20/100 visual acuity - Follows light to midline - Quiets when hears voice - Small, throaty sounds, comfort sounds when feeding - Sensorimotor phase stage 1 - Watches parent's face intently when talking

Preschooler Nutrition

- 90 kcal/kg - 1000-1800 calories - Fluid: 100 mL/kg - Protein: 13-19 g - Calcium 1-3 years old: 700 mg - Calcium 4-8 years old: 1000 mg - 4-6 oz fruit juice

Complicated Greif

- > 1 year later - Intense intrusive thoughts - Pangs of severe emotion - Distressing yearnings - Feelings of excessive loneliness + emptiness - Unusual sleep disturbance - Maladaptive levels of loss of interest in personal activities

How to most accurately measure oral meds?

- A hollowed handled medicine spoon - Measure the drug ordered in tsp in mL - 1 tsp = 5 mL

Association

- A nonrandom pattern of congenital malfromations for which a cause has NOT been determined - VACTERL (vetebral defects, anal atresia, cardiac defect, tracehoesophageal fistual + renal + limb defects)

Pulse

- A pulse can be taken RADIALLY in children > 2 years - In infants + those < 2 years, the APICAL IMPULSE (AI) is more reliable - Count pulse for a full 1 minute in children because of possible irregularities in rhythm - However, when frequent apical rates are necessary, use shorter counting times (15-30 seconds) - For greater accuracy, measure apical rate while child is asleep - Record the child's behavior along with the rate - Compare radial + femoral pulses at least ONCE during infancy to detect the presence of circulatory impairment such as coarctation of the aorta

Preschool Play

- ASSOCIATIVE PLAY: play in similar or identical activities but without rigid organization or rules - Imitative, imaginative + DRAMATIC play - Probably at no other time is the reproduction of adult behavior so faithful + absorbing as in the 4-5 year olds - At end of preschool period, children are less satisfied with make believe or pretend objects + enjoy doing the actual activity, such as cooking + carpentry - Make believe is a REALITY during play + only becomes fantasy when the toys are put away - Appearance of imaginary companions occurs between 2 1/2 to 3 years old - Children benefit from play that occurs between them + a parent. MUTUAL PLAY fosters development from birth through school years + provides enriched opportunities for learning.

FTT Nursing Care

- Accurate assessment of initial weight + height + daily weight, as well as recording of all food intake is imperative - Because part of the difficulty between parent + child is dissatisfaction + frustration, the child shold have a primary core of nurses. They can learn to percieve the child's cues + reverse cycles of dissatisfaction, especially in the area of feeding - First goal is to STRUCTURE the feeding environment to encourage eating - Health care providers may need to feed the child themselves to assess problematic feeding patterns - Nursing care must involve a "family systems" approrach. For the entire family to become healthy, each member must be helped to change.

When to introduce solid food to infants?

- Addition of solid foods before 4-6 months is NOT recommended - During early months, solid foods are not compatible with the availability of GI tract + infants nutritional needs - Feeding solids to young infants exposes them to food antigens that may produce food protein allergy - Introduction of foods other than maternal milk in first 6 months predisposes children to an increased risk for food allergy development - Foods known to be allergenic (peanuts, eggs, fish, seafood) should be introduced later than 9 months old - Developmentally, infants are not ready for solid food - Extrusion (protrusion) reflex is strong + causes them to push food OUT of the mouth - Infants instinctively SUCK when given food - Because of their limited motor abilities, infants are unable to push food away so feeding solid foods is sometimes seen as a forced feeding that may lead to predisposition of allergies, excessive weight gain and iron deficiency anemia

Reducing Stress of Burn Care Procedures

- Administer analgesics - Remind child of procedure + allow time to prepare - Allow child to test + approve temp of water - Allow child to select area of body to begin - Allow child to request short rest period during procedure - Allow child to remove dressings if desired - Provide child constructive to do during procedure (such as holding a package of dressings or roll of gauze) - Inform child when procedure is near completion - Praise child for cooperation

Preschooler Aggression

- Aggression refers to behavior that attempts to hurt a person or destroy property. - Differs from anger, which is a temporary emotional state, but anger may be expressed through aggression - Frustration, or the continual thwarting of self satisfaction by disapproval, humiliation, punishment, or insults, can lead children to act out against others as a means of release. Especially if they fear their parents, these children will displace their anger on others, particularly peers + other authority figures. Often applies to children who are well behaved at home but have a discipline problem at school - Modeling, or imitating behavior, is a powerful influecing force on preschoolers - Reinforcement can shape aggressive behaviors

FTT Therapeutic Management

- Aimed at reversing CAUSE of growth failure - Reversing malnutrition - Goal to provide sufficient calories to "catch up" growth- at a rate of growth greater than expected for age - Adding calories + multivitamin supplements - Any coexisting medical problems are treated - An interdisciplinary team of physician, nurse, dietitian, child life specialist, occupational therapist, pediatric feeding specialist + social worker or mental health professional - Family thereapy - Forster home placement - Hospitilization is indicated for : 1.) Evidence of (anthropometric) SAM 2.) Child abuse or neglect 3.) Significant dehydration 4.) Caretaker substance abuse or psychosis 5.) Outpatient management that does not result in weight gain 6.) Serious infection

Unsuitable Alternatives to Breastmilk

- All cow's milk (while, low fat, skim) - Other animal's milk - Imitation milk - They have limited digestibility, increased risk for contamination + lack of nutrients needed for appropriate growth - Whole milk can cause iron deficiency anemia in infants, possibly as a result of occult GI blood loss - Pasteruized cow's milk is dficient in C, iron, zinc + has a high renal solute load

Dead Space

- Allows fluid to remain in syringe + needle after the plunger is pushed completely forward - 0.2 mL of solution remains in standard needle. To minimize dead space: - When 2 drugs are combined in the syringe, always draw them up in the same order to maintain a consistent ratio between the drugs - Use same brand of syringe - Use one piece syringe units (needle permantely attached to syringe)

Corneal Reflex Test

- Also known as the Hirschberg test - Shine a flashlight directly in patients eyes from about 16 inches - If light falls OFF CENTER in one eyes, then the eyes are MISALIGNED - EPICANTHAL FOLDS (excess folds of skin that extend from the roof of the nose to the inner termination of the eyebrow that partially or completely overlap the inner canthus of the eye) may give a FALSE IMPRESSION of misalighmente (pseudostrabismus)

Ethical Principle of Double Effect

- An ethical standard that supports the use of interventions intended to relieve pain + suffering even though there is a forseeable possibility that death may be hastened An action that has one good (intended) and one bad (unintended but forseeable) effect is permissible if the following conditions are met: - Action itself must be good or indifferent. Only the good consequences of the action must be sincerely intended. - The good effect must not be produced by the bad effect - There must be a compelling or proportionate reason for permitting the forseeable bad effect to occur

Anal Reflex

- Anal wink - To assess the tone of the anal sphincter - Gently scratch the anal area to result in an obvious quick contraction of the external anal sphincter

Measles (Rubeola) Therapeutic Management

- Antipuretics - Bed rest - Antibiotics to prevent secondary bacterial infection - Administer Vitamin A: 200,000 units for children 12 months older, 100,000 for children 6-11 months old, 50,000 units children less 6 months

Fever Controlling Measures

- Antipyretics: NSAIDs and Tylenol - Wearing minimum clothing - Exposing skin to air - Reducing room temp - Increasing air circulation - Applying cool, moist compresses to skin (forehead) are effective approximately 1 hour AFTER giving antipyretics so that the set point is lowered - Cooling procedures (sponging or tepid baths) are INEFFECTIVE in treating febrile children (these measures are effective for hyperthermia) either when used alone or in combination with antipyretics + they cause considerable discomfort

Cognitive Impairment

- Any type of intellectual disability - Intellectual disability replaced the term "mental retardation" - Diagnosis is usually made AFTER there is suspicion that the child's developmental progress is delayed - High index of suspicion for developmental delay + behavioral signs needed for early diagnosis - In absence of clear cut evidence of a cognitive impairment, it is more appropriate to use diagnosis of developmental disability

Toddler Nutrition

- As growth rate slows, the need for calories protien + fluid decrease - Protein: 13 g day - 3 meals + 2 snacks - At approximately 18 months old, most toddlers manifest this decreased nutritional need with a decreased appetite, a phenomenon known as PHYSIOLOGIC ANOREXIA. They become picky, fussy eaters with strong taste references. - May eat large amounts one day and almost nothing the next - If the plate is overfilled, they are likely to push it away, overwhelmed by the size - Mealtime more closely associated with psychological components than with nutritional ones - Eat with fingers + enjoy foods of different colors + shapes - RITUALISM dictates certain principles in feeding practices. Like to have same dish, cup or spoon every time they eat. May reject favorite food as its served on different dish. - If one food touches another, they often refuse to eat - At 12 months old, most eat the same foods as rest of family - Most cannot use spoon until 18 months old - Grazing (nibbling + snacking) good way to ensure proper nutrition - 1 tbs of solid food per year of age, or 1/3-1/4 of adult portion - Interest in food parallels a growth spurt - Plan a nutritionally balanced WEEK instead of day as toddlers may restrict food intake

Toddler Temper Tantrums

- Assert their independence by violently objecting to discipline - An indication of the child's inability to control emotions - Prone to tantrums because their strong drive for mastery + autonomy is frusterated by adult figures or lack of motor + cognitive skills - Requires consistency + developmentally appropriate expectations + rewards - During tantrums, stay calm + IGNORE behavior, provided that it does not injury the child. Continue to be present to provide a feeling of control + security to the child when the tantrum has subsided. - During period with NO tantrums, practice developmentally appropriate positive reinforcement - Can be sign of serious problems. If last past 5 years old, longer than 15 minutes, occur more than 5 times a day are considered abnormal + may indicate a serious problem

If Child Refuses to Cooperate With Physical Assessment

- Assess reason for uncooperative behavior; consider that the child who is afraid may of had a traumatic experience - Try to involve child + parent in process - Avoid prolonged explanations about examining procedure - Use a firm, direct approach regarding expected behavior - Perform exam as quickly as possible - Have attendant gently restrain child - Minimize any disruptions or stimulation - Limit number of people in a room - Use isolated room - Use quiet, calm, confident voice

Toddler's Piaget Preoperational Phase

- At 2 years, enter the PRECONCEPTUAL phase (subdivison of the Preoperational Phase), which lasts until about 4 years old - Preconceptual Phase is primarily one of transition that bridges the purely self satisfying behavior of infancy + the rudimentry socialized behavior of latency - Preoperational Thinking implies that children cannot think in terms of operations: the ability to manipulate objects in relation to each other in a logical fashion. Rather, they think in the basis of THEIR perception of the event. - Problem solving based on what they see or hear directly rather than on what they recall about objects + events - Within second year, increasingly uses language symbolically + is concerned with the "why" and "how" of tings.

Toddler's Erickson Stage

- Autonomy vs. Shame + Doubt - Negativism + ritualism are typical of toddlers in their quest for autonomy - As toddlers attempt to express their will, they often act with negativism, giving a negative response to requests - Ritualism, the need to maintain sameness + relability, provides a sense of comfort - Development of the Ego becomes evident when they are able to tolerate delayed gratification - Rudimentry beginning of the Superego

Physical Exam of Infant

- Before able to sit alone: supine or prone in parent's lap; before 4-6 months, can place on exam table - After able to sit alone: sit in parents lap whenever possible; if on table, place within parent's view - Exam head to toe - Elicit reflexes as body part examined - Perform traumatic procedures LAST (Eyes, ears, mouth) - Elicit Moro Reflex LAST - Leave diaper on male infant - Gain cooperation with distraction, bright objects, rattles + talking - Smile at infant - Use soft, gentle voice - Pacify with bottle of sugar water or feeding - Enlist parent's aid for restraining to examine ears, mouth - Avoid abrupt, jerky movements

5 Month Old Growth + Development

- Beginning signs of tooth eruption - Birth weight doubles - No head lag when pulled to sitting position - When sitting, able to hold head erect + steady - Able to sit for longer periods when back is well supported - Back straight - When prone, assumes symmetric positioning with arms extended - Can turn over from abdomen from back - When supine, puts feet to mouth - Able to grasp objects voluntarily - Uses palmar grasp, bi-dextrous approach - Plays with toes - Takes objects directly to mouth - Holds one cube while regarding a second one - Visually pursues a dropped object - Able to sustain visual inspection of an object - Can localize sounds made below ear - Squeals - Makes cooing vowel sounds interspersed WITH consonant sounds (ah-goo) - Smiles at mirror image - Pats bottle or breast with both hands - More enthusiastically playful but may have rapid mood swings - Able to discriminate strangers from family - Vocalizes displeasure when object is taken away - Discovers parts of body

8 Month Old Growth + Development

- Begins to show regular patterns in bladder + bowel elimination - Parachute reflex appears - Sits steadily unsupported - Readily bears weight on legs when supported; may stand holding onto furniture - Adjusts posture to reach an object - Has beginning pincer grasp using index, fourth + fifth fingers against lower part of thumb - Releases objects at will - Rings bell purposely - Retains 2 cubes while regarding 3rd cube - Secures an object by pulling on a string - Reaches persistently for toys out of reach - Makes CONSONATE sounds t, d, w - Listens selectively to familiar words - Utterances signal emphasis + emotion - Combines syllables, such as dada, but does not ascribe meaning to them - Increasing anxiety over loss of parent, particularly mother + fear of strangers - Responds to word "no" - Dislikes dressing, diaper change

School Age Child's Response to Pain

- Behaviors of young child, especially DURING actual painful procedure but less BEFORE procedure - Time wasting behavior such as "wait a minute" or "i'm not ready" - Muscular rigidity, such as clenched fists, white knuckles, gritted teeth, contracted limbs, body stiffness, closed eyes, wrinkled forehead

Preschool Understanding of Death

- Believe thoughts are sufficient to cause death; the consequence is the burden of guilt, shame + punishment - Egocentricity implies a tremendous sense of self power + omnipotence - Have some understanding on the meaning of death - Death is seen as a departure, a kind of sleep - No understanding of the universality + inevitability of death - Recognize the fact of physical death but do not separate it from living abilities - Death is seen as temporary + gradual; life + death can change places with one another - If they become seriously ill, they see the illness as some form of punishment - Feel guilt + responsible for death of a sibling - Greatest fear concerning death is separation from parents - If parent has died, encourage a consistent caregiver for child

12 Month Old Growth + Development

- Birth weight tripled - Birth length increased by 50% - Head + chest circumference EQUAL - 6-8 deciduous teeth - Anterior fontanel almost closed - Landu reflex fading - Babinski reflex disappears - Lumbar curve develops; lordosis evident during walking - Walks with one hand held - Cruises well - May attempt to stand alone momentarily; may attempt first step alone - Can sit down from standing position without help - Releases cube in cup - Attempts to build 2 block tower but fails - Tries to insert a pellet into a narrow necked bottle but fails - Can turn pages in a book, many at a time - Discriminates simple geometric forms (circle) - Amblyopia may develop with lack of binocularity - Can follow rapidly moving object - Controls + adjusts response to sound; listens for sound to recur - Says 3-5 words besides "mama" and "dada" - Comprehends meaning of several words (comprehension ALWAYS precedes verbalization) - Recognizes objects by name - Imitates animal sounds - Understands simple verbal commands ("give it to me" or "show me your eyes") - Shows emotion, such as jealousy, affection (may hug or kiss on request), anger, fear - Enjoys familar surroundings + explores away from parent - Is fearful in strange situation; clings to parent - May develop habit of "security blanket" or favorite toy - Increasing determination to practice locomotor skills - Searches for an object even if it has not been hidden but searches only where object was last seen

Administering Oral Meds to Infants

- Blowing a small puff of air in the face elicits a swallow reflex - Place dropper or syringe along the infant's tongue + administer the liquid slowly in small amounts, waiting for the child to swallow between deposits. - Meds NOT added to infants formula as the infant may later refuse the formula

Infant Vitamin D Deficiency Rickets Risks

- Breastfed by mothers with inadequate intake of vitamin D - Dark skin who are exposed to minimal sunlight - Those that live below a latitude of 33 degrees north + south where sunlight does not produce vitamin D - Children low in diets with vitamin D and calcium - Those that eat milk products not fortified with vitamin D - Obesity

Toddler Self Care

- By 15 months: feed themselves, drink from well covered cup, manage spoon with considerable spilling - 2 years: Use spoon well - 3 years: may use fork - Between 2-3 years, eat with family + like to help with chores such as setting the table but lack table manners + find it difficult to sit through entire meal - 15 months: putting arms or feet out for dressing + pulls of shoes + socks - 2 years: remove most articles of clothing + put on shoes + socks + pants. help needed to fasten clothes - Toddlers begin to develop concern for the feelings of others

Toddlers Dietary Guidelines Per Day

- Calories: 1000-1400 - Protein: 13 g - Dairy: 2-3 servings, 24-30 oz - Calcium: 500 mg - Iron fortified foods or supplements. 1 mg/kg - Vitamin D: 400 IU - 1 Cup Fruit - Vitamin C enhances iron absorption - 4-6 oz juice

Meningococcal Disease

- Cause of high morbidity in children - Infants younger than 1 year old are particularly susceptivle, yet the highest fatalities occur in adolescents - Risk of infection sis high in college freshmen living in dorms - May cause limb or digit amputation, skin scarring, hearing loss + neurologic disabilities - Nisseria meningitis is the LEADING CAUSE of bactreial meningitis in the US - Not recommended that children 9-10 years old - Children at increased risk of infection (HIV, immunocompromised, anatomic or functional asplenia) should receive the MCV4 vaccines (Menactra or Menveo) given at least 2 months apart - Children 2-18 years old who is at risk of an outbreak should recieve one dose of MCV4 (either Menveo or Menactra) - Children age 11-12 years old should receive a single dose of MCV4 (either Menactra or Menveo) + a booster at 16-18 years old - College freshmen in dorms + those in the military should receive a MCV4 dose

Herpetic Gingivostomatitis (HGS)

- Caused by HSV - May be a primary infection or be a recurrent herpes labialis - Cold sores, fever blisters - Primary infection usually begins with a fever; the pharynx become sedematous + erythematous; and vesicles erupt on the mucosa, causing severe pain. Cervical lymphadenitis often occurs and the breath has a distinctly foul odor - Vesicles appear on the lips - Cold sores can be cuase by emotional stress, trauma, immunosuppression or excessive sunlight - HSG usually caused by type 1 - Can last 5-14 days

Light Reflex

- Characteristic tenseness + slope of the tympanic membrane cause the light of the otoscope to reflect at about he 5 or 7 o'clock position - A well defined, cone shaped reflection, which normally points away from the face

Child with Fever: Call Provider Immediately

- Child < 2 years - Fever over 105 F - Child looks or acts sick, including a stiff neck, persistent vomiting, purplish spots on skin, confusion, trouble breathing after you have cleaned his or her nose or inability to be comforted.

