MATERNAL A 327 Maternal and child peds EXAM 1 study guide (Already Graded A)

Chapter 1: Perspectives of Pediatric Nursing Health Care for Children • Healthy People 2020 o Framework for identifying essential components for child health promotion programs o Designed to prevent future health pro ...

Chapter 1: Perspectives of Pediatric Nursing Health Care for Children • Healthy People 2020 o Framework for identifying essential components for child health promotion programs o Designed to prevent future health problems in children o Goal to increase quality and length of healthy life and eliminate health disparities • Substance abuse • Dental caries---single most common chronic disease of childhood o Begins practicing dental hygiene beginning w/ the first tooth eruption; drinking fluoridated water, including bottled water; and instituting early dental preventive care • Violence • Mental health disorders Child Health Promotion • Provides opportunities to reduce differences in current health status among members of different groups and ensure equal opportunities and resources to enable all children to achieve their fullest health potential • “Bright Futures”---book on kind of what to expect in the upcoming months or years –also provides family support, physical activity, healthy weight, dental carries o Really hits hard on safety! Case Study • A group of nursing students have been asked to participate in a pediatric health fair. They will talk to participants about health care for children. The nursing students know that the health fair will include both parents and children of all ages. Leading Health Indicators (Healthy People 2020) 1) Physical inactivity 2) Overweight and obesity (#1 nutritional problem in children) o Greater than the 95th percentile---child is considered obese 3) Tobacco use 4) Substance abuse 5) Responsible sexual behavior 6) Mental health 7) Injury and violence 8) Environmental quality 9) Immunization 10) Access to health care Development • Developmental processes are unique to each stage of development: o Infant o Toddler o Early Childhood o Adolescence • Continuous screening and assessment are essential for early intervention when problems are found. Nutrition in Infancy • Breast-feeding is BEST o Human milk is the preferred form of nutrition for all infants o Provides ▪ Micronutrients ▪ Immunologic properties ▪ Enzymes that enhance digestion and absorption Nutrition in Childhood • Lifelong eating habits established by age 3 • Parent teaching • Eating preferences and attitudes related to food are established by: o Family influences o Culture • Homelessness and low income associated with lack of resources to provide children with adequate, nutritious meals. Case Study (Cont.) • When talking to parents about childhood obesity and type 2 diabetes, which topics should the nursing students discuss with the parents? Select all that apply. a) Obesity in children and adolescents is defined as a body mass index at or greater than the 95th percentile for youth of the same age and gender. b) Easy access to television and video games has increased the incidence of obesity. c) Lack of physical exercise contributes to obesity. d) The importance of allowing children to choose their favorite foods every day, including sweets such as dessert. e) The importance of maintaining a normal body weight. f) Overweight youth have increased risk for not only type 2 diabetes, but also high blood pressure and dyslipidemia. Dental Care • Dental caries are preventable o Dental hygiene beginning with first tooth eruption o Role of fluoridated water o Early dental preventive care o Parent and child teaching Case Study (Cont.) • The single most common chronic disease of childhood is? a) Arthritis Cancer b) Dental caries c) Diabetes Immunizations: Role of Nurse • Review individual immunization records at every clinic visit • Avoid missing opportunities to vaccinate • Encourage parents to keep immunizations current (U.S. Department of Health and Human Services, 2009) • Keep up with changes in immunization schedules, recommendations, and research related to childhood vaccines • www.cdc.gov/vaccines • HPV--- usually given at 11 yrs of age o Girls pass out from HPV vaccine—less likely to happen if given at a younger age (9yrs) Childhood Health Problems • Obesity and Type 2 Diabetes, p. 3 • Childhood Injuries, p. 3 • Violence, p. 6 • Mental Health Problems, p. 6 Case Study (Cont.) • When talking to parents about pedestrian accidents, the nursing students know that the top reasons involving children are related to motor vehicle–related deaths. Most of these accidents will occur in which areas? Select all that apply. a) Driveways b) Freeways c) Intersections d) Midblock e) Parking lots Mortality statistics refer to the number of individuals who have died over a specific period • Infant Mortality o Death in first year of life per 1000 live births*** o 6 lives per 1000 live births (in 2011) ▪ neonatal mortality (<28 days of life) • low birth weight (less than 2500g---5lbsish) ▪ postneonatal mortality (28 days to 11 months) o the lower the birth weight, the higher the mortality o First 4 causes ( accounted for about half of all deaths of infants under 1 year of age) 1) Congenital anomalies 2) Disorders r/t short gestation and unspecified LBW 3) SIDS 4) Newborn affected by maternal complications of pregnancy • Childhood Mortality o Usually presented per 100,000 population o Ages 5-14 –have the lowest rate of death ▪ Usually do to accidental injuries o Sharp rise is really seen after the age of 14 driving, adolescence, think they are invincible Morbidity statistics show the prevalence of specific illness in the population at a particular time • Prevalence of a specific illness in a population • Childhood morbidity • Statistics generally rates per 1000 population • Difficult to define o May denote acute illness, chronic disease, or disability ▪ Resp. infections ▪ Diarrhea ▪ Common cold chief illness of childhood**** Childhood Morbidity • Acute illness: symptoms severe enough to limit activity or require medical attention • Respiratory illness = approximately 50% of all acute conditions • Infections and parasitic disease = 11% • Injuries = 15% • Leading cause of death from unintentional injuries in children= motor vehicle injuries o Leading cause of death in children older than 1 year of age • Drowning and burns are among the top 3 causes of death for boys and girls throughout childhood • Intentional poisoning, associated w/ drug and alcohol abuse and suicide attempt, is the second leading cause of death in adolescent females and the 3rd leading cause in adolescent males The “New Morbidity” • AKA Pediatric Social Illness o Behavior, social, and educational problems o Psychosocial factors ▪ Poverty, violence, aggression, noncompliance, school failure, and adjustment to parental separation and divorce o Mental health issues Philosophy of Care (from American Nurses Association, 2010): • Protection, promotion, and optimization of health and abilities • Prevention of illness and injury • Alleviation of suffering through the diagnosis and treatment of human response • Advocacy in the care of individuals, families, and populations Family-Centered Care: Two Basic Concepts • Enabling o Current abilities and competencies o Acquire new abilities and competencies as needed o Means we are giving the parents the tools they need to take care of their child ▪ Ex: baby admitted d/t FTT---give the parents the skills they need in order to be successful in taking care of that child • Empowerment o Interaction that allows the family to maintain or acquire a sense of control o Behaviors that foster family’s strengths, abilities, and actions o Giving the family the voice that they need---allow the parent to let their voice be heard. Empower the care givers so they are able to recognize & pay attention to own gut instincts and act on them Case Study (Cont.) • The nurse makes sure that the family maintains a sense of control over their lives while their child is in the hospital when the nurse provides family-centered care and positively acknowledges their strength and helping behaviors. What concept would this nurse’s actions demonstrate? a) Nonmaleficenceobligation to minimize or prevent harm Atraumatic Care b) Empowerment c) Atraumatic care eliminate or minimize distress (psychological/ physical) d) Enabling • Eliminate or minimize distress o Psychologic ▪ Anxiety, fear, anger, disappointment, sadness, shame, or guilt o Physical ▪ Sleeplessness and immobilization to disturbances from sensory stimuli such as pain, temperature extremes, loud noises, bright lights, or darkness Goals of Atraumatic Care • Prevent or minimize separation from the family • Promote sense of control • Prevent or minimize bodily injury and pain • Examples o Foster the parent-child relationship o Prepare child before any treatment or procedure o Control pain o Allow privacy o Provide play activities for expression of fear and aggression o Providing choices to children o Respecting cultural differences Role of the Pediatric Nurse • Therapeutic Relationship • Family Advocacy and Caring • Disease Prevention and Health Promotion • Health Teaching • Injury Prevention injuries kill or disable more children over 1 year old than all childhood diseases combined • Support and Counseling • Coordination and Collaboration • Ethical Decision Making Ethical Decision Making • Ethical dilemmas = competing moral considerations • Competing moral values may include o Autonomy patients right to be self-governing o Nonmaleficence minimize or prevent harm (do no harm) o Beneficence promote the patients well-being (do good) o Justice concept of fairness • Determine the most beneficial or least harmful action within the framework of o Societal mores o Professional practice standards o The law o Institutional rules o Family’s value system and religious traditions o Nurse’s personal values Evidence-Based Practice • Based on valid, important, and applicable patient-reported, nurse-observed, and research-derived information • Combines knowledge with clinical experience and intuition • Provides a rational approach to decision making that facilitates best practice GRADE Criteria for EBP • Evaluates the quality of research articles used to develop practice guidelines • Rates the quality of the evidence • Establishes a strong versus weak recommendation for practice change The GRADE Criteria to Evaluate the Quality of the Evidence CLINICAL REASONING AND THE PROCESS OF PROVIDING NURSING CARE TO CHILDREN AND FAMILIES Clinical Reasoning • Cognitive process that uses formal and informal thinking to gather and analyze patient data, evaluate the significance of the information, and consider alternative actions. Nursing Process • Assessment • Nursing diagnosis they provide the basis for the selection of nursing interventions o Clinical judgment about the clients response to actual or potential health problems. The outcome statement guides the necessary interventions. • Planning • Implementation • Evaluation Documentation: Written Evidence of Progress toward Outcomes • Initial assessments/reassessments • Nursing diagnoses and/or patient care needs • Interventions identified to meet patient’s nursing care needs • Nursing care provided • Patient’s response to, and outcomes of, care provided • Abilities of patient and/or, as appropriate, significant other(s) to manage continuing care needs after discharge Quality Outcome Measures • U.S. Department of Health and Human Services National Strategy for Quality Improvement in Health Care has three quality aims: o Better care o Healthy People/Healthy Communities o Affordable Care o Full report at www.qualityforum.org Chapter 2: Social, Cultural, Religious, and Family Influences on Child Health Promotion Family Theories • Consanguineous blood relationships • Affinal marital relationships • Family of origin family unit a person is born into • Family Systems • Family Stress o Worry about toxic stress--- frequently exposed to strong adverse events (ex: caregiver that has a substance abuse/ mental health issue)—what is the effect on the children long term? • Developmental Stages (Duvall) Family Nursing Interventions Family Structure • Traditional  consists of a married couple and their biologic children ( both biologic parents and, if siblings are present, only full brothers and sisters. o Nuclearcomposed of two parents and their children---parent-child relationship may