exam 4 nursing care of children ATI/cindy

Shortened rib cage Twelfth rib anomalies Pectus excavatum (sunken chest) or carinatum (sternum projects too far forward) Congenital heart defects common (e.g., atrial septal defect, ventricular septal defect)

Clinical Manifestations of Down Syndrome: Chest and Heart

*Is organized *Is progressive *Follows a predictable sequence across life stages

*Normal human development is?

*5- to 7-oz weight gain per week *Doubling of birth weight by age 6 months *Tripling of birth weight by age 1 year *Height increases by 1 inch per month x 6 months *Growth in "spurts" rather than gradual pattern

*Proportional changes in growth and development ____ to ____ oz per week doubling of birth weight by ___months ______ birth weight by 1 year height increases by ___ inch per month x _____ months

37.7 degrees C

1 year old expected temp axillary and rectal

36.6 celcius

13 yoa expected temp

Broad, short hands and stubby fingers Incurved little finger (clinodactyly) Transverse palmar crease Wide space between big and second toes* Plantar crease between big and second toes* Broad, short feet and stubby toes

Clinical Manifestations of Down Syndrome: Hands and Feet

High, arched, narrow palate* Protruding tongue Hypoplastic mandible Delayed teeth eruption and microdontia Abnormal teeth alignment common Periodontal disease Neck skin excess and laxity* Short and broad neck

Clinical Manifestations of Down Syndrome: Mouth and Neck

37.2 degrees Celsius

3 year old expected temp axillary, tympanic, oral, rectal

37.5 degrees Celsius

3-6 month old expected temp axillary and rectal

1. Combined type—Six (or more) symptoms of inattention and six (or more) symptoms of hyperactivity-impulsivity that persist for at least 6 months. Most children and adolescents with ADHD have the combined type. 2. Predominantly inattentive type—Six (or more) symptoms of inattention (but fewer than six symptoms of hyperactivity-impulsivity) that persist for at least 6 months. 3. Predominantly hyperactive-impulsive type—Six (or more) symptoms of hyperactivity-impulsivity (but fewer than six symptoms of inattention) that persist for at least 6 months. Inattention may often still be a significant clinical feature in such cases.

Children with ADHD demonstrate one of three subtypes

Separated sagittal suture Brachycephaly (flat head) Rounded and small skull Flat occiput Enlarged anterior fontanel Oblique palpebral fissures (upward, outward slant)* Inner epicanthal folds Speckling of iris (Brushfield spots)

Clinical Manifestations of Down Syndrome Head and Eyes

Small nose* Depressed nasal bridge (saddle nose)* Small ears and narrow canals Short pinna (vertical ear length) Overlapping upper helices Conductive hearing loss

Clinical Manifestations of Down Syndrome Nose and Ears

37.0 degrees on the Celsius scale

5 yoa expected temp axillary, tympanic, oral, rectal

36.8 degrees celcius

7 year old expected temp axillary, tympanic, oral

36.7 celcius

9-11 yoa expected temp axillary, tympanic, oral

Onlooker play

A child watches other children play, but does not join in

Skill play

After infants have developed the ability to grasp and manipulate, they persistently demonstrate and exercise their newly acquired abilities through this type of play, repeating an action over and over again. The element of sense-pleasure play is often evident in the practicing of a new ability, but all too frequently, the determination to conquer the elusive skill produces pain and frustration (e.g., putting paper in and taking it out of a toy car)

Mood

Amount of pleasant, happy, friendly behavior compared with unpleasant, unhappy, crying, unfriendly behavior exhibited by the child in various situations. an attribute of temperament

Threshold of responsiveness (sensory threshold)

Amount of stimulation, such as sounds or light, required to evoke a response in the child. is an attribute of temperament

focuses on the prevention of undesired behavior. Families are helped to identify new appropriate contingencies and reward systems to meet the child's developing needs. They may also receive instruction in effective parenting skills, such as delivering positive reinforcement, rewarding small increments of desired behaviors, and providing age-appropriate consequences (e.g., time-out, response cost). The use of organizational charts for completing self-care activities and the use of a word processor instead of manually writing assignments are emphasized. Through collaborative teamwork, parents learn techniques to help the child become more successful at home and in school.