Position for Extremity Venipuncture or Injection

- Child in parent's lap with child FACING the parent + in straddle position - Child's arm on firm surface - Nurse can partially stabalize the child's outstretched arm + have the parent hug the child's upper body, preventing movement; the nurse can then use the parent's arm to immobilize the venipuncture site - Comforts the child because of the close body contact + allows each person to maintain eye contact

Mumps Vaccine

- Children 12-15 months - Given in combination with measles + rubella - Should NOT be administered to infants younger than 12 months old - Immunization recommended for everyone born AFTER 1957 - MMR, MMRV vaccines

School Age Kohlberg Moral Development

- Children 6-7 know the rules + behaviors expected of them, they do NOT understand the reasons behind them. Rewards + punishment guide their judgement. May interpret accidents or misfortunes as punishment for "bad" acts - Older school age children are able to judge an act by the intentions that prompted it rather than just its consequences - For older children, a rule violation is likely to be viewed in relation to the total context in which it appears

Preschool Fears

- Concept of ANIMISM (ascribing lifelike qualities to inanimate objects) helps explain why children fear objects - Fear of annihilation + develop concerns related to loss of body parts - Best way to help them overcome fears is to actively involve them in finding practical methods to deal with the frightening experience. Such as keeping night light on. - Exposing children to feared object in a safe situation also provides a type of conditioning or DESENSITIZATION - Usually by 5-6 years, children relinquish their fears

School Age Piaget Stage

- Concrete Operations - When children are able to use thought processes to experience events + actions - The rigid, egocentric view of the preschool years is replaced by thought processes that allow children to see things from another's point of view - Their steady reduction in egocentricity helps form a basis for logical thought + the development + maturation of morality - One if the major cognitive tasks of school age children is mastering the concept of CONSERVATION. - 5-6: conservation of numbers - 6-7: conservation of liquids, mass + length - 9-10: conservation of weight - 9-12: conservation of volume or displancement

Newborn + Young Infant's Response to Pain

- Crying - Facial appearance of pain - Brows lowered + drawn together, eyes tightly closed + mouth open + squarish - GENERALIZED body rigidity or thrashing, possibly with local reflex withdraw from what is causing pain - No relationship between what is causing pain + subsequent response

Older Infant's Response to Pain

- Crying - LOCALIZED body response with deliberate withdrawl from what is causing the pain - Expression of pain or anger - Physical struggle, especially when pushing away from what is causing the pain

Young Child's Response to Pain

- Crying + screaming - Verbal expressions such as "ow", "ouch" or "it hurts" - Thrashes arms + legs to combat pain - Attempts to push away what is causing pain before it is applied - Lack of cooperation - Need for physical restraint - Begs for procedure to end - Clings to parent, nurse or others - Requests physical comfort, such as hugs or other forms of emotional support - Becomes restless + irritable with ongoing pain - Worries about the anticipation of the actual painful procedure

Coping Patterns Used by Children with Special Needs

- DEVELOPS COMPETENCE + OPTIMISM: Accentuates the positive aspects of the situation + concentrates more on what he or she has or can do than on what is missing or what they cannot do - FEELS DIFFERENT + WITHDRAWS: Sees self as different from others; views being different as negative; sees self as less worthy; focuses on things they CANNOT DO + sometimes over restricts activities needlessly - IRRITABLE, MOODY + ACTS OUT: Uses proactive + self initiate coping behaviors, although usually counterproductive in that the behaviors are not ego enhancing or socially responsible + do not result in desired outcomes; acts out irritability - COMPLIES WITH TREATMENT: Also uses behaviors that indicate developing independence - SEEKS SUPPORT: Talks with adults, children, physicians + nurses; develops plans to handle problems as they occur; uses downward comparison (realizes others have it worse)

Signs of Sepsis in Burn Patient

- Decreased LOC - Increased restlessness - Lethargy - Inadequate hydration (do cap refill + pulses), a spiking fever + diminished bowel sounds accompanyied by a paralytic ileus are noted and progressively increases over 48-72 hours, after which the temperature falls to subnormal limits. At this time, the wound deteriorates, the WBC count is depressed + septic shock becomes manifest - Hyperthermia progressing to hypothermia - Rising or falling blood glucose level - Tachycardia - Tachypenea - Thrombocytopenia - Absent or hypoactive bowel sounds - Rising or falling WBCs

Treatment for Conjunctivitis

- Depends on cause - Viral is self limited + depends on treating symptoms such as removing secretions - Bacterial treated with antibacterials such as polymyxin + bacitracin (polysporin), sodium sulfacetamide (Sulamyd) or Polytrim - Fluoroquinoones are best antimicrobials for over 1 years old

Infant Developmental Behaviors that Influence Attachment

- Differential crying, smiling + vocalization - Visual motor orientation - Crying when the mother leaves the room - Approaching through locomotion - Clinging - Exploring away from the mother while using her as a secure base

Skinfold Thickness

- Distinguishes between fat + muscle - Increasingly recommended as a routine measurement - Measured with special calipers such as the Lange calipers - Most common sites are the tricepts, scapular, suprailiac, abdomen + upper thigh - WHO growth curves are available

4 Month Old Growth + Development

- Drooling begins - Moro, tonic neck + rooting reflexes have dissapeared - Almost no head lag when pulled to sitting position - Balances head well in sitting position - Back less rounded, curved only in lumbar area - Able to sit erect if propped up - Able to raise head + chest off surface to angle of 90 degrees - Assumes predominant symmetric position - Rolls from back to side - Inspects + plays with hands; pulls clothing or blanket over face in play - Tries to reach objects with hand but overshoots - Grasps object with BOTH hands - Plays with rattle placed in hand + shakes it but cannot pick it up when dropped - Can carry objects in mouth - Able to accommodate to near objects - Binocular vision well established - Can focus on a 0.5 inch block - Beginning eye-hand coordination - Makes CONSONANT sounds: n, k, g, p, b - Laughs aloud - Vocalization changes according to mood - In stage 3, secondary circular reactions - Demands attention by fussing; becomes bored if left alone - Enjoys social interaction with people - Anticipates feeding when sees bottle or mother when breastfeeding - Shows ecitement with whole body, squeals, breathes heavily - Show interest in strange stimuli - Begins to show memory

Rx Medibottle

- Effective in delivering unplesat tasting oral med to infants than oral syringe - It allows the infant to suck juice or other liquids from a nipple attached to a specially designed bottle while receiving undiluted med dispensed in SPURTS from a syringe inserted into central sleeve of bottle

NORMALIZATION in Caring for Children Living with Chronic Diseases

- Efforts family members make to create a normal family life, their perceptions of the consequence of these efforts + the meanings they attribute to their management efforts - Attending school, pursuing hobbies + recreational interests + achieving employment + a level of independence - This can involve HOME CARE - Paralleling normalization with home care is the process of MAINSTREAMING, or integrating children with disabilities into regular classrooms

11 Month Old Growth + Development

- Eruption of lower lateral incisior may begin - When sitting, pivots to reach toward back to pick up an object - Cruises or walks holding onto furniture or with both hands held - Explores objects more thoroughly - Has neat pincer grasp - Drops object deliberately for it to be picked up - Puts one object after another into a container (sequential play) - Able to manipulate an object to remove it from tight fitting enclosure - Imitates definite speech sounds - Experiences joy and satisfaction when a task is mastered - Reacts to restrctions with frustration - Rolls ball to another request - Anticipates body gestures when a familiar nursery rhyme or story is being told (holds toes + feet in response to "this little piggy went to the market") - Plays games up-down "so big" or "peek-a-boo" - Shakes head for "no"

9 Month Old Growth + Development

- Eruption of upper lateral incisor may begin - Creeps on hands + knees - Sits steadily on floor for prolonged time (10 minutes) - Recovers balance when leaning forward but cannot do so when leaning sideways - Pulls self to standing position + stands holding onto furniture - Uses thumb + index finger in crude pincer grasp - Preference for use of dominant hand - Grasps 3rd cube - Compares 2 cubes by bringing them together - Localizes sounds by turning head diagonally + directly toward sound - Depth perception increasing - Responds to simple verbal commands - Comprehends "no no" - Parent (mother) is increasingly important for own sake - Shows increasing interest in pleasing parent - Begins to show fears of going to bed + being left alone - Puts arms in front of face to avoid having it washed

Cultural Differences in Assessing Pain

- Expression of pain can be greatly affected by communication barriers - Pain assessment tools have been validated ONLY in Caucasian + English speaking children - Observational scales + interview questionnaires for pain may not be as reliable for pain assessment as SELF REPORT scales for Hispanic children - Asian children (who may learn to read Chinease characters vertically downward + from right to left, may have difficulty using horizontally oriented pain scales

Child with Fever: Call within 24 Hours

- Fever between 104-105, especially if over 2 years - Fever for more than 24 hours without an obvious cause or location for infection - Fever for more than 3 days - Burning pain with urination - History of febrile seizures - Fever went away for more than 24 hours + then returned - Other concerns or questions

School Age Dental Health

- First permanent (secondary) teeth erupt at about 6 years old - With the appearance of the second permanent (12 years) molar, most permanent teeth are present - Permanent dentition is more advanced in girls than in boys - It is important to be aware of MALOCCLUSION problems that may result from irregular eruption of permanent teeth + may impair function - A tooth that is avulsed (knocked out) should be replanted by the child, parent or nurse + stabilized as soon as possible so that the blood supply to the tooth can be reestablished + the tooth kep alive

Intraosseous Infusion

- For rapid establishment of systemic access is vital + venous access may be hampered by peripheral circulatory collapse, hypovolemic shock (secondary to vomiting or diarrhea, burns, or trauma), cardiopulmonary arrest, etc - Recommended if venous access cannot be readily achieved in a pediatric resuscitation - Provides a rapid, safe + lifesaving alternate route for administration of fluids + meds until intravascular access is possible

Pertussis Vaccine + 2 Forms

- Fora all children 6 weeks - 6 years old (up to 7th birthday) - Tetanus + Diphtheria toxoids + acellular Pertussis vaccine (Tdap) for children 11-12 years old for those that have completed the DTaP/DTP series - When Tdap used as a booster doe, it may be administered regardless of the intraval from the previous tetanus, diptheria + pertussis vaccines - Children 7-10 who are not fully vaccinated for pertusis (did not receive the full schedule) should receive a dose of Tdap - Pregnant adolescents + women who are not protected against pertussis receive the Tdap vaccine optimally between 27-36 weeks of gestation or postpartum - Breastfeeding is NOT contraindication for Tdap - Highly purified acellular vaccine is associated with FEWER local + systemic reactions than those with whole cell vaccine - Acellular pertussis vaccine for 1st 3 immunizations + given at 2, 4 + 6 months old - Pentacel for infants 4 weeks old + (contains acellular pertussis, diptheria, tetanus, inactivated poliovirus, Hib conjugate) - Either the acellular or whole cell vaccine may be given for the 4th and 5th doses but acellular is preferred - Health care workers who may be susceptivel to pertussis should receive a single dose Tdap - Diagnosis of pertussis may be missed or delayed in unvaccinated infants, who often are seen with respiratory distress + apnea without the typical cough 2 Forms: 1.) Whole cell pertusis vaccine (from inactivated Bordetella pertussis) 2.) Acellular pertussis vaccine (contains 1 or more immunogens derived from the B. pertussis organism): Daptacel, Pediatrix, Kinrix (DTaP + IPV), Infanrix (Diptheria, tetanus toxoid, acellular pertussis conjugate)

Parental Grief

- Found to be the most INTENSE, complex, long lasting + fluctuating grief experience - Although the primary loss is of the child, many secondary losses are felt such as: loss of part of one's self, hopes + dreams for the child's future, the family unit, prior social + emotional community supports + often spousal support - Parental resolution of grief is the process of integrating the dead child into daily life in which the pain of losing a child is never completely gone but lessens - Parental grief work is NEVER completed + is a timeless process of accommodating the new reality of being without a child as it changes over time

Scarlet Fever Therapeutic Management

- Full course of PENICILLIN (Erythomycin in penacillin sensitive children) or CEPHALOSPORIN - Antiboitic therapy for newly diagnosed carriers (nose or throat cultures positive for streptocci) - Supportive: rest during febrile phase, analgesics for sore throat, antipruitics for rash if bothersome

Infant Maturation of GI System

- GI system immature at birth - Breast milk has properties that COMPENSATE for immature GI system - Amylase is present in small amounts but has little effect as food does not stay in mouth for long - RENNIN acts on milk to cause the formation of CURDS, coagulated semisolid pieces of milk that are retained in stomach long enough for digestion of milk to occur - Infants do not achieve adult levels of fat digestion until 4-5 months - Trypsin is secreted in sufficient quantities to catablize protein into polypeptides + some amino acids - During infancy, solid foods are passed incompletely broken down int he feces - An excess fiber easily disposes infants to loose, bulky stools - During stomach, the enlarges to accommodate a greater volume of food - By end of first year, infants are able to tolerate 3 meals a day + an evening bottle - 1-2 bowel movements a day - With any type of gastic irritation, infants are vulnerable to diarreha, vomiting + dehydration

Infant Proportional Changes

- Gain 5-7 oz WEEKLY until 6 months, slows during second 6 months - By 1 year, birth weight has tripled - Infants breastfed beyond 6 months gain LESS than those bottle fed, many think this has to do with developing self regulating energy intake, which can lead to less instances of childhood obesity + cardiovascular disease - Infants who were breastfed regulate their appitites better in childhood than those bottle fed - Height increases 1 inch a month during first 6 months + slows during 2nd 6 months - By 1 year, length has increased by 50% - Length increases in the trunk - By 1 year, head circumference increased by 33% - Expanding head size reflects the growth + differentiation of the nervous system - By 1 year, brain has increased in weight by 2.5 times - Maturation of the brain is exhibited in the dramatic developmental achievements of infancy - Heart grows less rapidly than rest of body - Heart is 55% of chest width

Measles Vaccine

- Given at 12-15 months old - During measles outbreaks, given 6-11 months old, followed by a second inoculation after 12 months old - 2nd measles shot at 4-6 years old (at school entry) but may be given earlier, provided 4 weeks have elapsed since previous dose - Revaccination by 11-12 years old if the vaccine was not given at school entry (4-6 years old) - Any child who is vaccinated BEFORE 12 months old should receive 2 additional doses beginning at 12-15 months old + separated by at least 4 WEEKS - Revaccination for everyone born AFTER 1956 who have not received 2 doses after 12 months old - People born BEFORE 1956 are immune - MMRV (Measles, mumps, rubella + varicella) given to children 12-15 months old + before or at 4-6 years old - Children with HIV should NOT get the MMRV - RISKS should be explained before giving - Risk of SEIZURE at 5-12 days in children 12-23 months old - Vitamin A to decrease morbidity + mortality with measles in developing countries

Fine Motor Development

- Grasping begins 2-3 months - 1 Month hands closed - 3 months hands open - 4 months regard both a small pellet + the hands + then look from the object to the hands + back again - 5 months able to voluntarily grasp objects - 6 months hold bottles, grasp feet + put them into mouth + feed themselves crackers - 7 months transfer objects from one hand to another, use one hand for grasping + hold a cube in each hand simultaneously. Enjoy banging objects + explore toys - Palmar grasp (using WHOLE hand) is replaced by PINCER grasp (using thumb + index finger) - 8-9 months use pincer grasp - 10 months neat pincer grasp to pick up raisins + finger foods - 11 months put objects into containers - 1 year try to build block towers but fail

Complementary + Alternative Medicine (CAM) for Pain

- Group of diverse medical + health care systems, practices + products that are not currently considered part of conventional medicine Five Classes: 1.) BIOLOGICALLY based: foods, herbs, vitamins, supplements 2.) MANIPULATIVE treatments: chiropractic, osteopathy, massage 3.) ENERGY based: reiki, bioelectric or magnetic treatments 4.) MIND-BODY tecniques: hypnosis, spiritual healing, relaxation 5.) ALTERNATIVE medical systems: homeopathy, naturopathy, traditional Chinese medicine, acupuncture

Failure to Thrive (FTT)

- Growth failure - Sign of inadequate growth resulting from an inability to obtain or use calories required for growth - No universal definition - Growth measurements alone are not used to diagnose. Rather, the finding of a pattern of persistent deviation from established growth parameters is cause for concern - Some advocate for a change in termonology to Growth Failure or Pediatric Undernutrition - 5-10% of children in primary care in US - Cause is often multifactorial + involves a combination of infant organic disease, dysfunctional parenting behaviors, and or poor parent infant bonding - Primary etiology is inadequate caloric intake regardless of cause 3 Classifications: 1.) Inadequate Caloric Intake: Incorrect formula preparation, neglect, food fads, lack of food availability, breastfeeding problems, behavioral problems affecting eating or CNS problems affecting intake 2.) Inadequate Caloric Absorption: Food allergy, malabsorption, pyloric stenosis, GI atresia, errors of metablolism 3.) Escessive Caloric Expenditure: Hyperthyroidism, malignancy, congenital heart disease, chronic pulmoary disease or chronic immunodeficiency

