Pediatrics Exam 1 PDF

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Ch. 25 Growth & Development of the Newborn & Infant Principles of Development  Continuous process through life  Orderly sequence  Predictable but unique ranges  Systems mature at different rates  More rapid in early periods  Cephalocaudal pattern  grow longer, head to ...

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Ch. 25 Growth & Development of the Newborn & Infant Principles of Development  Continuous process through life  Orderly sequence  Predictable but unique ranges  Systems mature at different rates  More rapid in early periods  Cephalocaudal pattern  grow longer, head to tail  Gross to refined skills  Newborn/neonatal period of infancy  from birth to 28 days  Infancy  28 days to 12 months Growth & Development  Nurse must be familiar w/normal development  while obtaining health hx, nurse can ask parent/caregiver if the skill is present and when it was attained  Ill or premature infants may exhibit delayed acquisition of physical growth and dev skills  when assessing the growth and dev, use the infants adjusted age to determine expected outcomes  Adjusted age  subtract the # of weeks that the infant was premature from the infant’s chronological age Physical Growth  Ongoing assessments of growth are important so too rapid or inadequate growth can be identified  Infants grow rapidly over the first 12 months  weight, length, head and chest circumference are all indicators of growth  Weight o The avg newborn weighs 3.4 kg (7.5lb) at birth o Newborns lose up to 10% of their body weight over the 1st week of life  then gain 30g/day and regains birth weight by 10-14 days of age o Most infants double their birth weight by 4 months and triple by the time they are 1 y/o  Height o Avg newborn is 50cm (20in) long o Length grows more quickly over the 1st 6 months o By 12 months  length increased by 50%  Head Circumference o Avg head circumference of full term newborn  35cm (14in) o Increases rapidly during 1st 6 months o Avg of 10 cm (4in) gain from birth to 1 y/o  Fontanel closure  posterior 6-8 weeks (2 months), anterior at 9-18 months  open for brain to grow pg. 1179  Teeth o Occasionally and infant is born w/1 or more teeth  natal teeth  or dev them in 1st 28 days  neonatal teeth

o Majority do not have teeth when born  1st teeth erupt btwn ages 6 & 8 months  primary teeth (deciduous teeth)  Causes ↑ saliva & drooling  Enzyme released w/teething causes mild diarrhea, facial skin irritation  Slight fever may be associated; not high fever (normal) o Gums around emerging tooth will usually swell  lower central incisors are usually 1st to appear followed by upper central incisors o The avg 12-month old has 4-8 teeth o Put toys in freezer to help w/inflammation or baby Orajel  Stranger Anxiety pg. 973 o May develop at around the age of 8 months o Previously happy and friendly infant may become clingy and whiny when approached by strangers o Stranger anxiety  indicator that the infant is recognizing themselves as separate from others o As the infant becomes more aware of new people/places they may view a stranger as threatening even if parent is there o Fam members that don’t see the child often  approach infant calmly and slowly w/parent in sight  sometimes will prevent a sudden crying spell  Separation Anxiety o May start is last few months of infancy o Infant becomes distressed when parent leaves  infant will eventually calm down & become engaged w/caregiver o 8 months’ protests loudly when mom leaves  Adaptive Behaviors  Gross Motor Skills pg. 968  Large muscles  head control, rolling, sitting, & walking  Dev in cephalocaudal fashion  ex. Baby learns to lift the head before learning to roll over & sit 1 month Lifts and turns head to side in prone position, head lag when pulled to sit, rounded back in sitting 2 months Raises head & chest, holds position. Improving head control 3 months Raises head to 45 degrees in prone, slight head lag in pull-to-sit 4 months Lifts head & looks around, rolls from prone to supine, head leads body when pulled to sit 5 months Rolls from supine to prone and back again, sits w/back upright when supported 6 months Tripod sits 7 months Sits alone w/some use of hands for support 8 months Sits unsupported 9 months Crawls, abdomen off floor 10 months Pulls to stand. Cruises 12 months Sits from standing position. Walks independently

