Pediatrics (concepts)

Varicella

(Chicken Pox) Varicella-zoster virus (VZV) Source is primary secretions Droplet contact Prevented by immunization Incubation period is 2-3 weeks

Pertussis

(Whooping Cough) Bordetella pertussis Direct droplet contact Incubabion 6-20 days, usually 7-10 Dry hacking cough, resp tract infection Short rapid cough followed by sudden inspiration with High pitched crowing sound or "whoop" Complications are many see page 182.

CRIES

- for neonates -Crying (0-2) -Requiring increased oxygen (0-2) -Increased vital signs (0-2) -Expression (0-2) -Sleeplessness (0-2) -Used in NICU -*0= no pain; 10=worst pain*

Risk Factors That Increase Children's Vulnerability to the Stresses of Hospitalization

-"Difficult" temperament -Lack of fit between child and parent -Age (especially between 6 months old and 5 years old) -Male gender Below-average intelligence -Multiple and continuing stresses (e.g., frequent hospitalizations)

Some toddler tasks are:

-Differentiation of self from others, especially mother & primary care givers -Tolerate separation from parents -Control over bodily functions -Learning socially acceptable behavior -Verbal means of communication -Able to interact with others **Mastery of these goals begin during infancy and toddler years and develop through adolescence.

Palliative care of the dying child

-Focuses on providing relief from the symptoms and stress of the illness -The goal is to Improve quality of life for the child and family.

The dying child

-Grieving -Palliative Care of the dying child -Hospice care -Nurse management of the dying child

Preferred sites for venous access in infants

-tunneled catheter -Groshong catheter -Implanted Ports (e.g., Port-a-Cath, Infus-a-Port, Mediport, Norport, Groshong Port)

Puncture site on sole of foot

in colored stippled area

Intraosseous fluids

in the bone

Partial restrain to give medication

sitting in moms lap

Etiological risk factors for cerebral palsy

stage 1: hypertonia stage 2: contractures stage 3: bony deformity stage 4: decompensation

Seven month milestone

transfers objects from one hand to another

Hypotonia suggests:

problem, possibly neurological, muscular, indicate paralysis or conditions such as Down's Syndrome (Trisomy 21)

Venipuncture

puncture of a vein

Developmental concerns

delays or abnormal patterns of development in the areas of communication/language, motor skills, problem-solving or social and adaptive behavior. These concerns are usually based on comparison to other children the same age.

Lumbar puncture

fetal position. post-neuro assess q15-30 until stable. flat 2-3 hour. encourage fluids, oral analgesics for headache.

Factors Affecting Parents' Reactions to Their Child's Illness

-Seriousness of the threat to the child -Previous experience with illness or hospitalization -Medical procedures involved in diagnosis and treatment -Available support systems -Personal ego strengths -Previous coping abilities -Additional stresses on the family system -Cultural and religious beliefs -Communication patterns among family members -Information and education provided to family throughout hospitalization -Socioeconomic status

Buritrol

-Usually used for children -Hospital will have an age range for use -Safety measure to avoid flash edema in children (overload of cardiac system)

5 month milestones

-abrupt change in personality -very easily distracted

4 year old toys

-color books -puzzles -cut and paste -dolls -building blocks -clay -toys that roll

Toys for 4 month olds

-mobiles -rattles -squeaky toys -picture books -balls -activity boxes

3 month milestones

-personality starts to form -wants to talk and play -goes from what they need to what they want

Milestones that should be accomplished by 1 year

-posterior fontanel by 8 weeks (2 months) -head locates sound by 3 months -steady head control by 4 months -able to roll form abdomen to back and back by 5-6 months -able to transfer objects from hand to hand by 7 months -social smiles at 2 months -sit unsupported by 8 months -able to crawl by 10 months -able to walk with assistance 10-12 months -fine pincher grasp at 10 months (could be up to 12 months) -Moro reflex disappears at 4 months -weight triples by 12 months from birth weight -can say a few words by the time they are a year old

Tanner stages- female

1 growth of breasts 2 growth of pubic hair 3 body growth 4 menarche 5 underarm hair 6 oil/sweat glands

Tanner stages- male

1 growth of testes 2 growth of pubic hair 3 body growth 4 growth of penis 5 change in voice 6 facial/underarm hair 7 oil/sweat glands

Site of origin for neuromuscular disorders

1, Cerebral palsy; 2, poliomyelitis, spinal muscular atrophy; 3, mononeuropathies, polyneuropathies; 4, myasthenia gravis, neurotoxic disorders; 5, muscular dystrophies.

Which vaccine would the RN expect to be prescribed for a 2-month-old brought into the pediatrician's office for a well-baby checkup? (Select all that apply). 1. DTaP 2. Hep B 3. Hep C 4. Haemophilus influenzae type b (HIB) 5. IPV 6. PCV

1. DTaP 2. Hep B 4. Haemophilus influenzae type b (HIB) 5. IPV 6. PCV

A parent is preparing a 5-year- old child for kindergarten. The child has not received any immunizations. Which vaccine would be given to this child? (Select all that apply) 1. Diphtheria, Tetanus and Pertussis (DTaP) 2. Inactivated polio virus (IPV) 3. Varicella 4. Pneumococcal conjugate vaccine (PCV) 5. Trivalent inactivated influenza vaccine (TIV)

1. Diphtheria, Tetanus and Pertussis (DTaP) 2. Inactivated polio virus (IPV) 3. Varicella

Health history

1.Identifying information Demographics 1.Chief Complaint Reason seeking healthcare 2. Present Illness Obtain details related to CC 3. Past History To begin profile of child's previous illnesses, injuries, surgeries 4. Review of Systems (ROS) List of every system to elicit information on any health problem (Box 4.4) 5. Family Medical History Identify genetic traits or diseases 6. Psychosocial History To elicit information of the child's self-concept 7. Sexual History Information on child's sexual conduct 8. Family History Information about family composition, community environment, occupation and education of family, culture and religion 9. Nutritional Assessment

Nurses role in child's hospitalization

1.Preparing children and family for hospitalization 2.Admitting the child to the facility Box 21.5 3.Addressing the effects of hospitalization on development 4.Preparing for surgery 5.Maintaining safety 6.Provide basic care 7.Provide play, activities, and recreation for the hospitalized child.