be biologic, step, adoptive, or foster. Sibling ties may be biologic, step, half, or adoptive. Parents are not necessarily married. o Blended (reconstituted)  include at least 1 step parent, stepsibling, or half-sbiling o Extended at least 1 parent, 1 or more children, and 1 or more members that are related or unrelated to the family • Single-Parent • Binuclear refers to parents continuing the parenting role while terminating the spousal unit divorced parent brings in a new spouse o Example: when joint custody is assigned by the court, each parent has equal rights and responsibilities for the minor child or children • Polygamous more than one spouse (usually more than one wife, but can be husband as well) • Communal rare—kind of the whole community plays a role in raising the children • GLBT legal or common law tie between the same sex who have children Family Roles and Relationships Parenting Styles • Authoritative (mix b/w permissive and authoritarian style) vs. Permissive o Authoritarian strict rules and punishment ▪ Children tend to be shy, sensitive, self-conscious, retiring and submissive o Authoritative firm controls, set limits, open discussion ▪ Children raised by these parents then to have high self- esteem and are self-reliant, assertive, inquisitive, content, and highly interactive w/ other children o Permissive warmth, few limits, child regulate behavior, rarely punish the children o Indifferent little interest in child, or role as parent • Types of Discipline to minimize misbehavior o Reasoning explaining why an act is wrong and is usually appropriate for older children, especially when moral issues are involved. o Scolding o Behavioral Modification (reward) reward for their behavior--- not always going to buy you prize.. but working up to the reward ( sticker chart works good) o Ignoring o Time-out place them in an environment that doesn’t has a lot of stimulation o Corporal (Physical punishment) spanking, etc. Special Parenting Situations • Parenting the adopted child • Parenting and divorce • Single parenting • Parenting in Dual-earning families • Foster parenting Sociocultural Influences on Families • Surrounding Environment o School/learning environment o Peer cultures o Social roles • Local Community Influences • Social Determinants o Race and ethnicity influence o Social class (wealth vs. poverty) o Religious and traditional influences o Mass media influences Understanding Culture • Cultural Definitions • Components of Cultural Humility o Assess Family health beliefs and practices Cultural Traditions to Maintain, Protect, and Restore Health • Physical aspects of caring for the body o Special clothes o Foods o Medicines • Feelings, attitudes, rituals, actions related to health • Spiritual aspects of health o Identity (who I am) o Customs/prayers/healing Health Beliefs and Practices • Natural forces • Supernatural forces • Imbalance of forces • Health protection o Folk healers o Practices and remedies o Faith healing and religious rituals Chapter 4: Communication, Physical, and Developmental Assessment Communication and Interviewing • Establishing the setting o Introduction o Ensure privacy and confidentiality o Appropriate computer and phone communication Case Study • A nurse is assessing children in a pediatric health clinic. As part of the physical assessment, the nurse knows that communication is key to a successful interview with the parents and the child. Using an organized approached and including patient teaching will be most effective throughout the process. • Communication Parents/ Caregivers o Directing the focus o Encouragement during interviewing o Cultural awareness o Listening/ using silence o Empathy o Providing anticipatory guidance process of understanding upcoming developmental needs and then teaching caregivers to meet those needs o Avoiding blocks and information overload o Using an interpreter Case Study (Cont.) • When interviewing a child and parent(s) at the beginning of a visit, it will be important for the nurse to follow which of the guiding principles? Select all that apply. a) Address parents however you think would be appropriate b) Include children in the interaction by asking them their name, age, and other information c) Provide as much privacy as possible d) Inform the family of the limits of confidentiality e) Young children should be given play provision to keep them occupied during the parent-nurse interview Communication Techniques • Play • Developmentally appropriate creative techniques • Verbal o I messages o Third person • Nonverbal o Writing o Drawing Case Study • When a 10-year-old child asks if a procedure is going to hurt, as the nurse, you know it will hurt for a little bit. The best response is: a) Be honest and answer, “Yes, for a little bit.” b) Change the subject and say, “It’s beautiful day outside, isn’t it?” c) Say, “NO, because you’re a big boy. It won’t hurt a bit.” d) Smile broadly and ask, “What do you think?” Chapter 5: pain assessment and management in children Pain Assessment: Influencing Factors • Age • Developmental level • Cause and nature of the pain • Ability to express the pain Six Core Domains • Intensity • Satisfaction with treatment • Symptoms and adverse events • Physical recovery • Emotional response • Economic factors Types of Pain • Acute • Chronic or recurrent Chronic and Recurrent Pain Assessment • Chronic o Pain that persists for 3 months or more o Pain that persists beyond expected period of healing • Recurrent Pain o Episodic o Recurs o Examples include migraine headaches, episodic sickle cell pain, recurrent abdominal pain, and limb pain Pain Assessment Tools • Behavioral o Infants to age 4 years • Physiologic • Self-report o Not valid for children younger than 4 years Behavioral Pain Assessments • Assessment of vocalization, facial expression, and body movements with specific tool • Most reliable for short, sharp pain • Most reliable for pain in infants • Less reliable for recurrent or chronic pain • Less reliable for pain in older children o May not correlate with child’s self-report of pain Behavioral Pain Assessment Tools • FLACC o Measures each behavior on a 0-10 scale ▪ Facial expression, leg movement, activity, crying, consolability • CHEOPS o The children’s hospital of eastern Ontario pain scale ▪ 6 categoriesCry, facial expression, verbal, torso, touch, and legs ▪ 0-3 pain scale • TPPPS • PPPRS COMFORT Scale • The only tool recommended for use with unconscious and ventilated infants, children, and adolescents. • Eight indicators: Score each between 1 and 5. 1) Alertness 2) Calmness/agitation 3) Respiratory response 4) Physical movement 5) Blood pressure 6) Heart rate 7) Muscle tone 8) Facial tension • Observe for 2 minutes and add the scores of each indicator. • The total scores range from 8 to 40. • Score of 17 to 26 = Adequate sedation and pain control. FACES Pain Scales • Wong-Baker FACES Pain Scale: Six cartoon faces o Smiling face = “no pain” o Tearful face for “worst pain” o The child chooses a face that describes his or her pain o The WB FACES widely used in United States • Bieri Faces Pain Scale—Revised: Six faces = 0 to 5 o No smiling face at the “no pain” end o No tears face at the “most pain” end o Equivalent to a 0 to 10 metric system Numeric Pain Ratings • For 8 years and older • 0 to 10 scale widely used • Easy to use • Little research for reliability and validity Visual Analog Scale (VAS) • “No hurt” to “biggest hurt” are more appropriate than “least pain sensation to worst intense pain imaginable.” • Requires a higher degree of abstraction than the Numeric Rating Scale (NRS). • Recommended because of the lack of supportive evidence through psychometric studies with the NRS in children and adolescents. Adverse Events • Signs, symptoms, laboratory findings, or diseases that occur after medications for pain are initiated • Constipation Most common o Need to screen Multidimensional Assessments • Adolescent Pediatric Pain Tool (APPT) o Assesses pain location, intensity, and quality ▪ Anterior and posterior body outline on one side ▪ 100-mm word-graphing rating scale with a pain descriptor o Facilitates assessments of pain quality + location Pediatric Pain Questionnaire (PPQ) • Assesses patient and parental perceptions of pain • Cognitive and developmental considerations • Eight areas of inquiry: pain history, pain language, the colors children associate with pain, emotions children experience, the worst pain experiences, the ways children cope with pain, the positive aspects of pain, and the location of the child’s current pain • Three components of the PPQ o VASs o Color-coded rating scales o Verbal descriptors • The child, parent, and physician each complete the form separately Chapter 23: Pediatric Nursing Interventions and Skills General Concepts Related to Pediatric Procedures • Informed consent o Age of majority/competence age 18! o Should include the expected care or treatment; potential risks, benefits, and alternatives; and what might happen if the patient chooses not to consent • Requirements for obtaining informed consent o “Assent” for older children and adolescents o Assent means the child or adolescent has been informed about the proposed treatment, procedure, or research and is willing to permit a health care provider to perform it. • Eligibility for giving informed consent o Treatment without parental consent o Emancipated minor o Mature minor Assent • Not necessarily a legal binding form.. but more of an ethical thing that can be done o More involved in their care • Meaning—Child has been informed and is willing • Developmentally appropriate awareness of the nature of his or her condition • Telling the patient what to expect • Assessing understanding • Soliciting an expression of child’s willingness to accept the proposed procedure Emancipated Minor • Legally under the age of majority but is recognized as having the legal capacity of an adult under circumstances prescribed by state law, such as pregnancy, marriage, high school graduation, independent living, or military service Treatment Not Requiring Parental Permission or Knowledge • AKA “medically emancipated” conditions • All 50 states have legislation, but it varies o Sexually transmitted infections o Mental health services o Alcohol and drug dependency o Pregnancy o Contraceptive advice Preparation for Procedures • Psychologic preparation o Age-specific guidelines for preparation o Based on developmental characteristics • Establish trust and provide support • Parental presence and support • Explanation to the child Performing Procedures • Benefits of using special treatment room for procedures • Expect success • Involve the child • Provide distraction Postprocedural Support • Encourage expression of feelings • Positive reinforcement • Use of play in procedures Using Play to Ease Children’s Fears Infection control Patient with HIV would be under “standard precautions”--- which involves the use of barrier protection, such as gloves, goggles, gown, or mask to prevent contamination from blood, all body fluids, secretions, and excretions except sweat, regardless of whether they contain visible blood; nonintact skin; and mucous membranes Growth and Development Principles of Growth & Development Growth and development Increase in number and size of cell Growth increase in physical size of a whole or any of its parts • Stages of Development: o Infancy (birth to 12 months)---most rapid period of growth ▪ Neonatal—birth to 28 days ▪ Infancy—1-12 months o Early Childhood (1-6 years) ▪ Toddler (1-2) ▪ Preschool (3-4) ▪ Kindergarten/ Early grade school (5-6) o Middle Childhood (6-11 years) ▪ Pre-teen “tween stage” (11-12) o Later Childhood (adolescent) (11-12/13) • Patterns o Directional trends---we will typically grow and develop in a specific regular related direction ▪ 1st-- head to toe (ex: babies have bigger heads) • Cephalocaudal: head to toe--- development proceeds from head downward through body towards feed ▪ 2nd—proximaldistal or near too far. Trunks to tips • Midline, core organs first, then arms and legs • Process by which development proceeds from center of body outward to extremity ▪ 3rd—general to specific or simple to complex • Differentiation development from simple operations to more complex activities and functions o Sequential trends--- order in which you typically develop ▪ Crawl before walk, walk before run o Developmental pace ▪ How quickly each individual develops o Sensitive