Warning signs that may indicate probs w/motor dev  arms and legs are stiff or floppy, child cannot support head at 3-4 months of age, child reaches w/one hand only, child cannot sit w/assistance at 6 months, child doesn’t crawl by 12 months, child cannot stand supported by 12 months of age  Fine Motor Skills pg. 969  Includes the maturation of hand and finger use  dev in a proximodistal fashion (center to the periphery)  Ex. A newborn’s hand movements are involuntary in nature whereas a 12-month old is capable of feeding themselves  By 12 months the infant should be able to eat with their fingers & assist w/dressing (pushing an arm through the sleeve) 1 month Fists mostly clenched, involuntary hand mvmts 3 months Holds hand in front of face, hands open 4 months Bats at objects 5 months Grasps rattle 6 months Releases object in hand to take another 7 months Transfers object from one hand to the other 8 months Gross pincer grasps (rakes) 9 months Bangs objects together 10 months Fine pincer grasp. Puts objects into container and takes them out 11 months Offers objects to others and releases them 12 months Feeds self w/cup and spoon. Makes simple mark on paper. Pokes w/index finger  Language Development  For several months, crying is the only means on communication of newborn and infant  crying = unmet needs  1 to 3 month  coos, makes other vocalizations, and demonstrates differentiated crying  4 to 5 months  simple vowel sounds, laughs aloud, “raspberries,” and vocalizes in response to voices, responds to their name and begins to respond to “no”  4 to 7 months  distinguishes emotions based on the tone of voice  6 months  squealing and yelling, could be displeasure or joy  7 to 10 months  babbling begins and progresses to strings (mamama, dadada) without meaning, can respond to simple commands  9-12 months  beings to attach meaning to “mama” and “dada” and starts to imitate other speech sounds  the average 12-month old uses 2-3 recognizable words w/meaning, recognizes objects by name, and starts to imitate animal sounds  very impt for caregiver to talk to infant to learn communication skills  sometimes regression in language dev occurs briefly when the child is focusing energy on other skills (crawling, walking)  as long as hearing is normal, language should progress continually

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Warning signs that may indicate probs w/language dev  infant doesn’t make sounds at 4 months, doesn’t laugh/squeal by 6 months, doesn’t babble by 8 month, doesn’t use single words w/meaning by 12 months Social and Emotional Development Newborn spends most of the time sleeping  by 2 months, ready to socialize First real smile  2 months, should spend a great deal of time watching/observing what’s going on around 3 months  will start an interaction w/a caregiver by smiling widely and maybe gurgling  caregiver responds and child responds back w/more smiling, cooing, arm/leg mvmt 3-4 months  mimic parent’s facial mvmts  widening eyes, sticking tongue out  infant may cry when pleasant interactions stop 6-8 months  may enjoy socially interactive games like peek a boo Nutrition pg. 977 Breast milk or formula supplies all of the infant’s daily nutritional requirements until 6 months of age, at which time solid foods may be introduced Breast milk is the preferred method of newborn and infant feeding, it provides complete infant nutrition Formula or breast milk for 1 year After 6 months, infants usually require the nutrients available in solid foods in addition to breast milk or formula o Infant should be assessed for readiness to progress and parents need instruction in choosing the appropriate solid foods and support in the progression o Tongue extrusion reflex which is needed for sucking needs to be absent  introducing solids foods before 4-6 months will result in extrusion of the tongue o The ability to swallow foods doesn’t become completely functional until 4-6 months of age. Enzymes to appropriately digest solid food are also not present until 4-6 months of age o Solids should be fed w/a spoon in the upright position Choosing appropriate solid foods o Iron fortified rice cereal mixed w/a small amount of breast milk or formula is a good choice for the 1st solid food o The cereal is easily digested and the taste is generally well accepted o Once cereal is accepted, other pureed single foods may be introduced o Intro of one new food every 3-5 days is recommended  allows for identification of food allergies o Around 8 months  ready for more texture in foods  soft, smashed table food without large chunks o Finger foods  cheerios, soft green bean pieces, or soft peas  avoid hard food o 10-12 months  can intro strained, pureed, or mashed meats No bottle propping  easy for them to choke Bottle weaning at 1 year A cup should be introduced at 6-8 months  1oz of milk in cup while learning  newer non spill sippy cups are not recommended