The RN directs the unlicensed assistive personnel (UAP) to play with a 4-year-old on bed rest. Which activity would the RN recommend? (Select all that apply) 1. Monopoly board game 2. Checkers 3. 100-piece puzzle 4. Hand puppets 5. Coloring book

2. Checkers 4. Hand puppets 5. Coloring book

While receiving IV antibiotics for sepsis, a 2-month-old infant is crying inconsolably, despite the parent's presence. The RN recognizes that the infant is exhibiting symptoms related to which likely condition? 1. Allergic reaction to antibiotics 2. Pain related to IV infiltration 3. Separation anxiety from parent 4. Hunger and thirst

2. Pain related to IV infiltration

The RN is caring for a 2-year-old child suspected of having croup. Which early sign of respiratory distress requires the RN's immediate attention? 1. Cyanosis 2. Restlessness 3. Crying 4. Barking cough

2. Restlessness

The RN is reinforcing teaching for a school-age child and the child's parent regarding the administration of inhaled beclomethasone dipropionate and albuterol for the treatment of asthma. Which statement by the parent indicates that teaching has been effective? 1. "My child knows which refrigerator shelf the inhalers are kept." 2. "My child only needs to use inhalers when the peak flow numbers are in the red." 3. "My child will take the bronchodilator first, then the corticosteroid." 4. "My child will take the corticosteroid first, wait a few minutes, and then take the bronchodilator."

3. "My child will take the bronchodilator first, then the corticosteroid."

The RN reinforcing discharge teaching for parents of a 4- year-old with Cystic Fibrosis. Which statement by the parents demonstrates understanding of the teaching presented? 1. "We will discourage our child from playing outdoors." 2. "We will use pancreatic enzymes only if needed." 3. "We will wash our child's hands after toileting." 4. "We will schedule a physical therapist evaluation."

3. "We will wash our child's hands after toileting."

The RN is caring for a child who had a tonsillectomy 2 hours ago. Which sign or symptom most likely relates to a complication? 1. Apical rate 90 bpm 2. Blood pressure 96/50 3. Frequent swallowing 4. Nasal congestion

3. Frequent swallowing

Grieving

The emotional and physical feeling that deals with separation and loss

A 4-year-old is brought to the clinic with a fever of 103F, sore throat, and moderate respiratory distress caused by a suspected bacterial infection. Which medical diagnosis is a contraindication to obtaining a throat culture in the child? 1. Tonsillitis 2. Streptococcal infection 3. Bronchiolitis 4. Epiglottitis

4. Epiglottitis

Preventing or minimizing separation

A primary nursing goal is to prevent separation, particularly in children younger than 5 years old. Many hospitals have developed a system of family-centered care. Efforts to collaborate with families and encourage their involvement in the patient's care include optimizing family visitation, family-centered rounding, family presence during procedures or interventions, and opportunities for formal and informal family conferences

Enteral nutrition-- gavage feeding

A, Measuring the tube for orogastric feeding from the tip of the nose to the earlobe and to the midpoint between the end of the xiphoid process and the umbilicus. B, Inserting the tube.

School-age child (6-12 years)

A. Developmental milestones 1. Children may lose their first tooth during this time. 2. Activities include painting, drawing, riding a bicycle, and jumping rope. B. Erickson's stage of development 1. Industry vs. Inferiority C. Nursing implications 1. The hospitalized school-age child may need more support from parents than the child wishes to admit. 2. Maintaining contact with peers and school activities is important during hospitalization. 3. Providing an explanation of all procedures is important. The child can learn from verbal explanations, pictures, and books, as well as by handling equipment. 4. Privacy and modesty are important and should be respected during hospitalization (e.g., close curtains during procedures, allow privacy during baths). 5. Participation in care and planning with staff fosters a sense of involvement and accomplishment. 6. Toys for the school-age child include board games, card games, and hobbies, such as stamp collecting, puzzles, and video games.

Adolescent (12 to 19 years)

A. Developmental milestones (see Table 5.1) 1. Girls' growth spurts during adolescence begin earlier than boys' (may begin as early as 10 years for girls). 2. Boys catch up at around 14 years of age and continue to grow. 3. Girls finish growth at around age 15, and boys at around age 17. 4. Secondary sex characteristics develop. (Transgender, new pronouns, etc) 5. Adult-like thinking begins around age 15. They can problem-solve and use abstract thinking. 6. Family conflicts develop. B. Erikson's stage of development 1. Identity vs. Role Confusion C. Nursing implications 1. Hospitalization of adolescents disrupts school and peer activities; it is important that teens maintain contact with both. 2. They should share a room with other adolescents. 3. Illnesses, treatments, and procedures that alter the adolescent's body image can be viewed by the adolescent as devastating. 4. Teaching about procedures should include time without the parents being present, so that the teen can ask 162 questions that they may not be comfortable asking in front of their parents. It is important to direct questions to the adolescent when the parents are present in order for all involved to hear the same information. 5. The age of assent for making medical decisions in children and adolescents ranges from 7 to 14 years. Parental consent is also needed for treatment. 6. For prolonged hospitalizations, adolescents need to maintain identity (e.g., have their own clothing, posters, and visitors). A teen room or teen night is very helpful. The adolescent should be part of the decision regarding a parent's rooming-in. 7. When teaching adolescents, the focus should be on the here and now. a. "How will this affect me today?"

A two-year old child's blood work is evaluated by the RN. Considering that the child is prescribed furosemide, captopril, and digoxin for congestive heart failure, which value would the RN verify by the laboratory?

Answer: Hypokalemia Rationale: Furosemide and digoxin in combination can deplete potassium stores and place the client at risk for digoxin toxicity.

physical exam: infant

Before able to sit alone—supine or prone, preferably in parent's lap; before 4-6 months, can place on examining table After able to sit alone—sitting in parent's lap whenever possible; if on table, place with parent in full view ------------------------- If quiet, auscultate heart, lungs, abdomen. Record heart and respiratory rates. Palpate and percuss same areas. Proceed in usual head-to-toe direction. Perform traumatic procedures last (eyes, ears, mouth [while crying]). Elicit reflexes as body part is examined. Elicit Moro reflex last. ------------------------- Completely undress if room temperature permits. Leave diaper on male infant. Gain cooperation with distraction, bright objects, rattles, talking. Smile at infant; use soft, gentle voice. Use pacifier (if used) or bottle with feeding (if bottle feeding). Enlist parent's aid for restraining to examine ears, mouth. Avoid abrupt, jerky movements.

