NSG-434 Exam 1

infancy

-1 to 12 months -Weight: doubles birth weight by 6 months; triples birth weight in 1 year -Height: increases 50% by 1 year -Head growth is rapid; brain increases in weight 2.5 times by 1 year head circumference exceeds chest circumference -Posterior fontanel closes at 2 to 3 months -Anterior fontanel closes at 12 to 18 months -Infants' kidneys are not as effective at concentrating urine compared to an adult's because of the immaturity of the renal system and slower glomerular filtration rate; puts an infant at greater risk for fluid and electrolyte imbalance. -The infant's metabolic rate is faster than adults. -Their GI system is immature but able to process proteins and lactase but the ability to digest and absorb fat does not reach adult levels until 6-9 months of age. -Brain growth depends on nutrition and the function of the other organs. The brain is 10-12% of the body weight. -Primitive reflexes disappear and the motor areas of the brain continue to develop from arms first and then legs. -The respiratory system: lungs increase to three times their weight and 6 times their volume. -Trachea remains small, supported only be soft cartilage. -The immature resp. system places the infant at risk for respiratory infections. -The eustachian tube is short and relatively horizontal, increasing the risk of middle ear infections. -The CV system: pulmonary circulation increases, heart doubles in size and weight, heart rate gradually slows (but remains faster than an adult) and BP increases. -The immune system is maturing but maximum protection against infection is not achieved until early childhood. This immaturity places the infant at risk for infection. Gross Motor: -At two months, the infant is able to briefly hold the head erect when in a prone position -Although their neck muscles are stronger there is still some head lag present at 2 months -Gains head control by 4 months -Rolls from back to side by 4 months -Rolls from abdomen to back by 5 months -Rolls from back to abdomen by 6 months -Sits alone without support by 8 months -Stands holding furniture by 9 months -Crawls with abdomen on floor by 10 months -Creeps with abdomen off floor by 11 months -Cruises (walking upright while holding furniture) by 10-12 months -Walks well with one hand held by 12 months -Stands alone without support by 12 months Fine Motor Development: -Hand predominantly closed at 1 month -Desires to grasp at 3 months -Two-handed, voluntary grasp at 5 months -Holds bottle, grasp feet at 6 months -Transfers from hand to hand by 7 months -Pincer grasp established by 10 months -Refined pincer grasps with thumb and finger by 12 months Sensory Development: -Hearing and touch well developed at birth -Sight not fully developed until 6 years -Differentiates light and dark at birth -Prefers human face; socially smiles at 2 months -Usually searches and turns head to locate sounds by 2 months -Has taste preferences by 6 months -Responds to own name by 7 months -Able to follow moving objects -Visual acuity 20/50 or better -Amblyopia may develop by 12 months -Can vocalize four words by 1 year Nutrition: -Human breast milk is most complete and easily digested -Iron-fortified formula - recommended for first 12 months -Iron-fortified rice cereal introduced first (6 months) mixed with formula/breast milk -Introduce fruits or vegetables at 6-8 months -Exclusively breastfeed infants for a minimum of 4 months and preferably 6 months; avoiding introducing solid food until 4 - 6 months of age. -The infant's appetite and growth velocity decreases in the second half of infancy. -Due to the risk of allergies and intestinal problems it is best to wait until the infant is at least 1 year old before giving cow's milk. -Bedtime bottles are contraindicated because of their high sugar content, which leads to dental decay in the primary teeth. Safety: -Primary concern as infant becomes more mobile -Car seats: •Rear facing in the middle back seat until 20 lbs and 1 year of age (AAP recommendation - until 2 years) -Cribs: •No drop-down crib sides •Distance between crib slats - no more than 2 3/8 inches apart Sudden Infant Death Syndrome (SIDS) Prevention: -Put infant to sleep in supine position for first year -Firm mattress and tight fit -No soft or loose bedding -No toys in the bed -No smoking around infant -Room temperature not too hot -Pacifiers should be used at nap time and bedtime during the first year -Pacifiers should not be used during the first month for breast-fed infants or forced on babies who protest -Place babies' cribs in parents' bedrooms, which can facilitate nighttime breast-feeding -Return babies to their cribs after nursing -Do not allow infants to sleep in adults' beds -Train infants to sleep on their backs -Do not allow side sleeping; it is too unstable and should be avoided Teach Injury Prevention: -Aspiration of foreign objects -Suffocation -Falls -Poisonings -Burns Play (solitary): -Provide black/white contrasts for premature and newborn infants -Hang mobile 8-10 inches from infant's face -Provide sensory and tactile stimuli, large toys, balls -Expose to environmental sounds -Use variety of primary-colored objects -Provide toys that let infants practice skills to grasp and manipulate objects Toys and Activities (Birth to 2 Months): -Mobiles, black-and-white patterns, mirrors -Music boxes, singing, tape players, soft voices -Rocking and cuddling -Moving legs and arms while listening to singing and talking -Varying stimuli: different rooms, sounds, visual images Toys and Activities (3 to 6 months): -Rattles -Stuffed animals -Soft toys with contrasting colors -Noise-making objects that are easily grasped Toys and Activities (6 to 9 months): -Teething toys -Social interaction with adults and other children -Don't freeze teething rings with gel: monitor, make sure it's not frozen solid (could harm baby if frozen solid) -Banana teether and teething mitten are very useful as well -Mesh fruit teether: make sure infant is greater than 6 months old and that the fruit have no seeds Toys and Activities (9 to 12 months): -Large blocks -Toys that pop apart and back together -Nesting cups and other objects that fit into one another or stack -Surprise toys such as jack-in-the-box -Games such as peek-a-boo -Push and pull toys

adolescence

-13 to 18 years -Weight: rapid period of growth causes anxiety; -Girls gain 15 to 55 lbs. -Boys gain 15 to 65 lbs. Height: -Attain final 20% of mature height -Girls: •Height increases approximately 3 inches/year •Slows at menarche •Stops at 16 years -Boys: •Increases 4 inches/year •Growth spurt at approximately 13 years •Slows in late teens Puberty: -Related to hormonal changes -Apocrine glands become active, may develop body odor -Appearance of acne on face, back, trunk -Girls tend to get acne on their faces and chests, while boys tend to get acne on their faces and their backs Development of Secondary Sex Characteristics: -Girls: •Breast development •Menarche (average age 12 ½ years) •Pubic hair -Boys: •Enlargement of testes (13 years) •Increase in scrotum and penis size •Nocturnal emission •Pubic hair •Vocal changes •Possibly gynecomastia -Tanner sexual-maturing ratings are used to stage adolescent sexual development. -It is based on predictable stages of puberty that are based on primary and secondary sexual characteristics. -The puberty stage in girls begins with breast development and genital enlargement in boys. -These stages are not predictable as the age at which an adolescent enters puberty is variable and is not based on chronological age. Nutrition: -Requirements •60 to 80 kcal/kg/day •1500 to 3000 kcal/day (11 to 14 years) •2100 to 3900 kcal/day (15 to 18 years) •Protein: 34-52 grams/day -At risk for fad diets (vegan, Keto, etc.) -Require increased calcium for skeletal growth Safety: -Accidents are leading cause of death -Motor vehicle, sports, firearms, suicide -Body art: very little regulation exists in the tattoo industry; the cleanliness of tattoo parlors varies. -Tattoos carry the risk for contracting bloodborne diseases such as Hep B and HIV. -Infection, allergic reaction to the dye, scarring, or keloid formation can occur. -Should an MRI ever be required, it is important to notify the HC professionals, because the dyes can contain iron and other metals. -Support needed for LGBT groups -Provide drug and alcohol education -Provide sex education -Discourage risk-taking activities -May display lack of impulse control, reckless behaviors, a sense of invulnerability Teach Injury Prevention: -Proper use of sports equipment -Diving, drowning -Provide driver's education -Use of seat belts -Violence and weapon prevention -Crisis intervention -Injuries claim more lives during adolescence than all other causes of death combined. -Causes: physical growth, peer pressure, insufficient physical coordination for the task, impulsivity, and inexperience. -Feeling of invulnerability persists, little thought to the negative consequences for certain behaviors. Play/Activities: -Enjoys sports, school activities, peer group activities -Interest in relationships (heterosexual or otherwise) common -Peer relationships are very important during adolescence by providing the adolescent with a feeling of belonging and a sense of strength and power. -The parent/child relationship changes from one of protection-dependency to one of mutual affection and quality. -Parents continue to play an important role in the personal and health-related decisions.