6 Month Old Growth + Development

- Growth rate may begin to decline - Weight gain 3-5 oz a week, next 6 months - Height gain 0.5 inch monthly, next 6 months - Teething may begin with eruption of 2 lower central incisiors - Chewing + biting occur - When prone, can lift chest + upper abdomen off surface, bearing weight on hands - When about to be pulled to a sitting position, lifts head - Sits in high chair with back straight - Rolls from back to abdomen - When held in standing position, bears almost all of weight - Hand regard absent - Re-secures a dropped object - Drops one cube when another is given - Grasps + manipulates small objects - Holds bottle - Grasps feet + pulls to mouth - Adjusts posture to see an object - Prefers more complex visual stimuli - Can localize sounds made above ear - Will turn head to the side + then look up or down - Begins to imitate sounds - Babbling resembles one-syllable utterances- ma, mu, da, di, hi - Vocalizes to toys, mirror image - Tags pleasure in hearing own sounds - Recognizes parents - Begins to fear strangers - Holds arm out to be picked up - Has definite likes + dislikes - Begins to imitate (cough, protrusion of tongue) - Excites on hearing footsteps - Briefly searches for a dropped object (object permanence beginning) - Frequent mood swings, from crying to laughing, with little to no provocation

HBV Vaccine

- HVB infections that occur during childhood can lead to fatal consequences from cirrhosis or liver cancer during adulthood - It is recommended that newborns receive HepB before hospital discharge if the mother is hep B surface antigen negative - Monovalent Hep B should be given as the birth dose, wherease combination vaccine containing Hep B may be given for subsequent doses in the servies - Infants born to mothers whos Hep B surface is POSITIVE or unknown should receive Hep B + Hep B immue gloublin, 0.5 mL within 12 hours of birth at TWO different injection sites - Because the immue response to Hep B is not optimum in newborns weighing less than 4.4 lbs, the first Hep B dose should be given to such infants at a chronological age of 1 month old, as long as the mother's Hep B antigen status is negative - If a preterm infant is givne a does at birth, they shouldbe givne the full series (3 additional doses) at 1, 2, and 6 months old - Children should receive immunizations before 11 years old - IM injection in vastust lateralis in newborns or deltoid for older infants + children - Reguardless of age AVOID the dorsodluteal site as it is associated with low antibody seroconversion rate, indicating a LOWER immune response - Can be administered with DTaP, MMR + Hib vaccines

Peripheral Blood Samples from Infants < 6 months

- Heel stick - Before blood sample is taken, warm heel for 3 minutes + cleanse area with alcohol - Use an automatic lancet devise as it delivers a more precise puncture depth + less painful than regular lancet - Most serious complication is NECROTIZING OSTOCHONDRITIS from lancet penetrating the underlying calcaneus bone, infection + abscess of the heel - To avoid ostochondroitis, the puncture should be no deeper than 2 mm + should be made at the OUTER aspect of the heel. - The boundaries of the calcaneus can be marked by an imaginary line extending from a point between the 4th + 5th toes + running parallel with later aspect of heel + another line running from middle of great toe + running parallel with medial aspect of heel. - Repeated trauma to walking surface of the heel can cause fibrosis + scarring that may interfere with locomotion

Haemophilus Influenzae Type B Vaccine

- Hib - Protects against bacterial meningitis, epiglottitis, bacterial pneumonia, septic arthritis + sepsis - NOT associated with the viruses that cause influenza, "the flu" - PedvaxHIB, Pentacel, Comvax, Hiberix, ActHIB - MenHibrix for children 6 weeks to 18 months old + provides protection against meningococcal (groups A, C, Y + W) as well as Hib. A 4 dose series at 2, 4, 6 + 12-15 months old - Hiberix is for use as the FINAL booster dose of Hib for children 15 months - 4 years old - Only 1 dose of Hib should be given to children 15 months or older who have not been previously vaccinated - The use of meningococcal + diptheria proteins in combination vaccines does NOT mean the child has received adequate immunization for meningococcal or diptheria + MUST be given the appropriate vaccine for that specific disease

Nutrition for Infants in the First 6 Months

- Human milk is the most desirable complete diet for infants during the first 6 months - A healthy infant generally requires no specific vitamin + mineral supplements with few exceptions - Supplements of Vitamin D + B12 may be indicated if the mother's intake of these vitamins are inadequate - 400 IU of vitamin D in first few days of life prevents rickets + vitamin D deficiency - Vitamin D supplements should continue until infant is consuming at least 1 L/day of vitamin D fortified formula - Nonbreastfed infants who are taking < 1 L/day of vitamin D fortified formula should also receive a daily suplement of 400 IU vitamin D - If the infant is being breastfed AFTER 4 months, iron supplementation (1 mg/kg/day) - Infants do NOT require additional fluids, especially water or juice during first 4 months of life - Excessive water intake could lead to hyponatremia - Expressed breast milk may be stored in refrigerator at 39 degrees F for up to 5 days - Pumping milk away from home may be needed every 3-4 hours to maintain adequate supply - Breast milk may be espressed by hand or pump - Breast milk may be frozen for up to 6 months - HONEY should be avoided in first 12 months as risk of botulism

3 HPV Vaccines

- Human papillomavirus - To prevent HPV related cervical cancer in women - Prevents likelihood of genital warts in men - First dose given at 11-12 (minimum age 9 years old) - Second dose given 2 months after first dose - Third dose given 6 months after first dose 1.) 9vHPV or HPV9 (females or males) 2.) 4vHPV (females or males) 2.) 2vHPV (Cervarix, females only age 10-25 years)

Polio Vaccine

- IPV (inactivated poliovirus vaccine) recommended for all children - 4 doses of IPV at 2 months, 4 months, 6-18 months + 4-6 years old - Change from the use of oral polio vaccine (OPV) to the exclusive use of IPV is related to the rare risk of vaccine associated polio paralysis from OPV - Pediarix is a combination vaccine containing DTap, Hep B, IPV

Pain in Neonates

- Impact of early pain exposure greatly affects the developing nervous system, with persistent long term effects - This makes neonatal assessment extremely important, although difficult, because the most reliable indicator of pain, self report, is not possible - Evaluations must be based on PHYSIOLOGIC changes + behavioral observation - Crying associated with pain is more INTENSE + SUSTAINED - Facial expression is the most consistent + specific characteristic - Sales available to systematically evaluate facial features, such as eye squeeze, brow bulge, open mouth + taut tongue. Most infants respond with increased body movement, but the infant may be experiencing pain even when lying quietly with eyes closed - Infants in awake or alert states demonstrate a more robust pain reaction to painful stimuli than infants in sleep states - An infant receiving a muscle paralyzing agent (Vecuronium) is INCAPABLE of visible pain response - In infants with diminished ability to respond to pain, it is imperative to PRESUME that PAIN EXISTS in all situations that are usually considered painful for adults + children, even in the absence of signs - CRIES tool - PIPP tool - NPASS scale

Schedule for Immunization

- In the USA 2 organizations govern the recommendations for immunizations: Committee on Infectious Diseases of the American Academy of Pediatrics + the Advisory Committee on Immunization Practices of the Centers for Disease Control + Prevention - Should start at birth or within 2 weeks of birth - Children born PRETERM should receive the full dose of each vaccine at the appropriate chronologic age - A recommended catch up schedule for children not immunized during infancy - Children who begin primary immunization at the recommended age but fail to receive all the doses do NOT need to begin the series again but instead recieve only the missed doses - For situation in which there is doubt that the child will return for immunization, HBV, DTaP, IPV, MMR, Varicella + Hib vaccines can be administered SIMULTANEOUSLY at different injection sites - Parenteral vaccines are given in separate syringes in different injection sites

Sinus Arrhythmia

- In which the heart rate increases with inspiration + decreases with expiration - An arrhythmia that occurs NORMALLY in children - Differentiate this rhythm from a truly abnormal arrhythmia by having child hold their breath - In sinus arrhythmia, cessatio of breathing causes the heart to remain steady

Growth Measurements

- Include: weight, height (length), skinfold thickness, arm circumference + head circumference - Data plotted on percentile charts - Percentile charts compared with those of general population

Consequences of Untreated Pain in Infants

- Infant pain often remains inadequately managed - Mismanagement of infant pain is usually the result of misconceptions regarding the effects of pain on the neonate - Infants respond to noxious stimuli through physiologic indicators (> HR, > BP, variability in HR + ICP, < in arterial oxygen saturation + < skin blood flow) and behavioral indicators (muscle rigidity, facial expression, crying, withdrawl, sleplessness) - Pain triggers a number of physiologic stress responses in the body + they lead to negative consequences that involve multiple systems- Unrelieved pain may PROLONG the stress response + adversely affect an infant's or child's recovery - When pain is unrelieved, sensory input from injured tissues reaches spinal cord neurons + may enhance subsequent responses. Long lasting changes in cells within spinal cord pain pathways may occur after a brief painful stimulus + may lead to the development of chronic pain conditions - Windup Phenomenon: attributed to a decreased pain threshold + chronic pain

Infant Thumb Sucking + Pacifers

- Infants chief pleasure is sucking - May not be satisified by breastfeeding or bottle feeding - It is such a strong need that infants with cleft lip, suck on their own tongues - Some newborns are born with sucking blisters on their hands from in utero sucking - Researches suggest that pacifiers should NOT be introduced to breastfed infants unless medically necessary - Pacifier use associated with increased risk of otitis media - Pacifiers usage should be reduced in the second 6 months of life - Pacifiers should be cleaned + replaced regularly - Pacifier use during painful procedures in neonates has been shown to have an analgesic effect

Position for Bone Marrow Aspiration or Biopsy

- Infants, tibia - Children, posterior or anterior iliac crest - If posterior iliac crest, child positioned prone with a small pillow under hips - Children should receive adequate analgesia or anesthesia to relieve pain - If child awakes, they need to be held by 2 people: 1 to immobilize upper body and 1 to immobilize lower body

Human parovirus B 19

- Infects + lyses RBC precursors, thus interrupting the production of RBC - The virus may precipitate a severe aplastic anemia crisis in patients who need increased RBC production to maintain normal RBC volumes, such as those with sickle cell - Thrombocytopenia + neutropenia may also occur as a result of human parovirus B19 infection - The fetus can develop severe anemia + hydrops as a result of maternal human parovirus B19 - Fetal death rates are 2-6%

Preschool Erikson Stage

- Initiative vs. Guilt - Conflict arises when children overstep the limits of their ability + inquiry + experience a sense of guilt for having not behaved properly - Development of superego (conscience) begins toward the end of toddler years + is a major task for preschoolers - Learning right from wrong + good from bad is the beginning of morality

Partial-Thickness (Second Degree) Burns

- Involve the epidermis + varying degrees of the dermal layer - Painful, moist, red, blistered - Dermal elements intact - Sensitive to temp changes, exposure to air + light touch - Heals in 14-21 days with variable amounts of scarring - DEEP DERMAL BURNS: Appear to be 3rd degree but are only 2nd. May appear mottled, with pink, red or waxy white ares exhibiting blisters + edema formation. May take beyond 21 days to heal. Systemic effects similar to 3rd degree burns

Nursing Interventions for Pertussis (Whooping Cough)

- Isolation during catarrhal stage - Standard + droplet precautions - Nasopharyngeal culture for diagnosis - Encourage fluids - Ensure adequate oxygenations - Position infant on side to decrease chance of aspiration with vomiting - Provide humidified oxygen - Suction as needed to prevent choking - Observe for signs of airway obstruction

Weaning Infant off Breastfeeding

- It is a psychologically significant as infants are required to give up a major source of oral pleasure + gratification - No one time is best for every child, but generally, most infants show signs of readiness during second half of first year - Imitation becomes a motivator and by 8-9 months old they enjoy using a cup or glass - Should be gradual by replacing one bottle or breastfeeding session at a time - Nighttime feeding is usually last feeding to be discontinued - If breastfeeding terminated by 5-6 months old, it should be to a bottle to provide for the infant's continued sucking needs - If discontinued later, weaning can be directly to a cup, especially by 12-14 months old

10 Month Old Growth + Development

- Labyrinth-righting reflex is strongest when infant is in prone or supine position - Able to raise own head - Can change from prone to sitting position - Stands while holding onto furniture; sits by falling down - Recovers balance easily while sitting - While standing, lifts one foot to take a step - Crude release of an object beginning - Grasps bell by handle - Says "mama" and "dada" with meaning - Comprehends "bye bye" - May say one word, "hi", "bye", "no" - Inhibits behavior to verbal command of "no no or own name - Imitates facial expressions; waves bye-bye - Extends toy to another person but will not release it - Develops object permanence - Repeats actions that attract attention + cause laughter - Pulls clothes of another to attract attention - Plays interactive pat-a-cake - Reacts to adult anger; cries when scolded - Demonstrates independence in dressing, feeding, locomotive skills + testing of parents - Looks at + follows picture in book

Toddler Gross + Fine Motor Development

- Major gross motor skill is the development of locomotion - By 12-13 months, toddlers walk alone using a wide stance for extra balance + by 18 months they try to run but fall easily - 2 years: walk up + down stairs - 2.5 years: jump using both feet, stand on one foot + tiptoe - End of 2nd year: stand on one foot, climb stairs with alternate footing - Increasingly skillful manual dexterity - By 12 months, able to grasp a small object - 15 months: drop raisin into a narrow necked bottle - 18 months: throw a ball overhead without loosing balance

Toddler Social Development

- Major task is differntiation of self from others, especially the mother - Differntiation consists of 2 things: SEPARATION (child's emergence from a symbiotic fusion with the mother) + INDIVIDUATION - Appearance of unfamiliar people does not represent such a significant threat to their attachment to their mothers - The separation-individuation phase encompasses the phenomenon of RAPPROCHEMENT: as toddler separates from the mother + begins to make sense of experiences in the environment, the child is drawn back to mother for assistance in identifying the meaning of the experiences - Transitional objects provide security + this should not be discouraged + helps with dealing with periods of separation - Learning to tolerate + master brief periods of separation are important developmental tasks for children

Selection of BP Cuff

- Most IMPORTANT factor in measuring BP - CUFF SIZE refers only to the INNER inflatable bladder, not a cloth covering - Choose a cuff with a bladder width that is at least 40% of the arm circumference midway between the olecranon + the acromion - The cuff bladder should cover 80-100% the circumference of the arm - Cuffs too narrow or wide affect accuracy of BP - If cuff too SMALL, the reading is falsely HIGH - If cuff too BIG, the reading is falsely LOW

Habits to Explore During Health Interview

- Nail biting, thumb sucking, pica, rituals (security blanket or toy) unusual movements (head banging, rocking, overt masterbation, walking on toes) - Hours of sleep, time of waking, naps, exercise, regularity of stools + urination, age of toilet training, bedwetting - Unusual disposition; response to frustration - Abuse of alcohol, drugs, coffee or tobacco

Atraumatic Care with Immunizations

- Needle length is an important factor. Fewer reactions are observed when the vaccine is given deep into the muscle rather than into SC tissue as muscle tissue has a better blood supply + fewer pain receptors than adipose tissue - Use an air bubble to clear the needle after injecting the vaccine (theoretically beneficial but unproved)

Normothermia

- Normal temperature - When temperature is altered, receptors in the skin, spinal cord + brain respond in an attempt to achieve normothermia

Alternate Cover Test

- Occlusion shifts back + forth from one eye to the other + movement of the eye that was covered is observed as soon as the occluder is removed while the child focuses on a point in front of them - If normal alignment is present, shifting the cover from one eye to the other will not cause the eye to move - If misalignment is present, eye movement will occur when the cover is moved - Preform the cover test at close + far distances

Toddler Regression

- Occurs in instances of discomfort or stress when one attempts to conserve psychic energy by reverting to patterns of behavior that were successful in earlier stages of deveolpment - Common in toddlers as almost any additional stress hinders their ability to master present developmental tasks - Any threat to their autonomy, such as illness, separation, disruption of routines or adjustment to a new sibling represents a need to revert to earlier forms of behavior such as increased dependency - Regression appears accptable +comfortable for children, but the loss of newly acquired achievements is frightening + threatening because children are aware of their helplessness - Parents become concerned about regressive behavior + force the child to cope with the additional stress. These predictable times of regression (TOUCHPOINTS) which are an opportunity to prepare parents for the next step in the child's development. - When regression does occur, it is best to IGNORE it while praising existing patterns of appropriate behavior

Femoral Hernia

- Occurs more frequently in girls - Felt or seen as a small mass on the anterior surface of the thigh just below the inguinal ligament in the femoral canal (a potential space medial to the femoral artery) - Feel for a hernia by placing the index finger of your right hand on the child's right femoral pulse (left hand for left pulse) + the middle finger flat against the skin toward the midline. The ring finger lies over the femoral canal, where the herniation occurs

Tolerence

- Occurs when the dose of an opioid needs to be INCREASED to achieve the same analgesic effects that was previously achieved at a lower dose - May develop after 10-21 days of morphine administration - Treatment of tolerance involves INCREASING dose or decreasing DURATION between doses

