Peds Exam 1 Study Guide

Physical Development in Infants

3rd month: Purposefully put hands into mouth. Able to swallow solid foods (extrusion reflex decreased). Colored mobiles provide visual stimulation. Coos and babbles. 4th month: Seize object put to mouth. Turns from back to side - prevent from rolling off. Introduce thumb apposition in grasp. Support weight with legs. Reaches out w/ hands, brings hand together. Holds head erect when in sitting position. Enjoys social interaction. Solitary play. 5th month: No head lag when in sitting position. Rolls from abdomen to back and rolls completely over. Trans toy from one hand to the other. Reaches for object with palmar grasp Reaches out to be held. Cries when toy is removed. Doubles birth weight. 6th month: Can sit alone briefly. Turns from back to abdomen. Lifts head in anticipation to sitting position. Holds bottle, now a good time to introduce cup. Drops toy to reach when another one is offered. Picks up dropped object. Imitates sounds. Plays peek-a-boo. Has stranger anxiety. Head control while prone. Infant lifts head, chest, and upper abdomen and can bear weight on hands. 7th month: Transfers obj from hand to hand. Bites aggressively. Resists unwanted objects Wary of strangers. Cries when mother leaves. 8th mo: Creeps, sits alone without support. Pincer grasp. Fears strangers, separation from mother. Responds to words - no, bye, bye. 9th mo: Pulls self to stand. Shows hand pref. Says mama, dada. Plays ball, pat-a-cake. 10th mo: Brings self down from standing to sitting position. Creeps & crawls. Walks holding 2 hands. Responds to name. Understand simple commands. Aware of approval/disapproval. 11th & 12th mo: Walks holding one hand. Soft, flexible shoes or bare ft best for walking. Stands, holds cup alone. Has 3 word vocabulary. Recognizes objects by name. Explores environment Has favorite toy/blanket. Scribbles w/ crayon.

Health promotion

A. Vision Screening: Binocularity test for strabismus, if not detected & corrected by 6yrs, amblyopia results Tests: corneal light reflex, cover test. Visual acuity tests: Snellen E (preschoolers/illiterate child), Snellen alphabet chart. Criteria: 3yrs - vision either eye - 20/50 or worse 4yrs - vision either eye - 20/40 or worse B. Hearing Test: Conduction tests: Rinne & Weber tests. Pure tone audiometry (audiogram) bone conduction hearing impairment

Accident Prevention

Accident Prevention: Emphasis on education. Accidents at home is leading cause of death during toddler period. Supervise closely. Motor vehicle accidents : street safety - teach to wait at curb, obey traffic rules; seat belts Drownings: teach to swim Burns: not to play w/ matches or lights, how to escape from burning home Strangers: not to talk to or take anything from strangers, basic sex education Immunizations: 2nd booster at 4-6 yrs. DTaP, IPV, HIB, HBV, MMR, TB dependent on exposure

Chicken Pox

An acute contagious disease caused by a herpes virus; characterized by a short or absent prodrome and a sequential rash consisting of papules, vesicles, pustules, and crusts Rash in 4 steps: Red spot then macules - Elevated then papules - w/in 24-48° for 1 cycle Fluid then vesicles then crusts w/ intense pruritus ("teardrop" appearance). Caused by: Herpes virus varicellae Prevalence: winter, early spring Epidemic: occur 3-4 yrs in highly populated areas. Spread: direct contact - droplet (nose & throat) Incidence: Incubation period: 10 and 21 days, commonly 14 -16 days Contagious 24-48 hours prior to outbreak of lesions → all lesions have crusted over (5-10 days), scabs not infectious Occur in children <10 years old Primary infection confers life-long immunity Virus resides in the dorsal root ganglia and reactivated at a later time as eruptions of "shingles" If children received only 1 dose of the 2 series vaccines, there can be a second episode of varicella Manifestations: 2-3 wks post exposure - low grade fever, some malaise, appearance of rash. Exanthem (skin rash) & constitutional symptom may occur spontaneously Lesions appear in crops w/ greatest concentration on the trunk (face & extremities < affected except in severe cases. Severe itching, high grade fever, marked lymphadenopathy Complication: Reye Syndrome. Prognosis excellent Rx: Symptomatic - control pruritus, antipyretics. Infected immunocompromised children should be hospitalized for IV antiviral therapy (acyclovir) VZV is a self-limited disease lasting 7 to 10 days Supportive treatment Control of pruritus with oatmeal baths, diphenhydramine (Benadryl), calamine lotion Acetaminophen for fever (avoid aspirin products due to risk of Reye syndrome) Oral acyclovir to decrease the duration of new lesion formation and to decrease the total number of lesions (20 mg/kg/dose, 4x/d; max 800 mg, 4x/d); started 24 hours of onset for max benefit Varicella-zoster immune globulin (VZIG) should be given to immune suppressed contacts for passive protection Oral acyclovir not recommended in healthy children with uncomplicated varicella Nursing Care: Control itching - calamine lotion, zinc oxide powder or antipruritus ung Antihistamines - Atarax, Benadryl & sedatives for severe itching Frequent starch bath w/ mild soap & water, dress in clean under clothings Fingernails clipped & hands kept clean Prevent accumulation of calamine (Caladryl) Gen kept at home until the last vesicle has dried Vaccine: Varicella vaccine available

Infectious Mono

An acute disease characterized by fever, exudative pharyngitis, lymphadenopathy, hepatosplenomegaly, atypical lymphocytosis, and presence of heterophil antibody (Kissing disease - Glandular disease) Affects most adolescents and adults Most commonly caused by Epstein-Barr virus (EBV), a gamma herpes virus of the lymphocryptovirus genus Contact with infected secretions or blood is required for transmission, virus is viable in saliva for several hours outside the body, fomite transmission is unknown Incubation period is 30 to 50 days No seasonal pattern Signs and Symptoms Fever (101-104°F), malaise, fatigue, headache, rhinitis, cough Abdominal pain, anorexia, nausea, vomiting Severe sore throat, difficulty swallowing, possibly to the point of dehydration Maculopapular rash induced by ampicillin derivatives -don't use ampicillin derivatives with IM Tender, enlarged lymph nodes, including posterior cervical chain Begins as URI s/s, with ↑ sore throat and enlarged tonsils and lymph nodes, along with increasing fatigue Physical Findings: Exudative tonsillitis with patchy white or gray exudates Inflamed pharynx; petechiae at junction of hard and soft palates Hepatosplenomegaly Tenderness anterior and posterior cervical nodes Jaundice Erythematous, macular, papular rash Periorbital edema Diagnostic Tests/Findings: Monospot (+) after 7-10 days, or (+) Epstein-Barr virus IgM titer with acute illness appears in the first 2 weeks of disease and may need 7 to 10 days to show a (+) test; children < 4 years of age are more often negative (+) IgG reveals post-acute or past infection Leukocytosis, 10,000-20,000 cells/mm3, with ≥ 60% lymphocytes and 20 to 40% atypical lymphocytes ↑ liver function tests with hepatomegaly and/or jaundice Rapid strep test and throat culture—would identify presence of hemolytic streptococcal infection Management/Treatment: Self-limiting, lasting 2-3 weeks Supportive treatment Bedrest and liquids during acute phase Antipyretics for fever and analgesics for pharyngitis and lymphadenitis Saline gargles for sore throat Isolation is unnecessary and may return to school or work Return activities until completely recovered and no longer with splenomegaly Avoid strenuous exercise and contact sports until fully recovered, and the spleen is no longer palpable Splenic ultrasound may be needed to show resolution prior to return to sports, particularly contact sports (3-4 weeks →2 mos from illness onset) AB Tx for pharyngitis—avoid ampicillin derivatives (amoxicillin and penicillins), → nonallergic morbilliform rash Short-course corticosteroids for pts with ↑ tonsillar hypertrophy and airway obstruction or dehydration, ↑ splenomegaly, myocarditis, or hemolytic anemia; oral prednisone prescribed at 1 mg/kg/d for 5-7 days with a taper Acyclovir or other antivirals are not needed for immunocompetent patients Complications: spleen rupture, chronic fatigue, hepatitis, Reye syndrome (with ASA Tx)

Scarlet Fever (Scarlatina)

An acute illness caused by group B-hemolytic Streptococcus Grp A that produce erythrogenic toxins through droplet infection Characterized by fever and a typical finely punctuate erythematous skin rash that blanches with pressure Rash appears initially on the trunk → generalized within a few hours to several days The face is flushed with circumoral pallor and ↑ erythema in skin folds (Pastia lines) Skin may feel rough ("sandpaper-like") Rash fades by one week → desquamation lasts for weeks Rare in infancy, common among 6-12 yrs old, ↑ during late winter & early spring Primary site of infection - pharynx Incubation period - 2-5 days Prodromal symptoms: starts w/ sore throat, vomiting, headache, malaise, and fever (101°F-105°F), chills WBC Elevated usually around 10-20,000; abdominal pain Tongue coated white (white strawberry tongue) → Red Strawberry tongue Pharynx beefy-red & swollen, tonsils ↑, rash appears w/in 12° p prodromal signs RF or acute glomerulonephritis may follow. Infection may be from other sites - impetigo, wound infections Dx: Clinical presentation, Streptococcus on throat or wound site culture, Dick test, ASO Tx: Same as that of streptococcal pharyngitis AB x 10 days even before results of culture Penicillin is drug of choice Management: Obtain Hx of the illness, C & S Bedrest during febrile phase Prognosis: Excellent if treated adequately Complications: Glomerulonephritis, rheumatic fever Liquid to soft diet depending on the amount of throat discomfort Regular diet when patient tolerated Increased fluid intake, antipyretics for fever -acetaminophen, Motrin Antipruritic lotion or cream Isolate one more day after start of AB therapy Observe for complications (suppurative - cellulitis, non-suppurative - glomerulonephritis, rheumatic fever) Return of child to school 5-7 days p start of therapy or when the strep throat has been eradicated.