Stages of protest

Behaviors observed during later infancy include the following: • Cries • Screams • Searches for parent with eyes • Clings to parent • Avoids and rejects contact with strangers Additional behaviors observed during toddlerhood include the following: • Verbally attacks strangers (e.g., "Go away") • Physically attacks strangers (e.g., kicks, bites, hits, pinches) • Attempts to escape to find parent • Attempts to physically force parent to stay Behaviors may last from hours to days. Protest, such as crying, may be continuous, ceasing only with physical exhaustion. Approach of stranger may precipitate increased protest.

Reflexes in newborn: eyes

Blinking or corneal reflex: Infant blinks at sudden appearance of bright light or at approach of object toward cornea; persists throughout life. Pupillary: Pupil constricts when bright light shines toward it; persists throughout life. Doll's eye: As head is moved slowly to right or left, eyes lag behind and do not immediately adjust to new position of head; disappears as fixation develops; if persists, indicates neurologic damage.

Spinal cord lesions

C2 - Head and Neck movements C3-C5 - breathing C5 - Shoulder movement C4-C6 - Heart rate C5 - Shoulder movement and elbow movement C7-T1 - Finger movement (and head movement?) T1-T12 - Sympathetic tone including temperature regulation and trunk stability T11-L2 - Ejaculation L2 - Hip motion L3 - Knee extension L4 - foot dorisflexion L5 - Big toe dorsiflexion L5 - Knee flexion S1-S2 - foot plantarflexon S2-S4 - penile erection and bowel/ bladder activity

Minimizing loss of control

Children feel a loss of control due to physical restrictions, changed routines, and enforced dependency.

Suggested toys: 7-12 months

Colored blocks Nested boxes or cups Books with rhymes and bright pictures Strings of big beads Simple take-apart toys Large ball Cup and spoon Large-piece wood puzzles Jack-in-the-box Rattles of different sizes, shapes, tones, and bright colors Squeaky animals and dolls Records with light, rhythmic music Soft, different-texture animals and dolls Sponge toys, floating toys Squeeze toys Teething toys Books with textures and objects, such as fur and zipper Activity box for crib Push-pull toys Wind-up swing

Diptheria

Corynebacterium diphtheria Discharge from mucous membranes of nose, nasopharynx, skin Incubation is 2-5 days but virility is variable could be 2-4 weeks. Preventive childhood immunization Complications-toxic cardiomyopathy and toxic neuropathy Smooth, adherent white or grey membrane, lymphadenitis, toxemia, septic shock, dyspnea, airway obstruction, cyanosis and death in 6-10 days.

Cerebral palsy

Delayed Gross Motor Development • A universal manifestation • Delay in all motor accomplishments • Increases as growth advances • Delays more obvious as growth advances Abnormal Motor Performance • Very early preferential unilateral hand preference • Abnormal and asymmetric crawl • Standing or walking on toes • Uncoordinated or involuntary movements • Poor sucking • Feeding difficulties • Persistent tongue thrust Alterations of Muscle Tone • Increased or decreased resistance to passive movements • Opisthotonic posturing (arching of back) • Feels stiff on handling or dressing • Difficulty in diapering • Rigid and unbending at the hip and knee joints when pulled to sitting position (early sign) Abnormal Postures • Maintains hips higher than trunk in prone position with legs and arms flexed or drawn under the body • Scissoring and extension of legs with feet plantar flexed in supine position • Persistent infantile resting and sleeping position • Arms abducted at shoulders • Elbows flexed • Hands fisted Reflex Abnormalities • Persistence of primitive infantile reflexes • Obligatory tonic neck reflex at any age • Nonpersistence beyond 6 months of age • Persistence or hyperactivity of the Moro, plantar, and palmar grasp reflexes • Hyperreflexia, ankle clonus, and stretch reflexes elicited in many muscle groups on fast, passive movements Associated Disabilities • Altered learning and reasoning • Seizures • Impaired behavioral and interpersonal relationships • Sensory impairment (vision, hearing)

Parental absence during infant hospitalization

Familiar surroundings also increase the child's adjustment to separation. If the parents cannot stay with the child, they should leave favorite articles from home with the child, such as a blanket or a toy. Children gain comfort and reassurance from holding onto these possessions.

effects of strength training on pediatric population with spastic cerebral palsy

GMFCS level 1 GMFCS level 2 GMFCS level 3 GMFCS level 4 GMFCS level 5

Rubella

German Measles Rubella virus present in nasopharyngeal secretions, blood, stool, and urine. Lymphadenopathy, sore throat, cough, coryza, conjunctivitis, headache, fever lasts 1-5 days. Treatment: Vaccine

Play during infancy: 7-9 months

Give infant large toys with bright colors, movable parts, and noisemakers. Play peek-a-boo, especially hiding face in towel. Make funny faces to encourage imitation. Give ball of yarn or string to pull apart. Call infant by name. Repeat simple words such as "dada," "mama," "bye-bye." Speak clearly. Name parts of body, people, and foods. Tell infant what you are doing. Use "no" only when necessary. Give simple commands. Show how to clap hands, bang a drum. Let infant play with fabrics of various textures. Have bowl with foods of different sizes and textures to feel. Let infant "catch" running water. Encourage supervised "swimming" in large bathtub or shallow pool. Give wad of sticky tape to manipulate. Hold upright to bear weight and bounce. Pick up, say "up." Put down, say "down." Place toys out of reach; encourage infant to get them. Play pat-a-cake.