Poison Ivy/Oak + Sumac

- Offending substance in these plants is an oil + urushiol that is extremely potent - Sensitivity to urushiol is NOT imborn rather it is developed after 1-2 exposures + may change over a lifetime - All of the plant contains oil, including the dried leaves - Smoke from burning plants can produce a reaction - Animals are not affected by the oil - Has an effect as soon as it touches the skin - It penetrates through the epidermis as a mixture of compund molecules called CATECHOLS. These catechols bond skin proteins + initiate an immune response. The full blown reaction is evidnet in about 2 days with redness, swelling + itching at sight of contact

Functional Burden

- Often experienced by parents with children with chronic diseases - Considers the issues related to caring for + living with the child in relation to the family's resources + ability to cope

Chronic Sorrow

- Often experienced by parents with children with chronic illnesses - Feelings of sorrow + loss that recur in waves over time - As child's condition progresses, parents experience repeated losses that represent further declines + new caregiving demands

Cover Test

- One eye is covered + the movement of the uncovered eye is observed while the child looks at NEAR (13 inches) or distant (20 feet) object - If the uncovered eye does NOT move, it is aligned - If the uncovered eye MOVES, a misalighment is present because when the stronger eye is temporarily covered, the misaligned eye attempts to fixate on the object

Mainstreaming

- Paralleling normalization with home care is the process of MAINSTREAMING, or integrating children with disabilities into regular classrooms

Development of Body Image

- Parallels sensorimotor development - Acheiving the concept of object permanence is basic to develpment of self image - By the end of the first year, infants recognize that they are distinct from their parents - At the same time, they have an increasing interest in their image, especially in the mirror - As motor skills develop, they learn that parts of their bodeis are useful - All of these achievements transmit messages to them about themselves - Therefore, it is important to transmit positive messages to infants about their bodies

Estimate Average Requirement (EAR)

- Part of Dietary Reference Intake (DRIs) - Estimated to meet the nutrient requirement of HALF of healthy individuals for a specific age + gender group

Tolerable Upper Intake Level (UL)

- Part of Dietary Reference Intake (DRIs) - Highest nutrient intake level likely to pose no risk of adverse health effects

Recommended Dietary Allowance (RDA)

- Part of Dietary Reference Intake (DRIs) - Sufficient to meet the nutrient requirement of nearly ALL healthy individuals for a specific age + gender group

Developmental Milestones

- Part of growth + development assessment - Age holding up head - Age of sitting alone - Age of walking - Age of saying first words - Grade in school - Scholastic performance - If child has a best friend - Interactions with other children, peers + adults

Encouraging Opening the Mouth for Examination

- Perform the exam in front of a mirror - Let the child first examine someone else's mouth, such as the parent, nurse or puppet - Instruct the child to tilt the head back slightly, breathe deeply through the mouth + hold the breath; this action LOWERS the tongue to the FLOOR of the mouth without the use of a tongue blade - Lightly brushing the palate with a cotton swab also may open the mouth for assessment - Leave it to the END of the exam

Acute Consequences of Untreated Pain in Infants

- Periventricular-intraventricular hemorrhage - Increased ICP - Increased hormone release - Breakdown of fat + carbohydrate sotres - Prolonged hyperglycemia - Higher morbidity in ICU - Memory of painful events - Hypersensitivity to pain - Prolonged response to pain - Inappropriate innervation of the spinal cord - Lower pain threshold

Toddler Piaget Phase

- Peroperational Phase: Preconceptual (2-4) + Intiuitive Thought (4-7) - Shift from totally egocentric thought to social awareness + ability to consider other viewpoints - Egocentricity is still evident - Language develops + remains primarily a vehicle of egocentric communication - Increasingly use language without comprehending the meaning of words such as left or right, causality + time - Causality resembles logical thoughts. Explain a concept as they heard it described by others but their understanding is limited - Time still incompletely understood, they will intrepret it according to their own frame of reference such as "a long time means until christmas" - Time is BEST explained to them in relationship to an event, such as "your mother will visit after you finish your lunch" - Avoid "yesterday, tomorrow, next week, Tuesday" to express time + instead associate it with expected daily events to help children learn about temporal relationships while increasing their trust in other's predictions - MAGICAL THINKING, believe thoughts to be ALL POWERFUL - Believe in power of words + accept their meanings literally

Toddler Negativism

- Persistent negative response to every negative request - Assertion of self control - Reduce opportunites for a "no" answer. Instead of asking "do you want to go to sleep now?" tel the child that it is time to go to sleep + proceed accordingly - In their attempt to exert control, children like to make choices - Give a choice of food, rather than asking a yes or no answer. If response is negative, make a choice for them. - Do not ask "can i listen to your heart?" say "I am going to listen to your heart"

Pertussis (Whooping Cough) Therapeutic Management

- Pertussis booster (Tdap) is recommended for adolescents - Antimicrobal therapy (erythomycin, clarithromycin, azithromycin) - Increased oxygen + humidity - Adequate fluids - Intensive care + mechanical ventilation needed for infants < 6 months old

Erikson Psychosocial Development of Infant

- Phase 1: Trust vs. Mistrust - Acquiring a sense of trust while overcoming a sense of mistrust - The trust that develops is a trust of self, others and the world - Crucial element for the acheivement of this task is quality of the parent(s) + the relationship + care recieves - Food, warmth + shelter is inadquate by itself for the development of strong sense of self - Failure to learn to delay gratification leads to mistrust. - Mistrust can result from either too much or too little frustration - If parents always meet their child's needs before the child signal their readiness, infants will never learn to test their ability to control the environment. If the delay is prolonged, infants will experience constant frustration + eventually mistrust others in their efforts to satisfy them - Consistency is essential - Erikson has divided the 1st year into 2 oral-social stages

Toddler Biologic Changes

- Physical growth slows - 4-6 lbs per year - 3 inches height per year - Elongation in legs, than trunk - Average height 2 year old is 34 inches - Average weight 2 year old is 26.5 lbs - Head circumference = chest circumference - Anterior fontanel closes between 12-18 months - Visual acuity of 20/40 - By end of first year, all brain cells are present but continue to increase in size - Myelination of the spinal cord is ALMOST COMPLETE by 2 years old, which parallels completion of gross motor skills - Brain growth is 75% complete by 2 years old - With mylenation of spinal cord, control of anal + urethral sphincters is achieved - Ability to control spincters occurs between 18-24 months - By 14-18 months, urine can be retained for up to 2 hours or longer

Example of Denial of Child's Chronic Disease

- Physician shopping - Attributing the symptoms of illness to a minor condition - Refusing to believe the diagnostic tests -Delaying consent for treatment - Acting happy + optimistic despite the revealed diagnosis - Refusing to tell or talk to anyone about the condition - Insisting that no one is telling the truth, regardless of others attempts to do so - Denying reason for admission - Asking no questions about diagnosis, treatment, prognosis

2 Month Old Growth + Development

- Posterior fontanel CLOSED - Crawling reflex disappears - Assumes less flexed position when prone - Less head lag when pulled to sitting position - Can maintain head in same plane as rest of body when held in ventral suspension - When prone, can lift head almost 45 degrees off table - When moved to sitting position, head is held up but bends forward - Assumes symmetric tonic neck position intermittently - Hand s often open - Grasp reflex fading - Binocular fixation + convergence to near objects beginning - When supine, follows dangling toy from side to point beyond midline - Visually searches to locate sounds - Turns head to side when sound is made at ear level - Vocalizes, distinct from crying - Crying becomes differentiated - Coos - Vocalizes to familiar voice - Demonstrates social smile in response to various stimuli

Orthostatic Hyoptension

- Postural hypotension or orthostatic intolerance - Manifestes as syncope (fainting), vertigo (dizziness), or lightheadedness - Cauesd by cerebral hypoperfusion (decreased blood flow to the brain) - One of the most common causes is HYPOVOLEMIA, which may be caused by meds such as diuretics, vasodilators - May be caused by prolonged immobility or bed rest - May be caused by dehydration, diarrhea, emesis, sweating, alcohol intake, dysrhythmias, diabetes mellitus, sepsis + hemorrhage - BP measurements should be taken supine + then standing with 2 minutes in each position, to assist in the diagnosis of orthostatic hypotension - A sustained drop in systolic pressure of 20 mm Hg or a drop in diastolic pressure of 10 mm Hg or more after standing for 2 minutes without an increase in heart rate of more than 15 beats per minute most likely has an autonomic deficit

Physical Exam of School Age Child

- Prefer sitting - Cooperative in most positions - Younger child prefers parent's presence - Older child may prefer privacy - Proceed head to toe - May examine genitalia last in older child - Respect need for privacy - Request self undressing - Allow to wear underpants - Give gown to wear - Explain purpose of equipment + significance of procedure - Teach about body function + care

Physical Exam of Preschool Child

- Prefer standing or sitting - Usually cooperative prone or supine - Prefer parent's closeness - If cooperative, proceed head to toe - If uncooperative, proceed as with TODDLER - Request self undressing - Allow to wear underpants if shy - Offer equipment for inspection; briefly demonstrate use - Make up story about procedure, "i'm seeing how strong your muscles are" - Use paper-doll technique - Give choices - Expect cooperation - Use positive statements, "open your mouth"

PIPP

- Premature Infant Pain Profile - Developed specifically for preterm infants - The category "gestational age at time of observation" gives a higher pain score to infants with LOWER gestational age - Infants who are asleep 15 seconds before procedure are given additional points for their blunted behavioral responses to pain - Variables: gestational age, eye squeeze, behavioral state, nasolabial furrow, heart rate, oxygen saturation, brow bulge - 21 is WORST pain

Nursing Management of Acute Phase Burn

- Primary emphasis during the emergent phase is treatment of burn shock + management of pulmonary status - IV infusion begin immediately + is regulated to maintain a urinary output of at least 1-2 mL/kg in children weighing less than 66 lbs + 30-50 mL/hr in children weighing MORE than 66 lbs - Require constant assessment for complications - Restlessness, irritablity + increased work of breathing + alteration in blood gas values can indicate that changes in respiratory function + gas exchange - Check pulse EVERY HOUR. If unable to palpate, use a Doppler. If pulse is lost, escharotomy may be necessary to relieve the edema causing pressure on blood vessels to restore adequate circulation - Core body temperature is supported when energy is conserved with an environmental temperature of 82.4-91.4 F - Warmed solutions, linens, occlusive dressings, heat shields, radiant warmer + warming blankets assist in preventing hypothermia - Cheif danger is INFECTION

3 Month Old Growth + Development

- Primitive reflexes fading - Able to hold head more erect when sitting but still bobs forward - Has only slight head lag when pulled to sitting position - Assumes symmetric body positioning - Able to raise head + shoulders from prone position to a 45-90 degree angle from table; bears weight on forearms - When held in standing position, able to bear slight fraction of weight on legs - Regards own hand - Actively holds rattle but will not reach for it - Grasp reflex absent - Hands kept loosely open - Clutches own hand; pulls at blankets + clothes - Follows objects to periphery (180 degrees) - Locates sound by turning head to side + looking in same direction - Begins to have ability to coordinate stimuli from various sense organs - Squeals aloud to show pleasure - Coos, babbles, chuckles - Vocalizes when smiling - "Talks" a great deal when spoken to - Less crying during periods of wakefulness - Displays considerable interest in surroundings - Ceases crying when parent enters room - Can recognize familiar faces + objects, such as feeding bottle - Shows awareness of strange situations

Inguinal Hernia

- Protrusion of peritoneum through the abdominal wall in the inguinal canal - Occurs mostly in boys - Frequently bilateral + may be visible as a mass in the scrotum - To locate a hernia, slide the little finger into the external inguinal ring at the base of the scrotum + ask the child to cough - If the child is too young to cough, have them blow a pinwheel or bubbles or laugh to raie hte intraabdominal pressure sufficently to demonstrate the presence of an inguinal hernia - If a hernia is present, it will hit the tip of the finger

Vaccine Informing Statements (VISs)

- Provide updated info on vaccines - Available at state department - A VIS should be given to each patient + documented that it was given + include publication date - Giving a VIS helps represent INFORMED CONSENT Available for: - Adenovirus - Anthrax - Tetanus - Diptheria - Pertussis - MMR, MMRV - IPV - HPV - Varicella - Hib - Influenza - Meningococcal - Pneumococcal - Rabies - Rotaviurs - Shingles - Smallpox - Yellow fever - Japanease encephalitis - Typhoid - Hep A + B

Children with Chronic Illness + Complex Pain

- Questionnaires + pain assessment scales do not always provide the most meaningful means of assessing pain in children, particularly for those with COMPLEX pain - Some children cannot relate to a face or a number that describes their pain - Those that experience MULTIPLE symptoms may find it difficult to ISOLATE the pain from other symptoms - Rating the pain is only one aspect of assessment + does not always accurately convey to others how they really feel - The most important aspect of pain assessment for those with chronic illness + complex pain is a sense of what the pain experience means to the child + family - Pain can interfere with ADLs -

Diptheria Vaccine + 5 Forms

- Rare disease though can result in significant morbidity - Respiratory manifestations that can occlude the airway - Administer a single does of equine antitoxin IV to the child with clinical symptoms because of the often fulminant progression of the disease - Diptheria vaccine does NOT produce absolute immunity, the protection persists for 10 years or more when given according to schedule - Boosters given every 10 years for life - Several vaccines contain Diptheria toxoid (Hib, meningococcal, pneumococcal) but this does not confer immunity to the disease 5 Forms: 1.) Combination with tetanus + pertussis vaccines, DTaP OR DTaP and Hib combination vaccines for children younger than 7 2.) Combination with Hib vaccine 3.) Combination with teatnus (DT) for children younger than 7 who hae some contraindication to receiving PERTUSSIS vaccine 4.) Combination iwth teatnus + acellular pertussis (Tdap) for children 11 years + 5.) As a single antigen

Prescool Development of Body image

- Recognize that individuals have desirable or undesirable appearances - Recognize differences in skin color + are vulernable to learning prejudices + biases - Aware of meanings of pretty + ugly - By 5 years, compare size with that of their peers + become conscious of being short or tall - Intrusive experiences are frightening, especially those that disrupt skin integrity of the skin, such as injections + surgery

Exanthem Subitum (Roseola Infantum) Complications

- Recurrent febrile seizures (possibly from latent infection of central nervous system that is reactivated by fever) - Encephalitis - Hepatitis (rare)

Head Circumference

- Reflection of BRAIN growth - Measure circumference in children up to 36 months + in any child whose head size is questionable - Measure head at its greatest frontoocipital circumference, usually slightly above the eyebrows + pinna of the ears + around the occipital prominence at the back of the skull - Use a paper or nonstretchable tape - Do NOT use cloth tape, which can stretch - Measure to nearest 1 mm or 1/16th inch - Plot measurement on appropriate growth chart - Generally, head + chest circumferences are EQUAL at about 1-2 yeas old - During childhood, chest circumference EXCEEDS head size by about 5-7 cm (2 - 2.75 inches)

FTT Prognosis

- Related to the cause - Few long term studies provide data on prognosis - Children who have FTT as infants are at risk for shorter heights, delayed development - Poor prognosis: severe feeding resistance, lack of awareness in and cooperation from the parents, low family income, low maternal educational level, adolescent mother, preterm birth, IUGR + early age onset - Many have lower IQ scores - Higher likelihood of behavioral and eating issues - Long term placement + follow up care are needed for optimum development

Stomatitis Treatments

- Relief of symptoms - Pain relieved by Tylenol + NSAIDs - For severe cases Codeine may be needed - Topical anesthetics: Orabase, Anbesol + Kank-A - Lidocaine (Xylocaine Viscous) for child to keep ` tsp in mouth for 2-3 minutes + spit out - A mixture of diphenhydramine + Maalox provides mild analgesia, antiinflammatory + coats the lesions

Decreasing Opoids in Children

- Requires a systemic approach - For children on opioids for < 5 days, decrease opioid by 20-30% every 1-2 days - For children who have been on opoids for longer than 5-7 days, a slower weaning is recommended: Wean by 20% reduction on first day, follow with opioid reductions of 5-10% each day as tolderated until a total daily dose of morphine of 30 mg for an adolescent of a doe of 0.6 mg/kg/day is reached

Monitoring Side Effects of Analgesics

- Respiratory depression is most serious complication + most likely to occur in sedated patients - Respiratory rate may decrease gradually or abruptly - Lower limits of normal are not established in children but ANY significant change from a previous rate calls for increased vigilance - A slower respiratory rate does NOT necessarily reflect decreased arterial oxygenation; an increased DEPTH may compensate for the altered rate - Stool softeners + laxatives to treat decreased peristalsis + increased anal sphincter tone. Dietary fiber is usually NOT sufficient to promote regular bowel evacuation. However, INCREASED FLUIDS are encouraged. - Nausea, vomiting + sedation usually subside after 2 days of opioid administration - Physical dependence is a normal, natural, physiologic state of "neuroadaptation" - When opioids are abruptly discontinued without weaning, withdrawal symptoms occur in 24 hours + peak in 72 hours

Home Care for Children Living with Chronic Diseases

- Return to a system + set of priorities in which family values are as important in the care of a child with a chronic health problem as they are in the care of other children - Normalize the life of the child - Minimize the disruptive impace of the child's condition on the family - Foster child's maximum growth + development - Paralleling normalization with home care is the process of MAINSTREAMING, or integrating children with disabilities into regular classrooms

Guideline for Preforming Pediatric Physical Exam

- Room temp warm - All strange + potentially frightening equipment out of sight - Dolls, stuffed animals, games available - Provide privacy - Provide time for play + becoming aquainted - If several children, begin with most cooperative to model desired behavior - Provide choices, such as sitting on parent's lap - Allow child to hold or handle equipment - Encourage child to use equipment on doll, family member or nurse - Explain each step in simple language - Exam body in organized sequence (head to toe) - Examine painful areas LAST - Reassure child throughout exam - Discuss findings with family at end - Praise child for cooperation + give a reward such as a toy or sticker