Down Syndrome

Approximately 95% of all cases of Down syndrome are attributable to an extra chromosome 21 (group G), thus the name nonfamilial trisomy 21. Many of these children have congenital heart malformations, the most common being septal defects. Respiratory tract infections are prevalent and, when combined with cardiac anomalies, are the chief causes of death, particularly during the first year of life. Hypotonicity of chest and abdominal muscles and dysfunction of the immune system probably predispose the child to the development of respiratory tract infection. No cure but surgery to repair congenital defects. These children also benefit from evaluative echocardiography soon after birth and regular medical care. Evaluation of sight and hearing is essential, and treatment of otitis media is required to prevent auditory loss, which can influence cognitive function. Periodic testing of thyroid function is recommended, especially if growth is severely delayed. The constant stuffy nose forces the child to breathe by mouth, which dries the oropharyngeal membranes, increasing the susceptibility to upper respiratory tract infections. Measures to lessen these problems include clearing the nose with a bulbtype syringe, rinsing the mouth with water after feedings, increasing fluid intake, and using a cool-mist vaporizer to keep the mucous membranes moist and the secretions liquefied. When eating solids, the child may gag on the food because of mucus in the oropharynx. Decreased muscle tone affects gastric motility, predisposing the child to constipation. The skin gradually becomes rough and dry and is prone to cracking and infection. Skin care involves the use of minimum soap and application of lubricants.

Infant Feeding/Nutrition

Breastfeeding - Most desirable diet for 1st yr. Flouride supp regardless of H2O supply & Fe by 6 months. Vit D (400 U) if mother's diet inadequate or infant not exposed to sunlight to prevent rickets and vitamin D deficiency. Formula Fe-fortified for 1st half. Supplemental Fluoride (0.25mg) second 6 months of first year of life if fluoride in drinking H2O < 0.3 ppm. The addition of solid foods before 4 to 6 months of age is not recommended - Not compatible with the GI system, unable to break the food down. Feeding solids to young infants exposes them to food antigens that may produce food protein allergy. Physiologically and developmentally, infants 4 to 6 months of age are in a transition period. By this time, the gastrointestinal tract has matured sufficiently to handle more complex nutrients and is less sensitive to potentially allergenic foods. Tooth eruption is beginning and facilitates biting and chewing - extrusion reflex has disappeared and infants can swallow food more easily. Iron-fortified infant cereal is generally introduced first because of its high iron content 1st foods - strained, mashed. "Finger foods" teething crackers, raw fruits, veg. by 6-7 mos. Chopped table food or commercially prep Jr foods by 9-12 mos. Order of introduction variable, sequence is wkly. Begin w/ fruit, veg. then meat. Limit form to 900 ml (30 oz)/d. Cereal - Commercially prep Fe-fortified infant cereals given daily 18 mos. D/c Fe supp once cereal given. Fruits & Veg. Applesauce, bananas, pears are well tolerated. Avoid veg. & fruits in cans because of increased lead, sugar, sodium and preservatives. Offer fruit juice from a cup . Meat, Fish & Poultry: Avoid fatty meats. Bake, steam. Include liver. If soup is given, ingredients should be familiar to child's diet. Eggs & Cheese. Serve egg yolk hard boiled, soft cooked, poached. Intro Egg white in small quantity. Use cheese as meat & finger food. SOLIDS SHOULD NOT BE PERCIEVED AS A SUB FOR BREASTMILK UNTIL 12 MONTHS.

Nutrition

Caloric requirement: 80 kcal/kg come home very hungry from school. appetite ↑, breakfast important for school performance. influenced by mass media, > likely to eat junk food because of ↑ time away fr home. Nutrition Educ: food plate/pyramid, basic cooking skills, meal planning, nutritious snacks. Childhood obesity common - ↓ activity & ↑ food intake.

Sudden Infant Death Syndrome

Certain groups of infants are at increased risk for SIDS: -Maternal smoking, cosleeping, prone sleeping, use of blankets over face, soft beds, bean bags etc. • Low birth weight • Low Apgar scores • Recent viral illness • Siblings of two or more SIDS victims • Male sex • Infants of American Indian or African-American ethnicity Death of infant or child, unexpected, unexplained by hx, w/c an adequate cause can't be determined. #1 cause of death bet ages 1 wk and 1 yr. Incidence: 0.6:1000 live births, > 50% decrease over the preceding 10 years Peak age: 2-4 mos, 90% occur by 6 mos. Sex: > males affected. Time of death: always during sleep. Time of year: > during winter & early spring. Race: > non-whites. SEC: > in ↓ SEC. Feeding habits: ↓ with breast feeding Birth: > premies, multi birth, ↓ APGAR, w/ CNS disturbance Siblings: 5x > incidence Etiology: unclear - infants at risk may have abnormal arousal and hypoxic drive (apnea and chronic hypoxia), delayed C-P system maturation. Dx: + dx by autopsy: an apparent healthy, symptomless infant is put to bed and found lifeless sometime later. minor middle ear or resp tract inflam, petechiae over the pleura and pulmonary edema often hemorrhagic. most likely suffers progressive hypoxia and hypercapnea → respiratory cessation. Management: Crisis intervention explain to parents that they are not resp for infant's death (parents feel guilty). allow to say good-bye, to vent of feelings, supp parents cope w/ loss, grief & mourning. refer to SIDS organization/support groups: National SIDS Foundation. refer to community support such as church, community mental health centers. follow up care as indicated. Prevention - Put infants to sleep on their backs

Communicable Diseases

Communicable diseases - head lice, pinworms, tinea infections, chicken pox, measles, scarlet fever, 5th disease, infectious mono, impetigo

Sex Ed

Continue sex education, reinforce avoidance of friendly strangers Discuss normal anatomy & physiology, expected maturational Δs expected of this age. Provide reassurance that normal variations adaptive. Provide non-judgmental, accepting attitude, answer question matter-of-factly. Sexual abuse - school age are more able to express themselves, dolls still excellent medium for expressing painful exp.

Dental Health

Dentist visits, start by meeting dentist and seeing equipment Plaque removal via brushing, best if parents do it for starters. • Stand with the child's back toward the adult. (When done in front of a bathroom mirror, both the child and the adult can see what is being done in the mirror.) • Sit on a couch or bed with the child's head resting in the adult's lap. • Sit on the floor or a stool with the child's head resting between the adult's thighs. Use one hand to cup the chin and one to brush the teeth. Prevention involves eliminating the bedtime bottle completely, feeding the last bottle before bedtime, substituting a bottle of water for milk or juice, not using the bottle as a pacifier, and never coating pacifiers in sweet substances. Juice in bottles, especially commercially available ready-to-use bottles, is discouraged; these beverages are especially damaging because the sugar is more readily converted to acid. Juice should always be offered in a cup to avoid prolonging the bottle feeding habit. Toddlers should be encouraged to drink from a cup at the first birthday and weaned from a bottle by 14 months of age. Nurses are in an excellent position to counsel parents regarding the dangers of this habit and other aspects of dental care. Limit cavity forming foods such as sweets, gums, sugary drinks etc.

Health Promotion in the First Year

Disease prevention via immunization. Schedule of Visits: Well Baby Clinic every month for fist 6 months every 2 months for the 2nd 6 months every 3 months up to 24 months every 6 months up to 3 yrs every year thereafter

Enuresis

Enuresis (bedwetting), or nocturnal enuresis, is a common and troublesome disorder that is defined as intentional or involuntary passage of urine into bed (usually at night) in children who are beyond the age when voluntary bladder control should normally have been acquired - must occur atleast twice a week for at least 3 months. Types: Functional - has it only when tired. Organic - has organic problems Diurnal - daytime enuresis Nocturnal - nighttime enuresis Primary - bladder training not achieved, (smaller bladder capacity) Secondary - bladder training is achieved for at least 6 mos. Bladder awareness occurs at 2, not enuretic before 5th B-day, seek medical help p 5 years old More boys than girls, maybe familial Nursing Care: Bed-wetting - benign & self limiting, emphasize to parents Treatment minimal unless condition interferes w/ child's normal social activities or cognitive development Change bedding & clothing immediately, be non-punitive Encourage toileting before prolonged activity & bedtime Therapeutic techniques used to manage nocturnal enuresis include medications, complementary and alternative medicine techniques such as hypnotherapy, restriction or elimination of fluids after the evening meal, avoidance of caffeinated and sugar-containing beverages after 4 PM, purposeful interruption of sleep to void, motivational therapy, and various devices designed to establish a conditioned reflex response to waken the child at the initiation of voiding (alarms). Drug therapy is increasingly being prescribed to treat enuresis. Three types of drugs are used: tricyclic antidepressants (TCAs), antidiuretics, and antispasmodics. Parents need reassurance that bedwetting is not a manifestation of emotional disturbance and does not represent willful misbehavior. Encourage parents to be patient, to be understanding, and to communicate love and support to the child. Children should be encouraged to void before bedtime and diapering should be avoided.