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No fruit juice until 6 months  limit to 2-4oz/day  larger amount can displace important nutrients from breast milk or formula Foods to avoid in infancy o Honey o Egg yolk and meats (until 10 months) o Excessive amounts of fruit juice o Foods likely to cause choking  peanuts, popcorn, other small hard foods (raw carrots), grapes and hot dog slices (cut smaller) o Foods likely to result in allergic reaction  citrus, strawberries, wheat, cow’s milk, egg whites, peanut butter Psychological Development pg. 967 Trust vs. Mistrust  Erik Ericson  birth to 1 year Dev of a sense of trust is crucial in the 1st year as it serves as the foundation for later psychological tasks When the infant’s needs are constantly met, the infant develops this sense of trust  if this doesn’t happen, mistrust can dev Cannot spoil  meet needs Caregiver responds to basic needs  feeding, changing diapers, cleaning, touching, holding, and talking to the infant = trust As the nervous system matures, infants realize they are separate from caregiver. Over time the infant learns to tolerate small amounts of frustrations and trusts that although gratification may be delayed, it will eventually be provided Personality Influences attachment Easy, difficult, slow to warm up Active, average, quiet Promoting Growth & Dev Through Play pg. 975 Infants practice their gross and fine motor skills and language through play  it is a natural way for infants and children to learn Play is critical in infant dev  opportunity to explore their environment, practice new skills, and solve problems Newborn prefers to interact w/parent vs toys  parents should talk/sing to baby when participating in daily activities (feeding, bathing, etc.)  they love to watch people’s face and will mimic the expressions they see Provide age appropriate toys to promote fine motor dev Solitary play  when play w/toys, the infant usually doesn’t share w/other infants or directly play w/other infants Onlooker  when a child watches others play but does not engage Accident Prevention pg. 976 Anticipate development Aspiration infants love to explore w/their mouth  small objects/hard foods pose a choking hazard Safety in car  infant car seats should face the rear of the car until 12 months and weight of 9kg (20lb), seat should be secured in the center of the back seat

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Safety in the home o Firm mattress that fits snuggly in the crib on a secure support, well fitting sheets o Crib side rails always raised when parent is not right next to the crib o Infant walkers are not recommended  may tip over and baby can fall out, also allows them to be in reach of things like hot stove and things on counters o As infant grows, new safety issues arise  safety gates should be at the top and bottoms of stairways o Cover electric outlets, gates to block rooms w/sharp edged furniture o Avoid stuffed animals w/eyes or buttons, keep floor free of small items o Suffocation  crib should not have pillows, comforter, stuffed animals, or other soft items in them o Keep window blinds and drapery out of reach  strangulation Ch. 45 Nursing Care of the Child with an Alteration in Tissue Integrity/Integumentary Disorder Seborrheic Dermatitis (SD)  Seborrhea is a chronic inflammatory dermatitis that may occur on the skin or scalp  occurs most often on the scalp, commonly referred to as cradle cap  The yeast in Pityrosporum ovale is believed to play a role in dev  genetic and environmental factors influence the course of the disease  Presents as dry, mild, white or yellow scales  more severe appear as dull, red plaques w/thick white or yellow scale in a diffuse distribution  In infants it may also manifest on the nose or eyebrows, behind the ears, nasolabial folds, inguinal areas, or in the diaper area  usually resolves over a period of weeks to months  Therapeutic mgmt  treating the skin lesions w/corticosteroid creams or lotions. Antidandruff shampoos containing selenium sulfide, ketoconazole, or tar are used to treat the scalp  Nursing Assessment o Health hx, determining onset and progression of skin and scalp changes o Inspect the scalp and forehead, behind the ears, and the neck, trunk, and diaper area for thick or flaky greasy scales  Nursing Mgmt o Wash or shampoo the affected areas w/a mild soap o Apply anti-inflammatory cream to lesions if prescribed o Apply mineral oil to the scalp, massage it well w/a washcloth, then shampoo 10-15 mins later, using a brush to gently lift the crusts Diaper Dermatitis pg. 1751  Refers to an inflammatory reaction of the skin in the area covered by the diaper  nonimmunological response to a skin irritant that results in skin cell hydration disturbance  Prolonged exposure to urine and feces  skin breakdown  Diaper wearing ↑ skin’s pH, activating fecal enzymes that further contribute to skin maceration  May occur as a result of contact w/disposable diapers, soaps, fabric softeners, acid of feces and bacteria of urine from infrequent cleaning of skin, excessive heat in warm climates, or diarrhea

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Nursing Assessment o Determine if infant wears diapers o Ask about onset/progression of rash and tx and response o Inspect skin for erythema and maceration o Rash shouldn’t be bumpy; it starts as a flat red rash in the convex skin creases o May appear red and shiny and may or may not have papules o Untreated, it may become more widespread or severe  Nursing Mgmt o Prevention is best but topical ointments or creams containing vitamins A, D, and E; zinc oxide; or petrolatum are helpful to provide a barrier to the skin  Prevention and Mgmt o Chg diapers frequently o Avoid rubber pants o Gently wash the diaper area w/a soft cloth, avoiding harsh soaps o Use baby wipes but avoid wipes that contain fragrance or preservatives o Once rash has occurred  allow child to go diaperless for a period of time each day to allow the rash to heal. Blow dry the diaper area/rash area w/the dryer set on the warm setting for 3-5 mins o Sitz baths  baking soda in tub several times/day for a few mins  pat area dry, apply ointment o For candida rashes  Lotrimin  avoid topical corticosteroid ointments o Bacterial infection  antibiotic  Mupirocin Atopic Dermatitis (Eczema)  Extremely pruritic skin disorder involving cutaneous hypersensitivity  inflamed, reddened, and swollen skin  relapse and remitting in nature  The skin response occurs in response to specific allergens, usually food or environmental triggers  Contributions to flare ups  high or low ambient temps, perspiring, scratching, skin irritants, or stress  Genetic predisposition  if 1 parent has allergies  60% chance of AD, if both parents  80% chance of AD  Correlation btwn asthma and AD  atopy fam  Characteristic lesions dev secondary to trauma (scratching)  Self-image may be affected  psychological distress from chronic itching  Difficulty sleeping may occur bc of itching  irritable and difficulty concentrating and fam life disrupted  Parents stress ↑, child’s anxiety ↑= ↑ itching and scratching  Child may outgrow AD or can have difficulties into adult years  Nursing Assessment o Health hx  hx of asthma or allergic rhinitis, food/environmental allergies, disrupted sleep, scratch marks, dry skin o Determine onset of rash, location, progression, severity, response to tx used  Clinical Manifestations