Erythema infectiosum (fifth disease)

Human parvovirus B19 Mainly school age children Resp secretion spread, blood and blood products Erythema of the face (cheeks) Rash and maculopapular red spots Rash subsides and patient looks sunburned Fever, myalgia, lethargy, nausea, vomiting and abdominal pain Serious complications include: anemia, hydrops, fetal death, Aplastic crisis in children with immunodeficiency

Reflexes in newborn: extremities

Grasp: Touching palms or soles near base of digits causes flexion of hands and toes (see Fig. 7.10, A); palmar grasp lessens after age 3 months, to be replaced by voluntary movement; plantar grasp lessens by 8 months of age. Babinski: Stroking outer sole of foot upward from heel and across ball of foot causes toes to hyperextend and hallux to dorsiflex (see Fig. 7.10, B); disappears after age 1 year. Ankle clonus: Briskly dorsiflexing foot while supporting knee in partially flexed position results in 1-2 oscillating movements ("beats"); eventually no beats should be felt.

Scarlet fever

Group A beta hemolytic streptococci Incubation period 2-5 days and communicable during incubation period and clinical illness approx. 10 days. Tonsils enlarge, high fever, increased pulse, vomiting, headache, chills, malaise, abdominal pain, halitosis Tonsils covered with red patches, beefy read pharynx by 5th day white coat sloughs off of tongue leaving A prominent papillae (red strawberry tongue) Complications: Peritonsillar and retropharyngeal abcess Acute glomerulonephritis, Acute rheumatic fever, polyarthritis

Addressing common development concerns

If your child does not meet the developmental milestones, a parent should discuss it with a doctor or nurse. Developmental delays could indicate a serious problem, early intervention is important.

Age-Specific Preparation of Children for Procedures Based on Developmental Characteristics

Infant - Developing Trust and Sensorimotor Thought Toddler- Developing Autonomy and Sensorimotor to Preoperational Thought Preschooler - Developing Initiative and Preoperational Thought School Age - Develop Industry and Concrete Thought Adolescent - Developing Identity and abstract Thought

Signs and symptoms of respiratory syncytial virus

Initial Rhinorrhea Pharyngitis Coughing, sneezing Wheezing Possible ear or eye infection Intermittent fever With Progression of Illness Increased coughing and wheezing Fever Tachypnea and retractions Refusal to nurse or bottle feed Copious secretions Severe Illness Tachypnea >70 breaths/min Listlessness Apneic spells Poor air exchange; poor breath sounds Cyanosis

Play during infancy: birth to 1 month

Look at infant at close range. Hang bright, shiny object within 20-25 cm (8-10 inches) of infant's face and in midline. Hang mobiles with black-and-white designs. Talk to infant; sing in soft voice. Play music box, tape, or compact disc. Have ticking clock or heartbeat doll nearby. Hold, caress, cuddle. Keep infant warm. Swaddle infant with hands to face. Rock infant; place in cradle. Use stroller for walks.

Rubeola

Measles, virus, direct droplet contact Symptoms: Fever, malaise, coryza, cough, conjunctivitis, KopliK spots seen on buccal mucosa opposite molars. Rash appears at 3-4 days Treatment: Vaccine

Reflexes in newborn: mass

Moro: Sudden jarring or change in equilibrium causes sudden extension and abduction of extremities and fanning of fingers, with index finger and thumb forming a C shape, followed by flexion and adduction of extremities; legs may weakly flex; infant may cry (Fig. 7.9, A); disappears after age 3-4 months, usually strongest during first 2 months. Startle: Sudden loud noise causes abduction of arms with flexion of elbows; hands remain clenched; disappears by age 4 months. Perez: While infant is prone on firm surface, thumb is pressed along spine from sacrum to neck; infant responds by crying, flexing extremities, and elevating pelvis and head; lordosis of spine, defecation, and urination may occur; disappears by age 4-6 months. Asymmetric tonic neck: When infant's head is turned to one side, arm and leg extend on that side, and opposite arm and leg flex (Fig. 7.9, B); disappears by age 3-4 months, to be replaced by symmetric positioning of both sides of body. Trunk incurvation (Galant) reflex: Stroking infant's back alongside spine causes hips to move toward stimulated side; disappears by age 4 weeks. Dance or step: If infant is held so that sole of foot touches hard surface, there is reciprocal flexion and extension of leg, simulating walking (Fig. 7.9, C); disappears after age 3-4 weeks, to be replaced by deliberate movement. Crawl: When placed on abdomen, infant makes crawling movements with arms and legs; disappears at about age 6 weeks (Fig. 7.9, D). Placing: When infant is held upright under arms and dorsal side of foot is briskly placed against hard object, such as table, leg lifts as if foot is stepping on table; age of disappearance varies.

Suggested toys: birth-6 months

Nursery mobiles Unbreakable mirrors Music boxes Musical mobiles Crib dangle bells Small-handled clear rattle Stuffed animals Soft clothes* Soft or furry quilt* Soft mobiles Rocking crib or cradle Weighted or suction toy Infant swing

Foreign body aspiration

Most inhaled FBs lodge in a mainstem or lobar bronchus, a few find their way into more distal portions of the lung field, and the remaining FBs lodge in the trachea. They also may shift over time so symptoms can change. The site is determined by the object's size, weight, and configuration. For example, heavy objects such as bullets, coins, and nails are more likely to drop into the dependent portions of the tracheobronchial tree. The object may remain in the same location or move in the airway. It can be coughed from a smaller to a larger airway and re-aspirated in a different passage— or it might be ejected forcefully into the mouth and subsequently swallowed.

Posthospital Behaviors in Children: older children

Negative behaviors include the following: • Emotional coldness followed by intense, demanding dependence on parents • Anger toward parents • Jealousy toward others (e.g., siblings)

Stages of despair

Observed behaviors include the following: • Is inactive • Withdraws from others • Is depressed, sad • Lacks interest in environment • Is uncommunicative • Regresses to earlier behavior (e.g., thumb sucking, bedwetting, use of pacifier, use of bottle) Behaviors may last for variable length of time. Child's physical condition may deteriorate from refusal to eat, drink, or move.

Stages of detachment

Observed behaviors include the following: • Shows increased interest in surroundings • Interacts with strangers or familiar caregivers • Forms new but superficial relationships • Appears happy Detachment usually occurs after prolonged separation from parent; it is rarely seen in hospitalized children. Behaviors represent a superficial adjustment to loss.