Psychosocial Development

Erikson maintained that the chief psychosocial task of this period is acquiring a sense of initiative. Children are in a stage of energetic learning. They play, work, and live to the fullest and feel a real sense of accomplishment in their activities. Conflict arises when children overstep their abilities and feel a sense of guilt. As a sense of rivalry or competition develops between the child and samesex parent, the child may think of ways to get rid of the interfering parent. In most situations, this rivalry is resolved when the child strongly identifies with the same-sex parent and peers during the school years. Initiative vs Guilt (Central Process of Identification). Sense of Initiative - energetic & eager to learn. Char: by vigorous intrusive behavior & strong imagination. Period of discovery, curiosity, imaginative fantasies & imaginary fears. Explore physical world w/ all their powers. Learn to do things & derives satisfaction from activities, imitates role models. Sense of Guilt - when made to feel imaginings or are bad. Foster initiative: Allow to seek out & explore activities as well as initiate own play Punish only dangerous & socially unacceptable acts Psychosexual dev't - FREUD Phallic or genital phase - Oedipal & Electra Complex: Castration complex or penis envy, attachment to parent of opposite sex Resolution: ID w/ same sex parent or sex typing Outcome: Developmental task of initiative - Direction & Purpose

Strabismus

Eye deviates from point of fixation = strabismus. If constant → lazy eye → brain suppress image production by that eye - amblyopia (blindness) Malalignment of eyes - esotropia - inward deviation of eye. Exotropia - outward deviation. downward (hypotropia), or upward (hypertropia) Eyes cannot simultaneously view the same object → diplopia → response to diplopia is visual axis suppression (to eliminate diplopia) Screening - observe for conjugate movement of eyes and symmetric corneal light reflex (symmetric) Screening at 3-4 mos when infant can fixate and follow an object Children fixate one visual field w/ both eyes simultaneously at 3-4 mos. Supplement alternate cover/uncover test (older children) Can follow an object at midline by 2 mos, 180° by 4 mos Ask parents presence of crossed eyes or lazy eye Flat nasal bridge or epicanthal fold obscure medial sclera giving false impression of strabismus (pseudo strabismus) Pseudo strabismus—eyes appear to be crossed due to epicanthal folds on either side of bridge of nose; no ocular deviation Tx: depends on cause. Occlusion Tx (patch the good stronger unaffected eye) Surgery - repair weak muscles (myectomy or myotomy) Anticholinesterase to ↓ accommodation, eye glasses to correct refraction Orthoptic exercises improve muscle coordination-mild cases Early dx important prevention for vision loss (before 6 yrs old) discuss importance of eye patching Altered facial appearance Stress importance of wearing corrective lenses if prescribed Teach parents correct procedures for instilling anticholinesterase Nursing Care: Discuss importance of eye patching, allow verbalization of feelings re: altered facial appearance Stress importance of wearing corrective lenses if prescribed Teach parents correct procedures for instilling anticholinesterase.

Erythema Infectosum - 5th Disease

Fifth Dis - benign mildly contagious disease primarily of children. it was the fifth childhood exanthem described after measles, rubella, scarlet fever, and roseola Caused by: Human parvovirus B19 Char by: typical rash, early rosy to bright red "slapped cheek" appearance -> lacy, net like erythema that affects face arms & trunk. Children 5-14 years of age, during winter and spring months Etiology/Incidence Human parvovirus B19 Typically seen in 5- to 14-year-old children Outbreaks during late winter and spring months Incubation period between 4 and 14 days, 21 days Mode of transmission includes respiratory secretions and blood Most infectious prior to rash About 60% of adults are immune Diagnostic tests - Parvovirus B19 IgM antibody confirms current infection, or infection within past several mos Parvovirus B19 IgG antibody indicates previous infection and immunity Physical Findings: Early—bilateral erythema on cheeks ("slapped cheek" appearance) Late—erythematous, lacy-reticular rash appears as facial erythema begins to diminish and is seen on upper arms and legs, trunk, hands and feet; palms and soles are spared Signs and Symptoms: Prodromal symptoms: mild URI for 2-3 days, preceding the rash by 7-10 days; low-grade fever, headache, chills, malaise, myalgia, pharyngitis, conjunctivitis, arthralgias, arthritis (common in adolescents and adults) Rash - erythema on cheeks with circumoral pallor ("slapped cheek" appearance) →upper arms, legs, trunk, but- tocks, hands, and feet Rash lasts from 2 to 39 days, average 11 days Can cause aplastic crises in young children, patients with hemolytic diseases, or if immunocompromised Management: Symptomatic Benign and self-limiting Prevention of spread

Physical Development

Growth less dramatic, slow & regular. Motor skills & coordination > refined w/ practice. Participation in sports refine skills for boys & girls. 6 yrs - jumps, hops well, ties shoe laces, prints. 7 yrs - vision fully dev, read regular sized prints, ride bicycle, swim Transposes letters & numbers - normal. 8 yrs - writes than prints, more smoothness and speed. 9 yrs - fully dev eye-hand coordination, individual capabilities & talents emerge 10 yrs - more strength, stamina & coordination. 11 year olds - awkward, nervous energy (drumming fingers, etc). Wt gain: 3-6 lbs/yr Ht: 1-2 in/yr Aver wt: 6 yo - 48 lbs Aver ht: 6 yo - 46 in Aver wt: 12yo - 84 lbs Aver ht: 12 yo - 59 in. V/S: T: 37°C (98.6°F) PR: 90/min RR: 21-22 BP: 110/70 Dentition: Losses baby teeth. 6 yo: 1st perm teeth emphasize good dental 12 yo: 28 perm teeth hygiene & care

Immunization

Immunity: Inherited or acquired in w/c indiv. is resistant to occurrence on effects of a spec dis. Natural Immunity: innate immunity. Acquired Immunity: exposure to the invading agent, bacteria, virus or toxins. Active Immunity: Individual actively forms immune bodies against specific antigens, either naturally by having the dis. or artificially by the introduction of an antigen (vaccine). Passive Immunity: temp immunity by trans of plasma pro either artificially from another human or animal that has been actively immunity against an antigen SEE Recommended Immunization Schedule for Persons Aged 0 Through 6 Years.

Play in Toddlers

Increased locomotive skills make push-pull toys, straddle trucks or cycles, a small gym and slide, balls of various sizes, and riding toys appropriate for energetic toddlers. Finger paints; thick crayons; chalk; blackboard; paper; and puzzles with large, simple pieces use toddlers' developing fine motor skills. Interlocking blocks in various sizes and shapes provide hours of fun and, during later years, are useful objects for creative and imaginative play. The most educational toy is the one that fosters the interaction of an adult with a child in supportive, unconditional play. Interactive toys are most conducive to toddler development rather than mechanical toys that the child watches or video games which are more passive. Language development toys such as talking toys, age appropriate CDs Play - (Parallel) Purpose: transition from solitary to coop play. Types: imitative toys - dolls, dress-up toys, cars, trucks, push-pull toys, blocks ; building toys, telephone, balls, stuffed toys & dolls, large crayons, coloring books, clays, finger paints Games: likes to throw & retrieve objects. Know milestones - encourage & reward achieve & avoid unrealistic goals. Offer appropriate toys. Health Promotion: Schedule: 2 years q 3 mos; 3 years q 6 mos.

Socialization

Independent, selfish, impatient, aggressive physically & verbally. Capable of sharing, dresses self completely, boasts & tattles. Learns appropriate social manners, helps w/ chores. Needs exposure to variety of experiences & play materials. Consider nursery school - assess readiness. Ability to wait & take turns, to share. Imaginative - reality vs fantasy is blurred, has imaginary friend. Exaggerated fears: mutilation, castration, intrusive procedure.

Reaction to Stress and Hospitalization

Industry vs Inferiority School age secure in their dependence on parents. Separation - from family, friends, & peers, easier because of better time concept - do not protest, despair or detachment. loneliness, displaced anger, boredom aggressiveness, hostility, depression may indicate separation as well as fears. Separation resolved by key traditional objects & toys acting out. Fear of loss of control: thru enforced dependency, altered family roles, immobility, disability. Death as seen in children: fear of injury & death, death anxiety ↑- see it as the end. 5 yr old - see death as temporary 7 yr old - death in someone else - bogey man 9 yr old - seen as the end doesn't want others see loss control - crying fear of intrusive procedure of sexual in nature. Pain: uses passive coping strategies (lies rigidly still, shut eyes, clenches teeth) Coping Mechanisms: Seeks info, groans, whines, postpone events Tries to act brave, community about pain. Nursing Care Plan help child maintain degree of self control - give choices if there are any. provide child education - pictures, simple anatomic diagrams, dolls - teaching models, books. maintain education level during long term hospitalizations, need for accomplishment, homework, in-hospital teacher. hospital prep differ in younger child - picture books few days before hospital or procedure. allow to participate in care planning.