Behavioral Therapy for ADHD

Dextroamphetamine (Dexedrine) monitor growth rate closely in children

CNS stimulant for ADHD boost dopamine and norepinephrine

Protruding, lax, and flabby abdominal muscles Diastasis recti abdominis Umbilical hernia Small penis Cryptorchidism(testicles fail to descend) Bulbous vulva

Clinical Manifestations of Down Syndrome: Abdomen and Genitalia

Short stature Hyperflexibility and muscle weakness* Hypotonia (decreased muscle tone) Atlantoaxial instability Dry, cracked, and frequent fissuring Cutis marmorata (mottling)

Clinical Manifestations of Down Syndrome: Musculoskeletal and Skin

Reduced birth weight Learning difficulty (average intelligence quotient [IQ] of 50) Hypothyroidism common Impaired immune function Increased risk for leukemia Early-onset dementia (in one-third)

Clinical Manifestations of Down Syndrome: Other

respiratory care of Down Syndrome

Decreased muscle tone compromises respiratory expansion. In addition, the underdeveloped nasal bone causes a chronic problem of inadequate drainage of mucus. The constant stuffy nose forces the child to breathe by mouth, which dries the oropharyngeal membranes, increasing the susceptibility to upper respiratory tract infections. Measures to lessen these problems include clearing the nose with a bulb-type syringe, rinsing the mouth with water after feedings, increasing fluid intake, and using a cool-mist vaporizer to keep the mucous membranes moist and the secretions liquefied. Other helpful measures include changing the child's position frequently, practicing good hand washing, and properly disposing of soiled articles, such as tissues. If antibiotics are ordered, the nurse stresses the importance of completing the full course of therapy for successful eradication of the infection and prevention of growth of resistant organisms.

Sequential Trends of growth and development

Definite, predictable sequence For example, children creep before they crawl, crawl before they stand, and stand before they walk. Later facets of the personality are built on the early foundation of trust. The child babbles, then forms words, and finally sentences; writing emerges from scribbling.

infant>toddler>preschooler>school age>adolescent>young adult>middle adult>older adult

Developmental Stages across the Lifespan

Down Syndrome dietary needs

Dietary intake needs supervision. Decreased muscle tone affects gastric motility, predisposing the child to constipation. Dietary measures, such as increased fiber and fluid, promote evacuation. The child's eating habits may need careful scrutiny to prevent obesity. Height and weight measurements should be obtained on a serial basis.

2

Double the child's height at ___ years of age to estimate how tall he or she may be as an adult.

skin care with Down Syndrome

During infancy, the child's skin is pliable and soft. However, it gradually becomes rough and dry and is prone to cracking and infection. Skin care involves the use of minimum soap and application of lubricants. Lip balm is applied to the lips, especially when the child is outdoors, to prevent excessive chapping.

10

Each degree of fever increases the basal metabolism __%, with a correspondingly increased fluid requirement.

Adaptability

Ease or difficulty with which the child adapts or adjusts to new or altered situations. an attribute of temperament.

Distractibility

Ease with which a child's attention or direction of behavior can be diverted by external stimuli. an attribute of temperament

Industry versus inferiority (6 to 12 years of age) school age

Erikson Having achieved the more crucial stages in personality development, children are ready to be workers and producers. They want to engage in tasks and activities that they can carry through to completion; they need and want real achievement. Children learn to compete and cooperate with others, and they learn the rules. It is a decisive period in their social relationships with others. Feelings of inadequacy and inferiority may develop if too much is expected of them or if they believe that they cannot measure up to the standards set for them by others

Identity versus role confusion (12 to 18 years of age)

Erikson characterized by rapid and marked physical changes. Previous trust in their bodies is shaken, and children become overly preoccupied with the way they appear in the eyes of others compared with their own self-concept. Adolescents struggle to fit the roles they have played and those they hope to play with the current roles and fashions adopted by their peers, to integrate their concepts and values with those of society, and to come to a decision regarding an occupation. An inability to solve the core conflict results in role confusion. The outcome of successful mastery is devotion and fidelity to others and to values and ideologies.

