Peds Review 1 PDF

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Pediatrics Review - 40 Topics Physical/Cognitive/Psychosocial Development, Vaccinations, Cardiac, GI/GU Conditions, Spinal Cord/Spina Bifida, ICP, Hydrocephalus 1. Physical development 

Infant: 0-1 year old i. Physical development- Birth weight doubles in 6 months and triples at 12 months. ii. Cephalocaudal -holds head upright before walking not answer iii. Proximal to distal- center to periphery, control trunk and fine motor skills iv. Respirations of 30-60 are normal for infants. They are nose breathers. Don’t want the baby to stop breathing over 20 seconds. v. Growth: Head circumference is measured from birth until age 2 to make sure brain has room to grow.

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3 month old: i. Psych: Smile , knows primary caregiver. ii. Toys: mobile, mirror.

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6 month old: i. Psych: apprehension of stranger’s babbles and coos. ii. Motor: Laughs, rolls, sits, no head lag, hand-to-hand transfer. iii. Toys: rattles (palmar grasp), and soft toys

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9 month old: i. Psych: waves, stranger anxiety, crying, object performance, peekaboo ii. Motor: sits, (Pincer grasp), pulls to stand (Cruising) 1st steps of walking using furniture for support.

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Toddler 1-3 years old: i. Physical development: birth weight quadruples by 3 yrs. anterior fontanel closes at 12-18 months. Sphincter control begins by age 2. (Potty training) Potbelly appearance, bowed legs

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12 month old/ 1 year old: i. Psych: imitates, mama & dada has meaning, 2 words ii. Motor: turns pages, walks with assistance, and stands without assistance iii. Toys: Push toys, Nesting toys

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18 month old: i. Psych: up to 25 words & 2-3 phrases, expressive jargon, MY, separation anxiety ii. Motor: Walks independently by 15 months, uses spoons and shovels, climbs, 3-4-block tower. Should be concerned if they are not walking by 15 months iii. Toys: Push and pull toys, blocks, cause and effect.

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24 month old/ 2 year old i. Psych: negativistic behavior, transitional objects, temper tantrums, NO! ii. Motor: can go up and down stairs, removes clothes iii. Play: Parallel play (two toddlers playing side by side separately), manipulation of environment

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Preschool Age 3-6 year olds i. Physical Development: weight gain + 3-5 pounds per year, vision 20/40, 20 deciduous teeth, handedness established, day time toilet training complete,

associative play. ii. Play- Associative play (playing together) associative and dramatic: loosely organized groups, rules change role play: mommy, daddy, daughter, doctor, nurse, teacher iii. Toys: tricycle, dress up, dolls, coloring books iv. Hospital nursing care: Give them control and choices. What juice would you like to take with your medication apple juice or orange juice? Daddy will be back when barney is playing on TV. 

3 year olds i. Psych: talkative, agreeable, nightmares, knows first and last name, knows gender differences, masturbates which is normal manage with diversion, ii. Motor: runs well, peddles a tricycle, walks on tip toe, alternative feet going up and down, 9-10 block tower.

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4-5 year olds i. Psych: magical thinking/ fear of monsters so says you have monster spray to kill monsters under their bed. They are concrete thinkers. ii. Stuttering is normal, fear of body mutilation needs Band-Aid for everything, inquisitive ii. Motor: alternative feet on stairs, uses scissors, catches ball

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School age child 6-12 year olds i. Physical Development: permanent teeth, weight doubles between ages of 6 and 12 boys and girls close in size, 20/20 vision on Snellen chart, enuresis and sleepwalking are common issues. ii. Psych: same gender friends, collections, enjoys school (competition and

cooperation), Develops morals bring schoolwork to hospital iii. Motor- refinement of coordination and balance, two wheeler, cursive writing 

Adolescence 13-18 year olds i. Physical Development: 1. Rapid growth rate 2. Puberty (Tanner Scale 1-5), a. Female begins at 10-14 years old, order of girls’ secondary development: height spurt, breast development, pubic hair, and menarche. Menarche 12-13 years (hgt 95% of adult at onset), b. Male onset is 12-16 years (95% of adult height at age 15). Order of boy’s secondary development: testes enlarge, pubic hair, penis increases, height spurt, voice change, facial hair. ii. Psych: rebellious, peer pressure, body image, fearless, sneaking out, invincible, friends are the most important thing of life, first intimate relationship, heartbreak) iii. Play: activities, clique formation, team sports, intimate relationships iv. Hospitalizations: separation, body image (privacy and clothes), and noncompliance