Characteristics of Parental Overprotection

- Sacrifices self + rest of family for the child - Continually helps the child even when the child is capable - Is inconsistent with regard to discipline or uses no discipline; frequently applies different rules to the siblings - Is dictatorial + arbituary, making decisions without considering the child's wishes, such as keeping the child from attending school - Hovers + offers suggestions; calls attention to every activity; overdoes praise - Protects child from every possible discomfort - Restricts play, often because the child will be injured - Denies the child opportunities for growing up + assuming responsibility, such as learning to give own meds or treatments - Does not understand child's capabilites and sets goals too high or too low - Monopolize's the child's time, such as sleeping with the child, permitting few friends or refusing participation in social or educational activities

Physical Exam of Adolescent

- Same as for school age child - Offer option for parent's presence - May examine genitalia last - Allow to undress in private - Give gown - Expose only area to be examined - Respect need for privacy - Explain findings during exam - Matter of factly comment on sexual development - Emphasize normalcy of development

Toddler's Piaget Sensorimotor Stage

- Sensorimotor's final 2 phases: Tertiary Circular (12-18 months) + Early Representational Thought (18-24 months) - OBJECT PERMANANCE has advanced. Still cannot find an object that has been invisibly displaced + is no longer visible or moved from one pillow to another without seeing the change, they are increasingly aware of the existence of objects behind closed doors, in drawers + under tables - SPATIAL RELATIONSHIPS developed as ability to recognize different shapes + their relationships to one another - DOMESTIC MIMICRY and sex role behavior become increasingly common - Actively uses experimentation to achieve previously unattainable goals - Awareness of a CASUAL RELATIONSHIP between two events - Beginning of categorizing data into distinct classes + subclasses - If allowed to turn over a toy receptacle, the child will just as quickly to the same to other containers. Expecting the child to judge which receptacle are permissible to explore is not appropriate. They should be kept out of reach - Can infer cause ONLY when experiencing an effect - Able to search for an object in several potential hiding places - Can infer than an object was hidden in any number of places even if they only saw the original hiding place - 1 minute can seem like 1 hour. Limited attention span indicate their sense of immediacy + concern for the present

Full-Thickness (Third Degree) Burns

- Serious injuries that involve the entire epidermis + dermis + extend into subcutaneous tissue - Nerve endings, sweat glands + hair follicles are destroyed - Red to tan, waxy white, brown or black, dry, leathery - Lack sensation in area of injury because of destruction of nerve endings - Most 3rd degree burns have areas of 1st and 2nd degree burns around them, where nerve endings are intact - As peripheral fibers regenerate, painful sensations return - Pain related to size + depth of burn - No capable of re-epithelialization + require surgical excision + grafting to close wound

Dietary Reference Intakes (DRIs)

- Set of 4 evidenced based nutrient reference values that provide quantitative estimates of nutrient intake for use in assessing + planning dietary intake - USDA has an online DRI tool for health care professionals to calculate nutrient requirements based on age, gender, height, weight + activity 1.) Estimate Average Requirement (EAR) 2.) Recommended Dietary Allowance (RDA) 3.) Adequate Intake (AI) 4.) Tolerable Upper Intake Level (UL)

Varicella Vaccine

- Single does of 0.5 mL SC injection - 1st dose given for 12-15 months old - 2nd dose given 4-6 years old. The 2nd does MAY be given before age 4 as long as there is a period of 3 months between doses - Children 13 years + old + who are susceptable should receive two doses administered 4 weeks apart - Children 13-18 years old who have only received one previous varicella vaccine should receive a second varicella vaccine - 2 dose regimen was adopted to protect children who did not have adequate protection with one does, not because of waning immunity to the vaccine - Those that receive 2 doses are 1/3 less likely to hae breakthrough illness in the first 10 years in comparison with those who have only one dose - Children who do contract varicella after immunization have milder cases with fewer vesicles, lower degree of fever + faster recovery - Antibodies persist for 8 years - Keep vaccine FROZEN + in lyophilic form (stable particles that go into a solution) + use within 30 minutes - MMRV (ProQuad) for children 12 months - 12 years old - Varicella can be administered simultaneously with MMR. However, separate syringes + injection sites should be used

Toddler Play

- Solitary play of infancy progresses to PARALLEL PLAY; toddlers play alongside, not with, other children - IMITATION is one of the most distinguishing characteristics of play + enriches children's opportunity to engage in fantasy - Talking is a form of play for toddlers - TV appropriate for OVER age 2 + only for 1 hour a day - Tactile play is important for toddlers

Antitoxin

- Solution of antibodies derived from the serum of animals immunized with a specific antigens and used to confer passive immunity + for treatment - Diptheria antitoxin - Botulinism antitoxin

Body Surface Area (BSA) Method of Drug Dosing

- Some meds (such as chemotherapy drugs) are more precisely dosed using BSA - Ratio of BSA to weight varies INVERSELY with length; therefore, an infant who is shorter + weighs less than an older child or adult has a relatively more BSA than would be expected from weight - Base on the WEST NOMOGRAM + is easily determined using conversion programs widely available on internet

Hepatitis A Vaccine

- Spread fecal oral + from person to person contact - Has an abrupt onset, fever, malaise, anorexia, nausea, dark urine + jaundice - Children < 6 years old represent 1/3 of all cases + the disease may be asymptomatic + jaundice rarely occurs - All children should have vaccine beginning at 1 years old (so from 12 - 23 months old) - The 2nd dose in in the 2 does series may be administered no sooner than 6 months AFTER the 1st dose

Snellen Chart

- Stands 10 feet away - Children who wear glasses, should keep them on during test - Children unable to read letters + numbers, the Tumbling E or HOTV test is useful, especially for preschool children

Height

- Stature - Measurement taken when child is standing UPRIGHT - Wall charts + flip up horizontal bars (floppy-arm devices) mounted to weighing scales should NOT be used to measure the height of children as they are NOT steady + do not maintain a right angle to the vertical ruler, preventing an accurate + reliable height - Measure height by having child REMOVE shoes, stand as tall + straight as possible with head in midline, line of vision parallel to ceiling + floor - Be certain that the child's back is touching the wall or other vertical flat surface - Check for correct slumping of shoulders, positional lordosis, bending of knees or raising of heels - For the most ACCURATE measurement, use a WALL MOUNTED unit such as a Stadiometer - To improvise a flat, vertical surface, attach a paper or yardstick to wall + position child adjacent to tape + place a 3-d object such as a book on top of head - Measure to nearest 1 mm or 1/16th inch - Reposition child + measure at least twice (ideally 3 times) Average measurements for final value

Pneumococcal Disease Vaccine

- Streptococcal pneumococci responsible for generalized infections (septicemia, meningitis) or localized infections (otitis media, sinusitis, pneumonia) - Incidence is 2-3 time higher in children in daycare + in those who are immunocompromised - PCV13 (Prevnarl13, 13 valent pneumococcal vaccine) for children 6 weeks to 24 months old. 4 doses at 2, 4 + 6 months + 4th dose at 12-15 months old - A single supplemental doe of PCV13 for children 14-59 months old - PCV13 for all children < 24 months old - PCV13 for all children 24-71 months old who have high risk diseases: sickle cell, asplenia, nephrotic sndrome, chronic renal failure, immunocompromised, organ transplant recipients, cytoreduction therapy, long term systemic corticosteroid therapy, diabetes mellitus, cochlear implants, congenital immunodeficiency, HIV, cerebrospinal fluid leaks, chronic cardiovascular diseaese (congestive heart failure, cardiomyapthy), chronic pulmonary disease (emphysema, cystic fibrosis), chronic liver disease (cirrhosis) - PPSV23 for children < 24 months old who do NOT have one of the high risk conditions

If Behaviors that Signal Child is Ready to Cooperate with Physical Assessment are NOT Observed

- Talk to parent while "ignoring" child, then gradually focus on child or a favorite object such as a doll -Make complimentary remarks about child such as their appearance or favorite object - Tell a funny story or play a simple magic trick - Have a nonthreatening "friend" available, such as a hand puppet to "talk" to the child for the nurse

Behaviors that Signal Child is Ready to Cooperate with Physical Assessment

- Talking to nurse - Making eye contact - Accepting offered equipment - Allowing physical touching - Choosing to sit on examining table rather than parent's lap

Conjunctivitis Caused by a Foreign Body

- Tearing - Pain - Inflamed conjunctiva - Usually only ONE eye affected

Childrearing Practices Related to an Infant's Temperament

- Tests that measure temperament: Revised Infant Temperament Questionnaire, Infant Behavior Questionnaire, Early Infancy Temperament Questionnaire - With knowlege of the infants temperament, nurses are better able to: 1.) Provide parent's with background info that will help them see their child in a better perspective 2.) Offer a more organized picture of their child's behavior + possibly reveal distortions in their perceptions of the behavior 3.) Guide parents regarding appropriate childrearing techniques - Allows the nurse to assess normal growth + minor or abnormal deviations - Helps parents gain realistic expectations of their child's ability + provides guidelines for suitable play + stimulation

Tetanus Vaccine + 3 Forms

- Tetanus toxiod is used for routine immunization, usually in one of the combinations for diptheria + provides protection for 10 years - Tetanus, Diptheria toxoids along with acellular Pertussis vaccine (Tdap) recommended for children 11-12 ears old who have completed the recommended DTaP/DTP vaccine series but have not received the tetanus (Td) booster dose - Adolescents 13-18 years old who have not received the booster should receive a single Tdap booster, provided the routine DTaP/DTP childhood immunization series has been received - Because of the soaring incidence of Pertussis, it is not recommended that a Tdap booster be administered regardless of the time interval from the last tetanus or diptheria vaccine - Children 7-10 who are not fully vaccinated for pertussis should receive a dose of Tdap - Td boosters should be given every 10 ears - Boostrix (Tdap) for children 10-18 years old - Adacel (Tdap) for 11-64 years old - For wound management, passive immunity is available with TIG - For those 7 years + who need would prophylaxis, tetanus immunization with Td - If TIG not available, equine antitoxin may be administered after appropriate testing for sensitivity 3 Forms: 1.) Tetanus toxoid 2.) Tetanus immunoglobulin (TIG, human) 3.) Tetanus antitoxin (equine, NO longer in USA)

Play

- The activity of infants is primarily narcissistic + revolves around their own bodies - Body parts are primarily objects of play + pleasure - Birth-3 months, response to environment is global + largely undifferentiated. - 1 month, play is a quieting attitide - 2 moths, play is a smile - 3 months, play is a squeal - 3-6 months, infants discriminate interest in stimuli + play alone with rattles of soft, stuffed toys - 4 months, they laugh aloud + show preference for certain toys, become excited when food or a favorite object is brought to them. They recognize images in a mirror, smile at them + vocalize to them - 6-12 months, play involves sensorimotor skills. Games such as peek-a-boo and pat-a-cake are payed. Verbal repetition + imitation of simple gestures occur in response to demonstration. Play is much more selective, not only toys but of playmates. Play is solitary or one sidede but infants choose whom to interact with. - 6-8 months, refuse to play with strangers. Parents are definite favorites - 6 months, extend arms to be picked up - 7 months, cough to make presence known - 10 months, pull at parents clothing - 12 months, call parents by name - Infants need to be PLAYED WITH , not merely ALLOWED TO PLAY to develop properly - Type of toys is much less important that the quality of personal interaction that occurs.

Patient's Assent

- The assent means that the child has been informed about the proposed treatment, procedure or research + is willing to permit it. - Not a legal requirement but an ethical one to protect the rights of children

Piaget Sensorimortor Phase Cognitive Development

- Theory most commonly used to explain cognition - Birth to 24 months old SENSORIMOTOR PHASE - Infants progress from reflexive behaviors to simple repetitive acts to imitative activity 3 Crucial Events Occur: 1.) SEPARATION: learn to separate self from objects in environment. Realize others besides themselves control the environment + that certain readjustments must take place for mutual satisfaction to occur. Coincides with Erikson's concept of the formation of trust. 2.) OBJECT PERMANENCE: Realization that objects that leave the visual field still exist. Develops around 9-10 months old 3.) MENTAL REPRESENTATION: Ability to use symbols. Allows infants to think of an object or stiuation without actually experiencing it. Beginning of understanding time and space. STAGES: 1.) Birth-1 month: Identified by infant's use of reflexes 2.) 1-4 moths: Primary Circular Reactions, marks beginning of the replacemnt of reflexive behavior with voluntary acts. 3.) Lasts until 8 months: Secondary Circular Reactions stage, primary circular reactions are repeated + prolonged for the response that results. Grasping + holding become shaking, banging + pulling. Imitation, Play and Affect occur 4.) Coordination of Secondary Schemas + their Application to New Situations, infants use previous behavioral acheivements as the foundation for adding new intellectual skills

2% Lidocaine for Catheterization

- To make catheterization less uncomfortable for children - Lidocaine jelly applicator introduce into urethra 0.4-0.8 inch so lubricant flows only into urethra - 5-10 mL - After applied, wait 2-3 minutes to maximize absorption of anesthetic

Inhalation Burn Injury

- Trauma to the traceobronchial tree often follows inhalation of heated gases + toxic chemicals produced during combustion - Heat damage below vocal cords is rare. Inspired heated air is cooled in the upper airway before reaching the trachea. - Evidence of direct thermal injury to upper aiway includes burns of face, lips, singed nasal hairs + laryngeal edema - Clinical manifestations may be delayed as long as 24-28 hours - Wheezing, increasing secretions, hoarseness, wet rales + carbonaceous secretions are signs of respiratory tract involvement

Hyperthermia Treatments

- Unlike in fever, antipyretics are of NO value in hyperthermia as the set point is already normal - Cooling measures are use - Cool applications to the skin help reduce the core temp - Cooled blood from the skin surface is conducted to inner organs and tissues, and warm blood is circulated to the surface, where it is cooled + recirculated - The surface blood vessels dilate as the body attempts to dissipate heat to the environment + facilitate this cooling process - Cooling blankets or mattresses - Frequent temp monitoring is essential to prevent excessive cooling of body - Cool compresses decrease high temp. - For tepid tub baths, it is best to start with warm water + gradually add cool water until the desired temp of 98.6 is reached to acclimate the child to the lower temp. Generally, the temp of the water only has to be 2 degrees F less than the child's temp to be effective. The child is placed directly in the tub of tepid water for 15-20 minutes while water is gently squeezed from a washcloth over the back + chest or gently sprayed over the body from a sprayer. - In the bed, cool washcloths are used, exposing only one area of the body at a time. Continue sponging for 20 minutes - Temp retaken 30 minutes after the tub or sponge bath - Do not cool to the point of chilling the child! Chilling causes vasoconstriction, which defeats the purpose of the cool applications. In this condition, little blood is carried to the skin surface; the blood remains primarily in the viscera to become heated.

Infants Sleep Patterns

- Varies - 2 months = 15 hours (can range from 10-20 hours) - 6-12 months = 13 hours (can range from 9-17) - Generally, by 12 months, they develop a nighttime sleep pattern that lasts 8 hours - Infants take two naps by end of first year - Breastfed infants sleep for shorter periods, especially during night

Preschool Self Care

- Verbalize their request for independence + preform independently because of their much refines physical + cognitive development - By 4-5 they need little assistance with dressing, eating or toileting + can be trusted to obey warnings of danger - Internalized many of the standards + values of the family + culture - Begin to question parental values + compare them with those of their peer group + other authority figures - Become increasingly aware of their role + position in family

Visual Acuity Testing in Infants

- Vision is tested mainly by checking LIGHT PERCEPTION by shining a light in the eyes + noting responses, such as pupillary constriction, blinking, following the light to midline, increased alertness or refusal to open the eyes after exposure to the light - Another test of visual acuity is the infants ability to fix on + follow a target - VISUALLY EVOKED POTENTIALS, the eyes are stimulated with a bright light or pattern + electrical activity to the visual cortex is recorded through scalp electrodes - If visual fixation + following are not present by 3-4 months olds, further opthalmologic evaluation is necessary

Peripheral Vision

- Visual field of each eye - Have the child fixate on an object in front of them while an object (such as a finger or pencil) is moved from beyond the field of vision into the range of peripheral vision - As children see the object, tell them to say "stop". At that point, measure the angle from the anteroposterior axis of the eye (straight line of vision) to the peripheral axis (at which point the object can be seen) - Check each eye separately + for each quadrant of vision - Normally, children see about 50 degree upward, 70 degrees downward, 60 degrees nasal ward + 90 degrees temporally - Limitations in peripheral vision may indicate blindness from damage to structures within the eye or to any of the visual pathways

Toddler Toilet Training

- Voluntary control of anal + urethral sphincters is achieved sometime after the child is walking, between 18-24 months old - Child must be able to recognize the urge to let go + hold on + be able to communicate this sensation to the parent - No universal right age to begin toilet training or an absolute deadline to complete - Girls are ready to begin toilet training before boys - Nighttime bladder control normally takes several months to years after daytime training begins - Bedwetting is normal in girls up to 4 years + up to 5 years in boys - Children who do not have daytime dryness by 6 years old are likely to require intervention - Bowel training is usually accomplished before bladder training because of its greater regularity + predictability - Parents can talk about how adults + animals preform functions on a routine basis - Planting feet firmly on floor promotes defecation - If a potty chair is not available, having the child facing toilet tank provides added support - Practice sessions limited to 5-8 minutes - Children should be praised for cooperative behavior + successful evacuation - When the child begins to experience regular daytime dryness, parents may experiment with underwear during day - Regression may coincide with a stressful event + this is a NORMAL part of toilet training + does not mean a failure

