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PEDS Final 1
PEDIATRICS (ss)
Kentucky State University
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PEDS FINAL EXAM 1 Growth and Development Growth- increase in physical size of a structure or whole. -quantitative change. Two parameters of Growth 1. weight- most sensitive measure of growth, especially low birth rate. Wt doubles 6 months 3x 1yr 4x 2-2 ½ yrs 2. Height- increase by 1”/mo during 1st 6 months - average increase in ht - 1st year = 50% stoppage of ht coincide with eruption of wisdom tooth. Development- increase skills or capability to function - qualitative How to measure development 1. Observe child doing specific task. 2. Role description of child’s progress 3. DDST- Denver development screening test. MMDST (Phil) Metro Manila Developmental Screening Test. DDST measures mental 4 main rated categories of DDST 1. Language communication 2. personal social-interaction 3. fine motor adaptive- ability to use hand movement 4. gross motor skills- large body movement maturation- same with development “readiness” Cognitive development –ability to learn and understand from experience to acquire and retain knowledge. To respond to a new situation and to solve problems. IQ test- test to determine cognitive development Mental age x 100 = IQ Chronological age Average IQ – 90-100 Gifted child- > 130 IQ Basic Divisions of Life I. Prenatal stage from conception- birth II. 1. 2. Period of infancy Neonatal- 1st 28 days or 1st 4 weeks of life Formal infancy- 29 day – 1 year III. 1. 2. Early childhood Toddler – 1-3 yrs Pre school 4-6 years 1 IV. 1. Middle childhood School age- 7 – 12 yrs V. 1. 2. Late childhood Pre adolescent 11 – 13 yrs Adolescent 12 - 18 – 21 Principles of G & D 1. G&D is a continuous process -begins form conception- ends in death - womb to tomb principles 2. not all parts of the body grow at the same time or at same rate. - asynchronism Patterns of G&D 1. )renal digestive circulatory musculoskeletal grows rapidly during childhood 2. )Neuromuscular tissue (CNS, brain, S. cord) - grow rapidly 1-2 years of life - brain achieved its adult proportion by 5 years. 3. )Lymphatic system- lymph nodes, spleen grows rapidly- infancy and childhood to provide protection -infection - tonsil adult proportion by 5 years 4. )Repro organ- grows rapidly at puberty Rates of G&D 1. fetal and infancy – most rapid G&D 2. adolescent- rapid G&D 3. toddler- slow G period 4. Toddler and preschool- alternating rapid and slow 5. school age- slower growth fetal and infancy- prone to develop anemia 3. Each child is unique 2 primary factors affecting G&D A. Heredity R – race I – intelligence S – sex N - nationality Females are born less in weight than males by 1 oz. Females are born less in length than males by 1 inch B. Environment Q – quality of nutrition S – socio eco. status H – health O – ordinal pos in family P – parent child relationship Eldest- skillful in language and social skills 2 site of gratification -genitals activity- may show exhibitionism -increase knowledge of a sexes -accept child fondling his/her own genitalia as normal exploration -answer Childs question directly. Right age to introduce sexuality – preschool d.) Latent- 7-12 years -period of suppression- no obvious development. -Childs libido or energy is diverted to more concrete type of thinking -helps child achieve (+) experience so ready to face conflict of adolescence e.) Genital- 12-18 years -site of gratification -genitals -achieve sexual maturity -learns to establish relationships with opposite sex. -give an opportunity to relate to opposite sex. ERIC ERICKSON- psychoanalysis theory - stresses important of culture and society to the development of ones personality - environment - culture stages of psychosocial a.) trust vs mistrust – 0-18 months. -foundations of all psychosocial task -to give and receive is the psychosocial theme -know to develop trust baby 1. satisfy needs on time - breastfeed 2. care must be consistent and adequate -both parents- 1st 1 year of life 3.) give an experience that will add to security- touch, eye to eye contact, soft music. b.) Autonomy vs shame and doubt 18-3 years --- independence /self gov’t develop autonomy on toddler 1. give an opportunity of decision making like offer choices. 2. encourage to make decision rather then judge. 