2. Parallel play and associative play 

Parallel play - two toddlers playing side by side separately

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Associative play - Preschool aged kids playing together

3. Fontanels - physical changes at what point 

Posterior Fontanel- closes at 3 months

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Anterior fontanel- closes at 12-18 months

4. Safety for each age group - anticipatory guidance on each age group 

Infant: i. Car seat ii. Breathing iii. Sleeping iv. Body temperature

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Toddler: i. Discipline - time outs placing the child in a safe non-stimulating area. One minute for each year of age. ii. Water safety - never unattended iii. Car seats - until 4 years legally iv. Accidental ingestions - locks and latches, original containers v. Choking - small frequent meals, monitor feeding, all foods cut into small pieces for young toddlers vi. Positioning- monitor toddler

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Preschool: i. Street and bike/pedestrian safety - bikes travel with traffic on the right, pedestrian’s travel against traffic on the left. ii. Safety around animals- never approach animals you don’t know including

wild animals. iii. Car seat- until 4 years, and booster seats until 60 pounds. 

School age: i. Bike safety-helmets and right side of the road ii. Home fire drills iii. Interactions with strangers- (stranger danger)

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Adolescence: i. Nutrition (iron and calcium) ii. MVA iii. Personal safety issues (sex, suicide, drug abuse)

5. Sequence is specific not the rate. 

Not all children will have same patterns of growth and development however they will all achieve their milestones. Each child is different. It’s a sequential pattern Sequence is specific, not the rate. Rate is uneven and individual with greatest speed during infancy and puberty.

6. Nursing interventions for children in the hospital: 

Follow child’s daily routines, comfort measures, have parents present, consistent nurses, regression explain to parents this is normal i. Example: In the hospital try to keep the child's daily routine from their home. If they play, eat, and then nap do that in the hospital. ii. Regression is normal for children after hospitalization. This is temporary. The child will regain losses when they leave the hospital.

7. Erickson’s stages 

Infant (1month-1year) Trust vs. Mistrust

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Toddler (age 2-3) Autonomy vs. Shame and Doubt

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Preschool (age 4-6) Initiative vs. Guilt

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School (age 6-12) Industry vs. Inferiority

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Adolescent (age 12-18) Identity vs. Role confusion

8. Nursing assessment on infant: 

You always want to do the least invasive intervention before the more invasive intervention. i. Example: listen to lungs first before waking baby up. Listen to lungs before Blood pressure. Head circumference over a blood pressure so if the child is scared of you can do more things. All nursing interventions and safety are geared towards growth and development

9. Cruising: 1st steps in walking they hold on to furniture. It occurs right before the baby learns to walk independently. Usually develops at 9-13 months.

10. Pincer grasp- developed at 9 months. You can start giving baby cheerios and table food because they can pincer grasp it. 11. Infant nutrition- Nutrition question the answer will always be iron 

BM/ Formula: Fluoride, Iron, and Vitamin D

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Solids 4-6 months begin with rice. Saliva, sitting, tongue

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Table food at 9 months because they can Pincer grasp

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Healthy infants under 1 year are weaned onto commercially prepared iron fortified formula. They need supplemental iron to replaced used iron stores.

12. Speak to children in ways they understand: 

Example: Mommy will be back when Barney is on.

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When talking to a school aged child don’t talk about the nutrition label, talk about how a banana is good for them so they should eat them.

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When giving child medication ask if they want apple juice or orange juice with the medication?

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Never lie to the child and tell them its candy…they will never trust you again if you lie to them.

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Routine is important: i. “When Barney is over you are going to take your medication” (They don’t have concept of time so give them things they can relate to) – “You are going to play, take a nap, eat, and then daddy will be back.”

13. Regression is normal after hospitalization. 

While the child is in the hospital maintain routine, stick to consistent caregivers, and expect regression. Regression is normal after hospitalization. It’s only temporary. The child will regain losses when you leave.

14. Child’s age group -important things in hospitalization 

Infant - newborn assessment, infants needs to be met including nutrition, warmth, stimulation, sleep, and comfort. Encourage rooming in, place near the nurses station, consistent nursing staff, hold for feedings, sucking/ pacifier use.