school age years

-6 to 12 years of age -Weight: steady, slow growth; gains approximately 5 lbs./year -Height: increases 1 to 2 inches/year; boys and girls differ little at first, but by end of this period girls will gain more weight and height compared to boys -During the school-age developmental period, boys are approximately 1 inch taller and 2 pounds heavier than girls. Motor/Sensory Development: -Bone growth faster than muscle and ligament development -Susceptible to greenstick fractures -Movement becomes more limber, graceful, and coordinated -Have greater stamina and energy -Vision 20/20 by 6 to 7 years; myopia may appear by 8 years Cognitive Development: -Intuitive thought stage: 6-7 years old, thinking is based on immediate perceptions of the environment and the child's own viewpoint. -Cannot understand another's viewpoint, form hypotheses, or deal with abstract concepts. -Has difficulty forming categories and often solves problems by random guessing. -Concrete operation stage: 7 to 8 years old, child learns that their point of view is not the only one. -More flexible thinking. -Problem solving becomes more efficient and reliable as the child learns how to form hypotheses. -Learns the alphabet and how to read and attention span increases. -Reversibility: can take apart a toy and put it back together, can anticipate the results of an action. -Able to begin to add and subtract in early school age-years. -Conservation: gradually over the school-age years the child learns that objects do not change simply because their order, form or appearance has changed -Classification and logic: older school-age children are able to classify objects according to their shared characteristics, to place things in logical order, and recall similarities and differences. -Humor: around age 8, the increased mastery of language and the beginning of logic enables children to have a sense of humor and appreciate a play on words. -Love silly jokes, riddles, and puns. Nutrition: -Risk of obesity in this age group -Identify those falling above 95th percentile and below 5th percentile in weight and height on growth charts -Nutritional requirement: 85kca/kg/day and 19-35 grams/day protein Secondary Sex Characteristics: -Begin at 10 years in girls; 12 years in boys -Loses first deciduous teeth at age 6; by age 12 has all permanent teeth except final molars -Puberty occurs 1 ½ to 2 years later in boys. It is not unusual for girls to begin puberty at 9-10 years old and African American girls begin puberty approximately 1 year earlier than Caucasian girls. -Teaching of sex education should be presented as a normal part of growth and development. -The child should be encouraged to ask questions and need precise and concrete information. Safety: -Incidence of accidents/ injuries less likely -Teach proper use of sports equipment -Discourage risk-taking behaviors (smoking, alcohol, drugs, sex) -Introduce sex education Teach Injury Prevention: -Bicycle safety, including use of safety helmet by law -Firearms -Smoking education -Water safety -The leading cause of death in children of every age group beyond 1 year of age is unintentional injury. -For school age children, being struck by or striking an object that results in injury is the leading cause of nonfatal unintentional injuries after falls. -Lacerations, bites and stings, bicycle injury, and MV passenger injuries are prevalent Play: -Comprehends rules and rituals of games -Enjoys team play -Enjoys athletic activities -Provide construction toys: puzzles, erector sets, Legos -Good eye/hand coordination -Enjoys music, adventure, stories, competitive activities

anticipatory guidance

-A process of understanding upcoming developmental needs -Teach caregivers to meet those needs -Includes: •Health habits •Prevention of illness and injury •Prevention of poisonings •Nutrition •Dental care •Sexuality

atopic dermatitis (eczema)

-A type of pruritic eczema -Usually begins during infancy -Associated with an allergic contact dermatitis with a hereditary tendency (atopy) -Manifests in three forms based on the child's age and the distribution of lesions: •Infantile: usually begins at 2 to 6 months of age; generally undergoes spontaneous remission by 3 years of age •Childhood: may follow the infantile form; occurs at 2 to 3 years of age; 90% of children have manifestations by 3 years of age •Preadolescent and adolescent: begins at about 12 years of age; may continue into the early adult years or indefinitely Diagnosis: -A combination of history, clinical manifestations, and in some cases, morphologic findings -Family history of eczema, asthma, food allergies, or allergic rhinitis, which strongly supports a genetic predisposition Cause: -Unknown but appears to be related to abnormal function of the skin including alterations in perspiration, peripheral vascular function, and heat tolerance. -The disorder can be controlled but not cured. -Manifestations of the chronic disease improve in humid climates and get worse in the fall and winter, when homes are heated and environmental humidity is lower. Distribution of Lesions: -Infantile form: generalized, especially cheeks, scalp, trunk, and extensor surfaces of extremities -Childhood form: flexural areas (antecubital and popliteal fossae, neck), wrists, ankles, and feet -Preadolescent and adolescent form: face, sides of neck, hands, feet, face, and antecubital and popliteal fossae (to a lesser extent) Appearance of Lesions: -Infantile Form: erythema, vesicles, papules, weeping, oozing, crusting, scaling, often asymmetric -Childhood Form: symmetric involvement with clusters of small erythematous or flesh-colored papules or minimally scaling patches. -Adolescent or Adult Form: same as childhood manifestations with dry, thick lesions (lichenified plaques) common; papules may merge together. Therapeutic Management: -Hydrate the skin, relieve pruritus: tepid baths, emollient lotions -Antihistamines: •Diphenhydramine (Benadryl): •SE: drowsiness, dizziness, fatigue, disturbed coordination •Children are more sensitive to the effects of diphenhydramine •Nightmares, nervousness, and irritability are more likely to occur -Prevent flare-ups or inflammation: •Keep nails cut short •Topical steroids •New topical immunomodulators available by prescription -Control secondary infection: •Antibiotics - topical or oral; topical steroids have potential side effects such as striae, skin atrophy, and pigment changes Interprofessional Care: -Assessment •Family history of atopy •History of previous involvement •Examine skin lesions -Hypoallergenic diet may be prescribed; consult with dietician can help -Emotional stress is increased during acute phases; stress aggravates the severity of the condition; stress is not just for the child but also the entire family

