Peds Exam 1 Study Guide
Snellen eye chart
One of several charts used in testing visual acuity; letters, numbers, or symbols are arranged on the chart in decreasing size from top to bottom
FLACC Scale
Pain assessment tool that includes the five categories of behavior: Facial expression, leg movement, activity, cry, and consolability
safety concerns for school age children
Sexual abuse Burns Broken bones Concussions Drowning Guns and weapons Use of Internet Sports injuries (cognitive rest) Abduction Bullying (cyberbullying) Child mistreatment (nurse obliged to report to DCF) **Back seat until age 13
Importance of Peer Relationships in School Age Children
-Helps child gain independence from parents. -helps children learn how to deal with dominance and hostility, how to relate to persons in positions of leadership and authority, and how to explore ideas and the physical environment. -learn to argue, persuade, bargain, cooperate, and compromise -learn to dress, talk, and behave in a manner acceptable to the group -a time when they make "best friends" -lack of group identity leads to bullying
EMLA
-Topical anesthetics such as eutectic mixture of local anesthetics (EMLA) and LMX4 creams are used as a local anesthetic before intrusive procedures, including venipunctures, implanted port access, LPs, and subcutaneous or intramuscular injections -• Eliminates or reduces pain from most procedures involving skin puncture -• Must be placed on intact skin over puncture site and covered by occlusive dressing or applied as anesthetic disc for 1 hour or more before procedure -Use with caution for young infants (<3 months old) because of possible methemoglobinemia related to metabolism of prilocaine -Not effective for heel lancing or finger sticks -Vasoconstriction decreases vein visibility -May be applied by parent
Feeding - birth to 12 months
-breastmilk/iron fortified formula until 1st birthday -may begin to add solids by 4-6 months; iron fortified cereal at 4 months; first foods are strained, pureed -finger goods by 6 to 7 months -meat at 8 to 10 months -chopped table food by 9 to 12 months -introduce vegetables first -introduce food one food at a time, usually at intervals 4 to 7 days -eggs and cheese at 12 months -whole milk at 12 months
Communicating with early childhood
-children younger than 5 are egocentric; they see things only in relation to themselves and from their point of view. Therefore, focus communication on them -do not use analogies with them, they interpret words literally (a little stick in the arm) -use simple direct language rather than phrases that might be misinterpreted
Non-pharmacological pain management for preschoolers and school age children
-distraction -relaxation -guided imagery -positive self talk -thought stopping: positive remarks about procedure -behavioral contracting: rewards, point system
Family Composition
-family structure -consists of individuals, each with a socially recognized status and position, who interact with one another on a regular, recurring basis in socially sanctioned ways
common health care beliefs for preschoolers/school age
-may view illness or injury as a punishment for a real or imagined misdeed; wrongdoing provokes feelings of guilt -preschoolers often misinterpret illness as a punishment for real or imagined transgressions
Importance of Peer Relationships in Adolescents
-pressure to belong to a group is intensified -a sense of belonging -a frame of reference for self-assertion and rejection of the identity of their parents' generation -peers serve as a strong support -gives them a feeling of strength and power -positive health promotion -forms the transitional world between dependence and autonomy
The nurse's responsibility when orienting a child and family to the hospital room
-prevent separation/separation anxiety in children younger than 5 -length of explanation/session should be tailored to the child's attention span -introduce primary nurse to child/family -emphasize positive areas of pediatric unit -explain call light, bed controls, television, bathroom, telephone -explain hospital regulations/schedules
Appropriate play for infants
-primarily narcissistic and revolves around their own bodies -during first year, play becomes more sophisticated and interdependent -quiet attitude 1 month -smile 2 months -squeal 3 months -from 3 to 6 months, begin to play alone with rattles or soft toys -4 months laugh aloud; show preference for certain toys; become excited when food or favorite object is brought to them; recognize images in a mirror -6 months to 1 year, play involves sensorimotor skills: peek a boo, pat a cake; verbal repetition and imitation; solitary play -at 6-8 months, usually refuse to play with strangers -at 6 months, extend arms to be picked up -at 7 months, they cough to make their presence known -at 10 months, they pull their parents' clothing -at 12 months, they call their parents' name
Communicating with Adolescents
-they fluctuate between child and adult thinking -build a foundation; tolerate differences -respect their privacy -give undivided attention -listen -be courteous, calm, honest, open minded -avoid judging/criticizing
Communicating with infants
-they respond to any firm, gentle handling and quiet, calm speech -loud, harsh sounds, and sudden movements are frightening
Communicating with school-age children
-they want explanations for everything but require no verification beyond that -they are interested in the functional aspect of all procedure; they need to know what is going to take place and why it is being done -let them operate the equipment -they have heightened concern about body integrity -encourage them express their needs and voice their concerns
Sex Education: School Age
-two rules: find out what children know and think; be honest -Sex play as part of normal curiosity during preadolescence -Middle childhood is ideal time for formal sex education: -Life span approach -differentiate sex and sexuality -Information on sexual maturity and process of reproduction -Effective communication with parents
Adolescent Assessment
1. Same as for school-age child 2. Offer option of parent's presence 3. Same as older school-age child; May examine genitalia last. 4. Allow to undress in private; Give gown; Expose only area to be examined. 5. Respect need for privacy. 6. Explain findings during examination (e.g., "Your muscles are firm and strong"). 7. Matter-of-factly comment about sexual development (e.g., "Your breasts are developing as they should be"). 8. Emphasize normalcy of development. 9. Examine genitalia as any other body part; may leave to end.