Opioid Withdrawal

- When opioids are abruptly discontinued without weaning, withdrawal symptoms occur in 24 hours + peak in 72 hours - Neurologic excitability (irritability, tremors, seizures, increased motor tone, insomnia), GI dysfunction (nausea, vomiting, diarrhea, cramps) + autonomic dysfunction (sweating, fever, chills, tacypnea, nasal congestion, rhinitis) - Withdrawal symptoms can be prevented by WEANING patients from opioids that were administered for more than 5-10 days - A weaning flowsheet may be used to assess the efficacy of opioid weaning in NEONATES - In older infants + young children, the Withdrawal Assessment Tool may be used to assess + monitor withdrawal symptoms in pediatric critically ill children who are exposed to opioids + benzos for prolonged periods

Infant Dental Health

- When teeth erupt, cleaning should begin - Bottles shouldn't be given in bed, fruit juices in a bottle, avoid propping the milk bottle up before 6 months to stop development of cavities - Initially cleaned with damp cloth as tooth brushing is too harsh for tender gingiva - See the dentist by 6 months - Small, soft bristle toothbrush when more teeth erupt + infant adjusts to routine of cleaning - Water is preferred to toothpaste, which the infant will swallow - Flouride is needed beginning at 6 months if infants does not receive flouridated water

Urine Specimen from Infant

- Wipe abdomen with an alcohol pad + fan dry - Should void within 2 minutes - Apply pressure over suprapubic area or strole the paraspinal muscles to elicit the Perez reflex; in infants 4-6 months old, this reflex causes crying, extention of the back, flexion of the extremities + urination

Infants + Toddlers Understanding of Death

- With death of someone, they may act as though the person is still alive - As they grow up, they will be increasingly able to let do of dead person - Ritualism is important, a change in lifestyle is anxiety producing - Reacts more to the pain + discomfort of a serious illness than the fatal prognosis - Reacts to parental anxiety + sadness - Egocentricity + vague separation of fact + fantasy make it impossible for them to comprehend absence of life - Instead of understanding death, they are more affected by a change in lifestyle - If parent has died, encourage a consistent caregiver for child

Varicella Treatment

- Zovirax (antiviral) - IVIG (IV immune globulin) - Immune globulin - Diphenhydramine hydrochloride or antihistamines to relieve itching - Skin care to prevent secondary bacterial infection - Daily bath - Daily linen change - Calamine lotion - Apply mittens if child scratches

Toddler Development of Body Image

- body integrity is poorly understood + intrusive experiences are threatening. Ex. toddlers forcefully reject having temp taken. The procedure itself is not painful but it represents an INTRUSION into the child's personal space. - Assist in fostering positive body image by avoiding attaching negative labels onto body parts such as "skinny arms" or " chubby legs"

Grading of Pulses

0 = not palpable +1 = difficult to palpate, thready, weak, easily obliterated with pressure +2 = difficult to palpate, may be obliterated with pressure +3 = easy to palpate, not easily obliterated with pressure (NORMAL) +4 = strong, bounding, not obliterated with pressure

1 Supplement Recommended for All Women of Childbearing Age

0.4 mg of folic acid folic acid taken before conception + during early pregnancy can reduce risk of neural tube defects such as spinal bifida by 79% oral contraceptives + antidepressents may decrease folic acid absorption

8 Adaptive Tasks of Parents Having Children with Chronic Conditions

1.) Accept child's condition 2.) Manage condition daily 3.) Meet child's normal developmental needs 4.) Meet developmental needs of other family members 5.) Cope with ongoing stress + periodic crises 6.) Assist family members to manage their feelings 7.) Educate others about child's condition 8.) Establish a support system

5 Types of Intestinal Parasites

1.) Common Roundworm (Ascaris Lumbricoides) 2.) Hookworm (Necator americanus + Ancylostoma duodenale) 3.) Threadworm (Strongyloides stercoralis) 4.) Dogs + Cats Roundworm 5.) Whipworm (Trihuris trichiura)

Trends in Care for Children Living with Chronic Diseases

1.) DEVELOPMENTAL FOCUS 2.) FAMILY CENTERED CARE 3.) FAMILY HEALTH CARE PROVIDER COMMUNICATION 4.) ESTABLISHING THERAPEUTIC RELATIONSHIPS 5.) ROLE OF CULTURE IN FAMILY CENTERED CARE 6.) SHARED DECISION MAKING 7.) NORMALIZATION

2 Ways of Preforming a Health History

1.) DIRECT: Nurse asks for info via direct interview 2.) INDIRECT: By completing some type of questionnaire - Direct method is superior to indirect method or a combination of both - If a direct approach cannot be used, they should review the parent's written response + question them regarding an unusual answers

8 Characteristics of Preoperational Thought

1.) EGOCENTRICISM 2.) TRANSDUCTIVE REASONING 3.) GLOBAL ORGANIZATION 4.) CENTRATION 5.) ANIMISM 6.) IRREVERSIBLITY 7.) MAGICAL THINKING 8.) INABILITY TO CONSERVE

2 Different Attachment Disorder Patterns

1.) Emotionally withdrawn 2.) Indiscriminate-disinhibited

3 Tests for Cerebellar Function

1.) FINGER TO NOSE TEST: With the child's hand extended, ask child to touch the nose with the index finger with the eyes open + then closed 2.) HEEL TO SHIN TEST: Have the child stand + run the heel of one foot down the shin or anterior aspect of the tibia of the other leg, both with the eyes opened + then closed 3.) ROMBERG TEST: Have the child stand with the eyes closed + heels together; falling or leaning to one side is abnormal + is called the Romberg Sign

2 Rules to Govern Talking about Sensitive Questions such as Sex with Preschoolers

1.) Find out what the children know + think 2.) Be honest

Erikson's 2 oral-social stages:

1.) First 3-4 months, food intake is MOST important social activity in which the infant engages. Newborns tolerate little frustration or delay of gratificaiton. Primary Narcissim is at its height. As bodily processes become better controlled, infants use more advanced behaviors to interact with others. For example, rather than cry, infants may put their arms up to signify a desire to be held - Social modality involves a mode of REACHING OUT to others through grasping. grasping is initially reflexive, but even as a reflex, it has a powerful social meaning for the parents. The reciprocal response to the infants grasping is the parent's holding on + touching. There is pleasurable tactile stimulation for both the child + parents. - Tactile stimulation is extremely important in the total process of acquiring trust 2.) The more active + aggressive modality of biting occurs. infants learn that they can hold onto what is their own + can more fully control their environment. Infants may be confronted with one of their first conflicts. If they are breastfeeding, they learn that biting the breast causes the mother to become upset + withdraw the breast. Yet biting brings internal relief from teething discomfort and sense of power or control

During Adjustment phase, 4 Types of Parental Reactions to the Child

1.) OVERPROTECTION: Fear letting child achieve any new skill, avoid all discipline + cater to every desire to prevent frustration 2.) REJECTION: Parents detach themeslves emotionally from the child but usually provide adequate physical care or constantly nag + scold child 3.) DENIAL: Parents act as if the disorder does not exist or attempt to have the child overcompensate for it 4.) GRADUAL ACCEPTANCE: Parents place necessary + realistic restrictions on the child, encourage self care activities + promote reasonable physical + social abilities

4 Ways to Prevent Tantrums

1.) Offer the child OPTIONS instead of an "all or none" position 2.) Set clear boundaries + expectations with ALL caregivers 3.) Ensure a consistent response to child's behavior by ALL caregivers 4.) Praise positive behavior or provide a reward system (sticker chart)

3 Conditions for Informed Consent

1.) Person must be CAPABLE of giving consent by being over the age of majority (over age 18) and must be considered competent (possessing the mental capacity to make choices + understand their consequences) 2.) Person must RECEIVE THE INFORMATION needed to make an intelligent decision 3.) Person must ACT VOLUNTARILY when exercising freedom of choice without force, fraud, deceit, duress or other forms of constraint or coercion.

4 Sites for Measuring BP

1.) Upper Arm 2.) Lower Arm or Forearm 3.) Thigh 4.) Calf or ankle

Guidelines for Using the Blood Pressure Tables

1.) Use the standard height charts to determine the height percentile 2.) Measure + record the child's systolic BP + diastolic BP 3.) Use the correct gender table for systolic BP + diastolic BP 4.) Find the child's age on left side of the table. Follow the age row horizontally across the table to the intersection of the line for the height percentile (vertical column) 5.) Then, find the 50th, 90th, 95th + 99th percentiles for both systolic + diastolic BP - BP < 90th percentile is NORMAL - BP between 90th + 95th is PREHYPERTENSION. In adolescents, a BP > 120/80 is PREHYPERTENSION even if this is < than 90th percentile - BP > 95th percentile is HYPERTENSION 6.) If > 90th percentile, then the BP should be repeated TWICE at same office visit + an average BP should be used 7.) If BP > 95th percentile, BP should be staged. If BP is Stage 1 (95-99th percentile + 5 mm Hg), BP measurements should be repeated on TWO more occasions. If hypertension is confirmed, evaluation should proceed. If BP is Stage 2 (>99thh percentile + 5 mm Hg), prompt referral should be made for evaluation + therapy. If the patient is symptomatic, immediate referral + treatment are indicated.

how long do preschoolers sleep?

12 hours a night + infrequent daytime naps waking at night is common

Recommended Needle Length for Newborns to 2 Months

16 mm (5/8 inch)

Manifestations of Acute Pain in the Neonate

> HR > BP - Rapid, SHALLOW breathing < transcutaneous Ox saturation (TcPO2) < arterial Ox saturation (SaO2) - Pallor or flushing - Diaphroesis - Palmar sweating > muscle tone - Dilated pupils < vagal nerve tone > intracranial pressure - Hyperglycemia < pH > corticosteroids - Crying, whimpering, groaning, furrowed brow, chin quivering, eyes tightly CLOSED, mouth OPEN + squarish, limb withdrawal, thrashing, rigidity, flaccidity, fist clinching, listlisness - Changes in sleep-wake cycles, feeding behavior + activity level

Erythema Infectiosum (Fifth Disease)

AGENT: Human parovirus B19 SOURCE: Infected persons, mainly school children TRANSMISSION: Respiratory secretions + blood INCUBATION: 4-14 days; may be as long as 21 days PERIOD OF COMMUNICABILITY: Uncertain but before onset of symptoms in children with aplastic crisis

Mumps

AGENT: Paramyxovirus SOURCE: Saliva of infected person TRANSMISSION: Direct contact with or droplet spread INCUBATION: 14-21 days PERIOD OF COMMUNICABILITY: Most communicable immediately before + after swelling begins

2 Rotavirus Vaccines

Both administered ORALLY: 1.) RotaTeq (RV5): 2 mL, for infants 6-12 weeks, then two additional doses at 4-10 week intervals but NOT after 32 weeks old. Must be protected from light. 2.) Rotarix (RV1): 1 mL, administered at 6 weeks of age, with a second dose at least 4 weeks after first dose but before 24 weeks old.

Pertussis (Whooping Cough) Clinical Manifestations

CATARRHAL: Upper resp. infect., coryza, sneezing, lacrimation, cough + low fever; symptoms continue 1-2 weeks when dry, hacking cough becomes more severe PAROXYSMAL: Cough mostly at night that are short, rapid cough followed by sudden inspiration associated with a high pitched crowing sound or "whoop"; during paroxysms, cheeks may become flushed or cyanotic, eyes bulge + tongue protrudes; may continue until thick mucus plug is disloged; vomiting frequently follows attack; lasts 4-6 weeks, followed by convalescent stage - Infants < 6 months may not have "whoop" cough but have difficulty breathing because of secretions + vomiting - Additional symptoms in adolescents: difficulty breathing, postussive vomiting

Approach Behaviors

Coping mechanisms that result in movement toward adjustment + resolution of crisis EXAMPLES: - Asks for info regarding diagnosis + child's present condition - Anticipates future problems; actively seeks guidance + answers - Endows the condition with meaning - Shares burden of disorder with others - Plans realistically for future - Acknowledges + accepts the child's awareness of diagnosis + prognosis - Expresses feelings + realizes reason for emotion - Realistically perceives child's condition; adjusts to change - Recognizes own growth through passage of time, such as earlier denial + non-acceptance of diagnosis - Verbalizes possible loss of child

How to treat bee sting?

First remove stinger. As long as the stinger remain in the skin, the muscles push the stinger deeper + the venom is pumped into the wound. The longer the time interval, the greater the amount of venom.

How to treat poison ivy/oak?

First rinse with COLD water to remove as much of oil as possible Then apply calamine lotion

Kussmaul Respiration

Hyperventilaion, gasping + labored respiration; usually seen in diabetic coma or states of respiratory acidosis

Managing Opioid Induced Respiratory Depression

IF RESPIRATIONS ARE DEPRESSED: - Assess sedation level - Reduce infusion by 25% - Stimulate patient (shake, call by name, ask to breathe) - Administer oxygen IF PATIENT CANNOT BE AROUSED OR IS APNEIC: - Initiate resuscitation efforts as appropriate - Administer Narcan: --- For children < 88 lbs, dilute 0.1 mg in 10 mL sterile saline to make 10 mcg/mL solution + give 0.5 mcg/kg --- For children > 88 lbs, dilute 0.4 mg in 10 mL sterile saline + give 0.5 mL --- Administer bolus by slow IV every 2 minutes until effect is obtained --- CLOSELY monitor patient. Naloxon's duration of antagonist action may be SHORTER than the opioid, requiring repeated doses

Fixed Splitting

In which the split in S2 does not change during inspiration, is an important diagnostic sign of atrial septal defect

Extravasation

Inadvertant administration of vesicant solution or med into surrouniding tissue

Diptheria Clinical Manifestations

NASAL: Resembles common cold, serosnguineous mucopurulent nasal discharge without constitutional symptoms; may have frank epistaxis TONSILLAR-PHARYNGEAL: Malaise, anorexia, sore throat, low grade fever, increased pulse, SMOOTH, ADHERENT, WHITE or GREY MEMBRANE; lymphadenitis ("bull's neck"), in severe cases, toxemia, septic shock + death within 6-10 days LARNGEAL: Fever, hoarseness, cough, potential airway obstruction, dyspneic retractions, cyanosis

Toddler Sibling Rivalry

Natural jealousy + resentment toward a new child in the family or toward other children in family when a parent turns their attention from them + interacts with a sister or brother arrival of new infant represents a crisis for even the best prepared toddlers leads to DETHRONMENT (loss of sole parental attention) providing doll which toddlers can imitate parental behaviors is an excellent strategy

Measles (Rubeola) Clinical Manifestations

PRODROMAL (Catarral): Fever + malaise, followed in 24 hours by coryza, cough, conjunctiviits, Koplik spots (small, irregular red spots with a minute, bluish-white center first seen on buccal mucosa opposite molars 2 days BEFORE rash); symptoms gradually increasing in severity until second day after rash appears, when they begin to subside RASH: 3-4 days after prodromal onset; begins as erythematous maculopapular eruption on face + spreads downward; more severe in earlier sites (appears confluent) + less intense in later sites (appears discrete); after 3-4 days assumes brownish appearance + fine desquamation occurs over area of extensive involvement CONSITIUTIONAL SIGNS + SYMPTOMS: Anorexia, abdominal pain, malaise, generalized lymphadenopathy

Scarlet Fever Clinical Manifestations

PRODROMAL: Abrupt high fever, increased pulse out of proportion to fever, vomiting, headache, chills, malaise, abdominal pain, halitosis ENANTHEMA: Tonsils enlarged, edematous, reddened + covered with exudates; in severe cases it resembles diptheria; pharynx is edematous + beefy red; during first 1-2 days tongue is coated + papillae become red + swollen (white strawberry tongue) ; by 4-5th day, white coat sloughs off, leaving prominent papillae (red strawberry tongue); palate is covered with erthematous punctate lesions EXANTHEMA: Rash appears in 12 hours after prodromal; red pinhead-sized puntate lesions rapidly becomes generalized but are absent on face, which become generalized but are absent on face, which becomes flushed with striking circumoral pallor; rash more intense in folds of joints; by end of first week desquamation begins (fine, sandpaper like on torso; sheetlike sloughing on palms + soles), which may be complete 3 weeks or longer

Mumps Clinical Manifestations

PRODROMAL: Fever, headache, malaise, anorexia for 24 hours, "earache' that is aggraated by chewing PAROTITIS: By 3rd day, parotid glands (either unilateral or bilateral) enlarges + reaches a maximum size in 1-3 days; accompanied by pain + tenderness; other exercrine glands (submandibular) may also be swollen

Pupillary Reflex

Pupil constricts when a bright light shines towards it Persists THROUGHOUT life

Erythema Infectiosum (Fifth Disease) Clinical Manifestations

Rash appears in 3 stages: STAGE 1: Erythema on face, cheifly on cheeks ("slapped face" appearance); disappears by 1-4 days STAGE 2: About 1 day after rash appears on face, maculopapular red spots appear, symetrically distributed on upper and lower extremities; rash progresses from proximal to distal surfaces + may last > 1 week STAGE 3: Rash subsides bur reappears if skin is irritated or traumatized (sun, heat, cold) - In children with aplastic crisis, rash usually absent + prodromal illness includes fever, myalgia, lethargy, nausea, vomiting + abdominal pain - Those with sickle cell may have concurrent vaso-occlusive crisis

6 Subphases of Sensorimotor Stage

Reflexes 0-1 month = inborn reflexes Primary Circular Reactions 1-4 months = coordinating sensation Secondary Circular Reactions 4-8 months = repeat an action Coordination of Reactions 8-12 months = intentional actions Tertiary Circular Reactions 12-18 months = Trial and error experimentation Early Representational Thought 18-24 months = Begin to develop symbols

Primary Prevention of Communicable Diseases

Rests on Immunizations

Avoidance Behaviors

Result in movement AWAY from adjustment and represent maladaption to crisis EXAMPLES: - Fails to recognize seriousness of child's condition - Refuses to agree to treatment - Intellectualizes about the illness but in areas UNRELATED to child's condition - Angry + hostile to staff regardless of their attitude or behavior - Avoids staff, family members or child - Entertains unrealistic future plans for child with little emphasis on the present - Unable to adjust to or accept a change in progression of disease - Continually looks for new cures with no perspective toward possible benefit - Refuses to acknowledge child's understand of disease + prognosis - Uses magical thinking + fantasy; may seek "occult' help - Places complete faith in religion to point of relinquishing own responsibility - Withdraws + refuses help - Punishes self - Makes no change in lifestyle to meet needs of other family members - Drug + alcohol abuse - Suicidal ideation - Unable to discuss possible loss of child

Epidermal Stripping

Results when the epidermis is unintentionally removed when tape is removed.

how to treat an animal bite?