Vastus lateralis injection

On lateral aspect of leg- hand's breadth down from greater trochanter and hand's breadth up from knee

Mumps

Paramyxovirus in saliva Direct droplet contact Incubation 14-21 days Fever, headache, malaise, and anorexia for 24 hours, followed by earache that is aggravated by chewing. By third day, parotid gland enlarges and reaches maximum size. Accompanied by pain and tenderness Complications: Many see pg. 181

Therapeutic intervention for cerebral palsy

Physical Therapy Occupational Therapy Medication Therapy Behavior Therapy

Play during infancy: 4-6 months

Place infant in front of unbreakable mirror. Give brightly colored toys to hold (small enough to grasp). Talk to infant; repeat sounds infant makes. Laugh when infant laughs. Call infant by name. Place rattle or bell in hand. Give infant soft squeeze toys of various textures. Allow to splash in bath. Place nude on soft, furry rug and move extremities. Use swing or stroller. Bounce infant in lap while holding in standing position. Support infant in sitting position; let infant lean forward to balance self. Place infant on floor to crawl, roll over, sit.

physical exam: school age child

Prefer sitting Cooperative in most positions Younger child prefers parent's presence Older child may prefer privacy ------------------------- Proceed in head-to-toe direction. May examine genitalia last in older child. ------------------------- Respect need for privacy. Request self-undressing. Allow to wear underpants. Give gown to wear. Explain purpose of equipment and significance of procedure, such as otoscope to see eardrum, which is necessary for hearing. Teach about body function and care.

physical exam: preschool child

Prefer standing or sitting Usually cooperative prone or supine Prefer parent's closeness ------------------------- If cooperative, proceed in head-to-toe direction. If uncooperative, proceed as with toddler. ------------------------- Request self-undressing. Allow to wear underpants if shy. Offer equipment for inspection; briefly demonstrate use. Make up story about procedure (e.g., "I'm seeing how strong your muscles are" [blood pressure]). Use paper-doll technique. Give choices when possible. Expect cooperation; use positive statements (e.g., "Open your mouth").

PIPP

Premature Infant Pain Profile pain assessment tool: -items scored from 0-3 -eye squeeze, nasal labial furrow, HR, O2 sat, brow furrow -a 21 indicates the worst level of pain

Myelomenigocele

Protrusion of a portion of the spinal cord and meniges through a defect in the spinal column •A, Myelomeningocele with intact sac. • B, Myelomeningocele with ruptured sac

Play during infancy: 2-3 months

Provide bright objects. Make room bright with pictures or mirrors. Take infant to various rooms while doing chores. Place in infant seat for vertical view of environment (use a safe surface). Talk to infant. Include infant in family gatherings. Expose to various environmental noises other than those of home. Use rattles, wind chimes. Caress infant while bathing or changing diaper. Comb hair with a soft brush. Give massage. Use infant swing. Take in car for rides. Exercise body by moving extremities in swimming motion. Use cradle gym.

physical exam: adolescent

Same as for school-age child Offer option of parent's presence ------------------------- Same as older school-age child. May examine genitalia last. ------------------------- Allow to undress in private. Give gown. Expose only area to be examined. Respect need for privacy. Explain findings during examination (e.g., "Your muscles are firm and strong."). Matter-of-factly comment about sexual development (e.g., "Your breasts are developing as they should be."). Emphasize normalcy of development. Examine genitalia as any other body part; may leave to end.

Selecting nonthreatening words or phrases (words not to say-> what to say)

Shot, bee sting, stick-- Medicine under the skin, poke that will feel like a pinch Organ-- Place in body Test-- To see how (specify body part) is working Incision, cut-- Make an opening Edema-- Puffiness Stretcher, gurney Rolling bed, bed on wheels Stool/urine-- Child's usual term Dye-- Medicine to help place in your body show up on a picture Pain-- Hurt, discomfort, "owie," "boo-boo," sore, achy, scratchy, pinch Deaden, numb-- Not feel body part as much Fix-- Make better Take (as in "take your temperature")-- See how warm you are Take (as in "take your blood pressure")-- Check your pressure; hug your arm Put to sleep, anesthesia-- Different kind of sleep so you won't feel anything Catheter-- Soft tube, small straw Monitor-- Television screen Electrodes-- Stickers, ticklers Specimen-- Take some blood

Play during infancy: 10-12 months

Show infant large pictures in books. Play ball by rolling it to child, demonstrate "throwing" it back. Demonstrate building a two-block tower. Read infant simple nursery rhymes. Point to body parts and name each one. Imitate sounds of animals. Give infant finger foods of different textures. Let infant mess and squash food. Let infant feel cold (ice cube) or warm objects; say what temperature each is. Let infant feel a breeze (fan blowing). Give large push-pull toys. Turn in different positions.

physical exam: toddler

Sitting or standing on or by parent Prone or supine in parent's lap ------------------------- Inspect body area through play: "Count fingers," "tickle toes." Use minimum physical contact initially. Introduce equipment slowly. Auscultate, percuss, palpate whenever quiet. Perform traumatic procedures last (same as for infant). ------------------------- Have parent remove outer clothing. Remove underwear as body part is examined. Allow toddler to inspect equipment; demonstrating use of equipment is usually ineffective. If uncooperative, perform procedures quickly. Use restraint when appropriate; request parent's assistance. Talk about examination if cooperative; use short phrases. Praise for cooperative behavior.

Reflexes in newborn: nose

Sneeze: Nasal passages respond spontaneously to irritation or obstruction; persists throughout life. Glabellar: Tapping briskly on glabella (bridge of nose) causes eyes to close tightly; usually disappears in infancy.

Reflexes in newborn: mouth and throat

Sucking:Infant begins strong sucking movements of circumoral area in response to stimulation; persists throughout infancy, even without stimulation, such as during sleep. Gag: Stimulation of posterior pharynx by food, suction, or passage of tube causes infant to gag; persists throughout life. Rooting: Touching or stroking cheek along side of mouth causes infant to turn head toward that side and begin to suck; should disappear at about age 3-4 months but may persist for up to 12 months. Extrusion : When tongue is touched or depressed, infant responds by forcing it outward; disappears by age 4 months. Yawn: Infant has spontaneous response to decreased oxygen by increasing amount of inspired air; persists throughout life. Cough: Irritation of mucous membranes of larynx or tracheobronchial tree causes coughing; persists throughout life; usually present after 1st day of birth.