periods---positive or negative influences can have lasting effects on the overall child’s development ▪ Limited times during growth and development where neg. times can cause a delay -Children are individuals but not little adults -Not orderly and continuous, you grow in spurts, stair step graph (rapid development then plauteu) -Infancy is most active year of development -Puberty is the next most active year Erikson’s Stages of Psychosocial Development—KNOW!! • Infant : Trust vs. Mistrust  birth to 1 year o Needs to form sense of trust o Learn to love and be loved o Provide visual stimuli for active involvement ▪ Meet basic physiological needs • Mistrust develops if basic needs are inconsistently or inadequately met • Toddler : Autonomy vs. Shame  1-3 years o Learns independence ▪ Wants to do things themselves as much as they can ▪ A lot of their learning is from imitation o Makes decisions for self o Offer simple choices o Praise decision making o Role play, learn through imitation • Pre-schooler : Initiative vs. Guilt 3-6 years o Basic problem solving o That doing them is desirable o Provide for new activities o Develops a conscience o Demonstrates initiative by being able to formulate and carry out a plan of action o They live in a “fantasy” made up kind of world. Very strong imaginations o The child is just beginning to develop a conscious (early stages) o If successful, develops direction and purpose; if criticized, leads to feelings of guilt and a lack of purpose • School Age: Industry vs. Inferiority 6-12 years o Learns how to do things well ▪ Children are ready to be workers ▪ Want to feel they are an active engaged part of the family ▪ Need and want to feel a sense of achievement o Development of new interests involvement in activities o Provide short projects for child o Feels rewarded for accomplishment o Ready to be workers o Organized sports begin to become a part of their lives • Adolescent : Identity vs. Role Confusion 12-18 years o Learns what kind of person they will be o Rapid and marked physical changes o Adjust to new body image ▪ Body is rapidly changing and making physical changes ▪ Become overly preoccupied of the way they look to others o Preoccupation w/ physical appearance o Examines and redefines self, family, peer group, and community o Peer group is very important o Rejects the identity presented by his parents and attempts to create his own identity o Identity often based on peers o Seek emancipation from parents o Value system (struggles to keep rules that they have made) o Vocation o Provide for adolescent to discuss feelings Principles of Growth & Development Piaget’s Cognitive Development---KNOW!! • Sensorimotor (birth-2 years) o Progress from reflex activity to repetitive behaviors, to imitative behaviors---natural reflex of their body o Develop sense of cause and effect o Infant learns about world through senses and motor activity o Trial and error problem solving o Language enables child to better understand world o Develop object permanence---Ex: take rattle and remove it behind your back…. That child still knows the object exists ---actively searched for a hidden object • Preoperational Thinking (2-7 years) o Move from egocentric (unable to put oneself in the place of another) thought to social awareness o Increasing language skills o Use of imaginative play o Play becomes more socialized o Forms symbolic thought • Concrete Operational Thinking (7-10 years) o Thought becomes increasingly logical and coherent o Conservation of matter—being able to recognize that 4oz of water is the same amt no matter if it’s in a small wide glass, or a tall skinny glass. o Able to shift attention from one perceptual attribute to another (decentration) o Consider points of view other than their own o Able to classify and sort facts, do problem solving o Acquires conversational skills • Formal Operational Thinking (12+ years) o Think in abstract terms o Draw logical conclusions o Make hypothesis and test them o Able to logically manipulate abstract and unobservable concepts o Adaptable and flexible o Able to deal w/ contraindications o Uses scientific approach to problem solve Neonatal Period: Birth – 28 days • Normal Findings: o Pulse 110-160 bpm o Respirations: 32-60 breaths/min o Blood Pressure: 82/46 mmHg o Head circumference = Chest circumference o Head length is ¼th total body length • Behavior is under reflexive control have no purposeful actions or movements (EVERYTHING IS REFLEXIVE) Neonatal Reflexes • Rooting/Sucking touch cheek they will turn face towards—how they get food o Disappears at 4 months, becomes purposeful • Palmar /Plantar Grasp  place finger in palm and curl downward o Palmar—disappears at 3-4 mo. o Plantar—disappears at 8 mo. • Tonic Neck: turn head to left, arm and leg on left extend (or right) o infant needs to be asleep—disappears @ 3-4 months • Moro/Startle: hold child in semi sitting, allow head and trunk to fall back, flails arms out and then in o disappears around 4 months • Babinski: upside down/ backwards J on foot, toes fan OUT, signs on neuro damage in older individual o Usually disappears by 12 months of age o This is abnormal if this continues throughout life…. Could indicate a neurological damage • Labyrinth righting—Infant in prone or supine position is able to raise head; appears at 2 months, strongest at 10 months • Neck righting—While infant is supine, head is turned to one side; shoulder, trunk, and finally pelvis will turn toward that side; appears at 3 months, until 24 to 36 months • Body righting—A modification of the neck-righting reflex in which turning hips and shoulders to one side causes all other body parts to follow; appears at 6 months, until 24 to 36 months • Otolith righting—When body of an erect infant is tilted, head is returned to upright, erect position; appears at 7 to 12 months, persists indefinitely • Landau—When infant is suspended in a horizontal prone position, the head is raised and legs and spine are extended; appears at 6 to 8 months, lasts until 12 to 24 months • Parachute—When infant is suspended in a horizontal prone position and suddenly thrust downward, hands and fingers extend forward as if to protect against falling (see Fig. 10-1); appears at 7 to 9 months, persists indefinitely Infant Physical Growth & Development • Proportional changes o 5 to 7 ounces of weight gain every week o Signs of tooth eruption at 5 months (varies a lot) o Double birth weight by age 5-6 months**** o Triple birth weight by age 1 year*** o Height increases by 1 inch per month for 6 months ▪ Height increases 50% by 1 year o Head circumference exceeds chest circumference o Growth in “spurts” rather than gradually ▪ Growth spurts: eat and sleep more, very little energy left for much else o Tooth eruption—5 months Infant Fine Motor Development • 1 month : Grasp Reflex strong • 4 months: Grasps object with both hands • 7 months: Transfers object between hands*** o Infant can use on hand for grasping and hold a cube in the other at the same time • 10 months: Pincer grasp o Crude pincer grasp—8-9 months o Neat pincer grasp---11 months • 11 months: Removes objects from container • 12 months: Builds tower of two blocks • 15 months: scribbles spontaneously o Builds towers of 2 cubes • 18 months: builds towers of 3-4 blocks • 24 months: turns pages of book 1 @ a time Infant Gross Motor Development • Head control (see following slide) • 5 - 6 months: Rolls over o Abdomen to back  5 months o Back to abdomen  6 months • 8 months: Sits steadily unsupported • 9 months: Pulls self-up and holds onto furniture • 10 months: Moves from prone to sitting position • 12 months: Walks with one hand held • 15 months: walks w/out help • 18 months: runs clumsily, walks up stairs holding hand • 24 months: up and down stairs w/ 2 feet on each stair Improved coordinated b/w ages 2 and 3 Head Control: Gross Motor Development mplete head lag at 1 month Partial head lag at 2 months lmost no head lag at 4 months (should be no head lag at 5 months) • Infant momentarily lifts head at 1 month. • Infant lifts head and chest 90 degrees and bears weight on forearms at 4 months. • Infant lifts head, chest, and upper abdomen and can bear weight on hands at 6 months. Infant: Sensory Development know the order of occurrence, but not exact time/months • 1 month: Visual acuity 20/100; Follows light to midline • 2 months: Binocular fixation and convergence to near objects beginning • 3 months: Follows object to periphery • 5 months: Visually pursues dropped object • 7 months: Responds to own name; Has taste preference • 12 months: Begins to discriminate simple geometric forms Infant: Vocal Development • 1 month: Cries to express displeasure; Makes small throaty sounds; comfort sounds with feeding • 2 months: Coos; vocalizes to familiar voice • 3 months: Babble/Chuckle; Less crying while awake • 4 months: Laughs aloud; Starts making consonant sounds (n, k, g, p, b) • 6 months: Begins to imitate sounds • 8 months: Combines syllables such as dada • 12 months: dada, mama with meaning; May say 3-5 words Infant: Social Development • 1 month: Sensorimotor phase, Stage 1, Use reflexes • 2 months: Social smile responding to stimuli • 4 months: Enjoys social interaction • 6 months: Begins to recognize parents and fear strangers; Holds out arms to be picked up • 8 months: Increase anxiety over parent leaving; Responds to the word NO • 10 months: Develops object permanence; Waves Bye-Bye • 11-12 months: Plays “so big” and “Peek-a-boo”; Show emotions (jealousy, hug, kiss, anger, fear) Infant Nutrition • Human milk or formula for first 4 to 6 months exclusively • Nutritional supplements for exclusively breast fed babies: o Vitamin D—possibly within the first couple months o Iron • Breast milk: o Increases intelligence level, sense of independent o Decreases incident of childhood allergies, asthma, cancer o Maternal aspects  if a mother breastfeeds for 2 years of her life---her own personal risk of breast cancer will decrease as much as 50% ▪ Better bonding ▪ Better weight loss after baby o Infants who are breastfed of bottle fed do not need additional water during the first 4 months of life • Number and volume of feedings will vary over time o 30-32 oz./day is normal max o Bottle fed 3-4 hours, older 4-6 hours o Nurse about 8 times a day, initially • When and how to add food??? o Cereal/ “rice cereal”: 4 months o Fruits and vegetables: after 6 months ▪ Can do either 1 first: introduce 1 at a time and take 5-6 days before introducing next food ▪ Trying to prevent any allergic reaction—better to pinpoint the causing factor if less food is being given at the time o Mashed table food 6-7 months o 7-8 months: table foods, no more bottle can affect teeth development o Get rid of bottle about 8 months or so….move over and start using the cup. o 9-12 months old--- can almost be eating all types of table foods o Don’t give children honey until the age of 2 d/t fear of botulism o Don’t give peanut butter to a child—typically until they’re 2-3!