toddlers

-Ages 1 to 3 years -Weight: rate slows considerably; weight is 4 times the birth rate by 2 ½ years -Height: at 2 years height is 50% of future adult height -Head circumference: 19 ½ to 20 inches by 2 years; increases only 3 cm in second year; achieves 90% of adult-sized brain by 2 years -Anterior fontanel closes by 18 months Gross Motor Development: -Still clumsy at this age -Walks without help (usually by 15 months) -Jumps in place by 18 months -Goes up stairs (with 2 feet on each step) by 24 months -Runs fairly well (wide stance) by 24 months Fine Motor Development: -Uses cup well by 15 months -Builds a tower of 2 cubes or blocks by 15 months -Holds crayon with fingers by 24 to 30 months -Good hand-finger coordination by 30 months -Copies a circle by 3 years Sensory Development: -Binocular vision well developed by 15 months -Knows own name by 12 months, refers to self -Follows simple directions by 2 years -Identifies geometric forms by 18 months -Uses short sentences by 18 months to 2 years -Remembers and repeats 3 numbers by 3 years -Able to speak 300 words by 2 years -The toddler's ability to understand language is greater than their ability to speak it. -By 2 years of age, about 60-70% of the toddler's speech is understandable and their language development is rapidly accelerating by 15 to 24 months of age. -Object permanence: knowledge that an object or person continues to exist when not seen, heard, or felt -Ritualistic behavior: the toddler's need to maintain sameness and reliability; provides sense of comfort -Sibling rivalry: often have an intense feelings of jealousy and envy toward a new sibling. -Cannot understand that parents can love more than one child. -Teach parents to involve the toddler in caring for the baby/perform similar care on a doll and to make individual time just for the toddler. Nutrition: -Growth slows at age 12 - 18 months; thus appetite and need for intake decrease -Toddlers are picky, ritualistic eaters -Limit milk to less than 32 oz/day to prevent non-deficiency anemia -Avoid large pieces of food such as hot dogs, grapes, cherries, peanuts -Able to feed self completely by 3 years -Healthy People 2020 specifically addressed the problems of obesity in young children, ages 2-5 years. -10.7% of 2-5 year-olds were identified as obese. -Focus on increasing fruits and vegetables, increasing the percentage of whole grains, increasing calcium and iron intake, and decreasing solid fats, sodium and sugar. -Deciduous teeth (approx. 20) are present by 2 ½ to 3 years -Kids begin to lose deciduous teeth when they are school age -Primary (deciduous) teeth are replaced by permanent teeth. -By adulthood the child will have 32 permanent teeth. -Teach good dental practices (brushing, fluoride); do not allow to take a bottle to bed -Toddler nutritional requirement: at 1-3 years, there is a need for 102kca/kg/day and protein 11 grams/day Safety: -Childproof home environment -Suffocation -Burns -Falls -Aspiration/ Poisonings -Medications: locked cabinets needed; toddlers can climb so high places are not a deterrent to an exploring toddler. Play (Parallel): -Begins as imaginative and make-believe play; may imitate adults in play -Provide blocks, wheel toys, push toys, puzzles, crayons to develop motor and coordination abilities -Enjoy repetitive stories and short songs with rhythm -Kids often don't play together with kids, but are aware of other kids playing around them

preschool years

-Ages 3 to 6 years -Weight: growth is slow and steady; gains 4 to 5 pounds/year -Height: increases 2 to 3 inches/year Motor Development: -Skips and hops on one foot by 4 years -Rides tricycle by 3 years -Throws and catches ball well by 5 years -Balances on alternate feet by 5 years -Knows 2100 words by 5 years and uses correct grammar in sentences although typically has difficulty in pronouncing consonants clearly. -Increased strength and refinement of fine and gross motor abilities -Can dress self independently Nutrition: -Similar to toddler's eating patterns -Demonstrates food preferences -Influenced by others' eating habits -Nutritional requirement: -90kcal/kg/day and 13grams/day protein -Kids this age are still a little picky, but can be persuaded to try something if someone they like (such as their mom) tries it Safety: -All children should be in a safety or booster seat until 8 years or 80 lbs. (height 4 ft., 9 in) -Teach injury prevention: •Traffic safety •Strangers •Fire prevention/ safety •Water safety; drowning Play (Associative): -Enjoys imitative and dramatic play -Imitates same-sex role in play -Provide toys to develop motor and coordination skills (tricycle, clay, paints, swings, slides) -Parental supervision of television -Enjoys "sing-along" song with rhythm -Common to have imaginary friends

immunizations

-Also called vaccinations -Vaccination is the administration of a small amount of antigen, which is capable of stimulating an immune response but does not typically produce the disease. -Traditional: inactivated (killed) microorganism -Attenuated: live, weakened (attenuated) microorganism -Toxoids: inactivated toxins stimulate formation of antitoxins that produce active immunity (tetanus toxoid) -Conjugated vaccines (newer): require a protein or toxoid to link with disease-causing microorganism (H. influenza type B) -Recombinant subunit vaccines: insertion of genetic material (DNA) of pathogen into another cell where the antigen is produced in massive quantities (HepB) Requirements: -Infancy: •Primary schedule begins at birth •Diphtheria, Tetanus, and acellular Pertussis (DTaP); Poliovirus; Measles, Mumps, and Rubella (MMR); Haemophilus influenza type b (Hib); Hepatitis A virus (HAV); Hepatitis B virus (HBV); Pneumococcal Conjugate Vaccine (PCV); Influenza; Meningococcal; and, Varicella-zoster virus (VZV; Chickenpox). -Early childhood: •Primary schedule is completed; with the exception of boosters -Nurses - need to know where to obtain recommendations: •Advisory Committee on Immunizations Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) •Committee on Infectious Diseases of the American Academy of Pediatrics (AAP) •Schedules for Vaccinations and Catch-up Vaccination Schedules -Healthy People 2020 target goal of 90% was met for children aged 19 to 35 months who received the recommended doses of DTaP, polio, MMR, Hib, HepB, PCV, and varicella vaccines -Frequent changes in schedules due to advances in immunology -Schedules for preterm infants based on chronological age Reactions: -Safest and most reliable drugs available -Inactive components are incorporated: preservatives, stabilizers, antibiotics (neomycin in MMR) and purified culture medium proteins (eggs, yeast culture) -Child may react to the preservative (Thimerosal contains ethyl mercury) -Occur within a few hours to days: •Local tenderness •Erythema •Swelling at the injection site - cold compress; administer acetaminophen •Low grade fever - administer acetaminophen •Behavioral changes: drowsiness, eating less, prolonged or unusual cry •Additional side effects specific to individual vaccines Reporting and Safety: -Health care providers are responsible for reporting cases of vaccine preventable diseases and adverse reactions following immunization -Vaccine Adverse Events Reporting System (VAERS) -National Childhood Vaccine Injury Act of 1986 initiated the National Vaccine Injury Compensation Program (NVICP) -NVICP requires health care provider to distribute a Vaccine Information Statement (VIS) before the vaccine is administered Contraindications and Precautions: -Contraindication: a condition in an individual that increases the risk for a serious adverse reaction or anaphylaxis -General contraindication for all immunizations is a severe febrile illness -Minor illness such as common cold is not a contraindication -Live virus vaccines such as Varicella and MMR should not be administered to child who is severely immunocompromised -Known allergic response to a previously administered vaccine or a substance in the vaccine -Precaution: a condition in a recipient that might increase the risk for a serious adverse reaction or that might compromise the ability of the vaccine to produce immunity -If the child scheduled for vaccination is not feeling well, the healthcare provider might decide to reschedule the shot on another day -Don't administer a live virus vaccine to a severely compromised child Administration: -Communicating with parents about immunizations -Be flexible, provide options regarding multiple vaccines -Infants - 2, 4, 6 months; allow parents to space office visits to decrease the total number of injections at one time; some pediatrician offices have "Nurse only" appointments, provided the child is healthy, for immunization purposes only -Teach parent about administering acetaminophen 45 minutes before the immunizations -Application of EMLA cream to the injection site before administration helps to prevent discomfort -Fewer local reactions to immunizations when the vaccine is given deep into the muscle -Minimum of 25 mm (1 inch) needle length for anterolateral thigh with infants -Minimum of 25 to 32 mm (1 to 1 ¼ inches) needle length for toddlers -Minimum of 38 to 51 mm (1 ½ to 2 inches) needle length for older children -When multiple injections to be given, two may be given into the thigh: at least 2.5 cm (1 inch) apart -Sites: -Dorsogluteal muscle should be avoided at all times because of possibility of damaging sciatic nerve -Anterolateral thigh for infants (not walking) -Deltoid site for children older than 1 year -Ventrogluteal site for any age -SHARE reasons why the vaccine is right for the patient. -HIGHLIGHT positive experiences. -ADDRESS the patient's/ parent's questions about the vaccine. -REMIND the patient/parent that vaccines protect against disease. -EXPLAIN the costs and consequences of getting the disease.