Femoral venipuncture

Taking of blood sample from vein on the medial aspect of the hind limb.

Posthospital Behaviors in Children: Young Children

They show initial aloofness toward parents; this may last from a few minutes (most common) to a few days. This is frequently followed by dependency behaviors: • Tendency to cling to parents • Demands for parents' attention • Vigorous opposition to any separation (e.g., staying at preschool or with a babysitter) Other negative behaviors include the following: • New fears (e.g., nightmares) • Resistance to going to bed, night waking • Withdrawal and shyness • Hyperactivity • Temper tantrums • Food peculiarities • Attachment to blanket or toy • Regression in newly learned skills (e.g., self-toileting)

Spinal muscle atrophy

Type 1 (Werdnig-Hoffmann Disease) • Clinical manifestations within first few weeks or months of life • Onset within 6 months of life • Inactivity the most prominent feature • Infant lying in a frog-leg position with legs externally rotated, abducted, and flexed at knees • Generalized weakness • Absent deep tendon reflexes • Limited movements of shoulder and arm muscles • Active movement usually limited to fingers and toes • Diaphragmatic breathing with sternal retractions (diaphragmatic paralysis may occur) • Abnormal tongue movements (at rest) • Weak cry and cough • Poor suck reflex • Fatigues quickly during feedings (if breastfed, may lose weight before noticeable) • Failure to thrive (nutritional) • Alert facies • Normal sensation and intellect • Affected infants not able to sit alone, roll over, or walk • Early death possible from respiratory failure or infection Type 2 (Intermediate Spinal Muscular Atrophy) • Onset before age 18 months • Early—Weakness confined to arms and legs • Later—Becomes generalized • Legs usually involved to greater extent than arms • Prominent pectus excavatum • Movements absent during complete relaxation or sleep • Some infants able to sit if placed in position, but few can ambulate • For most, life span varies from 7 months to 7 years, although many have normal life expectancy Type 3 (Kugelberg-Welander Syndrome; Mild Spinal Muscular Atrophy) • Onset of symptoms after 18 months of age • Normal head control and ability to sit unassisted by 6-8 months of age • Thigh and hip muscles weak • Scoliosis common • Failure to walk a common presentation • In those who manage to walk: • Waddling gait • Genu recurvatum • Protuberant abdomen • Ambulation becoming increasingly difficult • Confined to a wheelchair by second decade • Deep tendon reflexes may be present early but disappear Type IV (Adult Spinal Muscular Atrophy) • Rare, adult-onset spinal muscular atrophy usually in second or third decade of life; muscle weakness is first symptom

Ear exam

Under 3 years old: Pull pinna down and back Over 3 years old : Pull pinna up and back ****This will straighten the auditory canal to visualize the tympanic membrane. Newborn screen consists of hearing screens for all newborns.

Ventrogluteal injection site

Upper outer hip area (gluteus medius)

Suggestion of pacifier use in infants

Using a pacifier during the first 6 months because of the benefit with regard to pain management during painful procedures and prevention of SIDS, but should be weaned off within the second 6 months of life

Promoting freedom of movement

Younger children react most strenuously to any type of physical restriction or immobilization. Although temporary immobilization may be necessary for some interventions such as maintaining an intravenous line, most physical restrictions can be prevented if the nurse gains the child's cooperation. For young children, particularly infants and toddlers, preserving parent-child contact is the best means of decreasing the need for restraint. Nearly the entire physical examination can be done in a parent's lap with the parent hugging the child for procedures, such as an otoscopic examination. For painful procedures, the nurse should assess the parents' preferences for assisting, observing, or waiting outside the room.

Enteral nutrition

alternate form of feeding that involves passing a tube into the gastrointestinal tract to allow instillation of the appropriate formula

Deltoid injection site

can be used for small volumes of fluid in children as young as 18 months of age. Its advantages are less pain and fewer side effects from the injectate

Hospice care

holistic, compassionate care given to dying people and their families

Parenteral Nutrition (PN)

method of supplying nutrients to the body by an intravenous route

NIPS

neonatal infant pain scale used for preterm and full term infants to determine pain. score 0-7 based on facial expression, cry, breathing, arms and legs

Factors Affecting Siblings Reactions to Child's Illness

• Being younger and experiencing many changes • Being cared for outside the home by care providers who are not relatives • Receiving little information about their ill brother or sister • Perceiving that their parents treat them differently compared with before their sibling's hospitalization

Two month milestones

•Begins to smile at people •Pays attention to faces and follows things with eyes. •Recognizes people from a distance •Begins to act bored (cries, fussy) if activity doesn't change •Coos and gurgles •Brings hands to mouth •Posterior fontanel closes *can hold head up, push up from prone

Erickson's stage of development

•Birth to one year-Trust vs Mistrust •Toddler (1to 3 years)-Autonomy vs Shame •Preschoolers (3 to 6 years)- Initiative vs Guilt •School age (6 to 12)- Industry vs Inferiority •Adolescents (12 to 19)-Identity vs. Role Confusion

Infant (birth to 1 year): normal growth

• Birth weight doubles by 6 months, triples by 12 months • Social smile occurs at 2 months • Plays "peek-a-boo" by 6 months • Sits upright without support by 8 months • Develops separation/stranger anxiety at 6 months • Crawls at 9 months • Fine pincer grasp by 10 to 12 months • Walking with support at 11-12 months

School age (6-12 years): normal growth

• Each year gains 4 to 6 lbs., grows 2 inches • Learns to tell time • Socialization with peers very important

Preschooler (3-5 year): normal growth

• Favorite word: Why? • Sentences of five to eight words

Otitis media

• Fever, pulling at ear, discharge • Administer antibiotics if prescribed • Position on the affected side • Reduce temperature to prevent seizures

Poisoning

• Frequent cause of childhood injury • Children < 6, with a peak at 2 yrs of age. • G.I. disturbance is common • Burns of the mouth and pharynx with caustic poisonings. • Identify agent immediately • Assess ABC's • Teach parent NOT to make child throw up (vomit) this could cause more damage • Call Poison Control Center or 911