---definitely no peanut butter the 1st year of life ▪ Family allergies, hold off o Breast milk or formula for first year of life o Whole milk at 1 year old (for the next year of life)---babies need the fat for their body Infant Play • Birth to 1 month o Look at infant at close range o Hang mobiles with black and white designs • 2-3 months o Provide bright objects o Take infant to various rooms while doing chores • 4-6 months o Place infant in front of unbreakable mirror o Give brightly colored toys to hold • 6-9 months o Give infant large toys with bright colors, movable parts and noisemakers • 9-12 months o Take infant to places where there are animals, many people, different objects o Play ball by rolling it to child Infant Injury Prevention Measures • Back to sleep---SIDS prevention • Home assessment on level of baby • Car seat—child in rear facing car seat until they are 20 lbs and 1 year old (must be both; not either or) o Must have strips tight enough for baby, as well as tight enough straps for actual car seat • Turn down water heaters with babies--- less than 120 o Turn down as soon as you bring baby home • Unintentional injury is the number 1 cause of death and hospitalization Immunizations Primary Immune Response • The macrophage must eat the antigen, then present it to TH cells • TH cells must activate B cells • B cells produce antibodies • Then plasma antibody levels rise • This can take 2–3 weeks • IgM is responsible for the primary immune response Secondary Immune Response • B memory cells respond to the antigen immediately • Plasma antibody levels rise within days • Guided by IgG KNOW FOR IMMUNIZATIONS!!! ■ Rxns ■ When is it given?? (look at cdc vaccine chart) ▪ http://www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-child-combined-schedule.pdf ▪ http://www.cdc.gov/vaccines/pubs/vis/default.htm o Child walks in; certain age---what vaccines will we give them? Hepatitis B --- contact with blood and bodily fluids • Well tolerated few side effects • Given at birth to infants born to mothers who are HBsAg positive o HBIG given as well within 12 hours of birth ▪ Birth ▪ 2 months ▪ 6 months • Contraindicated in allergic to baker’s yeast CDC info: -1st dose: birth -2nd dose: 1-2 months of age -3rd dose: 6-18 months of age □ Can cause: -loss of appetite -tiredness -pain in muscle, joints and stomach -diarrhea and vomiting -jaundice -liver damage -liver cancer -death -- If mom is positive for Hep. B they might get immunoglobin Hep B to stop the transfer Rotavirus---given orally • well tolerated- protect child against diarrhea • **contact isolation** • recommended doses: o 1st: 2 months of age o 2nd: 4 months of age o 3rd: 6 months of age (if needed) Child much get the first dose of this vaccine before 15 weeks of age, and the last by age 8 months. May safely be given at the same time as other vaccines ■ Tell doctor if your baby has severe allergies that you know of, including a sever allergy to latex ■ If the baby has had a type of bowel blockage called “intussusception”.. they should not get vaccine DTaP --- diphtheria and pertussis are spread from person to person (enters through cuts or wounds) -Diphtheria causes think covering in the back of the throat: can lead to breathing problems, paralysis, heart failure, and even death -Tetanus (lockjaw) causes painful tightening of the muscles, usually all over the body: can lead to “locking” of the jaw so the victim cannot open his mouth or swallow. Tetanus leads to death in up to 2 out of 10 cases -Pertussis (whooping cough) causes coughing spells so bad that it is hard for infants to eat, drink or breathe. Can last for weeks: can lead to pneumonia, seizures (jerking and staring spells), brain damage, and death. • Fever 24 – 48 hours after injection, low grade • Soreness, redness and swelling at site • Fussiness and general malaise • Contraindication o Underlying Neurological symptoms o Previous reaction • Adverse Reactions • Fever >105, Seizures (DTaP), Shock like-state o Seizure precaution ■ Give Tylenol (any age) ■ Ibuprofen (> 6 months age) o Can cause kidney failure – kidney production decrease CDC info: • Children should get 5 doses of DTap vaccine o 2 months o 4 months o 6 months o 15-18 months o 4-6 years • Children who are moderately or severely ill should usually wait until they recover before getting DTap • Never get another dose of DTap if you’ve experienced a life-threatening allergic reaction, or suffered a brain or nervous system disease within 7 days after a dose was given • DTap is not licensed for adolescents, adults, or children 7yrs or older o A vaccine called Tdap is similar to DTaP. A single dose of Tdap is recommended for people 11 through 64 years of age. Another vaccine, called Td, protects against tetanus and diphtheria, but not pertussis. It is recommended every 10 years. o Tdap pregnant women should get a dose of Tdap during every pregnancy, to protect the newborn from pertussis. Infants are most at risk for severe, life threatening complication from pertussis. Tdap • Can protect adolescents and adults from tetanus, diphtheria, and pertussis. • One dose of Tdap is routinely given at age 11 or 12 • Td—another vaccine which protects from tetanus and diphtheria o Should be given every 10 years IPV—polio prevention • Well tolerated, few side effects • Contraindications o Previous reaction to neomycin, streptomycin, or polymyxin B CDC info: -children get 4 doses of IPV (subq) -2 months -4 months -6-18 months -Booster dose at 4-6 years MMR--- spread from person to person through the air (LIVE VACCINE)** • Measles **airborne precaution** • Low grade fever, anorexia, and malaise 7-10 days after injection • Contraindications o Allergic reaction to antibiotic neomycin and eggs--- do not get vaccine o Immunodeficiency do not give to immunocompromised patients ▪ Ex: HIV/ AIDs –low cd4 count then do not give vaccine o Pregnancy—should not receive during pregnancy. Wait until after birth to receive the vaccine. ▪ Women should avoid getting pregnant for 4 weeks after vaccination with MMR vaccine. • Adverse reactions o Persistent fever with other signs of illness • Get within 12-15 months CDC info: -should get 2 doses of MMR -1st dose: 12-15 months of age -2nd dose: 4-6 years of age (may be given earlier, if at least 28 days after the 1st dose) □ MMR may be given at the same time as other vaccines Can see this mixed with varicella (chickenpox)—(MMRV) LIVE VACCINES Won’t have onset of s/s until 5-10 days Tell your doctor if the person getting the vaccine: -HIV/AIDS -using steroids -Has cancer or using radiation or drugs for treatment -low platelet count -has gotten another vaccine within the past 4 weeks -recent transfusion or received other blood products HIB this disease is serious that is caused by bacteria. Usually affects children under 5 years old. *germs spread from person to person * HIB disease was the leading cause of bacterial meningitis among children under 5 years old in the U.S. *commonly confused with the flu vaccine • Low grade fever, mild redness and soreness at injection site • No known contraindications • Doses of HIB usually recommended at these ages: o 1st dose: 2months of age o 2nd dose: 4 months of age o 3rd dose: 6 months of age (if needed, depending on brand of vaccine) o Final/booster dose: 12-15 months of age Can help protect from: Meningitis Epiglottis Ear infections Acute otitis media Varicella--- LIVE VACCINE** • **airborne precaution** • Pain, tenderness, redness at injection site • Mild rash at injection site • Contraindications o Immunocompromised ▪ Ex: low cd4 count (<200)---would not give this vaccine o Pregnancy ▪ Pregnant women should wait to get chicken pox vaccine until after they have given birth. Women should not get pregnant for 1 month after getting chickenpox vaccine o Corticosteroid use • Children who have never had chickenpox should get 2 doses of vaccine at: o 1st dose: 12-15 months of age o 2nd dose: 4-6 years of age (may be given earlier, if at least 3 months after 1st dose) • People 13 years of age and older (who have never had chickenpox or received chickenpox vaccine) should get 2 doses at least 28 days apart. Pneumococcal (PCV13) caused by bacteria that can spread from person to person through close contact • Low grade fever, fussiness, drowsiness, vomiting, and diarrhea • Contraindications o Pregnancy o Sensitivity to immunization • Routinely given: o At 2,4,6, and 12-15 months of age • 13 different type it immunizes against o Help decrease: ▪ Meningitis ▪ Otitis media • After the age of 5 if a patient has not been given HIB or PCV13—often do not catch them up on the vaccines (don’t worry about it; typically would of gotten the “disease” before 5) Influenza if you give child nasal influenza---you need to know this is a live vaccine. Would not want to give to an immunocompromised patient Flu Vaccine given at 6 months and then yearly after that! HPV 3 shot series 1st shot given at 11-12 yrs 2nd shot is given 1-2 months after the 1st shot 3rd shot given 6 months after the first shot Immunizations • For each vaccination answer the following questions: o General info about the vaccines o Routes of administration o Schedules o Expected reactions o Contraindications o Precautions • See pages 201-205 in textbook Immune Response • Body’s reaction to antigenic challenges • Physiologic and biochemical interactions cause maturation and activation of lymphocytes (B cells and T cells) o Lymphocytes are specific to ONE antigen ▪ B-Cells produce antibodies that react with antigen ▪ T-Cells attack the antigen directly o Once B and T-Cells have been exposed to an antigen it can “remember” the antigen o Antigens induce an immune response • LEADS TO IMMUNITY!! **Infant – 1 Month • Physical o Wt double at 6mnths, triple at 12mnth o Ht increase by 1 “ per month o HC increase ½ “ per month o HC 1” greater than Chest at birth • Gross Motor o Lifts head slightly when body is prone o Primitive Reflexes Present o Turns head side to side when prone o Follows objects to midline • Fine Motor o Palmar grasp o Clenches objects in fist • Sleep Rest o Sleep totals 10-22 hours per day • Nutrition o Feedings every 3-4 hours • Sensory o Follow light to midline o Visual acuity is 20/100 • Socialization o Watches face when spoken to o utters small throaty sounds • Health Management/Education o Protect from crowds o Protect from Sun o Teach bathing and skin care o Fluoride, vitamins, iron **Infant 2-3 Months • Physical o Posterior fontanel closed • Gross Motor o Holds head erect for short time o Follows past midline o Fist to mouth • Fine Motor o Swipes at objects o Plays with fingers and hand o Palmar grasp begins to fade • Sleep Rest o Waking time increases o Sleeps about 4 hours at a time • Nutrition o 850-900cc/24 hours • Sensory o Follows light to periphery o Vertical and horizontal vision o Listens to sounds • Socialization o Smiles in response to person or object o laughs aloud • Health Management/Education o Discuss daycare, babysitters o Care after immunizations o Signs and Symptoms of illness **Infant 4-5 Months • Physical o Drools o Birth wt double (5-6mn) • Gross Motor o Sit when back is supported o Balance head well o Reach and grasp for object o Roll stomach to back o Lifts head and shoulders when prone • Fine Motor o Toys to mouth o Hands to midline o Uses both hands to pick up items o Primitive Reflexes disappear • Sleep Rest o 70% will sleep through the night • Nutrition o 1050-1100ml/day, discuss beginning cereal • Sensory o Recognizes familiar people and objects • Socialization o Coos and gurgles, enjoys social interaction o Vocalizes displeasure when object removed • Health Management/Education o Discuss skin care o Reaction to first immunizations **Infant 6-7 Months • Physical o Teething begins, bottom 2 1st , then upper 2 • Gross Motor o Roll back to stomach and stomach to back o Sits fairly well unsupported o Plays with feet, puts in mouth • Fine Gross o Transfer toy from hand to hand o Eye coordination assist in reaching • Sleep Rest o Sleep 7-10 hours uninterrupted • Nutrition o Cereal – Vegetables/Fruit o Introduce cup, finger foods • Sensory o Taste preferences o Object permanence • Socialization o Stranger anxiety o Cries and laughs easily o Polysyllabic vowel sounds • Health Management/Education o Teething comfort aides o Bottle propping **Infant 8-9 Months • Gross Motor o Sits steady alone o Pulls to standing position o Good hand foot coordination o Crawls • Fine Motor o Pincer grasp o Manipulates 2 objects at the same time o Puts everything in mouth • Sleep Rest o Takes 2 to 3 naps o May begin bedtime ritual • Nutrition o 3-4 meals/day o Finger foods – feeds self o Begin using spoon • Sensory o Depth perception increases o Interest in small objects • Socialization o Reaches for familiar people o Responds to name o Cries when scolded o Imitative and repetitive speech o Dada, bye-bye **Infant 10-12 Months • Physical o Wt triples since birth o Ht increase by 50% o 6 to 8 teeth • Gross Motor o Creeps- crawl c abd off floor o Stand alone for short time o Walks with help o Sit down from standing position • FineMotor o Hold crayon o Tower of 2 blocks • Sleep Rest o 1-2 naps/day o Bedtime ritual may begin • Nutrition o Switch to whole milk o Feeds self o 3-4 meals/ day • Sensory o Visual acuity 20/50 o Discriminate simple shapes • Socialization o Show emotion, anger, jealousy, affection o Will explore o Stranger Anxiety may continue o Security item- blanket o Can say two words other than mama, dada o Understands simple commands • Health Management/Education o Discuss dental care o Snacks o Sun Screen Toddler : Physical Development • Weight gain slows to 4 to 6 pounds per year • Physical development slows down tremendously!! • Birth weight should be quadrupled by 2½ years of age • Childs 2 year height doubled is their expected adult height • Height increases about 3 inches per year • Growth is “step like” rather than “linear” Gross and Fine Motor Development • Locomotion o 15 months: Walks without help o 18 months: Runs clumsily, walks up stairs holding hand o 24 months: up and down stairs w/ 2 feet on each stair • Improved coordination between ages 2 and 3 • Fine motor development o 15 months: Scribbles spontaneously ▪ Builds tower of 2 cubes o 18 months: Builds tower of 3-4 cubes o 24 months: Turns pages of book 1 at a time Sensory and Language Development • 15 Months: o Identifies geometric forms o Binocular vision well developed o Asks for objects by pointing o Understands simple commands • 24 Months: o Approx. 