Failure to thrive

Infants who fail to gain wt w/ evidence of delayed development FTT may permanently inhibit cognitive development in children younger than 5 years of age Psychosocial FTT is more common in females Organic FTT: Physical cause: Malabsorption, neurological, metabolic, endocrine, enzymatic or genetic disease Inorganic FTT: Feeding problems, neglect, caregiver or patient depression. Has environmental or social cause and often w/ dysfunctional family The mother has specific characteristics. Unable to fulfill maternal role, unable to meet infant needs, stress, marital conflict, immature Lacks ability to develop a close relationship w/ infant, lacked early bonding w/ child Lacked nurturing as child, hx of FTT, isolated The Infant: Apathy, unable to sustain eye contact, no reaching, vocalizations, lacked interest Does not gain weight, < 5th percentile Dislike cuddling, lack of trust - has suspicious look Rejects food to gain attention. Has feeding problems Prolonged maternal deprivation - 6 mos -1 yr: Intellect and personality function irreversible, muscle atrophy. Comfort behavior: clinging to familiar object, rocking, head banging, fetal position. Indiscriminate trusting behaviors. FTT Evaluation: History Diet hx with focus on caloric intake, feeding Voiding and stooling patterns Mealtime behaviors and situations Perinatal problems (exposures, illnesses) Signs and symptoms (bowel habits, changes in skin or hair fevers, vomiting or reflux, developmental delay, acute illnesses, travel) Family situation/caregiver status Physical exam General appearance, VS, growth parameters Affect and interaction of the persons present Hair and skin changes, signs of chronic infection Signs of chronic infection Musculoskeletal/neurodevelopmental status Laboratory CBC (evidence of infection, inflammation, malignancy) ESR, C-Reactive protein (markers of inflammation) Electrolytes/BUN/Creatinine , urine pH (renal disease) Stool for O & P Stool fat (malabsorption) Thyroid studies, liver function tests (LFTs) sweat chloride, purified protein derivative (PPD), HIV antibody if there are known risk factors, regardless of symptoms Pre-albumin as a marker for nutrition status Evaluation of family interaction/home situation 85% of cases w/o identifiable organic cause - interactional problem Interdisciplinary approach with expertise in home health care, social work, nutrition, behavioral and developmental problems FTT Management and Care Tailored to identifiable cause Assess maternal/child, interactions between the two. Encourage mother to talk to child, repeating child's sounds, stroking, touching. If nurturing cannot be achieved at home Child Protective Services must be notified - placement to foster home. Encourage holding child, eye-to-eye contact, calm environment, no bottle propping. Consistent primary caregiver when necessary. Establish structured routine. Frequent measurements of child's growth parameters Evaluate effectiveness care by child's wt gain after admission.

Head Lice

Infestation of the body by pediculus humanus capitis (blood sucking org) Parasitic infestation of the: Head (capitis) - highly communicable create panic Body (corporis) - embarrassment in family Pubic area (phthirus pubis - crab lice) community Transmission: person-to-person on personal items, close contact. Not transmitted by household pets. Unable to survive away from host, totally dependent on host's blood, cannot fly or jump, crawl from host to host Incidence: No regard for SES, age, sex, infestation in overcrowded areas, more common in children than adults, head lice common in elementary school children, pubic lice in adolescents Treatment: Nix Creme Rinse (premethin 1%) - OTC Shampoo, leave for 10 min and rinse hair, towel dry, repeat in one week Lindane 1% (gamma hexachloride) Kwell, Kwellada - applied & repeated 7-10 days. Not effective against nits. Potentially toxic. 4 min applications, available in creams, lotions, shampoo. Good for scabies. Ovide, Prioderm 0.5% lotion (malathion lotion 0.5%) Use in children over 6 years. Kills 5 min w/ only 5% eggs hatching. Apply to hair, leave 8-12 hours then shampoo and fine tooth comb Rid A 200, Pyrinate, Nix, Tripple X (pyrethin w/ piperonyl butoxide) - applied to dry hair. Vinegar rinse - loosen the nits for easier removal. Management Educate on use of pediculocides Identification of presence of ova (nits) along hair shafts, pinpoint erythematous lesions, itching, excoriations, ↑ lymph nodes. Removal of nits & prevent spread - fine tooth comb discard contaminated brushes, combs. Pediculocide, teach parents danger of overuse, teach children not to exchange personal items.

Lead Poisoning

Ingestion of lead-based (heavy metal) material in child 18-30 mos of age - readily absorbed through the GI tract Assoc with pica, 50% have mothers with hx of pica Common in ↓ SEC Pattern of dependency, lacks stimulation, unable to discipline Daily ingest - 0.5mg (thumbnail = 100 - 200x safe daily ingestion) Children living in old flaky buildings Primary source of lead exposure in children - leaded paint and dust from deteriorated lead paint in houses built before 1978 Pathophysiology: -Poorly absorbed in tissues and slowly excreted in the kidneys, sweat glands, GI tract. -Retained lead deposits in bones, tissues, circulatory system, 90% attached to erythrocytes. -With chronic ingestion, ingestion exceeds excretion. -Even if ingestion stops, it takes 2x as long to excrete accumulated substances. Manifestations: GI: unexplained, repeated N&V, chronic abdominal pain. Renal: proteinuria, ketonuria → renal failure. Hemo: prevent synthesis of heme → pale, anemia Neuro: ↑ membrane perm → chronic encephalopathy → cerebral edema → ↑ ICP → tissue ischemia→ atrophy→ behavioral Δs → coma → death. CNS: irritability, drowsiness, ataxia, convulsion Children with low level lead poisoning have measurable and significant declines in intelligence Diagnosis: Screening at 1-2 years of age Blood lead level - 5 mcg/dL or higher = child may have unsafe blood lead levels → test periodically. Level > 40 mcg require Rx, may begin > 30 mcg Levels > 45 - oral chelation with 2,3-dimercaptosuccinic acid (Succimer), 60 mcg - chelation Tx Urine coproporphyrin, long bone X-ray, Hgb, Hct. Remove child from lead source, hospitalize. Cleansing enema if lead visible in X-ray. Treatment: Decontamination Removal of child from source of lead and abating source is the key intervention - whole bowel irrigation if lead is diffuse and located beyond stomach Endoscopy and removal if leaded foreign object in stomach Antidote BAL (British Anti Lewisite) Dimercaptrol-↑ removal of lead from brain and RBC. IM only q 4° x 5d (60 inj). Ca, phosphate, Vit D to ↑ excretion of lead from bones. Ca excreted with lead → hypocalcemia Penicillamine (Cuprimine, Depen)- 3-6 mos po with EDTA and BAL wkly. Succimer (Chemet) Management: Chelation Tx - prevent absorption and aid urinary excretion. Chelation is the term used for removing lead from circulating blood and, theoretically, some lead from organs and tissues. It is unclear whether chelation affects lead stores in bones Chelating Agents: 1) Ca Disodium edetate (CaNa2 EDTA) - increased lead excretion, IV (painful), watch for signs of hypocalcemia. 2) British antilewisite Monitor kidney function (EDTA toxic to kidney) increase fluid intake, increase dietary intake - SEs - anorexia For children who undergo chelation therapy, the nurse prepares them for the injections and makes all efforts to reduce injection pain - Chelating agents are injected deep into large muscles. Supportive and Nursing Care: Symptomatic treatment of seizure and anemia, prevent recurrence Prepare patient for Tx, painful inj. Educate, support, assist parents acquire needed services. Prevention: Wash hands and toys. To reduce hand-to-mouth transfer of contaminated dust or soil, wash children's hands after outdoor play, wash toys regularly. Clean dusty surfaces. Clean floors with wet mop. Wipe furniture, windowsills, dusty surfaces with a damp cloth. Run cold water. Older plumbing containing lead pipes or fittings, run cold water for a minute before using. Don't use hot tap water to make baby formula or for cooking. Prevent children from playing on soil. Provide them with a sandbox that's covered when not in use. Plant grass or cover bare soil with mulch. Eat a healthy diet. Regular meals and good nutrition may help lower lead absorption. Children especially need enough calcium and iron in their diets. Lead-based paint in an older home or lead contaminated bare soil in the yard are the major causes of lead poisoning in children. Lead can affect any part of the body including renal, hematological system however Of most concern for young children is the developing brain and nervous system, which are more vulnerable than those of older children and adults. even mild and moderate lead poisoning can cause a number of cognitive and behavioral problems in young children, including aggression, hyperactivity, impulsivity, delinquency, disinterest, and withdrawal

Methods of introducing food/ feeding problems

Introduce when hungry. Begin spoon feeding by pushing food back of tongue. Use small spoon with straight handle, begin with 1-2 tsp of food and gradually increase to 2 tbsp/fdg Introduce 1 food at a time, at intervals of 4-7 days, to allow for identification of allergies. As the amt of solids increases, decrease the amount of milk to < 1 L/d Do not intro foods by mixing w/ formula in the bottle. Weaning: Process of giving up 1 feeding for another No best time, introd a cup, spoon. Replace 1 bottle or breast feeding at a time. make night-time feeding last. If breast feeding is terminated before 5-6 months, wean to bottle; if later, wean directly to cup. Nutritional counseling: Prevent overfeeding. Nutritional allergies - occur at any age, p ingest of 1 or > of offenders (often outgrown). Prevention: Breastfdg x 3 mos. Avoid allergenic foods for child w/ strong hx. Avoid food for 6mos. ID food allergies - offer 1 food @ a time q 4-7 days. Feeding Problems: Regurgitation - return of undigested food from stomach, accompanied by burping. Persistent regurgitation requires med evaluation to rule out esophageal reflux. Spitting up - dribbling of unswallowed formula from infant's mouth immediately p fdg. Nursing Care Plan explain that these are insignificant. freq burping & min handling during & p fdgs. position on R side, head slightly ↑ p fdgs. use absorbent bib, irritation - apply thin film of petroleum jelly or A&D ointment. Rumination: Active voluntary return of swallowed foods in mouth. May lead to severe malnutrition. Purposeful, results from disturb in parent-child relationship. Nursing Care Plan: Goal - stop ruminating behavior & restore normal feeding behavior. Plan & Implementation: Assign the same nurse to feed child as often as possible continue (+) attention immediately post feeding, since ruminating infants often vomit after a feeding once left unattended.