diaper dermatitis

-Also known as diaper rash -Common in infants; caused either directly or indirectly by wearing diapers. -The peak age of occurrence is 9 to 12 months of age, and the incidence is greater in bottle-fed infants than in breastfed infants. -Caused by prolonged and repetitive contact with an irritant: urine, feces, soaps, detergents, ointments, friction -Primarily on convex surfaces or in folds -Eruptions involving the skin in most intimate contact with the diaper (e.g., the convex surfaces of buttocks, inner thighs, mons pubis, scrotum) -Nursing interventions are aimed at altering the three factors that produce dermatitis: wetness, pH, and fecal irritants. Controlling Diaper Rash: -Keep Skin dry - use superabsorbent disposable diapers (detergent- and alcohol free) -Expose skin to air -Apply ointment (zinc oxide) -Avoid over-washing skin - do not use perfumed soaps or commercial wipes -Change diapers as soon as soiled—especially with stool—whenever possible, preferably once during the night. -May use a moisturizer or non-soap cleanser, such as cold cream or Cetaphil, to wipe urine from skin.

impetigo contagiosa

-Bacterial skin infection -Organism: Staphylococci -Manifestations: •Begins as a reddish macule: vesicular •Ruptures easily •Exudate dries to form heavy, honey-colored crusts •Pruritus is common -Very contagious: kids can't go back to school until disorder is treated with antibiotics and cured -Management: •Topical bactericidal ointment, mupirocin (Bactroban) or triple antibiotic ointment •Oral or parenteral antibiotics for severe or extensive lesions •Penicillin is used •Vancomycin for lesions due to MRSA •Tends to heal without scarring

cellulitis

-Bacterial skin infection -Organism: streptococci, staphylococci, Haemophilus influenza -Manifestations: •Inflammation of the skin and subcutaneous tissues •Intense redness, swelling, firm infiltration •"Streaking" often seen •Involvement of the reginal lymph nodes •May progress to abscess formation •Systemic effects: fever, malaise -Management: •Oral or parenteral antibiotics •Rest and immobilization of both affected area and the child •Hospitalization may be required for children with systemic symptoms

preparation of the child

-Child's perception of painful procedures -Cooperation usually enhanced with parent's presence -Age-appropriate techniques -Positioning and preparation -Although the physical examination consists of painless procedures, for some children the use of a tight arm cuff, probes in the ears and mouth, pressure on the abdomen, and a cold piece of metal to listen to the chest are stressful. -For infants and toddlers, perform traumatic procedures last. -Encourage parent/caregiver to assist with holding the child. -Important to get down on a child's level; kids won't trust you unless you do -Don't touch children unless they give you permission (which they do in various ways) -Never hold a child down or ask a parent to hold them down for a procedure

childhood health problems

-Childhood obesity: most common nutritional problem among children in the US; increasing in epidemic proportions -Defines as a body mass index (BMI) at or greater than the 95th percentile for youth of the same age and gender. -TV, computers, and video games have contributed to the growing childhood obesity problem in the US. -Type II diabetes is also an issue -Emphasis on prevention strategies should be the focus of nurses -Childhood injuries: most common cause of death and disability to children in the US; majority of deaths from injuries are boys -The type of injury and the circumstances surrounding it are closely related to normal G & D. -As children develop, their innate curiosity compels them to investigate the environment and mimic the behavior of others. -Small infants: fall from unprotected surfaces -Crawling infant: putting things in their mouth (aspiration and poisoning) -Toddler: now mobile - falls, burns, and collisions with objects -School age: environmental hazards such as street traffic and water -Older children and adolescents: need to conform and gain acceptance -accepts challenges and dares -Violence: youth violence is a high-visibility, high-priority concern in the US. -Although the definitive reason is unknown, the prevalence of violence seen in TV shows, commercials, video games, and movies, all tend to desensitize the child towards violence. -Families that own firearms must be educated about their safe use and storage. -Pediatric nurses can assess children/ adolescents for risk factors related to violence -Bullying: involves emotional, physical, verbal, and cyber-related abuse -Behaviors are used to assert domination. -When youth are not well accepted by their peers, they are vulnerable to bullying; physical disabilities, obesity, and sexual orientation can be risk factors creating vulnerability Mental Health Problems: -1 in 5 children experience mental health problems -1 in 10 has a serious emotional problem that affect daily functioning -Problems often start around age 10 -Schizophrenia is the most common mental disorder in children -Currently the top 5 chronic conditions for children are related to mental health issues. -Nurses should be alert to symptoms of mental illness and potential suicidal ideation and be aware of potential resources for high-quality integrated mental health services

seborrheic dermatitis (cradle cap)

-Chronic, recurrent, inflammatory reaction usually on the scalp -Thick, adherent, yellowish, scaly, oily patches -May also involve the eyelids (blepharitis), external ear canal (otitis externa), nasolabial folds, and inguinal region. Care Management: -Shampoo daily with a mild soap or baby shampoo; shampoo is applied to the scalp and allowed to remain on the scalp until the crusts soften. Then the scalp is thoroughly rinsed. -Use fine-tooth comb or soft brush to loosen crusts after shampooing

age

-Chronological Age: age in years -Developmental Age: age based on functional behavior and ability to adapt to the environment

skin lesions causes

-Contact with injurious agents -Hereditary factors -External factor that produces a reaction in the skin (allergens) -Systemic disease in which lesions are a manifestation (measles)

Nutritional Assessment

-Dietary intake: recall of food consumption, especially amounts eaten, is frequently unreliable -Clinical examination of nutrition: hair, skin, mouth, eyes -Evaluation of nutritional assessment: malnourished, at risk, well nourished, overweight or obese

diphtheria, tetanus, and pertussis (DTap) vaccine

-Diphtheria vaccine: does not produce absolute immunity; need booster every 10 years -Respiratory manifestations of diphtheria result in morbidity -Tetanus vaccine: provides antitoxin levels for about 10 years; need booster every 10 years -Pertussis vaccine: increased cases of pertussis in children, adolescents and adults -CDC recommends administration of Tdap booster regardless of time interval from last tetanus -Four doses: 2, 4, and 6 months of age, and fourth dose on or after four years old - DTaP is recommended -Make sure you do not give a DTap vaccine meant for adults to a child!