300 word vocabulary o Verbalizes need for toileting, food, or drink Social Development • Differentiation of self from mother and from significant others • Separation • Increasing independence, ritualism, and negativism • Skills for independence may result in tyrannical, strong-willed, volatile behaviors o Skills include feeding, playing, and dressing and undressing self • Exploration of genitalia is common Toddler Nutritional Needs • 12-18 months growth rates slow o Physiologic anorexia o Grazing on nutritional snacks helps ensure proper nutrition o More on the quality of food, rather than the quantity of food • Ritualistic nature of toddlers: o Same dish, cup or spoon o Regular mealtimes • Serve approximately 1 tablespoon per year of age • Need whole milk for fat brain production from ages 1-2 (after 2, they can go back to skim milk) o Milk has nutrients we need, but it does not have majority of nutrients they need to survive Toddler Play • Parallel Play---playing next to each other, but not actually “with” each other (not interacting with each other) • Imitation • Increased locomotive skills • Starting to develop fine motor skills • Tactile play • Remember safety factors Toddler Injury Prevention Measures • Remember….toddlers are innately curious and very egocentric!!!!  don’t see world as dangerous, small body parts they put in places, head is heavy • Unintentional injury is the number 1 cause of death and hospitalization • Parent education is the most important prevention tool: o Lock cabinets o Never leave unattended o Check size of toy parts/food particles o Use safety plugs o Use safety gates o Use PROPERLY INSTALLED child restraint system o Prone to falling o Running into street o Sticking objects in areas of body (nose, ears)  if it can fit in shot glass or toilet paper roll… it is too small for under age 3 Toilet Training • Need to assess for readiness o Physical readiness voluntary control of the sphincters—typically in place somewhere between 18-24 months of age. Do they have the gross motor skills to get to the bathroom and take down their own pants?? o Mental readiness recognizing physiological sign, and having verbal or nonverbal cues to tell us o Psychological readiness does child give a hoot about making mom and dad happy? Able to sit still on potty for a little without getting fussy? o Parental readiness are the parents ready to take on the challenge? Drop anything at any moment. Don’t make it a battle • Tips for parents: o Provide a pleasant mood o Be aware (and patient) that child is curious about excretion products o Don’t refer to bowel movements as “dirty” or “yucky” o Teach hand washing o Teach front to back wiping o 18-24 months of age--- better control of sphincters Toddlers 15 Months • Motor o Walks well alone T 14 months o Builds tower of 2 blocks o Throws objects and picks them up o Drink from a cup, can use spoon • Sleep Rest o 11-12 of sleep/day o Naps last 1-2 hours • Nutrition o Finger foods o Decreased appetite, slowed growth • Socialization o Use 4 – 6 words including name o Learned NO • Health Management/Education o Need for balance of rest/activity o Types of activities and appropriate snacks Toddler 18 Months • Physical • Motor o Growth decreased, appetite lessened o Anterior Fontanel closes o Abdomen protrudes o Runs clumsily o Climbs stairs/furniture o Drinks well from a cup o Tower of 3-4 cubes • Socialization o Says 10 words or more o New awareness of strangers o Temper tantrums begin o Ritualistic Toddler - 24 Months • Physical • Motor • Sensory o Wt 26-28lbs (11-12kg) o Ht 32-33in (80-82cm) o 16 teeth, should begin dental visits o Good gross motor skills o Can walk up and down stairs, one step at a time o Tower of 6-7 blocks o Visual acuity 20/40 o Accommodation well developed • Socialization o Vocab of 300 words o Short 2-3 word phrases, use pronouns o Obeys simple commands o Signs of increasing autonomy o Makes simple choices o Ritualistic especially at bed time o Mine – does not share • Health Management/Education o Educate on slower growth rate o Teach to blow nose/cover mouth with cough o Limit setting, discipline Toddler – 30 Months • Physical • Motor o 20 teeth, full primary set o Decreased need for naps o Walks on tip toes, o Stands on one foot o Tower of 8 blocks o Copies horizontal or vert. Lines o May be toilet trained • Socialization o Begins to see self as separate individual o See other children as objects o Increasing independence, ritualism, and negativism Acetaminophen Poisoning • Toxic at 150 mg/kg • Hepatotoxicity: o >200 mcg/ml after 4 hours o 50mcg/ml after 12 hours • 3 stages of toxicity: o Initial o Latent o Hepatic involvement • Assessment: o GI distress • Intervention: o Acetylcysteine (antidote) Poison Management • Activated Charcoal o Binds with toxic agent to reduce absorption • Gastric lavage o Irriagation and removal of gastric contents • Antidotes o Specific agent that will bind with toxin • Cathartics o Promote stimulation and evacuation of the bowel to decrease systemic absorption • NO LONGER USE IPECAC SYRUP Plumbism (Lead Poisoning) • Ingesting or inhaling lead-containing substances • Who’s at Risk? • Pathophysiology: o Rate and absorption surpass the rate of excretion o Deposits in soft tissues, bone and RBCs ▪ Microcytic hypochromic anemia ▪ Increased urinary elimination of glucose and protein ▪ Fluid shift leading to encephalopathy and IICP • Diagnosis: o Blood Lead Level (BLL)> 10 mcg/dl Lead Poisoning • Clinical Manifestations: o Symptoms of anemia o Glycosuria, proteinuria o Crampy abdominal pain o Behavioral changes o Lead encephalopathy • Medical Management: o Chelation therapy o Succimer (Chemet) o Dimercaprol (BAL) o Edetate calcium disodium • Nursing Management: CDC Guidelines for Elevated BLL • BLL 10–19 mcg/dL o Education, repeat screening, case management to possible sources • BLL 20–44 mcg/dL o Medical evaluation, case management o Give succimer: works by trapping lead in the body and removing it in the urine • BLL 45–69 mcg/dL o Medical evaluation, chelation, case management o  give calcium EDTA—draw lead out of sof t tissue/bones • BLL >69 mcg/dl o Hospitalization, immediate chelation, case management Pre-School – Age 3 • Physical o Wt gain 4-6lbs (1.8-2.7 kg) o Avg. weight = 32 lbs o Ht gain 3in (7.5cm) o May have achieved nighttime bowel/bladder control • Gross and Fine Motor o Jump off bottom step o Stairs with alternating feet o Tower 9-10 cubes o Can unbutton front o Rides Tricycle---(3 yrs old; tricycle is 3 wheels) o Dresses and undresses self • Sensory o Visual acuity 20/30 • Language and Socialization o 900 word vocabulary o Four word sentences o Increased attention span o Feeds self completely o Begins to share • Cognitive o Begins to understand time o Magical thinking • Family o Attempts to please parents o Less jealous of younger sibling o Ability to separate from parent easily Pre-School – Age 4 • Physical o Ht and Wt increase same as 3yr ( 4-6 lbs, 3 in per year) o Length at birth is doubled • Gross and Fine Motor o Skips and hops on one foot o Tie shoes --- on average its closer to 5 years o Throw ball overhand o Use scissors o Drawing: ▪ Copy square ▪ Trace cross and diamond o Draws stick figure with 3 parts • Language and Socialization o 1500 word or more vocabulary o Questioning at Peak o Imaginary friend o Selfish, impatient o Physically and verbally aggressive o Exaggerates, boasts, tattles • Cognitive o Immediate perceptual cues dominate judgment o May count correctly but poor mathematic number concept • Family o Rebels if parent expects too much o Takes aggression / frustration out on parents / siblings Pre-School – Age 5 • Physical o Similar ht and wt increase as 4yr o Avg weight = 41.2 lbs o Avg height = 43.3 inches • Gross and Fine Motor o Well-developed gross motor o (skips, jumps, throws, catches, jumps rope, skates) o Print first name o Dress and wash self---may need a little help o Proficient climber o Rides bike with training wheels o Begins to tie shoes • Language and Socialization o 2100 word vocabulary o Names coins, colors, days, months, weeks, time in general o Talks constantly o Cooperative and sympathetic to others o Less rebellious and more responsible • Cognitive o May notice prejudice and bias in outside world o Use time oriented words with greater understanding • Family o Gets along with parents o May question parents’ thinking and principles o Enjoys sports, cooking, and shopping with parent of same sex Pre-Schooler Nutritional Needs • Essentially the same as toddlers • AAP states that IF you are going to give your child juice DO NOT give them any more than 4-6 oz/day • Food fads and strong preferences may still exist • Remember that QUALITY of food is more important than QUANTITY of food Pre-Schooler Play • Associative play--- “I will now play with you” • Play should provide opportunities for: o Physical development o Social development o Mental development • Play is characterized by: o Imitation o Imagination—totally normal. Do not need to stop it. More common in first born children o Dramatic play • Imaginary playmates • Mutual play Pre-Schooler Injury Prevention Strategies • Injury rates/deaths decrease some due to: o Improved gross and fine motor o Improved balance o Tendency to be less reckless o Listen better to parental guidance o Aware of potential dangers • Many of the same tips from toddlers still apply • Forward facing 5 point restraint car seat until the child is at least 4 years of age. (4 and 40) o Now the state law says the child needs to be 8 AND 80 pounds to be out of the booster seat (can be a high back or low back seat) School-Age Years (6-12) • Physical Growth o Permanent teeth –6yrs molars o Central incisors at 7-8yrs o Height increases by 2 inches per year o Weight increases by 2-3 kg per year o Girls 10-12: Pubescent changes may begin to appear • Motor • Sensory o Refinement of coordination o Visual acuity 20/20 should usually have this by the age of 7 • Cognitive o Knows right from left at 6 years o Develops concept of time, reads clock at 7 years o Use of reasoning and understanding at age 9-10 o Trial and error problem solving at age 10-12 Prepubescence • Defined as 2 years preceding puberty • Typically occurs during preadolescence • Varying ages from 9 to 12 (girls about 2 years earlier than boys) • Average age of puberty is 12 in girls and 14 in boys School Age Nutritional Needs • Quality of the child’s diet depends on the quality of the family’s diet • Develop a taste for a variety of foods--- try to maintain a balanced diet • Parents unable to monitor intake for a big part of the day • Nutrition education is important • Use http://myfoodpyramid.gov as a teaching tool with the child School Age Play • Increased physical skill, intellectual ability and fantasy • Like games with rules • Athletic competitions • Beginning to appreciate economics/financials School Age Injury Prevention Strategies • Most common cause of severe injury is the MVC o Need to be a booster seat until age 8 AND 80 lbs o Need to sit in the back seat • Use of helmets for: o Bike riding o Skateboards o Roller skates/in-line skates o Scooters Adolescent: Male • Physical Changes o Testes and scrotum growth:10 -13 o Pubic hair growth:10 -15 o Penis growth:11-14 o Voice change: 11-14 o Facial and Axillary hair – approx 2 yrs after pubic hair appears o Acne approx same time as axillary hair o Pubertal growth spurt ▪ Final 20-25% of linear growth ▪ Gain up to 50% of ideal adult body weight Adolescent: Female • Physical Changes o Breast growth begins: 7-13 o Pubic hair growth: 7-14 o Axillary hair growth – 2 years after pubic hair begins o Acne is seen around same time as Axillary hair growth o Menstruation: 10-16 ▪ Typically begins between 10-16 yrs of age o Pubertal growth spurt ▪ Final 20-25% of linear growth ▪ Gain up to 50% of ideal adult body weight Adolescents • Cognitive o Abstract thinking o Interest in exploring ideals than facts o Understand that the whole is more than sum of part o Longer attention span • Socialization o Peer group identity, cliques o Form close intimate relationship-major goal o Sexual exploration o By 15-16 feel should be treated as adult o Wants increased freedom o Discipline problems, Exploration, Risk-Taking Behavior • Adolescent Nutritional Needs o Rapid and extensive growth (ht, wt, muscle mass and sexual maturation) o Increased nutritional requirements o Less reserves due to increased need o Concerns: ▪ Obesity ▪ Anorexia/bulemia ▪ Anemia Sequence of Sexual Maturation • Girls: • Boys: o Breast changes o Rapid increase in ht and wt o Pubic hair o Axillary hair o Menstruation o Abrupt deceleration of linear growth o Enlargement of testicles o Pubic hair, axilla hair, facial hair o Rapid increase in ht o Voice changes o Nocturnal emissions o Abrupt deceleration of linear growth Adolescents: Tanner’s Stages of Sexual Maturation • Male Genital o Stage 1 - testes small in size with childlike penis o Stage 2 - testes reddened, thinner and larger (1.6-6ml) with childlike penis o Stage 3 - testes larger (6-12ml) and scrotum enlarging. Increase in penile length o Stage 4 - testes larger (12-20ml) with greater enlargment and darkening of the scortum. Increase in length and circumference of penis o Stage 5 - testes over 20ml with adult scrotum and penis Adolescents: Tanner’s Stages of Sexual Maturation • Female Breast o Stage 1 - no breast tissue with flat areola o Stage 2 - breast budding with widening of the areola o Stage 3 - larger and more elevated breast extending beyond the areola. o Stage 4 - larger and even more elevated breast. Areola and nipple projecting from the breast contours o Stage 5 - Adult size with nipple projecting above areola Adolescents: Tanner’s Stages of Sexual Maturation • Male and female pubic hair o Stage 1 none o Stage 2 small amount of long hair at base of male scrotum or female labia majora o Stage 3 moderate amount of curly and coarser hair extending outwards o Stage 4 resembles adult hair but does not extend to inner surface of thigh o Stage 5 adult type and quantity extending to the medial thigh surface Adolescents: Injury Prevention • At their developmental peak • Think that they are indestructable • MVC’s #1 cause of death • Suicide #2 cause of death (10-19 yrs of age)---followed behind this is homicide (#3) o Homicide is the 3rd leading cause of death in the 15-19 year age group • Driver’s education o Also need to educate on proper behavior as a passenger o Use of seat belt • Aggressively assess for depression Adolescent Interview: HEEADSSS • Home environment • Education and employment • Eating • peer-related Activities • Drugs • Sexuality • Suicide/depression • Safety from injury and violence Respiratory Disorders and Infectious Disease Major Anatomical Differences in Children • Diameter of the airway • Distance between structures • Short, open Eustachian tube Respiratory Assessment at a Glance • Appearance • Breathing • Circulation Clinical Manifestations of Respiratory Tract Infections Genearlized Manifestations o Fever o Poor feeding/anorexia o Vomiting/Diarrhea o Abdominal pain o Nasal blockage o Nasal discharge Respiratory sounds o Cough o Hoarseness o Grunting o Stridor o Wheezing o Crackles o Absence of breath sounds (no air movement) Generalized Nursing Care (notes in notebook) • Rest • Comfort • Hydration • Nutrition Otitis Media • Inflammation of the middle ear • Who’s at Risk? o Children under age of 4 d/t Eustachian tube going horizontal rather than vertical o Any time a kid has a respiratory tract infection (can be anything) o Any time a kid has had an allergic reaction will make them more susceptible • Pathophysiology: o Mechanical or functional obstruction of the Eustachian tube o Accumulation of secretions in the middle ear o Negative middle ear pressure • Clinical Manifestations: o Otalgia—ear pain o Fever o Otorrhea—ear discharge o May role head from side to side o Fussy o Irritable/ lethargic/ or even a loss of appetite due to pain while chewing o s/s wait 72 hours—if not improved then start the antibiotics • Nursing Diagnosis: o Pain o Infection • Treatment Plan: o Antibiotics o Feed in upright position o Return for reassessment in 2 weeks o Possible myringotomy (tubes in the ear) if recurrent ▪ Typically can last about 18 months---will fall out of their own ▪ Instill ear drops directly to the part that’s infected Effusion—fluid behind the ears; do not use antibiotics for an effusion probably allergies Externa—swimmers ear (drops, hydrogen peroxide) European model: don’t treat ear infection right away Viral: go away on own Bacteria: start antibiotics –pain control Tonsillitis • Acute/chronic inflammation of the tonsils • Who’s at Risk? o Not anything set in stone o Children in general have larger tonsils ▪ Can be a protective mechanism • Pathophysiology: • Clinical Manifestations: o Mild to severe sore throat o Exudate o Difficulty swallowing o Fever o Possible white spots on the back of the throat---bacterial infection ▪ Treat with antibiotics o Red swollen---typically viral ▪ No need to treat with antibiotics at this point in time • Nursing Diagnosis: o Pain o Ineffective clearance • Treatment Plan: o Antibiotics o Possible tonsillectomy o Comfort measures Tonsillectomy the removal of the palatine tonsils • Pre-Operatively: o Prepare and support child ▪ Bring children in prior to surgery—let them see the room they will be in • Show them gowns, tools, etc. o Have transitional object in room o Check for active bleeding – bleeding time ▪ Make sure child is able to clot • Post-Operatively o Prone or side-lying position ▪ d/t amount of drainage o Check for signs of bleeding: ▪ Frequent swallowing---thought is you are having a lot of bleeding • Most common is immediately post op and can be common about 5-7 days post op once scabs fall off ▪ Restlessness ▪ Vomiting bright red blood o Ice collar o No straws, forks, sharp objects---don’t want anything going into mouth that could potentially dislodge the sores Pharyngitis inflammation of the pharynx—causing a sore throat Viral: (about 80%-90%)—red throat • Clinical Manifestations: o Fever, general malaise • Lymphadenopathy o Erythematous pharynx • Treatment plan: o Treat symptoms Bacterial white spots on the throat **Group a streptococcus (strep)—one of the most common organisms of bacterial pharyngitis--- can lead to rheumatic fever • Clinical Manifestations o Erythematous pharynx o Fever, headache o Lymphadenopathy o Exudate on tonsils o Severe sore throat o Pin point/lacy rash • Treatment plan: o Antibiotics o Also pitch toothbrush so they don’t re-infect themselves o Stay home from school until they’ve been on antibiotics for at least 24 hours Upper Respiratory Tract Infection • Acute viral infection that causes inflammation of the upper respiratory tract o Nasopharyngitis—most common infectious disease process o Pharyngitis--- strep throat is most common • Who’s at Risk? o Kids are at risk for this (hand mouth obsession) • Pathophysiology: o Offending organism gains entry o Organism proliferates o Initiates inflammatory response ** Because of the diameter of the airway and the shorter distance from upper to lower kids will move/ progress quicker from upper respiratory infection to a lower respiratory infection **Avg. healthy child will get a cold at least 6-9 times a year d/t over 100 viruses that can cause the cold Nasopharyngitis: Clinical Manifestations • Younger Child o Fever o Irritability, restlessness o Poor feeding o Sneezing o Nasal mucus o Vomiting/diarrhea • Older Child o Dryness and irritation of the nose o Sneezing, chilling o Muscle aches o Cough In general--- rule of thumb- recommended to not give cough suppressant better for child to cough it up and get it out of lungs o Only time that suppressants are given is when its interfering with night time sleep (bedtime only) Epiglotitis*** • Inflammation and edema of the epiglottis o Epiglottis a flap of cartilage at the root on the tongue, which is depressed during swallowing to cover the opening of the windpipe • Who’s at Risk? o Mostly preschoolers and toddlers (2-8 years old) • Pathophysiology: o Serious obstructive inflammatory process of the epiglottis • Clinical Manifestations: o Absence of spontaneous cough o Drooling o Agitation o High fever o No cough o Tripod position o Anxious o Best intervention--- get instruments necessarily or call the doctor • Nursing Diagnosis: o Ineffective airway clearance o Ineffective breathing patterns • Treatment Plan: o Get to a peds ED ASAP!!!! o Antibiotics o Antipyretics/analgesia o Resuscitation equipment available • If you suspect epiglottitis--- you as the nurse, do not have child open the mouth and look into the throat--- this could cause the only opening for airway to start to spasm and close up. Only open airway if you are prepared to intubate the child (the doctor should do this) Croup • Severe inflammation & obstruction of the upper airwayinfectious o Edema in bronchial airway • Who’s at Risk? o Affects more boys than girls (typically can be a young child’s disease) o Typically 3 months – 5 years o Children born premature who had frequent or long term intubation ▪ As a result of prematurity—can lead to permanent damage ▪ Scar tissue may make them more prone to croup later in life • Pathophysiology: croup is typically viral o Spasmodic laryngitis o Acute obstructive laryngitis o Acute laryngotracheobronchitis • Clinical Manifestations: o Barking cough can be described like a sea lion/ seals barking o Crackles and decreased breath sounds o Inspiratory stridor o Muffled vocal sounds • Nursing Diagnosis: o Ineffective airway clearance o Ineffective breathing pattern o Pain • Treatment Plan: o Inhaled racemic epinephrine (extremely affective in decreasing the swelling--- very short half-life be very prepared for rebound obstruction due to short half-life) o corticosteroids o Antibiotics if bacterial o Antipyretics o Oxygen o Cool mist humidification (Ex: open the freezer and allow the child to breathe in cold air) ▪ Actually decreases the swelling Acute Bronchitis • Inflammation of the bronchial tree caused by an infectious organism or irritating agents (smoke, dust, pollen, etc) • Who’s at Risk? o Kids--- will progress to bronchitis quicker d/t shorter and narrow airway from top to bottom • Pathophysiology: o Inflammatory process o Leads to swelling and mucous production • Clinical Manifestations: o Fever o Dry hacking o Non-productive cough o Congestion o Tightness o Malaise • Nursing Diagnosis: o Ineffective breathing pattern o Ineffective airway clearance • Treatment Plan: o Bacterial—treat with antibiotic—give suppressant only if effecting night time sleep Bronchiolitis (RSV) • Inflammatory obstruction of bronchioles • Who’s at risk? o Primarily children less than 2 years of age—especially premature babies d/t their overall respiratory health than normal to term infants ▪ Can vaccinate against this---needs to be given again and again monthly • Pathophysiology: o Swollen bronchiole mucosa o Fill with exudate from inflammatory process • Clinical Manifestations: o Wheezing o Coughing — tends to be harsh, comes in fits and doesn't produce any phlegm ▪ Can become cyanotic during these coughing spells o Rapid or difficult breathing o Very contagious—can live on an object for up to 8 hours at a time • Nursing Diagnosis: diagnose by a nasal swab o Ineffective airway clearance o Ineffective breathing patterns o Pain o Parental anxiety • Treatment Plan: o Supportive o RSV IVIG given to at risk infants---pregnant women need to stay away from this therapy--- can have effects on the developing fetus o Fluid hydration is very important for these kids o Since it is viral do not give antibiotics—just supportive treatments • If it keeps coming back can mean there are other problems like asthma or cystic fibrosis • Contact precautions • RSV is the most common cause of bronchiolitis Another pneumonia pt can actually be roomed with an RSV patient --- do not room with an immunocompromised patient Pneumonia • Inflammation of the bronchioles, alveoli, interstitial tissues and on occasion the pleura as a result of infection • Who’s at Risk? o Children and infants can get much quicker due to shorter/narrower airways ▪ Viral is way more common in children • Pathophysiology: o Pathogen invade the lower respiratory tract o Antigen-antibody