Initiative versus guilt (3 to 6 years of age)

Erikson characterized by vigorous, intrusive behavior; enterprise; and a strong imagination. Children explore the physical world with all their senses and powers (Fig. 28.4). They develop a conscience. No longer guided only by outsiders, they have an inner voice that warns and threatens. Children sometimes undertake goals or activities that are in conflict with those of parents or others, and being made to feel that their activities or imaginings are bad produces a sense of guilt. Children must learn to retain a sense of initiative without impinging on the rights and privileges of others. The lasting outcomes are direction and purpose.

Trust versus mistrust (birth to 1 year of age) infancy

Erikson it is a time of "getting" and "taking in" through all the senses.

Autonomy versus shame and doubt (1 to 3 years of age)

Erikson symbolized by the holding on and letting go of the sphincter muscles. The development of autonomy during the toddler period is centered on children's increasing ability to control their bodies, themselves, and their environment. They want to do things for themselves using their newly acquired motor skills of walking, climbing, and manipulating and their mental powers of selecting and decision making. Much of their learning is acquired by imitating the activities and behavior of others. Negative feelings of doubt and shame arise when children are made to feel small and self-conscious, when their choices are disastrous, when others shame them, or when they are forced to be dependent in areas in which they are capable of assuming control. The favorable outcomes are self-control and willpower.

*Environment *Socioeconomic level *Parent child relationship *Ordinal position (order born) *Health *Nutrition

Factors Influencing Growth and Development

They have slower growth velocity between 6 months and 3 years of age and then again in adolescence. Puberty occurs earlier, and they achieve shorter stature.

Growth in children with Down syndrome differs from that in other children, what are they?

• Persistent neck pain • Loss of established motor skills and bladder or bowel control • Changes in sensation

Immediately report any child with the following signs of spinal cord compression:

Attention span and persistence

Length of time a child pursues a given activity and the continuation of an activity despite obstacles. an attribute of temperament

Activity

Level of physical motion during activity, such as sleep, eating, play, dressing, and bathing. an attribute of temperament.

skeletal

Linear growth, or height, occurs almost entirely as a result of ________ growth and is considered a stable measurement of general growth.

approach/withdrawal (temperament)

Nature of initial responses to a new stimulus, such as people, situations, places, foods, toys, and procedures (Approach responses are positive and are displayed by activity or expression; withdrawal responses are negative expressions or behaviors.) an attribute of temperament.

50-100 bpm 16-20 min

Normal pulse rate for adolescents (13-18) and RR

Sense-pleasure play

Objects in the environment (light and color, tastes and odors, textures and consistencies) attract children's attention, stimulate their senses, and give pleasure. Pleasurable experiences are derived from handling raw materials (water, sand, food), body motion (swinging, bouncing, rocking), and other uses of senses and abilities (smelling, humming)

Family History Medical History Developmental History Physical Assessment Parental Requests

Pediatric Indications for Genetic Consultation

• Behavioral disorders • Cognitive impairment or autism • Developmental and speech delays or loss of developmental milestones

Pediatric Indications for Genetic Consultation: Developmental History

Family history of hereditary diseases, birth defects, or developmental problems Family history of sudden cardiac death or early-onset cancer Family history of mental illness a minimum of three generations.

Pediatric Indications for Genetic Consultation: Family History

• Abnormal newborn screen • Abnormal genetic test result ordered by a nongenetics professional who lacks the knowledge and experience to discuss the implications of results • Excessive bleeding or excessive clotting • Progressive neurologic condition • Recurrent infection or immunodeficiency

Pediatric Indications for Genetic Consultation: Medical History

• Major congenital anomaly • Minor anomalies and dysmorphic features • Growth abnormalities • Skeletal abnormalities • Visual or hearing problems • Metabolic disorder (unusual odor of breath, urine, or stool) • Sexual development abnormalities or delayed puberty • Skin disorders or abnormalities