parent/caregiver communication

-Encourage parents/ caregiver to talk -Directing the focus to keep on the subject -Listening and cultural awareness are important for effective communication -Look for clues, verbal leads, and signals from the parent/ caregiver -Using silence can help the parent/caregiver gather their thoughts and develop answers for questions asked -Being empathetic -Providing anticipatory guidance (ex: client diagnosed with leukemia who will undergo chemotherapy) -Avoiding communication blocks for both the nurse and the parent/caregiver

growth and development

-Growth: an increase in the physical size, such as height and weight -Development: a continuous, orderly series of conditions leading to activities, new motives for activities, and patterns of behavior; a set of skills that must be mastered to progress to the next level -G&D is highly individualized -G&D is characterized by periods of rapid growth and plateaus Stages: -Infant: birth to 1 year -Toddler: 1 to 3 years -Preschool: 3 to 6 years -School-age: 6 to 12 years -Adolescence: 12 to 18 years -Cephalocaudal: head to tail (toe) -Proximodistal: from the center outward or from the midline to periphery (near to far) -Differentation: simple to complex progression of achievement of developmental milestones Factors Influencing Growth and Development: -Genetics (heredity): determines each individual's G & D rate; has the greatest influence on a child's G & D. -Although factors such as environment, culture, nutrition, and family can influence genetic traits, they do not eliminate the effect of the genetic endowment, which is permanent -Environment: both physical and psychosocial; prenatal exposures and socioeconomic status (mainly poverty) -Environmental Factors: abuse (physical, emotional, or sexual). -May experience delays in learning to trust others and experience disorders of attachment. -Neglect: (medical, emotional, educational, or abandonment). -Culture: the habits, beliefs, language, and values are significant factors influencing children as they grow toward adulthood -Nutrition: important because of the continuous supply of nutrients needed by children as they grow -Health Status: disease states that affect the G & D of the child -Family: relationships and influences have substantial determination on how children grow and progress; family structure and dynamics; practices and child-rearing philosophies influence how children grow and develop. -Intrauterine factors: poor nutrition = low-birth-weight babies and babies with slow development, comprised neurological performance, and impaired immune status. -Low levels of iron = anemia. -ETOH = fetal alcohol syndrome and delays. -Substance and drug abuse = neonatal addiction, convulsions, hyperirritability, poor social responsiveness, neuro disturbances, and changes in the cognitive function. -Certain maternal illness can harm the fetus (rubella). -Exposure to environmental factors (chemicals, radiation) can harm the fetus. -Birth events: prematurity can experience delayed G & D. -Premature infants are expected to reach developmental milestones at the same age they would have reached them if they were born at normal gestation. -Usually catch up by the age of 2. -Illness and Hospitalization: stress, possible separation of the family members -Chronic Illness: illness may interfere with normal progression through developmental levels Home - a safe and healthy home environment Assessment of Development: -Formal developmental screening at 9 months, 18 months, and 24 - 30 months -Denver Developmental Screening Test II (DDST-II): •Ages birth to 6 years •125 tasks •Identifies a child's developmental age •Compares with others of the same chronological age

sequence of the examination

-Head-to-toe sequence for assessing adult clients -Sequence for pediatric assessments generally altered to accommodate child's developmental needs -Use chronological age as the main criteria

measles, mumps, and rubella (MMR) vaccine

-Significance: due to recurrence of measles in older children and young adults, susceptible individuals should be immunized if 2 doses not administered previously -Two doses: 12 to 15 months of age and 4 to 6 years of age (school entry) -Measles, mumps, rubella, and varicella (MMRV) - attenuated live virus vaccine -During measles outbreaks, second dose may be given earlier provided 4 weeks have elapsed since previous dose -Rubella - mild infection in children; in pregnant women, serious risks to developing fetus -Measles, mumps, rubella, and varicella (MMRV) ProQuad - attenuated live virus vaccine should not be administered to children with immune deficiencies and pregnant females -ProQuad label states: STORE FROZEN and indicates specific temperatures for the storage. This is due to the Varicella. -Some of the vaccines require storage at a specific temperature -MMR and Varicella and ProQuad are given sub-Q -Measles hallmark sign: Koplik spots, two to three days after symptoms begin

health care for children

-Major goal for pediatric nursing: improve the quality of health care for children and their families -Health Promotion: child health promotion provides opportunities to reduce differences in current health status among different groups. -It strives to ensure equal opportunities and resources to enable all children to achieve their fullest health potential. -Health promotion integrates the surveillance of the physical, psychologic, and emotional changes that occur in children. -Through continuous screenings and assessments of development of the child, early interventions for deficiencies can be started. Development: -During infancy, the interaction between the parent and infant are central to promoting optimal developmental outcomes -During early childhood, early identification of developmental delays is critical. Anticipatory guidance strategies ensure that parents are aware of the specific developmental needs in each developmental stage. -During middle childhood, ongoing surveillance provides opportunities to strengthen cognitive and emotional attributes, communication skills, self-esteem, and independence. -During adolescence, recognition that adolescents differ greatly in their physical, social, and emotional maturity is important. Nutrition: -An essential component for healthy growth and development. -Children establish lifelong eating habits during the first 3 years of life. -Most eating preferences and attitudes related to food are established by family influences and culture. Oral Health: -Dental caries is the single most common chronic disease of childhood. -Preventing dental caries and developing healthy oral hygiene must occur early in childhood.

goals of pediatric assessment

-Minimize stress and anxiety associated with assessment of various body parts -Foster trusting nurse-child-parent relationships -Allow for maximum preparation of child -Preserve security of parent-child relationship, especially with young children -Maximize accuracy and reliability of assessment findings

pediculosis capitis (lice)

-Organism: Pediculus humanus capitis -Louse: •A blood-sucking organism •Female lays eggs (nits) at night at the junction of the hair shaft and close to the skin - hatch in 7-10 days -Causes a lot of embarrassment for the child and their parent -The nurse should emphasize that anyone can get lice; it has no respect for age, socioeconomic level or cleanliness -The eggs are close to the skin because they need a warm environment -Nits are tiny whitish oval specks that adhere to the hair shaft. -Can also be seen in the eyebrows and eyelashes -Manifestations: •Itching •Common sites - occipital area, behind the ears, nape of the neck -Therapeutic Management: •Application of pediculicides: permethrin 1% cream rinse (Nix); second treatment 7-10 after first treatment •Manual removal of nits: daily removal with a specialized comb •Lice do not fly or jump, but can be transmitted from one person to another on personal item •Children are cautioned against sharing combs, hair ornaments, hats, caps, scarves, coats, or other items used on or near the hair

rotavirus vaccine

-Significance: Acute gastroenteritis; contagious and may be particularly severe in infants and young children -Due to small increase in cases of intussusception from rotavirus vaccination, health care providers should weigh the potential risks and benefits of administering rotavirus vaccine to infants with a previous history of intussusception. -Both rotavirus vaccines are administered orally, by putting drops in the infant's mouth. Each requires multiple doses: •RotaTeq® (RV5) is given in three doses at 2 months, 4 months, and 6 months of age. •Rotarix® (RV1) is given in two doses at 2 months and 4 months of age.

inactivated poliovirus (IPV) vaccine

-Significance: Exclusive use of IPV due to rare risk of vaccine-associated polio paralysis (VAPP) from oral polio vaccine (OPV) -Four doses: 2 months, 4 months, 6 to 18 months, and 4 to 6 years of age -PEDIARIX: combination vaccine containing DTaP, Hep B, and IPV

hepatitis B virus (HBV) vaccine

-Significance: HBV during childhood and adolescence can lead to fatality from cirrhosis or liver cancer in adulthood -Newborn - administer before discharge (vastus lateralis site) -Three additional doses: 1, 2, and 6 months of age -Safe to administer at a separate site with DTaP, MMR, and Hib vaccines

human papillomavirus (HPV) vaccine

-Significance: Sexually transmitted and seen as cervical, vaginal, anal, and oropharyngeal cancers and genital warts -Beginning at 11 or 12 years old (can start as early as age 9) so that they are protected before ever being exposed to the virus -Age 9 to 14 years: 2 doses (at least 5 months apart) -Age 15 or older: 3 doses at 0, 1-2 months, and 6 months -Persons who have completed a valid series with any HPV vaccine do not need any additional doses

pneumococcal conjugate vaccine (PCV 13)