Measles (Red Measles - Rubeola)

Known as hard, red, and 7-9 day measles. Highly contagious viral disease occurring in the winter or spring. Cases dropped in US since vaccine was licensed in 1963. Characterized by prodrome of upper respiratory manifestations followed by generalized maculopapular eruptions - 4th day theres a rash - ears, forehead, neck, trunk, lower extremity is red-brown. Affects 5-10 yr olds & college age. Transfer: Droplet. Incubation period - 8-12 days Period of communicability - 5th day of incubation to 1st day of rash. Etiology/Incidence Caused by an RNA virus, a morbillivirus, in Paramyxoviridae family Transmitted by direct contact with infected secretions or via airborne droplets through sneezing or coughing Incubation period is 8 to 12 days Infected individuals are contagious 3 to 5 days before appearance of rash, to 4 days after appearance of rash Increased incidence during late winter and spring Preventable by active immunization Signs and Symptoms: History of inadequate immunization Acute onset of fever (103°-105°F), coryza, cough, conjunctivitis, malaise, anorexia Confluent, erythematous, maculopapular rash 3 to 4 days after initial symptoms; progresses in caudal direction, beginning behind the ears and at the hairline Physical Findings: Confluent, erythematous maculopapular rash; after 3 to 4 days, rash → brownish appearance Profuse coryza Conjunctivitis, photophobia, periorbital edema in prodrome Pulmonary findings (crackles, rhonchi), a hacking, bark-like cough Koplik spots (red eruptions with white centers on buccal mucosa) prior to appearance of rash Generalized lymphadenopathy Management/Treatment: Medical referral necessary No specific antiviral therapy; WHO recommends vitamin A to child with vit A deficiency Supportive—bed rest, adequate hydration; acetaminophen or ibuprofen for fever; antitussive Rx dim lights, darken room (photosensitivity), cool mist for cough, encourage soft or bland foods & fluids keep skin clean, use tepid baths Most common complication is OM—treated with same antibiotics as in standard OM Educate re: complications: OM, diarrhea, encephalitis, croup, pneumonia

Vocalization/Play

Play takes on new dimensions that reflect a new stage of development in the school years. Play involves increased physical skill, intellectual ability, and fantasy. In addition, children develop a sense of belonging to a team or club by forming groups and cliques. A more complex form of play that evolves from the need for peer interaction is team games and sports. Team play can also contribute to children's social, intellectual, and skill growth Although play at this age is highly active, school age children also enjoy quiet and solitary activities. The middle years are the time for collections, which constitute another ritual. Curious about meaning of words, expan vocab. Likes name calling, word games (eg. rhymes), giggles & laughs a great deal, silly. Knows clock & calendar times. Play (Cooperative, Team) Purpose: learn to bargain, coop & compromise, dev logic reason ability, ↑ social skills, learn fairness & unfairness, practice, refine motor skills. Types: Toys/activities: play figures, trains, model kits, puzzles, magic tricks books, jokes & comic books, storybooks, adventures & mystery TV, video games, records, radios, riding bicycle.

Gross/Fine Motor Development

Locomotion is the major gross motor skill development in toddlerhood. 15 Months walks alone creeps upstairs throws objects to floor scribbles spontaneously builds tower of cubes pushes & pulls toys pulls shoes, socks off uses cup, climbs 18 Months runs & falls walks upstairs w/ 1 hand held creeps downstairs backwards sits on chair alone spoon feed self helps remove clothes turns back pages 22 Months runs w/ wide stance jumps in place w/ both ft throws ball overhand w/o falling builds 3-5 blocks imitates single drawn stroke turns pages of a book 2-3 pages @ a time 24 Months goes up and down stairs with both feet. runs well draws vertical/circular strokes turns doorknobs removes screw lids from jars holds glass in one hand puts on shoes, socks, pants 30 Months jumps holds crayons w/ fingers draws 2 vertical lines in the form of cross Fine motor development is demonstrated in increasingly skillful manual dexterity. For example, by age 12 months, toddlers are able to grasp a very small object but are unable to release it at will. At 15 months, they can drop a raisin into a narrow-necked bottle. Casting or throwing objects and retrieving them become almost obsessive activities at about 15 months. By 18 months of age, toddlers can throw a ball overhand without losing their balance. By 2 years of age, toddlers use their hands to build towers, and by 3 years of age, they draw circles on paper.

Dental Health

Loss of deciduous teeth: eruption of permanent ones including 1st & 2nd molars. Dental carries are a major health problem - caused by poor nutrition, increased intake of sweets, inadequate dental hygiene Prevention: good brushing & flossing techniques, regular dental check-ups, good nutrition, good dental hygiene. Sleep: 8 - 9.5 hrs of sleep. Quiet activity before sleep - helps child to relax.

Immunizations

MMR: 4-6yrs or 11 yr Hep B vaccine: 10-11 yrs Tdap: 11-14 yrs Chicken pox: 1-12 yrs - 1 shot (0.5mL sc) 13 yrs & up - 2 shots 4-8-week interval Make sure parents check complete immunization records of children. Best way to prevent communicable diseases is thru immunization. Handwashing in one way to prevent spread of diseases.

Accident Prevention

Major cause of death ages 1-12 yrs. Aspiration: remove object that can fit to mouth Suffocation: remove all plastic materials. Falls: elevate crib rails, barriers in stairs, restrain. Poisoning: lead free, have poison control number. Burns: check bath water temp, limit time in sun. Motor Vehicles: restrain, rear-facing car seat until age 2. Bodily Injury: remove sharp instruments away. NCP - teach parents accident prev. Discipline - allow to explore but maintain consist. limit setting

Cognitive Development in Infants

Major milestones: Separation, Object permanence, Symbols Seperation: infants learn to separate themselves from other objects in the environment. They realize that others besides themselves control the environment and that certain readjustments must take place for mutual satisfaction to occur. Object Permanence: The realization that objects that leave the visual field still exist. Symbols: The use of symbols allows infants to think of an object or situation without actually experiencing it. Beginning of the understanding of time and space. 3rd month: What does not see does not exist (out of sight - out of mind). Wait brief periods, no stranger anxiety unless caregiver skills differs from normal routine. 4th month: Vague idea that unseen objects exist. Follows objects 180 degrees. 4-8 months Secondary Circular Reactions: beginning object permanence. Realizes that parents are present even if not in visual fields. Displeasure when activity inhibited. Tolerates some frustration & delayed gratification. 9-12 months: Coordination of secondary Schemata & its Application to New Situations Completion of object permanence Begin intellectual reasoning. Ventures away from mom. Understands meaning of words, simple commands. In essence they learn through: Conditioning and/or reinforcement. Imitation, insight. Natural innate capacity. 4-8 mos (cont) Imitates sounds & simple gestures, Increased interest in mirror image

Toddlers

Most trying times for parents. Period of ritualism exploration, negativism. Terrible two's. Constant activity, no perception of danger, preoccupied w/ self assertion.

Contraindications to Immunization

The general contraindication for all immunizations is a severe febrile illness (not simply the common cold). This precaution avoids adding the risk of adverse side effects from the vaccine to an already ill child or mistakenly identifying a symptom of the disease as having been caused by the vaccine. Live virus immunizations such as varicella and and MMR should not be administered to immunocompromised children because the immunizations may cause an immunization related illness. Another contraindication to live virus vaccines (e.g., MMR and varicella) is the presence of recently acquired passive immunity through blood transfusions, immunoglobulin, or maternal antibodies. Administration of MMR and varicella should be postponed for a minimum of 3 months after passive immunization with immunoglobulins and blood transfusions A final contraindication is a known allergic response to a previously administered vaccine or a substance in the vaccine

Safety

Motor vehicle - pedestrian - most common cause of severe injury in school age. Bicycle - bicycle safety - wear helmets Skate-boarding, roller skates - wear helmets Skiing, snow boarding, swimming - must learn sports before doing. Participation in competitive sports - match child w/ activities appropriate w/ their abilities. Educate children re: dangers of experimentation: illegal drugs, cigarette smoking, alcohol. Most significant skill during this period is ability to read.