Pediatric Indications for Genetic Consultation: Physical Assessment

Developmental Pace

Periods of accelerated and decelerated growth Does not occur in all areas at the same pace Once a skill has been achieved, the focus will shift to another area

noninvasive prenatal testing (NIPT)

Prenatal diagnosis of Down syndrome is possible through chorionic villus sampling and amniocentesis, because chromosome analysis of fetal cells can detect the presence of trisomy or translocation. However, recent advances in development of ______ _______ _______ is a measurement of cell-free deoxyribonucleic acid (DNA) from the plasma of pregnant women, detecting nearly all cases of Down syndrome

1.Trust vs. Mistrust: Hope 0 - 1 2.Autonomy vs. Shame: Will 1 - 3 3.Initiative vs. Guilt: Purpose 3 - 5 4.Industry vs. Inferiority: Competency 5 - 12 5.Identity vs. Role Confusion: Fidelity 12 - 18 6.Intimacy vs. Isolation: Love 18 - 40 7.Generativity vs. Stagnation: Care40 - 65 8.Ego Integrity vs. Despair: Wisdom65+

Psychosocial Development (Erikson) 8 stages

Weight gain: 7 to 30 kg (15.5 to 66 pounds) Mean: 23.7 kg (52.2 pounds) Height gain: 10 to 30 cm (4 to 12 inches); ≈95% of mature height achieved by skeletal age of 15 years of age Mean: 27.5 cm (11 inches)

Pubertal Growth Spurt Males: 11 to 16 years of age

Weight gain: 7 to 25 kg (15.5 to 55 pounds) Mean: 17.5 kg (38.5 pounds) Height gain: 5 to 25 cm (2 to 10 inches); ≈95% of mature height achieved by onset of menarche or skeletal age of 13 years of age Mean: 20.5 cm (8 inches)

Pubertal Growth Spurt of females 10-14 yoa

80-140 bpm 25/30 min

Pulse ranges for a 1-2 year old (toddler) and RR

skeletal or bone age

The most accurate measure of general development is?

physical growth

The most prominent feature of childhood and adolescence is _______ ________.

child with Down Syndrome feeding

The protruding tongue also interferes with feeding, especially of solid foods. Parents need to know that the tongue thrust is not an indication of refusal to feed but a physiologic response. Parents are advised to use a small but long, straight-handled spoon to push the food toward the back and side of the mouth. If food is thrust out, it should be refed.

Early Childhood: 1 to 6 Years of Age toddler (1-3) preschooler (3-6)

This period, which extends from the time children attain upright locomotion until they enter school, is characterized by intense activity and discovery. It is a time of marked physical and personality development. Motor development advances steadily. Children at this age acquire language and wider social relationships, learn role standards, gain self-control and mastery, develop increasing awareness of dependence and independence, and begin to develop a self-concept.

• Recognize multiple stressors, strains, and transitions in their lives (e.g., unmet family needs). • Discuss and implement strategies for reducing family demands (e.g., setting priorities and reducing the number of outside activities family members are involved in). • Identify and use individual, family, and community resources (e.g., humor, family flexibility, supportive extended family, respite care, local support groups, and Internet resources). • Expand the range and efficacy of their coping strategies (e.g., increase the use of active strategies such as reframing, mobilize their ability to acquire and accept help, and decrease the use of passive appraisal). • Encourage the use of an affirming style of family problem-solving communication (e.g., one that conveys support and caring and exerts a calming influence).

Van Riper's recommendations are useful for families of children with any type of genetic disorder:

Middle Childhood: 6 to 11 or 12 Years of Age

a development age period Frequently referred to as the school age, this period of development is one in which the child is directed away from the family group and centered around the wider world of peer relationships. There is steady advancement in physical, mental, and social development with emphasis on developing skill competencies. Social cooperation and early moral development take on more importance with relevance for later life stages. This is a critical period in the development of a self-concept.

development

a gradual change and expansion; advancement from lower to more advanced stage of complexity; increased capacity through growth, maturation, and learning

anaclitic depression

a pattern of depressed behavior found among very young children that is caused by separation from one's mother or father another term for separation anxiety