-Significance: Streptococcal pneumococci (bacterial infection) younger than 2 years who attend day care and are immuno-compromised •Septicemia •Meningitis •Otitis media •Sinusitis •Pneumonia -Protects against 13 types of pneumococcal bacteria -Four doses: 2, 4, and 6 months, and 12 to 15 months of age

varicella vaccine

-Significance: any susceptible child -Two doses: 12 to 15 months and 4 to 6 years of age -Administered subcutaneous injection -ProQuad is licensed combination vaccination MMRV -Must have 2 doses to ensure they will have one-third less breakthrough illness compared with children who have 1 dose -Children who do contract varicella have less vesicles, lower fever, and faster recovery. -Antibodies persist for at least 8 years -May be given simultaneously with DTaP, IPV, HepB, or Hib vaccine -May be administered with MMR -If not given with MMR, then must wait at least 1 month between vaccines Action: stimulates active immunity against natural disease Side Effects: pain and redness at injection site, fever, chickenpox-like rash (generalized or confined to area surrounding injection site) Adverse Effects: anaphylaxis, thrombocytopenia, encephalitis, Stevens-Johnson syndrome Contraindications: -Previous anaphylaxis to this vaccine or to any of its components -Pregnancy or possibility of pregnancy within 1 month -Immunocompromised vaccine recipient -Presence of moderate to severe acute illness -Active untreated tuberculosis Drug-Lab-Food Interactions: -Drug: separate from other live virus vaccines (e.g., MMR, intranasal flu) by 4 wk if not given on the same day; delay VV for up to 11 mo after blood transfusion or Ig; delay Ig for 2 mo after VV, high-dose immunosuppressant medications; avoid salicylates for 6 wk after VV Nursing Interventions: -Strictly adhere to vaccine storage requirements -Upon reconstitution, administer within time limits stated in package insert -Administer at separate sites -Do not mix vaccines in the same syringe -Document completely: date, route, and site of administration; the vaccine type, manufacturer, lot number, and expiration date; the name, business address, and title of the person administering the vaccine -Observe for adverse reactions -Keep epinephrine available for use in the case of anaphylactic reaction -Provide patient with record of immunizations received Patient Teaching: -Discuss vaccine-preventable diseases -Answer questions clearly -Advise females to avoid pregnancy for 1 month -Avoid contact with immunocompromised persons -Provide VIS before administering the vaccine -Patient or patient's family to maintain vaccine record -Provide return date for next immunizations -Advise to contact health care provider if signs of reaction occur

influenza vaccine

-Significance: especially to children with asthma, cardiac disease, HIV, diabetes, sickle cell disease that place them at risk for influenza-related complications -Recommended annually (usually in the Fall) starting at 6 months of age -First-time recipients: 2 separate doses 4 weeks apart -Assessment for egg allergies prior to administration -May give at same time as other vaccinations: •Use separate syringe •Use separate injection site -The amount of inactivated (injectable) vaccine that should be administered intramuscularly is based on the age of the child and the vaccine product being used. -For children 6-35 months of age, the correct dose is: 0.25 mL for Fluzone Quadrivalent 0.5 mL for FluLaval Quadrivalent -For children 3 years of age and older, the correct dose is 0.5 mL for all inactivated influenza vaccine products

meningococcal vaccines

-Significance: highest fatalities occur in adolescents and college freshmen living in residence halls; morbidities include limb or digit amputation, skin scarring, hearing loss and neurologic disability -Two doses: first at 11 to 12 years of age with second at 16 to 18 years of age -MCV-4 is single immunization; Menactra is licensed vaccination -May give at same time as other vaccinations: •Use separate syringe •Use separate injection site

Haemophilus influenzae type B (Hib) vaccine

-Significance: protect against serious infections •Bacterial Meningitis •Epiglottitis •Bacterial pneumonia •Septic arthritis •Sepsis -Four doses: 2, 4, 6, and 12 to 15 months of age -Administered by IM injection using separate syringe and a site separate from any concurrent vaccinations. -Not associated with the viruses that cause influenza, or "flu"

hepatitis A virus (HepA) vaccine

-Significant child health problem: •Fecal-oral route •Person-to-person contact •Ingested contaminated food or water -Daycare, diaper changes, handwashing: disinfect surface after changing each infant -Children in close proximity -Two doses: 1 year old and 6 months after first dose

history taking

-The format used for history taking may be (1) direct, in which the nurse asks for information via direct interview with the informant, or (2) indirect, in which the informant supplies the information by completing some type of questionnaire. -Informant: the person(s) who furnishes the information -Chief complaint: specific reason -Present illness: narrative of the chief complaint -Analyzing of symptom(s): assessment includes type, location, severity, duration, and influencing factors -Birth History: health during pregnancy, the labor and delivery, and infant's condition immediately after birth -Dietary History -Previous Illnesses, Injuries, and Operations: begin with a general question -Allergies: ask about commonly known allergic disorders; unusual reactions to drugs, food, or latex products; reactions to other contact agents, such as poisonous plants, animals, household products, or fabrics -Current Medications: vitamins, antipyretics (especially aspirin), antibiotics, antihistamines, decongestants, nutritional supplements, or herbs and homeopathic medications -Immunizations -Growth and Development: -Review the child's growth including the following: •Measurements of weight, length, and head circumference at birth •Patterns of growth on the growth chart and any significant deviations from previous percentiles -Habits: •Behavior patterns, such as nail biting, thumb sucking, pica (habitual ingestion of nonfood substances), rituals ("security" blanket or toy), and unusual movements (head banging, rocking, overt masturbation, walking on toes) •Activities of daily living, such as hours of sleep and arising, duration of nighttime sleep and naps, type and duration of exercise, regularity of stools and urination, age of toilet training, and daytime or nighttime bedwetting •Unusual disposition; response to frustration •Use or abuse of alcohol, drugs, coffee, or tobacco -Reproductive Health History: sexual activity, sexually transmitted infections, or testing for pregnancy -Family Health History: genetic or chronic diseases -Geographic Location: birthplace and travel to different areas in or outside of the country -Family Structure: structure and function -Psychosocial History: personal status, such as school adjustment and any unusual habits -Review of Systems

family-centered care

-The two basic concepts are enabling and empowering -Professionals enable families by creating opportunities and means for all family members to display their current abilities and competencies and to acquire new ones to meet the needs of the child and family. -Empowerment describes the interaction of professionals with families in such a way that families maintain or acquire a sense of control over their family lives and acknowledge positive changes that result from helping behaviors that foster their own strengths, abilities and actions. -Recognizes the family as the constant in a child's life. -An approach to the planning, delivery, and evaluation of health care that is grounded in mutually beneficial partnerships among health care providers, patients, and families -Incorporate into policy and practice that the family is the constant in the child's life -Facilitate family-professional collaboration -Exchange complete and unbiased information between family members and professionals -Incorporate and honor the family's cultural diversity, strengths, and individuality -Encourage and facilitate family-to-family support and networking -Ensure community and support services are flexible, accessible and comprehensive for children with special needs -Appreciate families as families and children as children possessing a wide range of strengths, concerns, emotions, and aspirations

communicating with children

-Until infants reach the age at which they experience stranger anxiety, they readily respond to any firm, gentle handling and quiet, calm speech. -Play is an effective way of communicating with younger children -Children younger than 5 years of age are egocentric. -Younger school-age children rely less on what they see and more on what they know when faced with new problems -Functional aspect of all procedures, objects, and activities -What is going to take place and why it is being done to them specifically -School-age children have a heightened concern about body integrity -As children move into adolescence, they fluctuate between child and adult thinking and behavior -Privacy and confidentiality is important to them General Tips: -Avoid sudden or rapid advances, broad smiles, extended eye contact, and other gestures that may be seen as threatening. -Talk to the parent if the child is initially shy. -Communicate through transition objects (such as, dolls, puppets, and stuffed animals) before questioning a young 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, and confident voice. -Speak clearly, be specific, and use simple words and short sentences. -State directions and suggestions positively. -Offer a choice only when one exists. -Be honest with children. -Allow children to express their concerns and fears. -Use a variety of communication techniques.