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Toddler- separation (rooming in, transitional object), loss of control (immobilization and isolation are major stressors, offer choices, set limits, painful procedure should

be done in the treatment room, preparation should be immediately prior to event), and regression (reassure and educate parents this is normal), and educate parents on choking, water, and car seat safety for all age groups. 

Preschool - rooming in, family pictures, phone calls, leaving parents belongings behind, body mutilation- fear of intrusive procedures, band aids on everything. Loss of control- offer choices, set limits. Example: “DO you want juice or milk with your medication?”; “You are going to have breakfast, then you will take a nap, and then daddy will be here.”

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School aged - separation from family and school, letters from peers, telephone calls, tolerates separation but prefers parents close by, maintain schoolwork. Fear of bodily/mutilation, fear of pain, scientific explanations. Need for privacy. Example: explain to them how bananas are good for you so you should eat them don’t explain the nutrition label.

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Adolescents - let friends visit, give them their phone. Separation, body image (privacy and clothes) and noncompliance.

15. Timeline of our active vaccines 

Birth- Hepatitis B

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1-2 months - Hepatitis B

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2 months- DTaP, Hib, IPV, PCV, Rota

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4 months- DTaP, Hib, IPV, PCV, Rota

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6 months- DTaP, Hib, PCV, Rota, Influenza at 6 months and then annually

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12-15 months- HIB, PCV, IPV, MMR, Varicella

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12 months- Hepatitis A and then 6 months later second dose

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15 months - DTaP

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6-18 months - Hepatitis B, IPV

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5 years - DTaP, IPV, MMR, Varicella

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9-18 years - HPV 3 doses

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11-12 years - Meningococcal

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Know contraindications - example: DTaP: don’t give if there has been a neurological effect

16. Understand toddler milestones- what we expect in a toddler - speech, physical, psychosocial development 

Speech - love saying NO

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Developing independence, tolerating frustration. They want to be independent. Potty training at 2

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18 month milestones i. Psych: up to 25 words and 2-3 word phrases, expressive jargon, MY, separation anxiety. ii. Motor: walks independently by 15 months. Uses tools: spoons and shovels. Climbs, 3-4 block towers. iii. Toys: Push and Pull toys, blocks, cause and effect.

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24 month/2 year milestones i. Psych: negative behavior, transitional objects, temper tantrums ii. Motor: up and down stairs, removes clothes iii. Play: parallel play and manipulation of environment iv. Nutrition: Toddlers need whole milk until age 2 they need more fat to grow. Biggest growth from birth - 2 years.

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3 year milestone i. Psychosocial: talkative, agreeable, nightmares/night terrors, knows first and last name, knows gender differences, masturbation (normal, managed with diversion) ii. Motor: Runs well, peddles tricycle, walks on tiptoe, alternates feet going up and down, 9-10 block tower.

17. Vaccines given at 2, 4, & 6 months. 

2 months - DTaP, Hib, IPV, PCV, Rota

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4 months - DTaP, Hib, IPV, PCV, Rota

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6 months - DTaP, Hib, PCV, Rota, Influenza at 6 months and then annually

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Select all that apply. DON’T PICK THE ANSWER WITH THE MMR. Remember MMR is to be given after 1 year.

18. If you remember what is not given its easy to remember what is given. MMR Varicella given after 1 year. 2 live vaccines MMR and Varicella given after 1 year because the baby needs 1 year to gain immune system. So a 2-month-old SHOULD NOT be given MMR and Varicella. 19. Major contraindications for the vaccines: anaphylaxis, & for DTAP if there is a neurological deficit 20. Cardiac- murmurs we talked about and what defect they come with 

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Congenital Heart Defects- Babies are born with this cardiac dysfunction o 3 types  Acyanotic (ASD, VSD, PDA)  Obstructive (Coarctation of the Aorta)  Cyanotic (tetralogy of Fallot) 4 types: (Ventricular septal defect, Pulmonary stenosis, overriding aorta, right ventricular hypertrophy) Acquired Heart Defects o Occurs after birth (infection/autoimmune disease) Atrial septum defect (ASD)