response o Air spaces become engorged o Cellular infiltration & congestion o Alveoli become airless • Clinical Manifestations: o Fever (bacterial) o Nonproductive cough o Crackles o Wheezing o Malaise o Difficulty eating o Tachypnea • Nursing Diagnosis: o Ineffective breathing pattern o Ineffective airway clearance o Pain • Treatment Plan: o Humidified oxygen o Suction to maintain patent airway o Chest physiotherapy o Antipyretics/Analgesia o Antibiotics if bacterial- (Rocephin) o Small frequent feedings Bronchopulmonary Dysplasia (BPD) • Chronic condition that occurs when the infant is still dependent on oxygen (on ventilator)at 36 weeks post-conceptional age o disease process of premature babies—when the child has been born a micro premature baby (born at 30 wks or less; typically in the 20’s) • Pathophysiology: o High levels of oxygen o Damage from oxygen-free radicals ▪ Damage to ciliary function in the lungs ▪ Cause alveoli to become thick and fibrotic o High positive pressure ventilation that causes lung injury • Clinical Manifestations o Atelectasis o Crackles or wheezes o Cyanosis—around lips or eyes o Dyspnea o Sternal retracations • Nursing Diagnosis o Ineffective breathing pattern o Ineffective airway clearance o Altered nutrition o Parental anxiety • Treatment Plan: o Bronchodilators o Diuretics o Preventative and supportive—depending on what other needs they have at this time o Chest physiotherapy o Continued ventilatory support and oxygen o No specific treatment exists for BPD except to maintain adequate arterial blood gases with the administration of oxygen and to avoid progression of the disease Sudden Infant Death Syndrome • Sudden death of an infant in which a postmortem examination fails to confirm the cause of death • Who’s at Risk? o Families—young moms o Low birth weight infant ---d/t some physiological problem o Premature birth o Multiple pregnancies o Little boys are more at risk than girls o Mom smoking during pregnancy or even after o Family history of SIDS o Prone sleeping o Having BPD **90% of SIDS deaths are going to occur before child is 6 months ** 60% of the 90% will occur between 2 and 4 months • Pathophysiology: o Sudden, unexplained death of infant < 1yr o Frothy, blood tinged fluids in mouth and nose ▪ Some aspects due pulmonary edema or the carbon monoxide poisoning • Nursing Diagnosis: o Knowledge deficit (prevention, compromised family coping) o Dysfunctional grieving o Impaired parenting • Nursing Interventions: o Educate parents – Back to Sleep o Reassure parents – nothing could be done o Reinforce need for autopsy for confirmation o Refer to national SIDS parent group o Air moving in the room decreases the incident o Sucking on a pacifier while child is sleeping may also help by decreasing the incidents o No pillows or blankets in crib while sleeping Asthma*** • Reversible, diffuse, obstructive pulmonary disease o Is reversible--- but there are long term consequences with asthma • Who’s at Risk? o More likely boys than girls o Exposed to 1st hand and 2nd hand smoke o Third hand smoke---in the clothes, hands, hair, etc. (carcinogens/ debris that’s left on individual that smoked) ▪ These children tend to have more respiratory difficulties o Low birth weight o Childhood obesity o GERD o Living in a large urban area (especially inner cities with pollutants) • Pathophysiology: o Exposed to trigger o Abnormal antibodies stimulate mast cells o Inflammation of the mucous membranes o Smooth muscle bronchospasm o Increased mucus secretion • Categories: • http://archive.prairiepublic.org/features/healthworks/asthma/diagnose.htm • Clinical Manifestations: o Diaphoresis o Dyspnea o Prolonged expiration with wheeze ▪ End expiratory wheeze o Unequal or decreased breath sounds o Use of accessory muscles o Cough—dry hacking, irritating cough at first ▪ Once attack is subsiding, then it’s a thick, phlegm producing cough • Nursing Diagnosis: typically will not diagnose a child with asthma unless they are over age 3 because airway will continue to grow---baby lungs are designed to be more sensitive to allergens to keep them clear since they are shorter/narrower o Risk for suffocation o Ineffective breathing patterns o Activity intolerance • Treatment Plan: o Bronchodilators---during the attack o Inhaled corticosteroids--- must rinse mouth out after to prevent fungal infection o Peak Flow Meters o Aero Chambers and spacers o Mass cell stabilizer Reactive Airway Disease – only about 30% will actually lead to asthma later in life • Generalized term that is used describe history of coughing, wheezing, or shortness of breath of unknown cause • Who’s at risk? o Typically in a child less than 3 • Pathophysiology: o Stimuli induce an allergen- antibody interaction o Inflammation o Diminished airway function • Clinical manifestations, Nursing Diagnosis, and Treatment Plan are the same as with Asthma Cystic Fibrosis • Autosomal recessive disorder of exocrine glands (both parents have to be carriers of this) • Usually Caucasians • Sweat chloride above 60meq/L • Increased viscosity of mucus • PANCREAS o becomes fibrotic c decrease enzyme production o Causes steatorrhea, nitrogen in stools o Inability to breakdown polysaccharides • LUNGS o Increased viscous mucus in trachea, bronchi o Increases # of resp infection (mucus) • Patho: o Mutated transport protein interferes with chloride channels which affects: ▪ Volume- absorbing epithelia ▪ Salt- absorbing epithelia ▪ Volume-secretory epithelia o Dehydration o Increase viscosity of mucus gland secretions o Obstructs glandular ducts • Manifestations o Meconium ileus (15%) o Failure to thrive o Bulky, greasy, foul smelling stools (steatorrhea) o Salty taste on the child’s skin o Recurrent respiratory infection o Chronic productive cough o Delayed meconium passage o Cough or wheeze a 6mnth o Cyanosis, clubbing of nails o Barrel shaped chest -R ventricle hypertrophy • Treatment o CPT (chest physical therapy) o Bronchiodilators—do this first before CPT to open up or expand the bronchioles o Abx o Pancreatic enzyme supplements---so they can stop the failure to thrive and receive their nutrients o High Cal/Protein diet to meet metabolic needs • Assessment o Resp status o GI status o FTT • NsgDX o Activity intolerance o Ineffective airway clearance o Altered Nutrition • Implementation o CPT o Pancreatic emzymes o Fat soluble vitamin – ADEK o High cal/prot diet o Regular exercise o Select cloths that hide protuberances • Outcomes o Patent Airway o Adequate caloric intake o Family ability to care for child Infectious Diseases Kinds of Infectious Agents o Prions---not destroyed by antibacterial or antiviral drugs o Viruses o Bacteria o Fungi o Parasites Incubation stage: pathogen begins to actively replicate within body—not really producing any symptoms (can spread to other people without even knowing) □ Prodromal stage: vague symptoms start to appear—just don’t feel “right” Acute stage: KNOW you’re sick. At your sickest. All the effects of the pathogen are occurring within your body Convalescent stage: starting to get better. Immune system is starting to fight Resolution stage: final stage when you’re back to normal self Endotoxins: poison that bacteria can release to destroy the cells—releases within cell Exotoxins: released during bacterial growth out in the body **In order for a virus to live, it needs to inject itself into the host cell---then it uses the machinery of the host to survive and replicate —in order to kill the virus, you need to kill the host cell itself Pediatric Infectious Disease: • Nursing Assessment o History o Physical exam o Labs • Nursing Diagnosis: o Hyperthermia o Risk for injury secondary to complications o Disturbed body image o Risk for impaired skin integrity related to scratching secondary to itch o Social isolation • Implementation: o Reduce exposure to other children o Manage temperature o Skin care to prevent breakdown o Bedrest during prodromal and/or febrile stage Roseola Infantum AKA false measles • Human herpes virus type 6 illness characterized by fever with subsequent rash • Who’s at Risk? o Infant 6-15 months of age • Clinical Manifestations: o High fever (102-105) usually for 3-4 days o Rash appears when the fever breaks ▪ Maculopapular non pruritic rash ▪ Doesn’t itch blanch if you press a finger on it with pressure ▪ Trunk, arms, neck, mild rash a little on face and legs ▪ Goes away in 24 hours ▪ Viral—can’t do anything for it unless the fever needs to be controlled • Therapeutic Management: o Antipyretic • Nursing Management: o Fever control Fifth’s Disease (Erythema infectiosum) AKA slapped cheek disease (viral) • Contagious illness from human parvovirus characterized by rose-colored eruptions starting on the cheeks o Causative agent: human parvovirus B19 o Communicable before the onset of symptoms o Once they exhibit the slapped cheek look, they are already done being contagious o Worry: if pregnant person is exposed to this--- it can be very harmful to the fetus • Who’s at risk? o School age ▪ More in kindergarten classrooms • Clinical Manifestations: o Rash appears in 3 stages: ▪ Erythema on face (slapped cheek look) ▪ Rash on extremities (slowly progress to upper and lower extremities—proximal to distal—core out to the fingers)---rash can last a week or more ▪ Rash reappears if skin is irritated or traumatized • Ex: extreme temperatures • Therapeutic Management: o Symptomatic • Nursing Management: o Cut nails o Tepid oatmeal baths to soothe itching Herpangina • Acute viral illness characterized by ulcerative lesions on the posterior oropharynx • Who’s at Risk? o 3-11 years old • Clinical Manifestations: o Ulcerative lesions in the oropharynx (mouth) o Fever o Sore throat/difficulty swallowing • Therapeutic Management: o Supportive/symptomatic o Antipyretic o Maalox/Benadryl solution—“ magic mouthwash” treats inflammation and coats so child can actually eat without pain • Nursing Management: o Soft foods o Encourage fluids Pityriasis rosea • Viral rash in children that begins on the thorax (chest) and is believed to be caused by the human herpes virus 6 o Non- contagious o Self- limiting o More common to occur in spring/ fall • Who’s at Risk? o School age kids/adolescents • Clinical Manifestations: o Initial phase—herald patch—typically found on back, chest, or abdomen (Christmas tree rash) o Progression o ~50% of individuals had sx of URI prior to herald patch (some linkages) • Therapeutic Management: o Symptomatic o Antihistamines • Nursing Management: o Sun exposure can help with rash Mononucleosis  AKA Kissing disease (Viral, passed by saliva)- this is viral, which means you cannot give antibiotics • Self-limiting infectious disease characterized by an increase in the mononuclear elements of the blood—caused by the epstein barr virus o Incubation stage is about 4-8 wks ▪ Can be transmitted during incubation stage (why it’s so contagious) • Who’s at Risk? o Adolescents and young adults o Younger kids can get this---but they do not get nearly as sick as adolescents or young adults • Clinical Manifestations: o Fever o Sore throat- 1st sign o Cervical adenopathy—all lymph nodes will be enlarged o Fatigue o Can also have enlarged liver and spleen—prevent spleen rupture ▪ Tell child/ individual--- no physical contact sports for 6-8 wks post infection to prevent spleen rupture • Therapeutic Management: o Symptomatic o Analgesic/antipyretic • Nursing Management: o Comfort measures o Encourage rest o Restrict physical activity o Increase fluids Rubella (German measles) AKA the 3 day measles • Contagious viral infection characterized by a red rash o Only reason we vaccinate against rubella is due to the effects on the unborn fetus • Who’s at Risk? o Unborn fetus not really a problem disease for us • Clinical Manifestations: o Rash accompanied by low grade fever (102 or lower) o Rash starts on face and spreads rapidly ▪ Begins on face, quickly spreads to trunk, then arms and legs and then disappears in the same sequence it appeared o HA o Stuffy/ runny nose o Inflamed/ red eyes o Enlarged lymph nodes • Therapeutic Management: o Symptomatic • Nursing Management: o Keep in isolation until 5 days after rash started---extremely contagious Measles (Rubeola) • Highly contagious viral disease that causes a characteristic maculopapular rash • Who’s at Risk? o Highest in children under age 2 o Immune deficiency • Clinical Manifestations: o Fever o Dry cough o *Koplik’s spots---tiny white spots with a