Methylphenidate (Ritalin) monitor bp and pulse obtain CBC with platelet counts

a stimulant used in treating ADHD inhibits the reuptake of dopamine and norepinephrine

Parallel play

activity in which children play side by side without interacting

Teratogens

agents, such as chemicals and viruses, that can reach the embryo or fetus during prenatal development and cause harm, birth defects

maturation

an increase in competence and adaptability, usually described as a qualitative change to function at higher level

growth

an increase in number and size of cells as they divide and synthesize new proteins; results in increased size and weight of whole or any of its parts

Solitary play

children play alone with toys different from those used by other children in the same area. They enjoy the presence of other children but make no effort to get close to or speak to them. Their interest is centered on their own activity, which they pursue with no reference to the activities of the others.

Associative play

children play together and are engaged in a similar or even identical activity, but there is no organization, division of labor, leadership assignment, or mutual goal. Children borrow and lend play materials, follow each other with wagons and tricycles, and sometimes attempt to control who may or may not play in the group. Each child acts according to his or her own wishes; there is no group goal (Fig. 28.8). For example, two children play with dolls, borrowing articles of clothing from each other and engaging in similar conversation, but neither directs the other's actions or establishes rules regarding the limits of the play session. There is a great deal of behavioral contagion: When one child initiates an activity, the entire group follows the example.

Amphetimine/ dextroamphetamine stimulant of the CNS monitor growth rate do not take in the evenings, may have trouble going to sleep take in morning and space doses every 4-6 hours

combination drug used to treat ADHD

Dramatic, or pretend, play

content of play It begins in late infancy (11 to 13 months of age) and is the predominant form of play in preschool children. After children begin to invest situations and people with meanings and to attribute affective significance to the world, they can pretend and fantasize almost anything. By acting out events of daily life, children learn and practice the roles and identities modeled by the members of their family and society. Children's toys, replicas of the tools of society, provide a medium for learning about adult roles and activities that may be puzzling and frustrating to them. Interacting with the world is one way children get to know it. The simple, imitative, dramatic play of toddlers, such as using the telephone, driving a car, or rocking a doll, evolves into more complex, sustained dramas of preschoolers, which extend beyond common domestic matters to the wider aspects of the world and the society, such as playing police officer, storekeeper, teacher, or nurse. Older children work out elaborate themes, act out stories, and compose plays.

Infancy period of development neonatal birth to 28 days infancy 1-12 months

developmental age period This period is one of rapid motor, cognitive, and social development. Through mutuality with the caregiver (parent), the infant establishes a basic trust in the world and the foundation for future interpersonal relationships. The critical first month of life, although part of the infancy period, is often differentiated from the remainder because of the major physical adjustments to extrauterine existence and the psychologic adjustment of the parent.

Later Childhood: 11 to 19 Years of Age Prepubertal: 10 to 13 years of age Adolescence: 13 to approximately 18 years of age

developmental age period the tumultuous period of rapid maturation and change known as adolescence is considered to be a transitional period that begins at the onset of puberty and extends to the point of entry into the adult world—usually high school graduation. Biologic and personality maturation are accompanied by physical and emotional turmoil, and there is redefining of the self-concept. In the late adolescent period, the young person begins to internalize all previously learned values and to focus on an individual, rather than a group, identity.

Intensity of reaction (temperament)

energy level of the persons response. an attribute of temperament

36.5-37.5 degrees Celsius

infant expected temp birth to 2 months

Social-affective play

infants take pleasure in relationships with people. As adults talk, touch, nuzzle, and in various ways elicit responses from an infant, the infant soon learns to provoke parental emotions and responses with such behaviors as smiling, cooing, or initiating games and activities. The type and intensity of the adult behavior with children vary among cultures. type of play