Abnormal opening between the 2 atria Acyanotic S/s: difficulty breathing when feeding Left side has more pressure so oxygenated blood pushes to the rt. causing pulmonary hypertension and cause right sided heart failure Ventricular Septal Defect (VSD) o Abnormal opening between the 2 ventricles o Acyanotic o S/s: same as ASD o Murmur sounds like a loud motorcycle o If baby is sweating while feeding baby is showing signs of distress Patent Ductus Arterious (PDA) o Ductus arteriosus connecting the aorta and pulmonary artery stay open (should close at birth and turn into a ligament) o Acyanotic o Machinery like sound o Management: NSAID given (Indomethacin) o S/s: same ASD, VSD, PDA (all acyanotic) all can lead to congestive heart failure (CHF) because of left to right shunts Left to right shunt common management o Diuretics (Lasix) o Digoxin but hold if bradycardia - infant less than 100 bpm or toddler no less than 80 o Tell the parent it slows and helps pump blood better from the heart o Soft nipple with bigger opening when feeding o High calorie formula b/c they burn so much calories from the heart issue and respiratory problems from this disease o Normal urine output 1-2 ml/kg/hr Coarctation of the aorta (COA) o Obstructive, Acyanotic defect o Poor perfusion o High pressure close to the area of the aorta (like the brain) o High BP in upper extremities and lower BP in lower o Bounding brachial pulses in comparison with femoral pulses and legs (weak or absent) o Echo can be done first, determines structure o Child can have leg cramps due to poor perfusion (hypoxic tissue) o Nose bleeds o Headaches o Catheterization – keep leg straight, and pressure in the site o o o o

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21. Cardiac babies 

Blood flow of the heart

o Inferior vena vena/superior vena cava right atriumright ventriclepulmonary artery (lungs) to exchange deoxgynated blood to oxygenated bloodpulmonary veinleft atriumleft ventricleaorta and out to the systemic area o Left side of the heart has more pressure 22. Failure to thrive - don’t grow may be metabolic, or from neglect they are not nourished and taken care of, or they have a cardiac defect, or cystic fibrosis. Feeding its work for them, they are burning calories; we want to avoid malnutrition for a child with a heart defect. Parent education is important for a child with cardiac defect Nursing intervention: they need to give them high calorie formula, increase density, GAVAGE: if they don’t finish their bottle you give it through OG or NG tube 23. Assessment of a child after cardiac catheterization 

Keep the legs straight and put pressure on the site

24. Bacterial infection can cause valvular issues 25. Babies that don’t feed well give higher calorie formula to the baby. Because they use calories trying to eat. Not necessarily small frequent meals but more of higher calorie formulas. 26. Acyanotic episode- nursing intervention 

Knees to chest

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Hyper cyanosis - put them in a knee check position. It has to do with the pressure changes to help the circulatory system them you can worry about oxygen. Blood gets thicker (Polycythemia), cyanotic

27. Digoxin 

Why is my baby getting Digoxin? Helps with contractility of the heart, decreases the heart rate and increases blood flow to the heart. More effective pump. Given

to pediatric patients who have left to right shunts. Give digoxin but hold if bradycardic - infant less then 100 bpm or toddler no less than 80 bpm 28. TET spell - Cyanotic episode 

NI - knee to chest first for infants and have toddler and older children kneel down, O2, fluids, morphine

29. Pyloric stenosis – develops in first few weeks of life (2-4 weeks) narrowing of the pyloric sphincter of the stomach to the small intestine that occurs in infants. Results in projectile vomiting. Palpate an olive shaped mass. Most easily palpated when child is quiet, stomach is empty, and abdominal muscles are relaxed. Pyloric ultrasound. Surgery is easy snip pyloric valve go home 24-48 hours.

30. Hirschsprung’s Disease (Megacolon) 

Disorder of Motility- Congenital anomaly. Obstruction from inadequate motility of part of the intestine. Absence of autonomic ganglion cells in the colon - no peristalsis. Intestinal contents accumulate and bowel distends=Megacolon

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Accounts for ¼ of all cases of neonatal intestinal obstructions. 4 times more common in males and follows a family pattern.

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Clinical manifestations- failure to pass meconium, food refusal, vomiting, intestinal obstruction, abdominal distention, FTT (failure to thrive) i. Ribbon-like, foul smelling stool. Bloody diarrhea, fever, and severe lethargy.

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Diagnosis- barium enema

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Management- surgery- removal of aganglionic portion of intestine to relieve obstruction. Temporary colostomy in many cases, prognosis is good.

31. Intussusception- obstructive disorder occurs between the ages of 3 months to 5 years.

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An invagination/telescoping of one part of the intestin...