Child Safety

Nurses are responsible for educating parents regarding the importance of car restraints and their proper use. Five types of restraints are available: (1) infant-only devices, (2) convertible models for both infants and toddlers, (3) boosters, (4) safety belts, and (5) devices for children with disabilities All infants and children up to 2 years old should ride in rear facing car seats. Children ages 2 years and older (or those younger than 2 years) who have outgrown the rear-facing height or weight limit for their car safety seat should use a forward-facing car safety seat with a harness up to the maximum height or weight recommended by the manufacturer. Best way to prevent accidents is safe proofing & limit setting. Common Accidents: Motor vehicle - safety seats, supervise near cars Drowning - supervise closely when near source of H2O, fence around swimming pool Burns - cover electrical outlets, don't leave unattended in tubs, near hot stove Poisoning - poisons, object out of reach, lock-up. Falls - climb over side rails, Δ to regular bed, use safety gates. Aspiration - avoid large chunks of meat. Bodily damage - do not allow to run w/ pencils.

Toilet Training in Toddlers

Parents should begin the readiness phase of toilet training by teaching the child about how the body functions in relation to voiding and having a stool. Parents should talk about how adults and animals perform such functions on a routine basis. Another suggestion is to make toilet training as easy and simple as possible. 2-3 yrs: daytime; 3-4 yrs: nighttime bladder control major task of toddlerhood myelinization nerve tract: 15-18m = Physio ready uses toileting activities to control self & others. physiologic readiness required, must recognize urge, hold on & communicate sensation. positive reinforcement - use training pants & encourage imitation by watching. bowel control accomplished 1st , urinary control completed by age 4-5. independent toileting depends on: physio & psycho readiness Ability to communicate needs, ability to get to toilet & manage clothing. Readiness to toileting, does the child react with soiling?

Colic

Paroxysmal abdominal pain or cramping, loud crying, more common in young infants. Infant gains weight & thrive. Crying for >3 hours, 3 days a week, > 3 weeks. May improve by 3-4 months or 4-5 months. Causes: Too rapid feeding, overeating, swallowing too much air, improper feeding technique, emotional stress or tension bet parent & infant. Gen caused by more fermentation & gas production in intestines. May be a sign of cow's milk sensitivity, allergy. Vicious cycle, child picks up mother's anxiety & frustration on the non-stop cry.  Management and Nursing Care for Colic Rx: Investigate cause. Thorough hx of usual events of crying. Drugs: Anti-gas - Mylicon, Anticholinergic (Atropine) - relieve muscle rigidity, antispasmodic or anti-flatulence. Breast feeding mothers - milk free diet x 5d to decrease symptoms. Relieve cramping - prone over hot water bottle, heated towel or heating pad 1 or 2 oz of warm diluted tea. Glycerine suppository/warm enema of 1-2 oz of warm water. Position, burp frequent, provide small frequent feedings. Support parents - encourage mother/parents to talk about frustrations.

Negativism

Persistent "no" to all requests One method of dealing with the negativism is to reduce the opportunities for a "no" answer. Asking the child, "Do you want to go to sleep now?" is an example of a question that will almost certainly be answered with an emphatic "no." Instead, tell the child that it is time to go to sleep and proceed accordingly. Nurses can take vital signs for example rather than asking telling the child "I will take your vital signs now etc. this won't hurt etc. etc."

Child Abuse / Neglect

Physical or mental injury, sexual abuse, negligent treatment or maltreatment of a child younger than 18 yrs by a person responsible for the child's welfare under circumstances indicating that the child's health or welfare is harmed or threatened Munchausen Syndrome by Proxy (MBP) - a form of child abuse in which parent or caregiver creates the impression the child is ill by either giving false information or inflicting harm on child Shaken baby syndrome, in which a frustrated caregiver shakes a baby roughly to make the baby stop crying, causing brain damage that often leads to severe neurological problems and even death. Characteristics of the mistreating adult: Difficulty controlling anger, aggression, violence Often socially isolated, poor self esteem Few family supports, poor coping skills Dysfunctional parenting, abused as a child Failure of adult to attach emotionally to child Inadequate knowledge of realistic expectations of child's development Characteristics of child that unintentionally place child at risk: Physically, mentally disabled Unwanted child, hyperactive child Child's personality perceived as difficult by adult Environment Chronic stress, socioeconomic factors Social context that increases child's risk Stress which becomes chronic - divorce, separation, economic problems, inadequate housing, substance abuse/addiction Birth of additional child Working parents with multiple commitments, substitute caregivers may be the abusers Incidence ~ 10% of all children are assaulted yearly in the US ~ 5% of all deaths in children accounts for homicide ~ 33% of abused children are neglected History of child abuse. Patterns learned in childhood are often what they use as parents. Without treatment the cycle of child abuse often continues. Stress and lack of support. Parenting can be a very time intensive, difficult job. Parents caring for children without support from family, friends or the community can be under a lot of stress. Teen parents often struggle with the maturity and patience needed to be a parent. Caring for a child with a disability, special needs or difficult behaviors is also a challenge. Caregivers who are under financial or relationship stress are at risk as well. Alcohol or drug abuse. Alcohol & drug abuse → lapses in judgment. Can interfere with impulse control making emotional and physical abuse more likely. Due to impairment caused by being intoxicated, alcohol and drug abuse frequently → child neglect. Domestic violence. Witnessing domestic violence, chaos, & instability = emotional abuse to a child. Domestic violence → physical violence against the child as well. History and type of injuries do not match Conflicting stories of how injuries occurred Accident described and injury inconsistent with child's developmental ability Delay in seeking medical attention Clinical Findings: Pathognomonic physical signs: marks of objects can be seen on child's skin Presence of physical injuries in various stages of healing (multiple bruises and fractures) Undernutrition, poor hygiene Indications of untreated illness (unhealed old injuries, secondary infections) Developmental delays in children less than 5 years of age - result of neglect or abuse Emotional neglect and abuse Extremes of behavior Poor self-esteem Sexual abuse Bruising of the genitalia STD Sudden change in behavior, regressive behavior Munchausen syndrome Abusive parent has medical knowledge Illness only occurs in parent's presence Parent "enjoys" hospital environment Differential Diagnosis Accidents Organic failure to thrive (OFTT) Disease processes (hemophilia, osteogenesis imperfecta) Cultural practices (Asian practice of coining) Sudden Infant Death Syndrome Normal skin pigment variants (Mongolian spots) Diagnostic Tests/Findings Hx to determine onset, type of injury, neglect, documentation required X-rays, photographs for documentation Complete PE and neurological screening Observation of child's behavior (extremes of behavior) Goals Emergency mx - resuscitation or treat injuries Preserve evidence - keep clothes etc, document findings Report cases, protect child from abusive family Crisis intervention, refer to community resources - educational programs, counseling services Collaborate with the community Nursing diagnoses Injury related to intentional trauma Altered skin integrity, nutrition, growth and development Pain management, fear and anxiety, hopelessness, powerlessness Fear for self harm and suicide, altered protection Child Abuse Management/Treatment: Refer for hospitalization if necessary (severe life threatening injuries, dehydration Refer, report to Child Protective Services (moderate to severe injuries - child is further threatened) Describe all injuries, marks in detail and document precisely Utilize team approach - Nurses, physician, social service personnel, parent support groups Utilize prevention by identifying potentially abusive situations Provide emergency intervention Identify negative attitudes toward pregnancy/child Identify the vulnerable child Identify predisposing social, environmental factors Identify dysfunctional parenting Identify violent behavior, substance abuse Recognize knowledge deficits in nutrition, child behavior, development Educate parents - realistic expectations of child, teach parenting strategies, point out strengths of child Initiate intervention Appropriate referrals to child care services, programs Refer to Child Protective Agency in potentially explosive situations Refer to appropriate agency for evaluation of the home situation before, after child is born if abuse is suspected Discuss with school personnel, refer to counselor Refer parents to support groups, self-help groups Develop high level of awareness of the S/S of abuse and initiate follow-up

Cognitive Development

Piaget - Concrete Operations 7-11 yrs. concrete operations, when children are able to use thought processes to experience events and actions. Thinking remains concrete. Understand principles of conservation - conserve (mentally retain) physical properties of matter even when form changed, ex: two clay balls, one is flattened, child realizes its the same mass, two pencils aligned but later one is moved child realizes that one isn't larger. Concept of reversibility, able to imagine process in reverse. Decentering - consider > than one characteristics Able to classify objects & verbalize concepts Reasons logically, think thru situation & anticipate consequences, alter course of action. Hobbies, sports, crafts, arts & other interests supplement formal schooling in satisfying need for industry. Likes to collect things.