3. set limits c. initiative vs guilt- 4-6 years -learns how to do basic things -let explore new places and events -activity recommended- modeling clay, finger painting will enhance imagination and creativity and facilitate fine motor dev’t d. industry vs inferiority 7-12 yrs -child learns how to do things well -give short assignments and projects e. Identity vs role confusion or diffusion 12-18 yrs - learns who he/she is or what kind of person he/ she will become by adjusting to new body image and seeking emancipation form parents -freedom form parents. f. Intimacy vs isolation 20-40 yrs -looking for a lifetime partner and career focus 4 g. generatively vs stagnation 40- 60 45-65 yrs h. ego integrity vs, despair 60-65 JEAN PIAGET- Swiss psychologists -develop reasoning power STAGES OF COGNITIVE DEVELOPMENT A-Sensory motor 0-2 yrs -“practical intelligence”- words and symbols not yet available baby communicates through senses and reflexes. (sub div.) Schema 1.) neonate reflex 2.) primary circular Age 1 month 1-4 months 3.) secondary circular reaction 4-8 months Coordination of secondary reaction 8-12 months Tertiary circular reaction 12-18 months Invention of new means there mental combination 18-24 months Behavior All reflexes -Activity related to body -repetition of behavior ex. thumb sucking -activity not related to body -discover obj and person’s permanence -memory traces present -anticipate familiar events. -exhibit goal directed behavior -increase of separateness (will search of lost toy, knows mom) -use trial and error to discover places and events -“ invention of new means” -capable of space and time perception (hits fork, spoon on table or drops fork) -transitional phase to the pre operational thought period. Preoperational thought 2-7 years Schema Preconceptua l age 2-4 yrs Initiative 4-7 yrs Behavior -thinking basically complete literal and static -egocentric- unable to view others interrupt -concept of dying is only now -concept of distance is only as fat as they can see. -concept of amenism inanimate object is alive -not aware of concept of r3eversibility- in every action theories an opposite reaction or cause and effect Beginning of causation Concrete Operational thought 7-12 years 1. able to find solution to everyday problems which systematic reasoning. 2. have concept of reversibility- cause and effect 3. have concept of longer uation – constancy despite of transformation. 4. 4. activity recommended- collecting and classifying 5. –stamps stationeries, dolls, rubber band markers. Formal Operational thought 12 and up. 5 head control complete needs space to turn Laugh aloud, bubbling sounds 5 months- turn both ways “roll over” -teething rings -handles rattle well -moro reflex disappears ( 4-5 months) 6 months- reaches out in anticipatory of being picked up -sits with support -uses palmar grasp -eruption of 1st temp teeth 6-8 months 2 lower incisors -say vowel sounds “ah”, “oh” -handles bottle well 7 months- transfer obj. hand to hand -likes obj that are good size 8 months- sits without support -peak of stranger anxiety -planters reflex disappears 8-9 months in prep for walking 9 months - creeps or crawls -neat finger grasp reflex - combine 2 syllables “mama” and “papa” - needs space for creeping 10 months – pull self to stand -understands “no” -responds to own name -peak a boo, pat a cake -can clap 11 months- cruisse - stands with assistance 12 months- stand alone take 1st step -walk with assistance -drink from cup, cooperate in dressing -says 2 words mama and dada -pots and pans, pull tay, nursery rhymes Toddler- parallel play- 2 toddlers playing separately -provide with similar toys -squeaky frog to squeeze waddling duck to pull trucks to push-push pull toy building blocks, pounding peg toys to ride on fear- separation anxiety begin 9 months peak 18 months 3 phases of separation anxiety (in order) 1. P- protect 2. d despair 3. d- denial 7 -don’t prolong goodbye -say goodbye firmly to develop trust- say when ul be back 15 months – plateau stage walks alone lateness in walking- mild mental retardation -puts small pellets into small bowl -holds spoon well - seats self on chair -creeps up stairs - 4 - 6 words 18 months- height of possessiveness favorite word- “mine” bowel control achieved (bowel 1st before bladder) -no longer rotates spoon -can run and jump in place walks up and down stairs holding railing or persons hand -1-20 words -name, body part -puts both feet on 1 step before advancing. 24 months- terrible two -can open doors by turning door knobs -unscrew lids -can walk upstairs alone –using both feet on same step at same time -50-200 words ( 2 words sentences) -daytime bladder control achieved ( daytime 1st- next nighttime bladder control) 30 months or 2 ½ years – makes simple lines or stroke for crosses with a pencil -can jump down from chairs -knows full name - copy a circle - holds up finger to show age - temp teeth complete post molar- last temp teeth to appear how many deciduous teeth -20 beginning of toothbrush – 2-2 ½ yrs tooth brushing with little assistance 3 yrs tooth brushing alone – 6 yrs right time to bring to dentist- when temp teeth complete 36 months or 3 yrs- trusting 3 - unbutton buttons (unbutton before learn to button) -draw a + - learns how to share -knows full name and sex (gender identity) - speaks fluently -nighttime bladder control -300-900 words -ride a tricycle 8 1. 2. 3. 