Toddler Assessment
1. Sitting or standing on or by parent 2. Prone or supine in parent's lap 3. Inspect body area through play: "Count fingers," "tickle toes." 4. Use minimum physical contact initially. 5. Introduce equipment slowly. Auscultate, percuss, palpate whenever quiet. 6. Perform traumatic procedures last (same as for infant). 7. Have parent remove outer clothing.Remove underwear as body part is examined. 8. Allow toddler to inspect equipment; demonstrating use of equipment is usually ineffective. 9. If uncooperative, perform procedures quickly. 10. Use restraint when appropriate; request parent's assistance. 11. Talk about examination if cooperative; use short phrases. 12. Praise for cooperative behavior.
How do you test a school-age child's vision?
Snellen letter chart
Infant Assessment
1. Before able to sit alone—supine or prone, preferably in parent's lap; before 4 to 6 months, can place on examining table 2. After able to sit alone—sitting in parent's lap whenever possible; if on table, place with parent in full view 3. If quiet, auscultate heart, lungs, and abdomen. 4. Record heart and respiratory rates. 5. Palpate and percuss same areas. 6. Proceed in usual head-to-toe direction. 7. Perform traumatic procedures last (eyes, ears, mouth [while crying]). 8. Elicit reflexes as body part is examined. Elicit Moro reflex last. 9. Completely undress if room temperature permits. 10. Leave diaper on male infant. 11. Gain cooperation with distraction, bright objects, rattles, talking. 12. Smile at infant; use soft, gentle voice. 12. Pacify with bottle of sugar water or feeding. 13. Enlist parent's aid for restraining to examine ears, mouth. 14. Avoid abrupt, jerky movements.
Atraumatic Care for encouraging a child's acceptance of oral medication:
1. Give the child a flavored ice pop or small ice cube to suck to numb the tongue before giving the drug. 2. Mix the drug with a small amount (≈1 tsp) of sweet-tasting substance, such as honey (except in infants because of the risk of botulism), flavored syrups, jam, fruit purees, sherbet, or ice cream; avoid essential food items because the child may later refuse to eat them. 3. Give a "chaser" of water, juice, soft drink, or ice pop or frozen juice bar after the drug. 4. If nausea is a problem, give a carbonated beverage poured over finely crushed ice before or immediately after the medication. 5. When medication has an unpleasant taste, have the child pinch the nose and drink the medicine through a straw. Much of what we taste is associated with smell. 6. Flavorings, such as apple, banana, and bubble gum (e.g., FLAVORx), can be added at many pharmacies at nominal additional cost. An alternative is to have the pharmacist prepare the drug in a flavored, chewable troche or lozenge.*
School Age Child Assessment
1. Prefer sitting 2. Cooperative in most positions 3. Younger child prefers parent's presence; Older child may prefer privacy 4. Proceed in head-to-toe direction; May examine genitalia last in older child. 5. Respect need for privacy; Request self-undressing. Allow to wear underpants. Give gown to wear. 6. Explain purpose of equipment and significance of procedure, such as otoscope to see eardrum, which is necessary for hearing. 7. Teach about body function and care.