physical assessment

General Appearance: -Physical appearance, state of nutrition, behavior, personality, interactions with parents and nurse (also siblings if present), posture, development, and speech Skin: -Assess skin for color, texture, temperature, moisture, turgor, lesions, acne, and rashes -Examination of the skin and its accessory organs primarily involves inspection and palpation -Touch allows the nurse to assess the texture, turgor, and temperature of the skin Accessory Structures: -Inspection of the accessory structures of the skin may be performed while examining the skin, scalp, or extremities. -Inspect the hair for color, texture, quality, distribution, and elasticity -Inspect the hair and scalp for general cleanliness -Examine the area for lesions, scaliness, evidence of infestation (e.g., lice or ticks), and signs of trauma (e.g., ecchymosis, masses, or scars) -Inspect the nails for color, shape, texture, and quality Lymph Nodes: usually assessed during examination of the part of the body in which they are located Head and Neck: -Observe the head for general shape and symmetry -Flattening of one part of the head, such as the occiput, may indicate that the child continually lies in this position -Marked asymmetry is usually abnormal and may indicate premature closure of the sutures (craniosynostosis) -Note head control in infants and head posture in older children -While examining the head, observe the face for symmetry, movement, and general appearance -Ask the child to "make a face" to assess symmetric movement and disclose any degree of paralysis -Note any unusual facial proportion, such as an unusually high or low forehead; wide- or close-set eyes; or a small, receding chin Eyes: -Inspection of external structures: eye is open, the upper lid should fall near the upper iris; eyes are closed, the lids should completely cover the cornea and sclera -Preparing the child: the nurse can prepare the child for the ophthalmoscopic examination by showing the child the instrument, demonstrating the light source and how it shines in the eye, and explaining the reason for darkening the room -Ocular alignment: Normally, by 3 to 4 months of age, 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. If the misalignment is constant, the weak eye becomes "lazy," and the brain eventually suppresses the image produced by that eye. If strabismus is not detected and corrected by 4 to 6 years of age, blindness from disuse, known as amblyopia, may result. Ears: -Inspection of external structures: measure the height alignment of the pinna by drawing an imaginary line from the outer orbit of the eye to the occiput, or most prominent protuberance of the skull. -Measure the angle of the pinna by drawing a perpendicular line from the imaginary horizontal line and aligning the pinna next to this mark -Positioning the Child: before beginning the otoscopic examination, position the child properly and gently restrain (sit on parent's lap and hold parent's hands) if necessary -Older children usually cooperate and do not need restraint -Prepare them for the procedure by allowing them to play with the instrument, demonstrating how it works, and stressing the importance of remaining still -A helpful suggestion is to let them observe you examining the parent's ear -Restraint is needed for younger children, because the ear examination upsets them -Nose: assess for drainage, patency, and the sinuses Mouth and Throat: -Most of the entire examination of the mouth and throat is done without the use of a tongue blade -Ask the child to open the mouth wide; to move the tongue in different directions for full visualization; and to say "ahh," which depresses the tongue for full view of the back of the mouth (tonsils, uvula, and oropharynx) -Infants and toddlers usually resist attempts to keep the mouth open -Because inspecting the mouth is upsetting, leave it for the end of the physical examination (along with examination of the ears) or do it during episodes of crying -However, the use of a tongue blade (preferably flavored) to depress the tongue may be needed -Place the tongue blade along the side of the tongue, not in the center back area where the gag reflex is elicited Chest: -Inspect the chest for size, shape, symmetry, movement, breast development, and the bony landmarks formed by the ribs and sternum Lungs: -Inspection of the lungs primarily involves observation of respiratory movements -Evaluate respirations for (1) rate (number per minute), (2) rhythm (regular, irregular, or periodic), (3) depth (deep or shallow), and (4) quality (effortless, automatic, difficult, or labored) -Note the character of breath sounds, such as noisy, grunting, snoring, or heavy -Listen to kids' lungs in the axillary area as well Heart: -Auscultate the heart with the child in at least two positions: sitting and reclining -If adventitious sounds are detected, further evaluate them with the child standing, sitting and leaning forward, and lying on the left side -Evaluate heart sounds for (1) quality (they should be clear and distinct, not muffled, diffuse, or distant); (2) intensity, especially in relation to the location or auscultatory site (they should not be weak or pounding); (3) rate (they should have the same rate as the radial pulse); and (4) rhythm (they should be regular and even). Heart Murmurs: -A murmur is produced by vibrations within the heart chambers or in the major arteries from the back-and-forth flow of blood -If a child has a murmur, you are most likely to hear it when you listen to their back Abdomen: -Examination of the abdomen involves inspection followed by auscultation and then palpation -Inspection: inspect the contour of the abdomen with the child erect and supine. Look at contour, symmetry, characteristics of umbilicus and skin, pulsations or movement -Auscultation: the most important finding to listen for is peristalsis, or bowel sounds. Also listen for bruits over the aortic, renal, iliac, and femoral arteries -Palpation: Mass, tenderness, size and location of organs Genitalia: -Examination of genitalia conveniently follows assessment of the abdomen while the child is still supine -In adolescents, inspection of the genitalia may be left to the end of the examination -The best approach is to examine the genitalia matter-of-factly, placing no more emphasis on this part of the assessment than on any other segment -It helps to relieve children's and parents' anxiety by telling them the results of the findings; for example, the nurse might say, "Everything looks fine here." -Good to have an escort with you when assessing genitalia: don't want any misconceptions Males: -Penis -Scrotum -Tanner stages (The Tanner sexual-maturing ratings are based on predictable stages of puberty that are based on primary and secondary sexual characteristics.) Females: -Visual inspection and gentle palpation -Labias Anus: -After examination of the genitalia, it is easy to identify the anal area, although the child should be placed on the abdomen -Note the general firmness of the buttocks and symmetry of the gluteal folds -Assess the tone of the anal sphincter by eliciting the anal reflex (anal wink) Spine: -Note the general curvature of the spine -Inspect the back, especially along the spine, for any tufts of hair, dimples, or discoloration -Mobility of the vertebral column is easy to assess in most children because of their tendency to be in constant motion during the examination -Test mobility by asking the child to sit up from a prone position or to do a modified sit-up exercise Extremities: -Inspect each extremity for symmetry of length and size; refer any deviation for orthopedic evaluation -Inspect the arms and legs for temperature and color, which should be equal in each extremity, although the feet may normally be colder than the hands -Assess the shape of bones -Toddlers are usually bowlegged after beginning to walk until all of their lower back and leg muscles are well developed -Unilateral or asymmetric bowlegs that are present beyond 2 to 3 years of age, particularly in African-American children, may represent pathologic conditions requiring further investigation Joints: -Evaluate the joints for range of motion -Palpate the joints for heat, tenderness, and swelling -These signs, as well as redness over the joint, warrant further investigation Muscles: -Note symmetry and quality of muscle development, tone, and strength -Observe development by looking at the shape and contour of the body in both a relaxed and a tensed state -Estimate tone by grasping the muscle and feeling its firmness when it is relaxed and contracted -A common site for testing tone is the biceps muscle of the arm -Children are usually willing to "make a muscle" by clenching their fists Neurologic Assessment: -The assessment of the nervous system is the broadest and most diverse part of the examination process, because every human function, both physical and emotional, is controlled by neurologic impulses -Much of the neurologic examination has already been discussed, such as assessment of behavior, sensory testing, and motor function Reflexes: -Testing reflexes is an important part of the neurologic examination -Persistence of primitive reflexes, loss of reflexes, or hyperactivity of deep tendon reflexes is usually a result of a cerebral insult -Also test cranial nerves