Pin Worms

Pinworm - enterobius vernicularis - Parasitic infestation of intestinal tract, common in the US Affect 20% of children Eggs ingested and inhaled, hatch in intestines, mature in 2-4 weeks then mate and migrate in the anus. Eggs float in air and can be swallowed Transmission: person-to-person, airborne, toilet seats Self reinfection- autoinoculation fingernails Dx: Cellophane tape wrap around tongue blade and place between buttocks in early AM before washing and drop in a container, stool for O & P, microscopic Adhesive cellophane tape "paddle" kit for parents' use Clinical manifestation Anal itch Appendicitis Secondary skin infect. Nocturnal anal itching Vaginal itching (pinworm crawls into vagina vaginitis) Insomnia (itching) Worm-like "threads"—seen in toilet or on underwear Differential Diagnosis Vulvovaginitis secondary to local irritation Poor hygiene Management/Treatment: Medication: Antihelmenthics (> 2 and non-pregnant) Pyrantel pamoate (Pin-X) 11 mg/kg x 1 dose (max dose 1 g); repeat in 2 weeks Mebendazole (Vermox) 100 mg one dose (same dose for all ages weights); repeat in 2 weeks Piperazine citrate (Antepar) SE transient abdominal pain, diarrhea in massive infection with expulsion of worms Eradication of pinworm infection requires at least 3 doses, separated by 3 weeks, reinfection likely Test family members and treat same time if infected Prevention Keep nails clean and short Bathing will remove eggs from skin and decrease pruritus Excellent hand washing, mitts to prevent scratching Antipruritus for intense itching Prevent infestation/reinfection - proper feces disposal Good handwashing & personal hygiene Tight fitting diapers & underwear Launder clothings and beddings daily, child sleeps Mitts or socks to prevent scratching

Preschool Children

Their control of bodily functions, experience of brief and prolonged periods of separation, ability to interact cooperatively with other children and adults, use of language for mental symbolization, and increased attention span and memory prepare them for the next major period: the school years. Biological development slows and is steady now rather than extreme spurts of growth. Thinner posture, more erect, more control over gross and fine motor skills. Walking, running, climbing, and jumping are well established by 36 months. Fine motor development is evident by preschool aged children ability to draw, etc. V/S: PR 100/min, T 37˚C (98.6˚F), RR 23-25/min, BP 100/60 mmHg

PLAY:

Proper stimulation through play is important. Play is the child's life. -Play must provide interpersonal contact and recreational and educational stimulation. Infants need to be played with, not merely allowed to play, it is not sufficient to place toys in a yard or a mobile in a crib. -Although the type of play infants engage in is called solitary, this is a figurative, not literal, term to denote one-sided play. The type of toys given to children is much less important than the quality of personal interaction that occurs. Narcissistic - plays w/ body. 0-3 months: Global, undifferentiated, plays w/ hands as if not part of body. @ 2 mos, looks at hands. Mobiles, brightly colored musical toys. 3-6 months: Rattles & objects, stuffed toys, plays w/ feet, fingers - sub for nipple, more interaction. 6-12 months: More sophisticated, plays peek-a-boo, pat-a-cake, verbal repetition. Nesting toys, brightly colored washable plastic toys. Language: 4 wks - small throaty sounds. 16 wks - coos & laughs. 40 wks - baba, dada, mama, no.

Psychosexual/Socialization

Psychosexual Development: Latency or the Quiescent years (Freud) Socialization: Prefers friends to family, life centered around school & friends. Learns appropriate masculine & feminine roles, curious about body functions. Develops conscience, morality & set of values needs. 8-9 year olds strong affiliations & loyal to group of same sex children, loyal to friends, learns to be independent. Likes to belong to clubs - cliques, clubs, sports groups very influential in socialization processes. Family remains primary agent of socialization but peer groups, relationships w/ adults other than parents increased importance Increased social sensitivity - learn to empathize & sympathize. More cooperative, improved manners. Char of clubs: use of code names, use secret password make own rules, exclude girls/boys same interests, initiation ceremonies parents not to intervene in children's rules. deal w/ issues matter-of-factly unless involves children's safety.

Preschoolers

Psychosocial Development: Industry vs Inferiority (Erikson) Develops sense of accomplishment academically, physically & socially. Learns value of doing things alongside others. Children need & want real achievement. Able to achieve sense of industry & accomplishment when rewarded for things accomplished. Gains competence in mastering new skills & tasks, assumes > responsibilities - Have inner directed quality (can take charge of pet care activities).

School Phobia

Result of increased competition, desire to succeed, fear of failure. Physical symptoms are prominent and may affect any part of the body; they include anorexia, nausea, vomiting, diarrhea, dizziness, headache, leg pains, and abdominal pains. Children may even develop a low-grade fever. A striking feature of school phobia is the prompt subsiding of symptoms when it is evident that the child can remain at home. When physical complaint disappear when allowed to stay home. Young school age like school. Desire for accomplishment so strong that young school age child creates rules of game to win, may cheat. Desire to get along socially, > responsive to peers. Need reassurance & support from family & trusted adult. Learn value of money. Encourage p school activities, stress (+s). Dev sense of inferiority when meets constant failure.

Regression

Reverting back to old behaviors and patterns of behavior in children. Regression is common in toddlers because almost any additional stress hinders their ability to master present developmental tasks. Any threat to their autonomy, such as illness, hospitalization, separation from a parent, disruption of established routines, or adjustment to a new sibling, represents a need to revert to earlier forms of behavior, such as increased dependency; refusal to use the potty chair; temper tantrums; demand for the bottle or pacifier; and loss of newly learned motor, language, social, and cognitive skills. The best approach to dealing with regression is ignoring it however praising acceptable patterns of behavior.

Acne in Adolescents

Sebaceous glands & sebum production increases which leads to acne. The apocrine gland starts to function which leads to malodor, use deodorants. Apocrine secretes thick sec + surface bacteria = odoriferous. Good health practices & frequent cleansing of skin w/ mild, nonabrasive soap help control acne. Improvement of the adolescent's overall health status is part of the general management. Adequate rest, moderate exercise, a well-balanced diet, reduction of emotional stress, and elimination of any foci of infection are all part of general health promotion. Gentle cleansing with a mild cleanser once or twice daily is usually sufficient. Antibacterial soaps are ineffective and may be too drying when used in combination with topical acne medications. Topical benzoyl peroxide is an antibacterial agent that inhibits the growth of P. acnes organisms - Physicians should check the willingness of the adolescent to participate in treatment. Because acne is so common and its appearance may seem so mild, the health care provider may underestimate the relative importance of the disease to the adolescent. The nurse can provide ongoing support for the adolescent when a treatment plan is initiated. The family is also encouraged to support the adolescent in his or her efforts.

Sibling Rivalry

Sibling Rivalry - Toddlers dislike changes. Crisis, most pronounced in first born. Most difficult in 2 yo child, 1-2 months is ample time to tell the child that a sibling is coming. 3-4 year olds are more secure in themselves. 5 year old may have difficulty again accepting new sibling Plan time to be w/ child, give attention.

1. Play in children, toys appropriate for age group

Solitary place of infancy progresses into parallel play in toddlerhood (playing alongside, not with other children) Selection of appropriate toys must involve safety factors, especially in relation to size and sturdiness. The oral activity of toddlers puts them at risk for aspirating small objects and ingesting toxic substances. Parents need to be especially vigilant of toys played with in other children's homes and toys of older siblings. Toys are a potential source of serious bodily damage to toddlers, who may have the physical strength to manipulate them but not the knowledge to appreciate their danger

Psychosocial Development

Some of the specific tasks to be dealt with include: • Differentiation of self from others, particularly the mother • Toleration of separation from parent • Ability to withstand delayed gratification • Control over bodily functions • Acquisition of socially acceptable behavior • Verbal means of communication • Ability to interact with others in a less egocentric manner ^ Some of these tasks are not completed fully however the foundations are being worked on. Negative feelings of doubt & shame when made to feel small & self-conscious, forced to be dependent. Erikson - Developmental stage of toddlerhood is acquiring a sense of autonomy while overcoming a sense of doubt and shame. Negativism - consistent negative response to requests. Many parents find the negativism exasperating and, instead of dealing constructively with it, give in to it, which further threatens children in their search for learning acceptable methods of interacting with others Ritualism - the need to maintain sameness & reliability in an environment. ego - common sense id - deal with id impulses superego - morals Favorable outcome: self control & will power. Freud: Anal - Urethral Stage Symbol by holding-on & letting-go Dev't centered around increased ability to control themselves & their environment Want to use newly acquired physical skills & coordination to do things for themselves. PIAGET: Continuation of Sensorimotor, start of Pre- operational Thought Sensorimotor: Tertiary Circular Reactions - 13 mos - 18 mos. Trial & error experimentation to understand object & events. Can carry out series of related, goal-directed activities. Open doors & closets. ID geometric shapes, put objects into holes. Most Advance Phase - 19 mos - 2 years. Transition to pre-operational thought - still cannot think Bound to concrete sensation & activity Cannot deal abstractly. Egocentric behav, thinking. Begin sense of time Pre-operational (2-7yrs) Pre-conceptual: 2-4 yrs. Intuitive Thought : 4-7 yrs Pre-conceptual: 2-3 Egocentrism - can't see other's point of view Concrete thinking = what they hear, see, or experience Animism - attributes lifelike char to inanimate obj. ↑ attention span