Preschool Child Assessment
1. Prefer standing or sitting; Usually cooperative prone or supine; Prefer parent's closeness 2. If cooperative, proceed in head-to-toe direction. If uncooperative, proceed as with toddler. 3. Request self-undressing.Allow to wear underpants if shy. 4. Offer equipment for inspection; briefly demonstrate use. 5. Make up story about procedure (e.g., "I'm seeing how strong your muscles are" [blood pressure]).Use paper-doll technique. 6. Give choices when possible. 7. Expect cooperation; use positive statements (e.g., "Open your mouth").
Blended Family
a married couple and their children from previous marriages
Three principles provide the framework of achieving goal of atraumatic care:
1. prevent or minimize the child's separation from the family 2. promote a sense of control 3. prevent or minimize bodily injury and pain
When does an infant develop object permanence?
10 months; when an infant realizes that items that leave the visual field still exist; searching for an object out of view
best practice to promote sleep/bedtime
An appropriate and consistent bedtime, nap schedule (as needed), and bedtime routine can help prevent and treat common sleep problems and night wakings experienced by young children
typical thinking of adolescents
Cognitive thinking culminates with the capacity for abstract thinking. This stage, the period of formal operations, is Piaget's fourth and last stage. Adolescents are no longer restricted to the real and actual, which was typical of the period of concrete thought; now they are also concerned with the possible. They think beyond the present. Without having to center attention on the immediate situation, they can imagine a sequence of future events that might occur, including college and occupational possibilities; how things might change in the future, such as relationships with parents; and the consequences of their actions, such as dropping out of school. At this time, their thoughts can be influenced by logical principles rather than just their own perceptions and experiences. They become increasingly capable of scientific reasoning and formal logic
Safety concerns for infants
Falls, suffocation, motor vehicle accidents, burns, aspiration, poisonings
6 month old milestones
Growth rate may begin to decline; Teething may begin with eruption of two lower central incisors; Chewing and biting occur; When prone, can lift chest and upper abdomen off surface, bearing weight on hands; When about to be pulled to a sitting position, lifts head; Sits in high chair with back straight; Rolls from back to abdomen; When held in standing position, bears almost all of weight; Hand regard absent; Re-secures a dropped object; Drops one cube when another is given; Grasps and manipulates small objects; Holds bottle; Grasps feet and pulls to mouth; Adjusts posture to see an object; Prefers more complex visual stimuli; Can localize sounds made above ear; Will turn head to the side and then look up or down; Begins to imitate sounds; Babbling resembles one-syllable utterances—ma, mu, da, di, hi; Vocalizes to toys, mirror image; Takes pleasure in hearing own sounds (self-reinforcement); Recognizes parents; begins to fear strangers; Holds arms out to be picked up; Has definite likes and dislikes; Begins to imitate (cough, protrusion of tongue); Excites on hearing footsteps; Briefly searches for a dropped object (object permanence beginning); Frequent mood swings, from crying to laughing, with little or no provocation
how do you develop rapport/trust with infant, toddler, preschooler, school age child?
The nurse who has spent time with and established a positive relationship with a child usually finds it easier to gain cooperation. If the relationship is based on trust, the child will associate the nurse with caregiving activities that give comfort and pleasure most of the time rather than discomfort and stress. If the nurse does not know the child, it is best for the nurse to be introduced by another staff person whom the child trusts. The first visit with the child should not include any painful procedure and ideally should focus on the child first and then on an explanation of the procedure.