Performing a physical exam

• Head to toe •Behavior observed •Neurological •Vision/Hearing •Respiratory •Cardiology •Musculoskeletal •Renal •GI

Bronchitis

• Inflammation of trachea and bronchi • Rhinitis and cough • Crackles and rhonchi • Symptomatic treatment

Respiratory syncytial virus bronchiolitis (RSV)

• Isolate the child (contact isolation) • Monitor respiratory status • Maintain patent airway • Antiviral agent (ribavirin aerosols) • RSV prophylaxis with monoclonal antibody palivizumab (Synagis) in high-risk children <2 years of age. (especially NICU babies)

Epiglottis

• Major cause of Hib • Fever, sore throat, muffled voice, drooling • IV antibiotics • Do Not examine the throat • Prepare for tracheostomy

Nasopharyngitis/tonsillitis

• May be viral or bacterial • Treatment important if related to streptococcal infection • Assess prothrombin time (PT) and partial thromboplastin time (PTT) before surgery • Monitor for bleeding • The highest risk for bleeding is during the first 24 hours and 5 to 10 days postoperative

Rheumatic fever

• Peaks in school age children • Most common cause of acquired heart disease • Affects connective tissue • S/S: • Sore throat that appears to be improving, then fever develops along with a rash, chorea, elevated erythrocyte sedimentation rate. *** Manifestations of rheumatic fever: Chorea, fever, history of recent strep throat, carditis, erythema marginatum, subcutaneous nodules, abdominal pain, polyarthritis.

Croup

• Primarily viral infection • Hoarseness, brassy or barky cough; respiratory distress; worse at night • Supportive measures • Cool mist humidity • Increased oral intake • Oral dexamethasone

Adolescence (12-19 years): normal growth

• Rapid growth, second only to the first year of life • Secondary sex characteristics develop • Development of identity

Cardinal signs of respiratory distress

• Restlessness • Increased respiratory rate • Increased pulse rate • Diaphoresis **** Remember respiratory failure usually occurs before cardiac failure.

Manifestations of CF

• Salty tears, saliva, sweat • Sinusitis, chronic cough, cyanosis, dyspnea, wheezing • Distended abdomen • Rectal prolapse • Meconium ileus (newborns) • Atrophy of thighs and buttocks • Clubbing of fingers and toes • Barrel-shaped chest • Obstructed pancreas • Deficiency of enzymes poor digestion • Abnormally thick mucous • Primarily lung and pancreatic involvement • + newborn screening test • First sign may be meconium ileus at birth • High sweat chloride concentration • Delayed growth, poor weight gain • Pancreatic enzymes with each meal and snacks, fat-soluble vitamins • Teach the family percussion and postural drainage techniques

Asthma

• The leading cause of chronic illness in children • Allergies influence persistence and severity of the illness • Complex disorder involving biochemical, immunologic, infections, endocrine, and psychological factors • S/S: tight cough, expiratory wheezing, decreased peak flow levels • Monitor for respiratory distress, need for O2 nebulizer therapy • Rescue vs. maintenance medication. • Evaluate the effects of β-adrenergic agonists, such as albuterol and levalbuterol, as well as corticosteroids.

Cystic fibrosis

• The most frequently occurring inherited disease of Caucasian children • Transmitted by an autosomal recessive gene • Chronic multisystem disorder

Toddler (1-3 years): normal growth

• Two to three-word sentences at 2 years • Toilet training starts around 2 years • Ritualistic • No concept of time • Frequent tantrums • Magical thinker

Concepts of bodily injury

•After 6 months cognitive development allows them to remember pain. •Fear of intrusive procedures •Fear of body mutilation •Fear of loss of control over their bodies •Concern concerning change in body image

Factors influencing pain

•Age and Gender •Cognitive Level •Temperament •Previous Pain Experience •Family and Culture •Situational Factors

Urine collection

•Application of urine collection bag. • A, On female infants, the adhesive portion is applied to the exposed and dried perineum first. •B, The bag adheres firmly around the perineal area to prevent urine leakage.

36 months (3 years) milestones

•Builds tower with more than 6 blocks •Turns book page one at a time •Copies a circle with pencil or crayon •Catches a ball against chest •Names actions in pictures (running, crying) •Answers "what" and "where" questions •Understands "in", "on", "under", "I", "me", and "we". •Carries a conversation using 2 or 3 sentences. •When looking at a book, can tell words from pictures •Starts to make friends •Learning to ride tricycle •Has all primary teeth •Three-to-four-word sentences •Can say first and last name •Can ride a tricycle

Factors affecting children's reaction to hospitalization

•Children may react to the stress of hospitalization before admission, during hospitalization and after discharge. •A recent qualitative study found that children 5 to 6 years of age were able to understand the association between stress and illness; this understanding is related to the child's developmental age and illness experience. • Nurses should avoid assuming the child has learned how to cope from prior medical experiences.

Cancer pain in children

•Children with cancer experience pain from different causes at different points throughout their cancer experience. •Pain may be a symptom of cancer and therefore children may be in pain when diagnosed with cancer (Table 5.2). •Survivors of childhood cancer may experience chronic pain from their cancer treatment, for example, from phantom limb pain, graft-versus-host disease, or postherpetic neuralgia. •Cancer treatment may also relieve cancer pain; however, treatment-related pain is also common.

18 month milestones

•Climbs onto and down from furniture assisted. •Points to pictures In a book with index finger •Stacks items such as blocks •Knows three parts of the body •Uses several words correctly "mine" •Plays with toys by their function (phone) •Tries to activate a toy (winding, switch) •Does things for attention and looks for reaction. •Anterior fontanel closed •Walks alone •May walk up steps or run •Pulls toys while walking •Helps to dress self •Drinks from a cup •Begins to use a spoon (mostly unsuccessful) •Throws a ball overhead

one year old cognitive (learning, thinking, problem solving)

•Explores things by shaking, banging, throwing •Finds hidden things easily •Looks at the right picture when subject of picture is named •Copies gestures •Starts to use things correctly, drinks from a cup, brushes hair •Bangs two things together •Puts things in a container, takes things out •Pokes with index finger •Follows simple directions, "pick up that toy"