Rinse with copious amounts of saline or lactated ringers solution under pressure via a large syringe + washing surrounding skin with mild soap. A clean pressure dressing is applied + extremity is elevated if wound is bleeding. Prophylactic antibiotics are indicated for puncture wounds + wounds in areas where infection could result in cosmetic (face) of functional impairment (hand).

Emergency Treatment of Minor Burns

STOP BURNING PROCESS: - Remove burned clothing + jewelry - Apply cool water to burn or hold burned area under cool running water - Do NOT use ice Do not disturb any blisters that form unless the injury is from a chemical substance Do NOT apply anything to burn COVER with a clean cloth if risk of damage or contamination

Emergency Treatment of Major Burns

STOP THE BURNING PROCESS: - Flame burns-smother the fire - Place victim in the horizontal position - Roll victim in a blanket or similar object; avoid covering the head - Remove burned clothing + jewelry Skin should NOT be cooled! This leads to a drop in core body temp + potential circulatory collapse. This can also result in impaired circulation + increased tissue damage. Assess for adequate airway + breathing If child is not breathing, begin resuscitation COVER burn with clean cloth Keep victim warm Begin IV + oxygen therapy as prescribed Transport to medical aid

What sort of drug can reduce the "death rattle"

Scopolamine an opioid usually worn as a patch

Children at HIGH Risk for Complications with Communicable Diseases

Those with immunodeficency Those with hemolytic disease

Mesh Graft

sheet of skin is removed from the donor site + passed through a mesher, which produces tiny slits in the skin that allow the skin to cover 1.5-9 times the surface area of the sheet graft. This results in less desirable cosmetic but functional outcome. donor site dressed with synthetic wound coverings or fine mesh gauze until the dressing separates at 10-14 days when the wound is healed

Affinal marital relationships

marital relationships

VERBAL Creative Communication Techniques with Children

"I" MESSAGES: - Relate a feeling about behavior in terms of "I" - Describe effect behavior had on the person - Avoid use of "you" - "You" messages are judgement + provoke defensiveness THIRD PERSON TECHNIQUE: - Express a feeling in terms of a third person ("he", "she", "they") - Less threatening than directly asking children how they feel because it gives them an opportunity to agree or disagree without being defensive FACILITATIVE RESPONSE: - Listen carefully + reflect back to patients the feelings + content of their statements - Formula: "You feel ________ because ___________." STORYTELLING MUTUAL STORYTELLING - Begin by asking child to tell + story + then tell another story that is similar to child's tale but with differences that help child in problem areas BIBLIOTHREAPY: books as therapy DREAMS "WHAT IF" QUESTIONS THREE WISHES RATING GAME WORD ASSOCIATION GAME SENTENCE COMPLETION PROS + CONS

Family Nursing Interventions

- In working with children, the nurse must include family members in their care plan - Nurse's choice of interventions depends on the theoretic family model that is used - Systems Theory: Focus is on the INTERACTION of family members within the larger environment. Also presents excellent opportunities for anticipatory guidance. Because each family member reacts to every stress experienced by that system, nurses can intervene to help the family prepare for + cope with changes - Family Stress Theory: Employs crisis intervention strategies to help the family cope with the challenging event - Developmental Theory: Provides anticipatory guidance to prepare members for transition to the next family stage

Qualities of Strong Families

- A belief + sense of commitment toward promoting the well being + growth of its members - Appreciation of both large + small that individual family members do well + encouragement to do better - Concentrated effort to spend time + do things together - Sense of purpose that permeates the reasons + basis for "going on" in both bad + good times - Sense of congruence among family members regarding the value + importance of assigning time + energy to meet needs - Ability to communicate in a way that emphasizes positive interactions - Clear set of family rules, values + beliefs that establishes expectations about acceptable + desired behavior - Varied repertoire of coping strategies that promote positive functioning in dealing with both normative + nonnormative life events - Ability to engage in problem solving activities designed to evaluate options for meeting needs + procuring resources - Ability to be positive + see the positive in almost all aspects of their lives - Ability to see crisis + problems as an opportunity to learn + grow - Flexibility + adaptability in the roles necessary to procure resources to meet needs - Balance between use of internal + external family resources for coping + adapting to life events + planning for the future

Guidelines for Communicating with Children

- Allow children TIME to feel comfortable - Avoid sudden or rapid advances, broad smiles, extended eye contact - Talk to the parent if the child is initially shy - Communicate through transition objects (dolls) before questioning the child directly - Give older children the opportunity to talk without the parents present - Assume a position that is at eye level with the child - Speak in a quiet, unhurried + confident voice - Speak clearly, be specific + use simple words + short sentences - State directions + suggestions positively - Offer a choice when one exists - Be honest with children - Use a variety of communication techniques

Blended Family

- Also called a Reconstituted Family - Includes AT LEAST 1 stepparent, stepsibling or half sibling - Stepsiblings do NOT share a common biologic parent, the biologic parent of one child is the stepparent of the other - Halfsiblings share only 1 biologic parent

Cupping

- An old world practice (also by the Vietnamese) - A container (tumbler, bottle, jar) containing stem is placed against the skin to "draw out the poison" or evil - When the heated air in the container cools, a vacuum is created that produces a bruise like blemish on the skin directly beneath the mouth of the container

Developmental Theory

- An outgrowth of several theories of development - Duvall described 8 developmental tasks of the family throughout its life span - Family is described as a small group, a semiclosed system of personalities that interacts with the larger cultural social system - As an interrelated system, the family does NOT have changes in one part without a series of changes in other parts - Addresses family change OVER TIME using Duvalls Family Life Cycle Stages, based on the PREDICTABLE changes in the family's structure, function + roles, withe the age of the oldest child as the marker for stage transition - The nurse can assess how well new parents are accomplishing the individual + family developmental tasks associated with transition to parenthood

Ages + Stages Questionares (ASQ)

- Are high quality screening tools that include 19 age specific surveys that ask parents about developmental skills common in daily life for children 1 month to 5 1/2 years old - Parents answer questions regarding their child's abilites (eg. "does your child climb on an object such as a chair to reach something she wants?) - Developmental (ASQ-3) - Social-Emotional (ASQ:SE) - Age range: 1 month to 66 months for ASQ-3, 3-66 months for ASQ:SE - Number of questionnaires: 21 for ASQ-3, 8 for ASQ:SE - Number of items: About 30 per questionnaire - Takes 10-15 minutes to complete - Professionals score it - Available in English + Spanish - Children whose development appears to fall significantly below results of other children their age are flagged for further evaluation - Can be used as a universal screening tool in pediatric clinics to identify children at risk for Social-Emotional developmental delays

Communication with Infants

- Because they are unable to use words, infants primarily use + understand nonverbal communication - Communicate needs + feelings though nonverbal behaviors+ vocalizations - Smile + coo when content - Cry when distressed - Crying is provoked by unplesant stimuli from inside or outside, such as hunger, pain, body restraint or loneliness - Infants respond to adults nonverbal behaviors - They become quiet when they are cuddled, rocked or other forms of gentle physical contact - Receive comfort from the sound of a soft voice even if they do not understand the words that are spoken - Until infants reach the age at which they experience stranger anxiety, they readily respond to any firm, gentle handling + quiet calm speech - Loud, harsh sounds + sudden movements are frightening

Positive Reinforcement

- Behavior that is rewarded will be REPEATED + behavior that is not rewarded will be EXTINGUISHED - Using rewards is a positive approach - With young children, paper stars is effective. For older children, the "token system" is appropriate, especially if a certain number of stars or tokens yields a special reward - A chart should be used to record stars or tokens - Always give rewards promptly - Verbal approval should always accompany extrinsic rewards

General Guidelines for Implementing Discipline

- CONSISTENCY: A pattern of intermittent enforcement of limits actually prolongs the undesired behavior as children learn that if they are persistent, the behavior is permitted eventually - TIMING: Discipline as soon as the child misbehaves - COMMITMENT: Follow though with the discipline + avoid distractions - UNITY: All caregivers should agree on the plan + are familiar with the details to prevent confusion + alliances between child + one parent - FLEXIBILITY: Choose disciplinary strategies that are appropriate to age, temperment + severity of misbehavior - PLANNING: Plan in advance + prepare child - BEHAVIOR ORIENTATION: Always disapprove of the behavior, NOT THE CHILD - PRIVACY: Administer discipline in private - TERMINATION: After the discipline is administered, consider the child as having a "clean slate" + avoid bringing up the incident or lecturing

Patient Signs of Information Overload

- Long periods of silence - Wide eyes + fixed facial expression - Constant fidgeting or attempting to move away - Nervous habits (tapping, playing with hair) - Sudden interruptions (asking to go to the bathroom) - Looking around - Yawning, eyes drooping - Frequently looking at a watch or clock - Attempting to change the topic of discussion

Traditional Nuclear Family

- Married couple + their biologic children - Children in this type of family live with both biologic parents + if siblings are present, only full brothers + sisters - NO step relatives, foster or adopted children, half siblings, other relatives or nonrelatives

Communication with Early Childhood

- Children < 5 are EGOCENTRIC, meaning they see things only in relation to themselves + from their point of view - Focus communication on them - Tell them what they can do or how they will feel - Experiences of others are of NO interest to them - It is futile to use another child's experience in an attempt to gain the cooperation of small children - Allow them to touch + examine articles they will come in contact with - Although they don't yet have sufficient language skills, TODDLERS can effectively use their hands to communicate ideas without words. They push an unwanted object away, pull another person to show them something, point + cover the mouth that is saying something they do not wish to hear. - Everything is direct + CONCRETE to small children - They are unable to work with abstractions + interpret words literally - Analogies escape them because they are unable to separate reality from fantasy - Use simple, direct language rather than phrases that might be misinterpreted

Cultural Practices the Dominant Culture May Consider Abusive

- Coining - Cupping - Burning - Female genital mutilation - Force kneeling - Topical garlic application - Traditional remedies that contain lead

Authoritative Parenting Style

- Combine both authoritarian + permissive styles - Direct their children's behavior + attitudes by emphasizing the reason for rules + negatively reinforcing deviations - They respect the individuality of each child + allow the child to voice objections to family standards or regulations - Parental control is firm + consistent but tempered with encouragement, understanding + security - Control is focused on the issue, not on withdrawal of love or the fear of punishment - Foster "inner-directedness", a conscience that regulates behavior based on feelings of guilt or shame for wrongdoing, not on fear of being caught or punished - Parent's realistic standards + reasonable expectations produce children with high self esteem who are self reliant, assertive, inquisitive, content + highly interactive with other children

Nuclear Family

- Composed of 2 parents + their children - Parent-child relationship may be biologic, step, adoptive or foster - Sibling ties may be biologic, step, half or adoptive - Parents are not necessarily married - No other relatives of nonrelatives are present in the household

Ignoring Behavior

- Consistently ignoring behavior will eventually EXTINGUISH or minimize the act - It is difficult to implement consistently - Parent's frequently "give in" and resort to previous patterns of discipline. Consequently, the behavior is actually reinforced because the child learns that persistence gains parental attention For ignoring to be effective, parents should: 1.) Understand the process 2.) Record the undesired behavior before using ignoring to determine weather a problem exists + to compare results after ignoring has begun 3.) Determine weather parental attention acts as a reinforcer 4.) Be aware of "response burst"

Impact of Divorce on Children

- Contributes to poor mental health outcomes, especially when combined with child abuse - Even when a divorce is amicable + open, children recall parental separation with the same emotions felt by victims of a natural disaster: loss, grief + vulnerability to forces beyond their control - Family characteristics are more crucial to the child's well being than specific child characteristics such as age or sex - A major problem occurs when children are "caught in the middle" between the divorced parents. They become the message bearer between the parents, are often quizzed about the other parent's activities + have to listen to one parent criticize the other - Feelings of children toward divorce vary with age - Divorce constitutes a major disruption for children of all ages - Some children feel a sense of shame + embarrassment - Sometimes children see themselves as different, inferior or unworthy of live, especially if they feel responsible for the family dissolution - A successful post divorce family can improve the quality of life for both adults + children. If conflict is resolved, a better relationship with one or both parents may result + some children may have less contact with a disturbed parent - Greater stability in the home + removal of arguing parents can be a positive outcome for the child's long term well being

Family

- Defined in many ways according to the individual's own frame of reference, values or discipline - NO universal definition of family - Family is what an individual considers it to be - Psychology emphasizes the interpersonal aspects + its responsibility for personality development - Economics views the family as a productive unit providing for material needs - Sociology depicts the family as a social unit interacting with a larger society, creating the context within which cultural values + identity are formed - Cosanguineous (blood relationships) - Affinal (marital relationships) - Family of origin (family born into) - "Household" is frequently used to describe the varieties of families

Family Systems Theory

- Derived from the general systems theory - Characterized by the interaction among the components of the system + between the system + the environment - Family is viewed as a system that continually interacts with its members + the environment - Emphasis is on the interaction between the members - A change in one family member creates a change in other members, which in turn results in a new change in the original member. - However, a problem or dysfunction does NOT lie in any one member but rather in the type of interactions used by the family - Because the interactions, NOT the individual members are viewed as the source of the problem, THE FAMILY BECOMES THE PATIENT + the focus of care - Examples: nonorganic failure to thrive, child abuse - The problem does NOT rest solely with the parent or child but with the type of INTERACTIONS between the parent + the child + the factors that affect their relationship - Family is viewed as a whole that is different from the sum of the individual members -For example: a household of parents + one child consists of not only 3 individuals, but also four interactive units. These units include 3 dyads (the marital relationship, the mother-child relationship, and the father-child relationship) and a triangle (mother-father-child relationship) - The family dyads are in the center of the circle surrounded by the extended family, the subculture, the culture, with the larger society at the periphery - A major factor that influences a family's adaptability is its boundary, an imaginary line that exists between the family + its environment - Families with OPEN boundaries may demonstrate a greater receptivity to interventions - Families with CLOSED boundaries often require increased sensitivity + skill on the part of the nurse to gain their trust + acceptance - The nurse who uses family systems theory should assess the familiy's ability to accept new ideas, information, resources + opportunities + to plan strategies

Ecological Framework

- Developed by Bronfenbrenner (1979) - Posits that individuals adapt in response to changes in their surrounding environments, whether that be the environment of the immediate family, the school, the neighborhood or the socioeconomic forces that may shape job availability in their geographic area - A person's behavior results from the interaction of their traits with the environment

Denver II

- Most widely used developmental screening test for young children - The American Academy of Neurology + the Child Neurology Society state that research has found the Denver II to be insensitive + lacks specificity + therefore do not recommend the use of the Denver II for primary care developmental screening

Duvall's 8 Developmental Stages of the Family

- Developmental theory STAGE 1: MARRIAGE + an INDEPENDENT HOME: The Joining of Families - Reestablish couple identity - Realign relationships with extended family - Make decisions regarding parenthood STAGE 2: FAMILIES WITH INFANTS: - Integrate infants into family unit - Accommodate to new parenting + grandparenting roles - Maintain marital bond STAGE 3: FAMILIES WITH PRESCHOOLERS: - Socialize children - Parents + children adjust to separation STAGE 4: FAMILIES WITH SCHOOLCHILDREN: - Children develop peer relationships - Parents adjust to their children's peer + school influences STAGE 5: FAMILIES WITH TEENAGERS: - Adolescents develop increasing autonomy - Parents refocus on midlife marital + career issues - Parents begin a shift toward concern for the older generation STAGE 6: FAMILIES AS LAUNCHING CENTERS: - Parents + young adults establish independent identities - Parents renegotiate marital relationship STAGE 7: MIDDLE AGE FAMILIES: - Reinvest in couple identity with concurrent development of independent interests - Realign relationships to include in laws + grandchildren - Deal with disabilities + death of older generation STAGE 8: AGING FAMILIES: - Shift from work role to leisure + semiretirement or full retirement - Maintain couple + individual functioning while adapting to the aging process - Prepare for own death + dealing with loss of spouse + others

Limit Setting + Discipline

- Discipline: Means "to teach". It refers to the action taken to enforce the rules after oncompliance - Limit setting: Establishing the rules or guidelines for behavior. The clearer the limits that are set + are more consistently that are enforced, the less need there is for disciplinary action - Children want + need limits - Unrestricted freedom is a threat to their safety + security - By testing the limits imposed on them, children learn the extent to which they can manipulate their environment + gain reassurance from knowing that others are there to protect them from potential harm

Communal Family

- Emerged from disenchantment with most contemporary life choices - May have divergent beliefs, practices + organization, the basic impetus for formation is often dissatisfaction with the nuclear family structure, social systems + goals of the larger community - Relatively uncommon today - Communal groups share common ownership of property -In cooperatives, property ownership is private, but certain goods + services are shared + exchanged without monetary consideration - Strong reliance on group members + material interdependence

Ethnocentrism

- Emotional attitude that one's own ethnic group is superior to others - That one's values, beliefs + perceptions are the correct ones - The group's ways of living + behaving are the best - Implies that all other groups are inferior - It is a common attitude among the dominant ethnic group + strongly influences a person's ability to evaluate objectively the beliefs + behaviors of others