safety concerns for adolescents
Unintentional injuries Motor vehicle safety Firearm safety Water safety
Appropriate play for preschoolers
associative play/group play -jumping, running, climbing -tricycles, wagons, gym/sports equipment, sandboxes, wading pools, swimming -imaginative play, imitative play, dramatic play -dress up clothes, housekeeping toys, dollhouses, medical kits -easy construction sets, blocks, counting fame, alphabet/number flash cards, large puzzles, clay
5 month old milestones
beginning signs of tooth eruption; birth weight doubles; no head lag; when sitting, able to hold head erect and steady; able to sit for longer periods; back straight; can turn over from abdomen to back; when supine, puts feet to mouth; able to grasp objects voluntarily; uses palmar grasp; plays with toes; takes objects directly to mouth; holds one cube while regarding a second one; visually pursues a dropped object; is able to sustain visual inspection of an object; can localize sounds made below ear; squeals; makes cooing vowel sounds; smiles at mirror image; pats bottle or breast with both hands; may have rapid mood swings; is able to discriminate strangers from family; vocalizes displeasure when object is taken away; discovers body part
8 month old milestones
begins to show regular patterns in bladder and bowel elimination; parachute reflex appears; sits steadily unsupported; readily bears weight on legs when supported; may stand holding onto furniture; adjusts posture to reach an object; has beginning pincer grasp reflex; releases objects at will; rings bell; retains two cubes while regarding a third; secures an object by pulling on a string; reaches persistently for toys out of reach; makes consonant sounds; listens selectively to familiar words; combines syllables; increasing anxiety over loss of parent; fear of strangers; responds to word "no"; dislikes dressing, diaper changes
12 month old milestones
birth weight tripled; birth length increased by 50%; has 6-8 teeth; walks with one hand held; cruises well; may attempt to stand alone; may attempt first step alone; can sit down from standing position without help; releases cube in cup; attempts to build two block tower, but fails; tries to insert a pellet into a narrow necked bottle but fails; can turn pages in a book; discriminates simple geometric shapes (circle); amblyopia may develop; can follow rapidly moving object; controls and adjusts response to sound; says three to five words besides dada/mama; comprehends meaning of several words; recognizes objects by name; imitates animal sounds; understands verbal commands; shows emotions; is fearful in strange situation; may develop habit of security blanket or favorite toy; has increasing determination to practice locomotor skills; searches for an object even if it has not been hidden but searches only where object was last seen.
9 month old milestones
eruption of upper lateral incisor may being; creeps on hands and knees; sits steadily on floor for prolonged time; recovers balance when leaning forward but cannot do so when leaning sideways; pulls self to standing position and stands holding onto furniture; uses thumb and index finger in crude pincer grasp; preference for use of dominant hand now evident; grasps third cube; localizes sounds by turning head diagonally and directly toward sound; depth perception increasing; responds to simple verbal commands; comprehends "no"; parent is increasingly important for own sake; shows increasing interest in pleasing parent; begins to show fears of going to bed and left alone; puts arms in front of face to avoid having it washed
typical thinking of school age children
children develop an understanding of relationships between things and ideas. They progress from making judgments based on what they see (perceptual thinking) to making judgments based on what they reason (conceptual thinking). They are increasingly able to master symbols and to use their memories of past experiences to evaluate and interpret the present. Although children 6 or 7 years old know the rules and behaviors expected of them, they do not understand the reasons behind them. Rewards and punishments guide their judgment; a "bad act" is one that breaks a rule or causes harm. Young children believe that what other people tell them to do is right and that what they themselves think is wrong. Consequently, children 6 or 7 years old may interpret accidents or misfortunes as punishment for "bad" acts. Older school-age children are able to judge an act by the intentions that prompted it rather than just its consequences. Rules and judgments become less absolute and authoritarian and begin to be founded on the needs and desires of others. For older children, a rule violation is likely to be viewed in relation to the total context in which it appears.
typical thinking for preschoolers
children perceive rules as definite and require no reason or explanation. They learn standards for acceptable behavior, act according to these standards, and feel guilty when they violate them. Preschoolers' thinking is often described as magical thinking. Because of their egocentrism and transductive reasoning, they believe that thoughts are all-powerful
Appropriate play for school aged children?
competitive and cooperative play. Peers of same gender.