Impetigo Contagiosa

Superficial bacterial infection caused by streptococcus or staphylococcus bacteria that invade the epidermis after break in skin Reddish macule -> vesicular, ruptures easily -> superficial erosion. Very contagious Bullous impetigo most common in neonates and infants; non-bullous impetigo most common in 2-5 year olds Children < 6 years old have a higher incidence than adults Highly communicable with incubation period of 1 to 10 days, autoinoculable Prevent scratching by keeping nails clipped, using mitts, or elbow restraints prn → Heals w/o scarring Signs and Symptoms Itching and tenderness Areas of erythematous swollen skin, blisters, and/or moist, honey-colored crusts (yellow brown) sharp, marginated irregular outlines, pruritus, systemic effects minimal or asymptomatic Physical Findings Nonbullous—underlying erythema with vesicles that erupt, → honey/ serous colored crusts with erosion of epidermis Bullous—underlying erythema with pustules and vesicles that erupt, resulting in smooth shiny appearance Regional adenopathy with tenderness Diagnostic Tests Culture confirms dx Rx: Removal of crust w/ 1:20 Burrow's compresses. AB: Topical bacterial ung: mupirocin (Bactroban), Neosporin, Penicillin Oral according to specific bacterial cause For staphylococci—dicloxacillin For streptococci—penicillin or erythromycin For MRSA—bactrim or clindamycin Educate re: meds dosage, signs of irritation, sensitivity of condition, treatment regimen, prognosis, prevention Exclude from school and other public programs until Txd for 48 hours due to ↑ communicability Refer for dermatologist's evaluation if condition does not improve Promote healing and prevent spread by: teach child to use own towels, washcloth until lesions heal

Tinea Infections (Ring Worm)

Superficial infections by fungi (dermatophytes) that invade the skin, hair & nails. Types: Head (capitis) Body (corporis) Jock itch (cruris) Athletes foot (pedis) - caused by microsporum canis Transmission: person to another or animals to humans, other sources: seats w/ headrest. Dx: microscopic exam of scales - green, florescent concentric ring under Wood's light, culture if doubtful. Etiology/Incidence Primary source—Trichophyton rubrum, Trichophyton mentagrophytes, Microsporum canis, Epidermophyton floccosum Direct/indirect contact with persons, animals, shower stalls, benches, and articles Microsporum canis transmitted through infected dogs or cats Occurs > in hot humid climates Incubation period unknown, possibly 4 to 14 days Communicability occurs as long as lesions with dermatophytes are present Diagnostic Tests/Findings Wood's lamp will fluoresce the Microsporum canis KOH scraping of lesion border—confirms hyphae and spores Dermatophyte test medium (DTM)—confirm diagnosis Signs and Symptoms Itching is major symptom—may persist 5 to 7 days after exposure (pruritus of affected areas) Pain—variable, stinging pain Single or multiple pink/red raised lesions on legs, abdomen, and exposed areas of upper body Pruritus of affected areas Erythematous, scaly, blistered areas anywhere on foot; cracks and scaling between toes Treatment/Management: Treat with topical antifungal medications Clotrimazole, haloprogin, miconazole, terbinafine, tolnaftate, ciclopirox, econazole, ketoconazole, naftifine, oxiconazole, sulconazole Treatment > 4 to 6 weeks before resolution Oral antifungal meds for extensive, recurrent, and/or unresponsive conditions, e.g., griseofulvin Oral - Griseofulvin - 4-6wks, instruct GI SEs GI upset; HA; fatigue; insomnia; photosensitivity. Leukopenia - assess liver and renal function. Topical - antifungal: Mycelex, Lotrimin cream, Mycostatin, Tinactin Educate re: medication dosage, signs of irritation, sensitivity Educate re: communicability and prevention Avoid sharing personal items, launder after each use Maintain good personal hygiene, dry well after bathing, shampoo frequently, cut hair Wash hands before and after applying topical treatment Avoid touching or scratching affected areas Avoid or shower after using public pools Don't wear tight clothes next to affected area, use cotton undergarments and change daily Pedis - light, clean socks; well ventilated shoes; restrict bare feet in public places until infection clears. Refer to dermatologist if condition does not improve

Temper Tantrums

Tantrums are an indication of the child's inability to control emotions; toddlers are particularly prone to tantrums because their strong drive for mastery and autonomy is frustrated by adult figures or lack of motor and cognitive skills. Tantrums are nearly universal in toddlerhood as independence and more complex tasks overwhelm the child emotionally. The best approach toward tapering temper tantrums requires parental consistency and developmentally appropriate expectations and rewards. Ensuring consistency among all caregivers in expectations, prioritizing what rules are important, and developing consequences that are reasonable for the child's level of development help manage the behavior. Popular time for tantrums is bedtime because toddlers want to stay up, they have difficulty slowing down so its beneficial to remind them "after this story, it will be bed time" Starting at 18 months, time-outs work well for managing temper tantrums. During tantrums, parents should ignore the behavior, provided the behavior is not injurious to the child, such as violently banging the head on the floor. They should continue to be present to provide a feeling of control and security to the child when the tantrum has subsided. At this time, a toy or a favorite activity can be substituted for the request. Other suggestions for tantrum management: • Offering the child options instead of an "all or none" position • Picking one's battles carefully and ignoring small skirmishes over unimportant issues • Giving comfort when the child is able to control his or her emotions but not giving in to the original request • Praising the child for positive behavior when he or she is not having a tantrum Temper tantrums are normal in toddlerhood however, can be signs of serious problems and nurses should be aware of potential problems.

Acetaminophen Poisoning

Toxicity and pathophysiology Most common drug admin to children Toxicity may occur in an acute dose of 150 mg/kg (10x the therapeutic dose of 10-15 mg/kg) Can occur after repeated ingestions as little as 20-30 mg/kg/dose or a total of 160 mg/kg (approximately 2x the therapeutic dose Clinical Findings: Three stages of acetaminophen poisoning Stage I (½ - 24 hours post-ingestion): often asymptomatic, occasional N & V diaphoresis, pallor Stage II (24-48 hours post-ingestion): Nausea, vomiting, RUQ pain, ↑ aspartate aminotransferase (AST), alanine aminotransferase (ALT), bilirubin, and alkaline phosphatase Stage III (72-96 hours post-ingestion): Fulminant hepatic failure with thrombocytopenia, prolonged prothrombin time, and hepatic encephalopathy. Renal failure and cardiomyopathy. If pt survives, complete resolution of liver abnormalities occurs. Diagnostic studies Acetaminophen level 4 to 24 hr post-ingestion - can predict potential toxicity and determine the need for antidote admin plotted on the Rumack-Matthew nomogram for acetaminophen poisoning Management GI decontamination - Activated charcoal 1 hr of ingestion to prevent absorption Antidote - admin of N-acetyl cysteine 12 hrs post-ingestion to pts with potential toxicity Supportive care - repeated testing q 12-24 hrs for liver damage (liver, renal function, antidote admin)

Language/Vocalization

Understand more than can express Sentences ~ 3-4 words. Vocab 300-900 words Speech char by hesitancy, non-fluency, normal 3 year old: constantly asks how & why questions 4 year old: talks incessantly, ask many questions 5 year old: vocabulary 1200 words. Use all parts of speech defines words by describing names Responds correctly to at least 4 preposition, understands preposition Names 1 or > colors, understands analogies, repeats 4 digits. Knows simple songs & tell exaggerated tales.

Play in preschoolers

Various types of play are typical of this period, but preschoolers especially enjoy associative play—group play in similar or identical activities but without rigid organization or rules. Play should provide for physical, social, and mental development. Play activities for physical growth and refinement of motor skills include jumping, running, and climbing. Tricycles, wagons, gym and sports equipment, sandboxes, wading pools, and activities at water parks can help develop muscles and coordination. Manipulative, constructive, creative, and educational toys provide for quiet activities, fine motor development, and self-expression. Easy construction sets, large blocks of various sizes and shapes, a counting frame, alphabet or number flash cards, paints, crayons, simple carpentry tools, musical toys, illustrated books, simple sewing or handicraft sets, large puzzles, and clay are suitable toys. Probably the most characteristic and pervasive preschool activity is imitative, imaginative, and dramatic play. Dress-up clothes, dolls, housekeeping toys, dollhouses, play store toys, telephones, farm animals and equipment, village sets, trains, trucks, cars, planes, hand puppets, and medical kits provide hours of self-expression - preschoolers enjoy imitating adults and would rather not "make believe" Play: Cooperative ( Pre-Gang) Interacts for longer time in larger group. Identifies w/ a small group, follows rules Purposes: Develop muscle strength, balance & coordination. Work off ↑ physical energy Communication - learn cooperation & sharing Imitation & learn adult roles - build self esteem Work thru painful physical & emotional experience Copes w/ make-believe play. Char: Imitative, imaginative, dramatic, creative, constructive, manipulative, educational. Appropriate plays & activities to ↑ development: Physical - balls, shovels, pails, ladders, swings, sleds, wagons, tricycles. Creative - paper, crayons, finger or water paints, chalk, art supplies, old adult clothes Quiet - books, puzzles, records, reading. Play is much a part of child's life that reality & fantasy are blurred Imaginary playmates become friends in times of loneliness Accomplishes what the child is in the process of accomplishing Playmate experience what the child wants to forget or remember. Allows child to enjoy a make-believe world Most children give up these friends when group process becomes more important