physical examination

Growth Measurements: -Growth charts -Length -Height -Weight -Skin full thickness and arm circumference -Head circumference -Physical growth parameters include weight, height (length), skinfold thickness, arm circumference, and head circumference. -Values for these growth parameters are plotted on percentile charts, and the child's measurements in percentiles are compared with those of the general population. -It is important to use the correct measurement tools for the child. -Because growth is a continuous but uneven process, the most reliable evaluation lies in comparing growth measurements over time because they reflect change. Weight: -Weight is measured with an electronic or appropriately sized balance beam scale Head Circumference: -Head circumference is a reflection of brain growth. -Measure head circumference in children up to 36 months of age and in any child whose head size is questionable. Length: -Until children are 2 years of age and able to stand alone (or 36 months of age if using a chart for birth to 36 months), measure recumbent length using a length board and two measurers. -Because of the normally flexed position during infancy, fully extend the body by (1) holding the head in midline, (2) grasping the knees together gently, and (3) pushing down on the knees until the legs are fully extended and flat against the table Height: -The term height (or stature) refers to the measurement taken when a child is standing upright. -Measure height by having the child, with the shoes removed, stand as tall and straight as possible. -Be certain the child's back is to the wall or other vertical flat surface, with the head, shoulder blades, buttocks, and heels touching the vertical surface. -Check for and correct slumping of the shoulders, positional lordosis, bending of the knees, or raising of the heels.

Piaget's theory of cognitive development

Sensorimotor (birth to 2 years): -An infant learns about the world through senses and motor activity -Progresses from reflex activity through simple repetitive behaviors to imitative behaviors -Develops a sense of "cause and effect" -Language enables child to better understand world -Curiosity, experimentation, and exploration result in the learning process -Object permanence is fully developed; at this stage, kids start to look for whatever it is that "disappeared" -Peek-a-boo teaches object permanence; the child learns that you did not disappear just because your hands are over your face Preoperational (2 to 7 years): -Forms symbolic thought -Exhibits egocentrism -Unable to understand conservation -Increasing ability to use language -Play becomes more socialized -Can concentrate on only one characteristic of an object -Divided into two portions: the preconceptual stage and the intuitive phase. -The preconceptual stage, ages 2 to 4, and the phase of intuitive thought, ages 4 to 7: one of the main transitions during these two phases is the shift from totally egocentric thought to social awareness and the ability to consider other viewpoints. -Children are able to think and verbalize their mental processes without having to act out their thinking. -They can only think of one thing at a time and are unable to thinks of all parts in terms of the whole. -Children at this age can be frightened by hospitalization because their thought processes are still egocentric, magical, and illogical. -They are very threatened by unfamiliar people and strange environments. -Teaching must take into account the child's vivid fantasies and underdeveloped sense of time Concrete Operational (7 to 11 years): -Thoughts become increasingly logical and coherent -Able to shift attention from one perceptual attribute to another -Concrete thinkers -Able to classify and sort facts, do problem solving -Acquires conservation skills -Teaching: give the opportunity to ask questions and explain things back to you. This allows the child to mentally manipulate information Formal Operations (11 years to death): -Able to logically manipulate abstract and unobservable concepts -Adaptable and flexible -Able to deal with contradictions -Uses scientific approach to problem solve -Able to conceive the distant future -Teaching: for the adolescent may be wide ranging because they are able to consider many possibilities from several perspectives. Can teach consequences, especially those related to the patient's behavior.

physiologic measurements

Temperature: -Electronic intermittent thermometer -Infrared thermometer -Electronic continuous thermometer -Temporal thermometer Pulse: -Radial -Apical: (heard through a stethoscope held to the chest at the apex of the heart) is most reliable -The best place to take a pulse on a child is the apical pulse -The best place to take a pulse on infants is the brachial pulse -Compare radial and femoral pulses at least once during infancy to detect the presence of circulatory impairment, such as coarctation of the aorta. -Respiration: count the respiratory rate; in infants, observe abdominal movements, because respirations are primarily diaphragmatic; if movements are irregular, count them for 1 full minute for accuracy Pediatric Blood Pressure: -Measurement devices -Selection of cuff -Cuff placement -BP measurement and interpretation -Measured annually in children 3 years of age through adolescence and in children with symptoms of hypertension, children in emergency departments and intensive care units, and high-risk infants -Auscultation remains the gold standard method of BP measurement in children -Use of the automated devices is acceptable for BP measurement in newborns and young infants, in whom auscultation is difficult, and in the intensive care setting where frequent BP measurement is needed -AAP recommends all children over age 3 have blood pressure taken at all exams -Adolescents with BP > 120/80 = hypertensive -Cuff size is important: too small = falsely elevated values, too large = inaccurate low values -The technique to establish an appropriate cuff size is to choose a cuff with a bladder width that is at least 40% of the arm circumference midway between the olecranon and the acromion -This will usually be a cuff bladder that covers 80% to 100% of the circumference of the arm -BP standards that are based on gender, age, and height provide a more precise classification of BP according to body size -This approach avoids misclassifying children who are very tall or very short. -Can measure blood pressure in the brachial artery, radial artery, popliteal artery, dorsalis pedis artery, and posterior tibial artery

Erickson's Psychosocial Theory

Trust vs. Mistrust (birth to 1 year): -Task of the first year of life is to establish trust in people providing care -Mistrust develops if basic needs are inconsistently or inadequately met Autonomy vs. Shame and Doubt (1 to 3 years): -Increased ability to control self and environment -Practices and attains new physical skills, developing autonomy -Symbolizes independence by controlling body secretions, saying "no" when asked to do something, and directing motor activity -If successful, develops self-confidence and willpower; if criticized or unsuccessful, develop a sense of shame and doubt about their abilities Initiative vs. Guilt (3 to 6 years): -Explores the physical world with all the senses, initiates new activities, and considers new ideas -Demonstrates initiative by being able to formulate and carry out a plan of action -Develops a conscience -If successful, develops direction and purpose; if criticized, leads to feelings of guilt and a lack of purpose -Learning right from wrong Industry vs. Inferiority (6 to 12 years): -Displays development of new interests and involvement in activities -Learns to follow rules -Acquires reading, writing, math, and social skills -If successful, develops confidence and enjoys learning about new things; if compared to others, may develop feeling of inadequacy; inferiority may develop if too much is expected Identity vs. Role Confusion (12 to 18 years): -Rapid and marked physical changes -Preoccupation with physical appearance -Examines and redefines self, family, peer groups, and community -Experiments with different roles -Peer group very important -If successful, develops confidence in self-identity and optimism; if unable to establish meaningful definition of self, develops role confusion