Nuclear Family
composed of two parents and their children. The parent-child relationship may be biologic, step, adoptive, or foster. Sibling ties may be biologic, step, half, or adoptive. The parents are not necessarily married. No other relatives or nonrelatives are present in the household
Best practices for discipline for toddlers/preschoolers:
consistency; time out; during temper tantrums, stay calm and ignore the behavior; during periods of no tantrums, practice positive reinforcement; offer the child options; set clear boundaries and expectations; praise the child for positive behavior; reward system
Traditional Nuclear Family
consists of a married couple and their biologic children
Overriding Goal of Atraumatic Care
do no harm
4 month old milestones
drooling begins; has almost no head lag; balances head well in sitting position; able to sit erect if propped up; rolls from back to side; inspects and plays with hands; tries to reach for objects with hand but overshoots; grasps object with both hands; plays with rattle placed in hand; cannot pick up rattle if dropped; can carry objects to mouth; able to accommodate to near objects; beginning eye-hand coordination; makes consonant sounds; laughs aloud; demands attention by fussing; becomes bored if left alone; enjoys social interaction with people; anticipates feeding when sees bottle; shows excited with whole body; begins to show memory
Contemporary Single-Parent Family
emerged partially as a consequence of the women's rights movement and also as a result of more women (and men) establishing separate households because of divorce, death, desertion, or single parenthood. In addition, a more liberal attitude in the courts has made it possible for single people, both male and female, to adopt children.
11 month old milestones
eruption of lower lateral incisor may begin; when sitting, pivots to reach toward back to pick up an object; cruises or walks holding onto furniture or with both hands held; explores objects more thoroughly; has neat pincer grasp; drops object deliberately; puts one object after another into a container; able to manipulate an object to remove it from tight-fitting enclosure; imitates definite speech sounds; experiences joy and satisfaction when a task is mastered; reacts to restrictions with frustration; rolls ball to another on request; anticipates boy gestures when a familiar nursery rhyme or story is being told; plays games up-down, so big, or peek a boo; shakes head no
7 month old milestones
eruption of upper central incisors; when supine, spontaneously lifts head off surface; sits, leaning forward on both hands; when prone, bears weight on one hand; sits erect momentarily; bears full weight on feet; when held in standing position; bounces actively; transfers objects from one hand to the other; has uni-dextrous approach and grasp; holds two cubes more than momentarily; bangs cubes on table; rakes at a small object; can fixate on very small objects; respond to own name; localizes sound by turning head in a curving arch; beginning awareness of depth and space; has taste preferences; produces vowel sounds and syllables; vocalizes four distinct vowel sounds; talks when others are talking; increasing fear of strangers; shows signs of fretfulness when parent disappears; imitates simple acts and noises; tries to attract attention by coughing or snorting; plays peek a boo; demonstrates dislikes of food by keeping lips closed; exhibits oral aggressiveness in biting and mouthing; demonstrates expectation in response to repetition of stimuli
safety concerns for toddlers
falls, suffocation, motor vehicle accidents, burns, aspiration, poisoning
Extended family
household made up of several generations of family members
Communal Family
individuals who share common ownership of property and goods and exchange services without monetary consideration
10 month old milestones
labyrinth-righting reflex is strongest when infant is prone or supine; able to raise head; can change from prone position to sitting position; stands while holding onto furniture; sits by falling down; recovers balance easily while sitting; while standing, lifts one foot to take a step; says "dada, mama"; comprehends bye bye; may say one word; inhibits behavior to verbal command of no no or own name; imitates facial expressions; waves bye bye; extends toys to another person but will not release it; develops object permanence; repeats actions that attract attention and cause laughter; plays interactive games, such as pat a cake; reacts to adult anger; cries when scolded; demonstrates independence in dressing, feeding, locomotive skills, and testing of parents; looks at and follows picture in book
Appropriate play for Toddlers
parellel play -dolls, carriages, dollhouses, dishes, cooking utensils, furniture, trucks, dress up. small gym, slide; balls of various sizes, riding toys -finger pains, thick crayons, chalk, puzzles with large pieces. talking, toy telephones -tactile play: water toys, sandbox, finger paints, bubbles
Binuclear Family
parents continuing the parenting role while terminating the spousal unit
safety concerns for preschoolers
pedestrian motor vehicle accidents, falls, head trauma, MVAs, drownings, bodily damage
2 month old milestones
posterior fontanel closed; crawling reflex disappears; assumes less flexed position when prone; less had lag when pulled to sitting position; can maintain head in same plane as rest of body when held; when prone, can lift head almost 45 degrees off table; hands often open; grasp reflex fading; binocular fixation and convergence to near objects beginning; when supine, follows dangling toy from side to point beyond midline; visually searches to locate sounds; turns head to side when sound is made at level of ear; vocalizes, distinct from crying; crying becomes differentiated; coos; vocalizes to more familiar voice; demonstrates social smile in response to various stimuli