Potential Long-Term consequences of untreated pain in premature neonates

•Higher somatic complaints of unknown origin •Greater physiologic and behavioral responses to pain •Increased prevalence of neurologic deficits •Psychosocial problems •Neurobehavioral disorders •Cognitive deficits •Learning disorders •Poor motor performance •Behavioral problems •Attention deficits

Developmental considerations

•Infants •Toddlers •Preschoolers •School Age Children •Adolescents •Common fallacies and myths about pain in children •Age-appropriate assessment of pain

2 year (24 months) milestones

•Kicks a ball and can walk on tip toes •Begins to run •Uses simple sentences •Follows simple directions •Sorts items by color, shape or size •Learning to share and take turns •Scribbles •Recites repeated phrases •Names items in a picture book •Repeats words heard in conversation •Independently feeds self with a spoon •Daytime toilet changing •Two-to-three-word sentences •mimics action and speech "thank you, chica)

Six to eight month milestones

•Knows familiar faces, begins to know stranger •Likes to play with people, parents •Responds to other's emotions •Responds to own name •Makes sounds to show joy, pleasure •Takes turns making sounds •Begins to say consonant sounds •Looks around for things •Shows curiosity •Passes things from one hand to the other •Begins to sit without support, rolls over both directions, supports weight on legs •Rocks back and forth •birth weight doubles •able to roll abdomen to back & back to abdomen

4 year old milestones

•Masters steering tricycle or pedal car around objects. •Colors within lines and can draw a face •Knows opposites (hot/cold, big/little) •Asks "when", "why", and "how" questions •Uses regular past tense ("ed") •Correctly counts out 10 items •Recognizes name in print •Pretends by role playing •Plays "mom", and "dad" •Sings a song from memory •Tells you what he thinks will happen next in a book •Hops and stands on one foot •Uses scissors •Tells stories

Nine to ten month milestones

•May be afraid of strangers •May be clingy to familiar adults •Has favorite toys •Understands "no" •Makes lots of sounds • "mamamama and bababa, dadads" •Copies sounds and gestures •Uses fingers to point to things •Watches the path of falling object Waves bye-bye" •looks for things he sees you hide •plays peek a boo •moves things from one hand to another •picks up things like cereal with thumb and finger •stands and holds on, pulls to stand •can get into sitting position •sits without support •crawls •walks with assistance

Children's reactions to hospitalization

•Non verbal communication •Communication with Children •Behavior Changes •Procedures •Separation anxiety

Age-appropriate pain scales

•PIPP •NIPS •CRIES •Wong Baker FACES Scale •Faces •Numeric Pain Scale

Acute consequences of untreated pain in premature neonates

•Periventricular-intraventricular hemorrhage •Increased chemical and hormone release •Breakdown of fat and carbohydrate stores •Prolonged hyperglycemia •Higher morbidity •Memory of painful events •Hypersensitivity to pain •Prolonged response to pain •Inappropriate response to nonnoxious stimuli •Lower pain threshold

Motor skills development

•Prehension Grasp •Reflex to voluntary (Pincher grasp) •Head control •Rolling over •Sitting •Locomotion •Balance

Nursing interventions

•Preventing or minimizing separation •Parental Absence During Infant Hospitalization •Minimizing Loss of Control •Promoting Freedom of Movement •Maintaining the Child's Routine •Encouraging Independence •Promoting Understanding •Preventing or Minimizing Fear of Bodily Injury •Providing Developmentally Appropriate Activities •Providing Opportunities for Play and Expressive Activities •Diversional Activities •Toys •Expressive Activities •Creative Expression •Dramatic Play •Providing Educational Opportunities •Providing Socialization

One month milestones

•Responds to sound •Lifts head when on tummy •Gurgles •Eyes track objects •Learns suck, swallow, breathe coordination •Smiles

Childhood illnesses

•Rubeola •Rubella •Mumps •Diphtheria •Pertussis •Chicken Pox •Scarlet Fever •Fifth Disease

Reaction to hospitalization: later childhood and adolescence

•School-age children may need and desire parental guidance or support from adults but may be unable or unwilling to ask for it • Cultural expectations to "act like a man" or to "be brave and strong" weigh heavily on these children, especially boys, who tend to react to stress with stoicism, withdrawal, or passive acceptance. Often the need to express hostile, angry, or other negative feelings finds outlets in alternate ways, such as irritability and aggression toward parents, withdrawal from hospital personnel, inability to relate to peers, rejection of siblings, or subsequent behavioral problems in school.

Reaction to hospitalization: early childhood

•Separation anxiety is the greatest stress imposed by hospitalization during early childhood. If separation is avoided, young children have a tremendous capacity to withstand any other stress. •Preschoolers may demonstrate separation anxiety by refusing to eat, experiencing difficulty in sleeping, crying quietly for their parents, continually asking when the parents will visit, or withdrawing from others. They may express anger indirectly by breaking their toys, hitting other children, or refusing to cooperate during usual self-care activities. Nurses need to be sensitive to these less obvious signs of separation anxiety in order to intervene appropriately.

one year milestones

•Shy around strangers •Cries when a parent leaves •Has favorite people and things •Shows fear •Hands you a book when he wants to hear a story •Repeats sounds and actions •Puts out an arm or leg when being dressed •Responds to request •Shakes head "no" •Make sounds that change tone •Says "mama" "dada" and exclaims "oh-oh" •Tries to say words parents say •birth weight triples •birth length increases by 50%

Four month milestones

•Smiles more spontaneously, especially at people •Likes playing with people, cries when playing stops •Copies movements and facial expressions •Begins to babble •Cries different for hunger, pain, sleepy •Responds to affection •Reaches for a toy with one hand, shakes it •Holds head steady, tummy to back •Follows moving things with her eyes •Moro reflex disappears (starts having muscle strength and growth/ doctors will make sure they have enough vitamin d and calcium [can develop rickets])

Newborn reflexes

•Sucking •Gag •Rooting •Grasp •Babinski •Moro •Startle •Tonic neck •Dance or Step (stand up on flat surface and take their legs like they are walking)

Nursing care of the family

•Support Family Members •Provide Information •Encourage Parent Participation •Preparing for Discharge and Home Care •Promote Schoolwork and Education During Hospitalization •Assess Needs of Family Members