Bowen's Family Systems Theory

- Empahsizes that the key to healthy family function is the members' ability to distinguish themselves from one another both emotionally + intellectually - The family unit has a high level of adaptability - When problems arise within the family, change occurs by altering the interaction or feedback messages that perpetuate disruptive behavior - FEEDBACK refers to processes in the family that help identify STRENGTHS + needs + determine how well goals are accomplished - Positive feedback INITIATES change - Negative feedback RESISTS change - When the family system is disrupted, change can occur at any point in the system

Family Stress Theory

- Explains how families react to stressful events + suggests factors that promote adaptation to stress - Predictable + unpredictable stressors - Stressors are cumulative, involving simultaneous demands from work, family + community life - Too many stressful events occurring within a relatively short period (usually 1 year) can overwhelm the family's ability to cope + place it at risk for breakdown or physical + emotional health problems among its members - When the family faces too many stressors for it to cope adequately, a state of crisis ensues - For adaptation to occur, a change in family structure or interaction is necessary - The resiliency model of family stress, adjustment, + adaptation emphasizes that the stressful situation is not necessarily pathologic or detrimental to the family but demonstrates that the family needs to make fundamental structural or systemic changes to adapt to the situation

Anticipatory Guidance

- Focuses on providing families information on normal growth + development + nurturing childrearing practices - The ideal way to handle a situation as it deals with it before it becomes a problem - Best preventive measure - For example: injury prevention, beginning prenatally, parents are given specific instructions on home safety

Genes

- Genes are segments of DNA that contain genetic info necessary to control a certain physiologic function or characteristic - These segments are often referred to as SITES or LOCI, indicating a physical or "geographic" location on a chromosome - When referring to a particular FORM of a gene, the term ALLELE is used - Variant forms of a gene (variant alleles) may lead to no measureable or observable differences, may cause the person to be susceptible to clinically recognizable pathology within specific environmental contexts, may cause a clinically recognized disease or disorder or may prove advantageous within a particular environmental context

Telephone Triage

- Guidelines for telephone triage include: asking screening questions, determining when to immediately refer to emergency medial services + determining when to refer to appointments or home care - Increases access to high quality health care services + empowers patients to participate in their child's health care - Unnecessary ED + clinic visits decreased - Patient satisfaction has improved - Successful outcomes depend on quality of nurse-patient communication

Telling the Children About Divorce

- If possible, the initial disclosure should include both parents + siblings, followed by individual discussions with each child - Sufficient time should be set aside for these discussions + they should take place during a period of calm, not after an argument - Parents who physically hold or touch their children provide them with a feeling of warmth + reassurance - These discussions should include the reason for the divorce, if age appropriate + reassurance that the divorce is not the fault of the children - Parents should not fear crying as their crying gives the children permission to cry also - Children need to ventilate their feelings - They may feel guilt, a sense of failure, or that they are being punished, anger, resentment, terror + abandonment - Children fear that if their parents stopped loving each other, they could stop loving them

Single Parent Family

- Mothers usually head single parent families - Result of more women establishing separate households because of divorce, death, desertion or single parenthood - A more liberal attitude by the courts has a made it possible for single people (female + male) to adopt - With women's increased psychological + financial independence + the increased acceptability of single parents in society, more unmarried women are deliberately choosing mother-child families - Frequently, single mothers are absorbed into the extended family

Communicating with Children

- Nonverbal components convey the MOST significant messages - Children are alert to surroundings + attach meaning to every gesture + move that is made, especially young children - Active attempts to make friends with children before they have had an opportunity to evaluate an unfamiliar person tend to increase their anxiety. Continue to talk to the child + parent but go about activities that do not involve the child directly, thus allowing the child to observe from a safe position - If the child has a special toy or doll "talk" to the doll first - Ask simple questions such as "does your teddy bear have a name?" to ease the child into the conversation

Developmental Assessment

- One of the most essential components of a complete health apprasial is assessment of developmental function - Screening procedures are designed to identify quickly + reliably children whose developmental level is below normal + require further investigation - Provide a baseline - Since the passage of the Public Law 99-457 (Education of the Handicapped Act Amendments of 1986) much greater empahsis is placed on developmental assessment of children with disabilities - 16% children affected by developmental disabilities but fewer than 30% of these children are identified before Kindergarten - Most widely used developmental screening tests for young children are the series of tests known as the Denver Develpmental Screening Test (DDST) that have been renamed as the Denver II

Using Silence

- Permits the patient to sort out thoughts + feelings + search for responses to questions - Can be a cue for the interviewer to go more slowly, reexamine the approach + not push too hard - Sometimes it is necessary to break the silence + reopen communication. Do this in a way that encourages the person to continue talking - Breaking silence by introducing a new topic or by prolonged talking essentially terminates the patient's opportunity to use the silence Suggestions for breaking silence: - "Is there anything else you would like to say?" - "I see you find it difficult to continue. How may I help?" - "I don't know that this silence means. Perhaps there is something you would like to put into words but find difficult to say?"

PLAY as a Communication Technique

- Play is a universal language of children - Nurse can pick up on clues about physical, intellectual + social developmental progress from the form + complexity of a child's play behaviors - May providers use therapeutic play to reduce the trauma of illness + hospitalization + to prepare children for therapeutic procedures - INFANTS: because their ability to perceive PRECEDES their ability to to transmit, infants respond to activities that register with their physical senses. Patting, stroking or other skin play conveys messages. - Much of the nursing assessment can be carried out while the infant remains in the safety of the parent's arms or lap - Talking to a foot or other body part is an effective tactic - The nurse can capitalize on the natural curiosity of small children by playing games, such as "which hand do you take?" and "guess what I have in my hand" or by manipulating objects such as a flashlight or stethoscope - Puppets serve as excellent means of communicating with small children - Threw play, children reveal their perceptions of interpersonal relationships with their family, friends, or health care personnel - Children may also reveal the wide scope of knowlege they have acquired from listening to others around them - Ex. thew needle play, children reveal how carefully they have watched each procedure by precisely duplicating technical skills

Minimizing Misbehavior

- Reasons for misbehavior may include attention, power, defiance + displace of inadequacy (ex. child misses class because fear that they are unable to do the work) - Children may also misbehave because the rules are not clear or consistently applied - Acting out behavior, such as a temper tantrum, may represent uncontrolled frustration, anger, depression or pain - Best approach is to structure interactions with children to prevent or minimize unacceptable behavior

Communicating with School-Age Children

- Rely less on what they see + more on what they know when faced with new problems - They want explanations + reasons for everything but require no verification beyond that - Interested in the FUNCTIONAL aspect of all procedures, objects + activities - They want to know WHY an object exists, WHY it is used + HOW it works + the intent + purpose of the user - They need to know what is going to take place + why it is being done to them specifically - Have a hightened concern about body integrity - Sensitive to anything that constitutes a threat or suggestion of injury to it. This concern extends to their posessions, so they may appear to overreact to loss or threatened loss of treasured objects - Encourage children to communicate their needs + voice their concerns + implement activities that reduce their anxiety Ex. If a shy child dislikes being the center of attention, ignore that child by talking + relating to other children. When the child feels more comfortable, they will usually interject ideas, feelings, etc. Ex. Explain a procedure such as taking blood pressure, show them how to squeeze the bulb + make the "arrow" move. Explain "I want to see how far the arrow moves when the cuff squeezes your arm"

Role Learning

- Roles are learned though the socialization process - During all stages of development, children learn + practice a set of social roles - Although role definitions are changing, the basic determinants of parenting remain the same - Role behaviors are positively reinforced through love, affection, friendships + honors - Negative reinforcement takes the form of ridicule, withdraw of love, expressions of disapproval or banishment

How To Minimize Misbehavior

- Set realistic goals for acceptable behavior - Structure opportunities for small successes to lessen feelings of inadequacy - Praise children for desirable behavior with attention + verbal approval - Structure the environment to prevent unnecessary difficulties (ex. place fragile objects in safe areas) - Set clear rules - Expect same behavior regardless of circumstances. If exceptions are made, clarify that the change is for one time only - Teach desirable behavior through own example - Use a quiet, calm voice rather than screaming - Review expected behavior before special or unusual events, such as having a visitor or going to a restaurant - Phrase request for behavior positively - Call attention to unacceptable behavior as soon as it begins - Use distraction to change the behavior or offer alternatives to annoying actions - Be attentive to situations that increase the liklihood of misbehaving, such as overexcitement or fatigue - Offer sympathetic explanations for not granting a request - Keep any promises made to children - Provide children with opportunities for power + control

Nurse Blocks to Communication

- Socializing - Giving restricted + sometimes unsought advice - Offering premature or inappropriate reassurance - Giving over ready encouragement - Defending a situation or opinion - Using stereotyped comments or cliches - Limiting expression of emotion by asking directed, closed ended questions - Interrupting + finishing the person's sentence - Talking more than the interviewee - Forming prejudged conclusions - Deliberately changing the focus

Foster Care

- The placement of a child in a stable + approved environment with a non-related family - Each state provides a standard for the role of foster parent + a process by which to become one - These "parents" contract with the state to provide a home for children for a limited duration - Most states require 27 hours of training before being on contract + at least 12 hours of continuing education a year - Children in foster care tend to have a higher than normal incidence of acute + chronic health problems + may experience feelings of isolation or confusion

Communicating with Adolescents

- They fluctuate between child + adult thinking + behavior - When tensions rise, they may seek the security of the more familiar + comfortable expectations of childhood - Anticipating these shifts in identity allows the nurse to adjust the course of interaction to meet the needs of the moment - No single approach can be relied upon consistently - It is a mistake to view an adolescent as an adult with an adult's wisdom + control as it is to assume that a teenager has the concerns + expectations of a child - If the parents + teenager are together, talking with the adolescent FIRST has the advantage of immediately identifying with the young person, thus establishing trust. However, talking with the parents FIRST may provide insight may provide insight into the family relationship. In either case, give BOTH parties to be included in the interview - Privacy + confidentiality are of great importance - Explain the legal + ethical limits of confidentiality - A dilemma in interviewing adolescents is two views frequently exist: the adolescent + parents. Clarification of the problem is a major task. Providing both parties an opportunity to discuss their perceptions can be therapeutic

Authoritarian Parenting Style

- Try to control children's behavior + attitudes through unquestioned mandates - They establish rules that they expect to be followed rigidly + unquestioningly - The message is: "do it because I say so" - Punishment need not be corporal but may be stern withdrawal of love + approval - Careful training often results in rigidly conforming behavior in the children who tend to be sensitive, shy, self conscious, retiring + submissive. More likely to be courteous, loyal, honest + dependable but docile. These behaviors are more typically observed when close supervision + affection accompany parental authority. - This style of parenting may be associated with both defiant + antisocial behaviors

Malformations

- Type of congenital anomaly - Abnormal formaitons of organs or body parts resulting from an abnormal developmental process - Most occur before 12 weeks gestation - Ex. Cleft lip occurs at around 5 weeks of gestation when the developing embryo naturally has 2 clefts in the area. Normally, between 5-7 weeks, cells rapidly divide + migrate to fill in those clefts. May be unilateral or bilateral. May also involve the palate

Deformations

- Type of congenital anomaly - Caused by extrinsic mechanical forces on normally developing tissue - Ex. Club Foot is an example of a deformation often caused by uterine constraint

Disruptions

- Type of congenital anomaly - Result form the breakdown of previously normal tissue - Congenital amputations caused by amniotic bands (fibrous strands of amnion that wrap around different body parts during development) are examples of disruption

Dysplasias

- Type of congenital anomaly - Result from abnormal organization of cells into a particular tissue type - Include: teeth, hair, nails or sweat glands - More than 100 types of Ectodermal Dysplasias

Guidelines for Evaluating Drawing

- Use spontaneous drawings + evaluate more than one drawing whenever possible - Interpret drawings in light of other available info, including age + stage of development - Interpret drawings as a WHOLE rather than focusing on specific details - Sex of figure drawn usually relates to the child's perceptions of his or her own sex role - Size of figures: Express importance, power or authority - Order: Expresses priority in terms of importance - Child's position in relation to other family members: Expresses feelings of status or alliance - Exclusion of a member: May denote feeling not belonging or desire to eliminate - Accentuated parts: Areas of special importance (large hands sign of aggression) - Absence of or rudimentary arms + hands: Suggest timidity, passivity or intellectual immaturity; tiny, unstable feet may express insecurity + hidden hands may mean guilt feelings - Placement of drawing on page + type of stroke: Free use of paper + continuous strokes suggest security. Drawings restricted to a small area + lightly drawn with wavering lines may be signs of insecurity - Erasures, shading, or cross hatching: express ambivalence, concern or anxiety in a particular area

Information Overload

- When patient receive too much information or overwhelming information - A block to communication - Patients often demonstrate signs of increasing anxiety or decreasing attention - Such signals should alert the interviewer to give LESS information or to clarify what has been said

Topical Garlic Application

- Yemenite Jews - Crushed garlic cloves or garlic petroleum jelly plaster is applied to the wrists to treat infectious disease. This can result in blisters or garlic burns.

PLAY as a Communication Technique in INFANTS

- because their ability to perceive PRECEDES their ability to to transmit, infants respond to activities that register with their physical senses. - Patting, stroking or other skin play conveys messages. - Repetitive actions, such as stretching infant's arms out to the side while they are lying on their back + then folding the arms across the chest or raising + revolving the legs in a bicycling motion, will elicit pleasurable sounds - Colorful items to catch the eye or interesting sounds, such as a ticking clock, chimes, bells or sinking can be used to attract infants attention - Older infants respond to simple games - Peek-a-boo is an excellent means of initiating communication with infants while maintaining a "safe", nonthreatening distance - After this intermittent eye contact, the nurse is no longer viewed as a stranger but as a friend. This can be followed by touch games - Clapping an infants hands together for pat-a-cake or wiggling the toes for "this little piggy" delights an infant or small child - Much of the nursing assessment can be carried out while the infant remains in the safety of the parent's arms or lap

3 Consequences for Misbehavior

1. NATURAL: Those that occur without any intervention, such as being late + having to clean up the dinner table 2. LOGICAL: Directly related to the rule, such as not being allowed to play with another toy until the used ones are put away 3. UNRELATED: Imposed deliberately, such as no playing until homework is completed or use of time out - Natural or logical consequences are preferred + effective if they are meaningful to children. For example, the natural consequence of living in a messy room may do little to encourage cleaning up but allowing no friends over until the room is neat can be motivating - Withdrawing privilages is often an unrelated consequence. - After the child experiences the consequence, the parent should refrain from any comment, because the usual tendency is for the child to try to place blame for imposing the rule - TIme out is an unrelated consequence

3 Phases of the Divorce Process

1.) ACUTE: - Married couple makes decision to separate - Includes the LEGAL steps of filing for divorce + the departure of one of the parents - Lasts from several months to more than 1 year - Accompanied by familial stress + a chaotic atmosphere 2.) TRANSITIONAL: - Adults + children assume unfamiliar roles + relationships - Accompanied by change in residence, reduced standard of living + altered lifestyle, larger share of the economic responsibility being shouldered by the mother + radically altered parent-child relationships 3.) STABALIZING: - A stable, functioning family unit is reestablished - Remarriage frequently occurs with concomitant changes in all areas of family life

4 Classifications of Congenital Anomalies

1.) Deformations 2.) Disruptions 3.) Dysplasias 4.) Malformations

4 External Assets that Youth Receive from their Community

1.) SUPPORT: Young people need to feel support, care + love from their families + neighbors. They also need organizations + institutions that offer positive, supportive environments 2.) EMPOWERMENT: Young people need to feel valued by their community + be able to contribute to others. They need to feel safe + secure 3.) BOUNDARIES+ EXPECTATIONS: Young people need to know what is expected of them 4.) CONSTRUCTIVE USE OF TIME: Young people need opportunities for growth though constructive, enriching opportunities + through quality time at home

3 Theories that Conceptualize how Children Experience the Media

1.) Social Learning Theory: emphasizes learning through observation + imitation 2.) Script Theory: Posits that the media provide youth with a "script" or directions for how to behave in new situations 3.) "Super Peer" Theory: Describes media as an extreme source of peer pressure on youth to participate in what is shown to be normal behavior (ex. adolescents not practicing safe sex)

9 Types of Families

1.) Traditional nuclear family 2.) Nuclear family 3.) Blended family 4.) Extended family 5.) Single Parent Family 6.) Binuclear Family 7.) Polygamous Family 8.) Communal Family 9.) LGBT Families

US Census Bureau 4 Definitions of Families

1.) Traditional nuclear family 2.) Nuclear family 3.) Blended family or household 4.) Extended family or household

Coining

A Vietnamese practice that may produce welt like lesions on the child's back when the edge of a coin is repeatedly rubbed lengthwise on the oiled skin to rid the body of disease.

Guidelines for Communicating with Adolescents

BUILD A FOUNDATION: - Spend time together - Encourage expression of ideas + feelings - Respect their views - Tolerate differences - Praise good points - Respect their privacy - Set a good example COMMUNICATE EFFECTIVELY: - Give undivided attention - Listen, listen, listen - Be courteous, calm, honest + open minded - Try not to overreact. If you do, take a break. - Avoid judging or criticizing - Avoid the "third degree" of continuous questioning - Choose important issues when taking a stand - After taking a stand: think threw all options + make expectations clear

Traditional Remedies that Contain Lead

Greta + Azarcon (Mexico: used for digestive problems), Palooah (Southeast Asia: used for rash or fever) and Surma (India: used as a cosmetic to improve eyesight)

Relative Standard of Poverty

Reflects the MEDIAN standard of living in a society + is the term used in referring to childhood poverty in the US

NONVERBAL Creative Communication Techniques with Children

WRITING DRAWING MAGIC PLAY

Cosanguineous

blood relationships