3 month old milestones
primitive reflexes fading; able to hold head more erect when sitting; slight head lag; able to raise head and shoulders from prone position; bears weight on forearms; able to bear slight fraction of weight on legs when held in standing position; regards own hand; actively holds rattle, but will not reach for it; grasp reflex absent; hands kept loosely open; clutches own hand; follows objects to periphery; locates sound by turning head to side and looking in same direction; begins to have ability to coordinate stimuli; squeals aloud to show pleasure; coos, babbles, chuckles; vocalizes when smiling; talks a great deal when spoken to; less crying during periods of wakefulness; displays considerable interest in surroundings; ceases crying when parent enters room; can recognize familiar faces and objects; shows awareness of strange situations
Philosophy of family centered care
recognizes the family as the constant in a child's life
anticipatory guidance
the ideal way to handle a situation before it becomes a problem; focuses on providing families information on normal growth and development and nurturing childrearing practices. -home safety -injury prevention
Atraumatic Care
the provision of therapeutic care in settings, by personnel, and through the use of interventions that eliminate or minimize the psychologic and physical distress experienced by children and their families in the health care system
common healthcare beliefs for adolescents
they are able to assume additional responsibility for their own health, including maintaining health practices, taking prescribed medications, keeping appointments, and performing procedures when necessary. Health professionals who work with adolescents should consider their increasing independence and responsibility while maintaining privacy and ensuring confidentiality
Best practices for discipline for Infants:
time out
1 month old milestones
weight gain 150-210 g (5-7 oz) weekly for first 6 months; height of 2.5 cm (1 inch) monthly for first 6 months; primitive reflexes present and strong; doll's eye reflex and dance reflex fading; obligatory nose breathing; assumes flexed position with pelvis high but knees not under abdomen when prone; can turn head from side to side when prone; lifts head momentarily; has marked head lag; hands predominantly closed; grasp reflex strong; hand clenches on contact with rattle; able to fixate on moving object in range; visual acuity 20/100; follows light to midline; quiets when hears a voice; cries to express displeasure; makes small throaty sounds; makes comfort sounds during feeding; watches parent's faces intently as she or he talks to infant
Growth grids during infancy include measures of
weight, length, head circumference
Children whose growth may be questionable include:
• Children whose height and weight percentiles are widely disparate (e.g., height in the 10th percentile and weight in the 90th percentile, especially with above-average skinfold thickness) • Children who fail to follow the expected growth velocity in height and weight, especially during the rapid growth periods of infancy and adolescence • Children who show a sudden increase (except during normal puberty) or decrease in a previously steady growth pattern (i.e., crossing two major percentile lines after 3 years old) • Children who are short in the absence of short parents
best practice for medication administration for infants/toddler/preschooler/school age/adolescent
• Give the child a flavored ice pop or small ice cube to suck to numb the tongue before giving the drug. • Mix the drug with a small amount (≈1 tsp) of sweet-tasting substance, such as honey (except in infants because of the risk of botulism), flavored syrups, jam, fruit purees, sherbet, or ice cream; avoid essential food items because the child may later refuse to eat them. • Give a "chaser" of water, juice, soft drink, or ice pop or frozen juice bar after the drug. • If nausea is a problem, give a carbonated beverage poured over finely crushed ice before or immediately after the medication. • When medication has an unpleasant taste, have the child pinch the nose and drink the medicine through a straw. Much of what we taste is associated with smell. • Flavorings, such as apple, banana, and bubble gum (e.g., FLAVORx), can be added at many pharmacies at nominal additional cost. An alternative is to have the pharmacist prepare the drug in a flavored, chewable troche or lozenge.*
Using Time-Out
• Select an area for time-out that is safe, convenient, and unstimulating, but where the child can be monitored, such as the bathroom, hallway, or laundry room. • Determine what behaviors warrant a time-out. • Make certain children understand the "rules" and how they are expected to behave. • Explain to children the process of time-out: • When they misbehave, they will be given one warning. If they do not obey, they will be sent to the place designated for time-out. • They are to sit there for a specified period. • If they cry, refuse, or display any disruptive behavior, the time-out period will begin after they quiet down. • When they are quiet for the duration of the time, they can then leave the room. • A rule for the length of time-out is 1 minute per year of age; use a kitchen timer with an audible bell to record the time rather than a watch.