110-160 bpm 30/60 min

newborn (0-4 weeks) pulse rate and RR

Down Syndrome

nonfamilial trisomy 21

90-160 bpm 25/30 min

normal infant pulse range (1-12 months) and RR

keep room warm and well lit perform exam in nonthreatening environment. keep medical equipment out of sight. provide privacy, determine if older school age children and adolescents prefer a caregiver to remain during exam. take time to play and develop a rapport prior to exam observe behaviors that demonstrate Childs readiness to cooperate explain each step of exam to child: use age appropriate language, demonstrate what will happen using dolls, puppets, or paper drawings, allow the child to manipulate and handle equipment, encourage child to use equipment on others. examine the child in a secure comfortable position. if child is uncooperative, assess reasons, be firm about expected behavior, complete assessment quickly, and in a calm voice. encourage questions

nursing actions for physical assessment of a child

Cooperative play

play is organized, and children play in a group with other children. They discuss and plan activities for the purposes of accomplishing an end: to make something, attain a competitive goal, dramatize situations of adult or group life, or play formal games. The group is loosely formed, but there is a marked sense of belonging or not belonging. The goal and its attainment require organization of activities, division of labor, and role playing. The leader-follower relationship is definitely established, and the activity is controlled by one or two members who assign roles and direct the activity of the others. The activity is organized to allow one child to supplement another's function to complete the goal.

cephalocaudal principle example: Infants have control over head, before control of trunk and lower extremities

principle that development proceeds in a head-to-tail direction, that is, that upper parts of the body develop before lower parts of the trunk

70-120 bpm 20/25 min

pulse rate for preschooler (3-5 yoa) and RR

60-110 bpm 20/25 min

pulse rate school ages children (6-12 yoa) and RR

can have appetite suppression, nausea/vomiting, sleep disturbances, abdominal pain have person eat before they take their med to make sure they get a meal in before appetite suppression

s/e of ADHD meds

stage of detachment (denial)

shows increased interest in surroundings, interacts with strangers or familiar caregivers, forms new but superficial relationships, appears happy this behavior is the result of resignation and is not a sign of contentment. The child detaches from the parent in an effort to escape the emotional pain of desiring the parent's presence and copes by forming shallow relationships with others, becoming increasingly self-centered, and attaching primary importance to material objects. This is the most serious stage

basal metabolic rate

the body's resting rate of energy output slightly higher in boys at all ages and further increases during pubescence over that in girls closely relates to the proportion of surface area to body mass, which changes as the body increases in size

temperament

the manner of thinking, behaving, or reacting characteristic of an individual" and refers to the way in which a person deals with life. From the time of birth, children exhibit marked individual differences in the way they respond to their environment and the way others, particularly the parents, respond to them and their needs

Proximodistal principle

the principle that development proceeds from the center of the body outward

Differentiation

the processes by which early cells and structures are systematically modified and altered

Rhythmicity

the regularity and predictability of the child's bodily functions such as eating and sleeping and elimination. an attribute of temperament.

Sensitive Periods

times in development when a person is particularly open to certain kinds of experiences

4-18

to be diagnosed with ADHD symptoms must have been present between ___ & ___ yoa, and also present in more than one setting, and not a symptom of another disorder.

Yearly gain: 2 to 3 kg (4.5 to 6.5 pounds) Birth length doubles by 4 years of age Yearly gain: 5 to 7.5 cm (2 to 3 inches)

weight and height gain of Preschoolers yearly weight gain of ____ to ____ kg birth length doubles by ____ years of age yearly gain is ___ to ___ cm

Yearly gain: 2 to 3 kg (4.5 to 6.5 pounds) Yearly gain after 7 years: 5 cm (2 inches) Birth length triples by about 13 years of age

weight and height gain of School-age children yearly weigh gain ___ to ___ kg yearly gain in height after 7 years is ____ cm birth length _____ in size by about 13 years

Birth weight quadruples by age 2 1/2 years Height at 2 years of age is ≈50% of eventual adult height Gain during second year: About 12 cm (4.7 inches) Gain during third year: About 6 to 8 cm (2.4 to 3.1 inches)

weight and height gain of toddlers Birth weight quadruples by age ______ years Height at __ years of age is ≈50% of eventual adult height Gain during second year: About 12 cm (4.7 inches) Gain during third year: About _ to _ cm