o Acute  pruritus and erythematous patches w/vesicles, exudate, and crust o Subacute  scaling w/erythema and excoriation, some patches may weep o Chronic  pruritus, dryness, scaling, and lichenification o Skin folds such as antecubital and popliteal areas are often affected  Nursing Mgmt o Focus on promoting skin hydration, maintaining skin integrity, and preventing infection o Avoid hot water and any skin/hair product containing perfumes, dyes, or fragrance o Bathe child twice/day in warm water, use mild soap to clean only the dirty areas o Pat dry after bath, don’t rub the skin and leave child moist then apply ointments to affected areas  apply fragrance free moisturizer over the ointment and all over the child’s body. Lubricants  petroleum, cetaphil, eucerin cream, Lubriderm, Crisco o Cut child’s fingernails short and keep clean  prevent infection o Antihistamines may be given HS o Topical steroids  apply thin layer 2x/day for 7-14 days, hydrocortisone cream Ch. 43 Nursing Care of the Child w/an Alternation in Urinary Elimination/GU Disorder Vesicoureteral Reflux pg. 1642  VUR  urine from the bladder flows back up the ureters  this reflux occurs during bladder contraction w/voiding  If reflux occurs when the urine is infected, kidney is exposed to bacteria  pyelonephritis  Increased pressure placed upon kidney  scarring and HTN later in life  severe = renal insufficiency or failure  Primary VUR from congenital abnormality in vesicoureteral junction  incompetence of the valve  Secondary VUR from structural/functional probs (bladder dysfunction, obstruction)  Graded scale I-V  I-II usually resolve spontaneously  III-V generally associated w/recurrent UTIs, hydronephrosis, & progressive renal damage  Goal of therapeutic mgmt  prev of pyelonephritis and renal scarring which can lead to HTN  antibiotic prophylaxis (no evidence of it being beneficial)  hygiene to prev UTI  Radionuclide VCUGs performed once to a few times/year to determine status of VUR. Also used to diagnose and grade  When doing health hx, ask about UTIs and fam hx of VUR. In follow up ask if any UTIs have occurred since last visit  Nursing Mgmt o Prevent infection  teach child to empty bladder completely and hygiene o Child will be on low dose antibiotic to prev UTI  best given HS o Parents should schedule serial urine cultures and follow up VCUG o Postop care  if severe, sx correction will be needed. IV fluids 24-48 postop. Monitor UO through Foley (bloody initially) and clearing within 2-3 days. Encourage ambulation. Antibiotics for 1-2 months after sx. Check output from all drains and record, observe drainage from abdominal dressing Exstrophy of the Bladder pg. 1638

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Congenital defect  bladder is open and exposed outside of the abdomen due to nonfusion of abdominal and anterior walls of the bladder during embryonic dev  Urine continuously leaks from an open urethra  Nursing mgmt  prev infection, skin breakdown, and provide post op care and catheterizing the stoma  Postop o Keep infant supine and quickly chg soiled diapers to prev contamination o Indwelling urethral cath or suprapubic tube will allow drainage and allow bladder to rest initially o Mgmt of bladder spasm  meds as ordered o Blood tinged urine clearing within hours to days  Catheterizing the Stoma o If bladder tissue is insufficient for repair, bladder is removed and a reservoir is created o A stoma is created on the abdominal wall and provides access to the reservoir  cath ~4 times/day to empty o Urine tends to be mucus-like and cloudier than urine from bladder o Teach parents cath procedure and to call Dr. if any s/s UTI occur  Side Note: children w/congenital urologic malformations are at high r/f dev of latex allergy. Primary prev of la...