bluish center found in mouth or inner-lining of the cheek o Conjunctivitis o *Photophobia o Skin rash o *Unbelievable contagious factor • Therapeutic Management: o Supportive care o Antipyretic/analgesia o Fluids --- make sure they don’t get dehydrated o Keep lights dem • Nursing Management: o Isolate until 5th day of rash---extremely contagious o Non- immunized infant--- infants may receive vaccines 72 hours within exposure to protect them from disease Mumps (parotitis)—(viral) • Acute inflammation of one or both parotid glands o Communicability--- 1 wk before swelling, to 1 week after swelling • Who’s at Risk? • Clinical Manifestations: o Swollen, painful salivary glands o Pain with chewing or swallowing o Ear pain o Fever o Chipmunk cheeks o 1 in 5 people that have this don’t even have symptoms • Therapeutic Management: o Symptomatic o Antipyretics/antinflammatories • Nursing Management: o Encourage fluids and soft foods o Avoid sour foods—bring on intense pain with salivation o Maintain isolation when communicable/contact precaution • Parent needs education about this disease if they state they will give “antibiotics” to child Chickenpox (varicella) • Acute, highly contagious viral infections that can occur at any age • Typically vaccinate this to prevent shingles later in life • Who’s at Risk? • Clinical Manifestations: o Stages of rash: ▪ Raised red/pink bumps (papules) ▪ Fluid-filled blisters (vesicles) ▪ Crusted over/scabbed vesicles o Contagious until every single bump is crusted over!! ▪ New spots may continue to appear for several days • Therapeutic Management: o Symptomatic o Acyclovir---if immunocompromised kid o IVIG---possibly use for immunocompromised kid o Oatmeal bath o Varicella vaccine • Nursing Management: o Isolation Poliomyelitis • Contagious viral illness that in its most severe form causes paralysis, difficulty breathing and sometimes death • Who’s at Risk? o Anyone who’s in contact with it (no specific age) • Clinical Manifestations: o Nonparalytic ▪ Fever ▪ Sore throat ▪ HA ▪ Vomiting ▪ Fatigue o Paralytic --- nonparalytic at first--- and then days later turn to paralytic ▪ Days later--- s/s • Lose or floppy limbs • Start losing reflexes • Sever muscle aches and spasms • Often worse on one side of the body or not o Post-polio syndrome very similar to shingles with ckn pox--- can occur decades after illness (30-40 years later) ▪ Polio virus lays dormant—very serious • Progressive/ serve muscle atrophy • Muscles involved with breathing may become infected—very serious issue o Possible cold flu like symptoms • Therapeutic Management: o Supportive • Nursing Management: o Physical therapy o Splinting o Prevent extremities from contracting --- maintain as much use out of them as you can Diphtheria • Serious bacterial infection affecting the mucous membranes of the nose and throat o Extremely deadly to children o Use to be the leading death in children ▪ Quickly occludes airway • Who’s at Risk? o • Clinical Manifestations: o Thick, patchy, grayish-green membrane over pharynx o Sore throat, rasping cough o Airway obstruction o Hoarseness o Painful swallowing • Therapeutic Management: o Antitoxin---to neutralize toxin that is already in the body o Antibiotics---typically penicillin or erythromycin o 3 negative cultures to be non-communicable • Nursing Management: o Bedrest Pertussis –AKA as whooping cough --- typically a bacterial infection • Highly contagious upper respiratory infection o Communicability is greatest before the whooping cough to 4 wks after the whooping cough starts • Who’s at Risk? • Clinical Manifestations: o Early symptoms ▪ Cold-like o Later symptoms ▪ Severe coughing attacks--- bringing up very thick phlegm ▪ May become very cyanotic during coughing spell • give oxygen during this time • Therapeutic Management: o Antibiotic o Hydration o Supportive care • Nursing Management: o Bedrest o Adequate oxygenation during paroxysm Impetigo • Highly contagious bacterial skin infection o Caused by group a beta hemolytic streptococcus • Who’s at Risk? o Most common in toddler, preschoolers and 2- 5 year olds • Types: o Nonbullous without blisters ( most common) ▪ Begins as a single macular, non- raised – leads to a vesicle ▪ Honey- colored crust over it ▪ Spreads in a linear way or the way the child is itching o Bullous with blisters ▪ Affects infants in children less than 2 years of age ▪ Very little crusting to eat ▪ Spread outward from initial blister ▪ Painless ▪ Itching • Clinical Manifestations: o Painless blisters o Itching • Therapeutic Management: o Antibiotics—need to remove crust (if crusted over) so antibiotic can get to source of infection ▪ Soak it, remove crust, cleanse area with antibacterial soap, and get ointment on site on infection. Wash with hot water and soap, and no one else uses the wash rag. o Hygienic measures • Nursing Management: o Frequent handwashing o Erythromycin (check allergies first) Cellulitis • Acute inflammation of the skin involving epidermis, dermis and underlying connective tissue • Who’s at Risk? o Occurs in all aged group o Occurs more commonly in immunocompromised • Pathophysiology: o Bacteria produce enzyme-spreading factors o These breakdown fibrin networks • Clinical Manifestations: o Red ,swollen, tender, warm at site o Pain o Fever • Therapeutic Management: o Antibiotic o Antipyretic/NSAID • Nursing Management: o Warm compresses o Marked improvement should be seen in 48 hours but need to continue full course of antibiotics o Continue antibiotics for the full coarse Pin Worms (Enterobius vermicularis) • Parasitic infection o Anal, oral kind of infection o Ingest or inhale eggs • Who’s at Risk? o More common in warm climates • Pathophysiology: o Pinworm eggs ingested/inhaled o Hatch in upper intestines o Travel through the intestines • Clinical Manifestations: o Itching---anal itching (when child is still at night) o Insomnia o Vague GI symptoms • Therapeutic Management: o Anti-helminth (worm) medication • Nursing Management: o Treat entire family** o Repeat medication in 2 weeks—get eggs that are in upper intestines that haven’t hatched yet Lice (pediculosis capitus) • Highly communicable parasite on the hair and scalp o Lice prefer blonde, thin, straight hair o Very rare in African Americans o Contagious--- sharing hats, wigs, costumes, etc. • Who’s at Risk? o Children at daycares, preschools, and schools ▪ Most common in school aged kids • Pathophysiology: o Lice live and reproduce only on humans o Bite human and release toxin that causes itching o Can live for 48 hours off the host and nits can live for 8-10 days off the host • Clinical Manifestations: o Intense itching---once lice bites, their saliva makes it itch • Therapeutic Management: o Medicated lotion and shampoo • Nursing Management: o Repeat treatment in 7-12 days*** o Wash at high heat o If it can’t be washed--- needs to be in a sealed plastic bag for at least 2 weeks to kill the nits Scabies • Contagious skin condition caused by the mite Sarcoptes scabiei • Who’s at Risk? School, parents working in long term heath care and prison settings • Pathophysiology: o Females burrow into skin and lay eggs ▪ Can lay 1-3 eggs a day for 30 days before “she” dies o Eggs hatch and lead to inflammatory response o Itching typically begins about a month after the manifestation (hatching) • Clinical Manifestations: o Itching –more at nighttime o Burrow tracks • Therapeutic Management: o Scabicidal lotion o Antihistamines • Nursing Management: o Treat all family members** o Treat belongings ▪ Non-washables in plastic bag for 4 days to kill o Repeat medication in 1 wk** Tinea • Fungal infection that affects skin, nails and scalp • Types: o Tinea capitis- scalp ▪ Most common in toddlers and school-aged children ▪ Animal to person or person to person transmission o Tinea corpis- body ▪ Round or oval red scaly patched. Cleared centrally o Tinea cruris- jock itch ▪ Similar to body version of it ▪ Very rare in pre-adolescent children o Tinea pedis- athletes foot ▪ Between the tones and plantar surface of the feet ▪ Transmission increasing due to rubber shoes we are wearing • Therapeutic Management: o Griseofulvin ( use this for tinea capitis, give with food or glass of milk) o Topical ointments (lotrimin) • Nursing Management: o Round nails Lyme’s Disease • Most common tick borne disorder • Bulls eye rash is first sign • Most common in summer, spring and in wooded areas • Who’s at Risk? o Whosever exposed to the tics • Pathophysiology: o Borrelia burgdorferi enters the bloodstream • Stages o Stage 1 ▪ Erythema migrans o Stage 2 ▪ Systemic involvement o Stage 3 ▪ Musculoskeletal pain • Therapeutic Management: o Prolonged antibiotic treatment • Nursing Management: o Education SEPSIS Neonatorum • Generalized bacterial infection ---spread rapidly through the bloodstream • Common in 1st month of life (first 28 days) • Neonates at risk d/t immature immune response • Group B strep most common cause • E Coli, group A strep, gonococci, Listeria • Pathophysiology: o Immature immune system o Inability to localize infection o Lack of IgM • Causes: o early onset—usually within first 3 days of life o late onset • Manifestations o Temp instability--- up and down of temp. don’t have a coordinated enough immune system to run a temperature o Poor suck/feeding o Weak cry o Lethargy, Irritability o Pallor, cyanosis, mottling o Tachycardia, irregular resp o Jaundice o Dehydration o SZ, full fontanels o +BC o Elevate WBC o Elevated ESR + CRP • Treatment o State of infection free o Monitor for shock o ABX o Broad spectrum antibiotics o Supportive therapies • Assessment o Poor feeding o High Temp o Lethargy • NsgDx o Risk for infection o Hyperthermia o Diarrhea o Fluid volume deficit • Implementation o Monitor IVF o O2 as needed o Administer ABX o Monitor for shock • Outcomes o Maintain fluid and electrolyte balance Cradle Cap • Chronic recurrent, inflammatory reaction of the skin on the scalp • Lesions are thick, adherent, yellowish, scaly • Nursing care: o Prevent w/ adequate scalp hygiene o Treatment directed at removing the crusts • Shampoo daily with a mild soap (baby soap) o Use a fine tooth comb to help remove the crusts from the hair Caput succedaneum a vaguely outlined area of edematous tissue situated over the portion of the scalp that presents in a vertex delivery Cephalhematoma  sharply demarcated boundaries that do not extend beyond the limits of the (bone) suture line Erythema toxicum neonatorum also known as flea bite dermatitis or newborn rash, is a benign, self-limiting eruption that usually appears within the first 2 days of life. The 1-to-3-mm lesions are firm, pale yellow or white papules or pustules on an erythematous base that resemble flea bites Herpes Simplex Virus rash appears as vesicles or pustules on an erythematous base—clusters of lesions are common. Lesions ulcerate and crust over rapidly. • Poor feeding • Lethargy • Fever • Irritability • Vesicular rash Strawberry hemangioma bright red, rubbery nodule with a rough surface and a well-defined margin that may be present at birth • Benign cutaneous tumors that involve only capillaries • May or may not appear at birth but enlarge during the first year of like and tend to resolve spontaneously by ages 2-3 yrs Necrotizing Enterocolitis (NEC) • Necrotic lesions of the mucosa of the intestines • Long –term complication of fight or flight response. Blood shunts to core organs and away from intestines. Intestines become ischemic, and even if they do not become necrotic, they are still more susceptible to bacterial infection. May lead to bowel perforation. • Who’s at Risk? o Premature babies (micro-preemies, born 25-27 weeks of gestation), occurs several weeks after birth o Has been shown to occur more often in formula-fed infants than in preterm infants fed human milk • Pathophysiology: o Intestinal ischemia due to shunting of blood • Clinical Manifestations: o Temperature instability o abdominal girth o gastric residuals o  or absent bowel sounds o Grossly bloody stools o Bowel sounds hyperactive above NEC, and absent below NEC o Palpable bowel loops because they are enlarged o Bile may be seen in vomit • Nursing Diagnosis: o Fluid volume deficit o Altered nutrition • Therapeutic Management: o Antibiotics o Intestinal rest: put them on TPN & lipids o Surgery • Nursing Management: o Early detection ▪ Observing tolerance of feeding, checking pre-gastric aspirates o Frequent abdominal girths o Observe tolerance of feedings