4. telling tall tales-over imagination imaginary friend- to release tension and anxieties sibling rivalry- jealousy to newly delivered baby. regression- going back to early stage -thumb sucking (should be oral stage only) -baby talk -bed wetting -fetal position 5. masturbation- sign of boredom -divert attention- offer a toy School Age Play- competitive play Ex. Tug of war, track and field, basket ball Fear. 1.) school phobia -orient to new environment 2.) displacement from school -teacher and peer of same sex 3. loss of privacy -wants bra 4.) fear of death -7-9yrs death is personified -death- permanent loss of life Significant Development a. boys- prone to bone fracture b. mature vision 20/20 6 years- temp teeth begin to fall perm teeth appear- 1st molar 1st temp teeth- 5 months 1st perm teeth- 6 yrs -yr of constant motion clensy mou’t recognize all shapes -1st grade teacher becomes authority figure -nail biting -begin interest in God. 7 yrs- assimilation age -copy a diamond -enjoys teasing and playing alone -quieting down period 8 yrs- expansive age -smoother mouth -loves to collect objects -count backwards 9 yrs –coordination improves -tells time correctly -hero worship -stealing and lying are common -takes care of body needs completely -teacher finds this group difficult to handle 10 yrs- age of special talent 10 -writes legibly -ready for competitive games -more considerate and cooperative -joins orgs. -well mannered with adult -critical of adults 11-12 yrs – pre adolescents -full of energy and constantly active -secret language are common -share with friends secrets -sense of humor present -social and cooperative Character Traits School Age 1. industrious2. modest 3. can’t bear to lose- will cheat 4. love collections- stamps Signs of sexual maturity GIRLS: I-inc size breast and genitalia (pelarche- 1st sign sexual mat. W- widening of hips A- appearance axillary, pubic ( adrenarch) M- menarche- last sign sexual mat. Girls BOYS: A-appearance axillary, pubic hair ( 1st sign sexual mat) D-deepening voice D- development of muscles I--inc in testes and penis size P- prod of viable sperm ( last sign sexual maturity) Adolescent Fear 1. obesity 2. acne 3. homosexuality 4. death 5. replacement from friends 6. significant person- opp sex. Significant dev’t 1. experiences conflict bet his needs for sexual satisfaction and societies expectation 2. change of body image and acceptance of opp/sex 3. nocturnal emission – wet dreams 4. distinctive odor- due to stimulation apocrine glands 5. sperm is viable by 17 yrs 6. testes & scrotum increase until age 17 7. breast and female genitalia increase until age 18 Personality Traits Adolescents 1. idealistic 2. rebellious 3. reformers 4. conscious with body image 5. adventuresome 11 2.) Establishing extra uterine circulation - circulation is initiated by lung expansion or pulmo ventilation and completed by cutting of cord. FETO PLACENTAL CIRCULATION -Placenta(simple diffusion) –oxygenated blood is carried by the umbilical vein- passes liver-ductus venousus- IVC- RT atrium 70% blood is shunted to foramen ovale- LT atrium mitral valve – LT ventricleaorta-lower extremities. -Remaining 30%- tricuspid valve- RT ventricle- pulmonary arteries- lungs (for nutrition) (vasoconstriction of lungs pushes blood to ductus arteriousus to aorta to supply upper extremities. SHUNTS-shortcuts Ductus venosus- -shunts from liver to IVF Foramen ovale- shunts bet 2 atrias Ductus arteriosus- from pulmonary artery to aorta Decrease PO2, increase PCO2 acidosis Will cause 1st breath /cry of baby Decrease pulmo artery pressure Increase PO2 Decrease blood flow Increase pressure to Lt side of heart Closure of ductus arteriosus Closure of ductus venosus & AVAClosure of foramen ovale What will sustain 1st breath- decreased artery pressure What will initiate lung circulation-lung expansion What will complete circulation- cutting of cord 4.) 2 way to facilitate closure of foramen ovale a.) Tangential Footstep- slap foot of baby 13 -never stimulate baby to cry if secretions not fully drained to prevent aspiration -check characteristic of cry normal cry- strong, vigorous and lusty cry cri-du-chat syndrome-chromosomal obliteration cat like cry b.) proper position -right side lying pos. -will increase pressure on left and foramen ovale will close Foramen Ovale and Ductus arteriosus will begin to close within 24h Obliteration-complete closure Structure F. Ovale Ductus Arteriosus Ductus Venosus Umbilical artery Umbilical vein Appropriate time of obliteration 1yr 1 month Structure remaining Failure to close Fossa Ovalis Ligamentum Arteriosum Atrial Septal Defect Patent ductus arteriosus 2 months Ligamentum venosum 2-3 months 1.) lateral umb. Ligament 2.) interior iliac artery -ligamentum teres ( round ligament of liver) 2-3 months Position of infant immediately after birth: NSD-trendelenberg/ T position for drainage contraindication of trendelenberg position - increase ICP CS- supine or crib level position Signs of increased ICP 1.) 2.) 3.) 4.) 5.) 6.) 7.) abnormally large head bulging and tense fontanel increase BP and widening pulse pressure Decreased RR, decreased PR projective vomiting- sure sign of cerebral irritation high deviation – diplopia – sign of ICP older child 4-6 months- normal eye deviation >6 months- lazy eyes High pitch shrill cry-late sign of ICP #3 & #4 are Cushings triad of ICP Temp Regulation - goal in temp regulation is to maintain it not less than 97% F (36 C) - maintenance of temp is crucial on preterm and SGA (small for gestational age) - babies prone to hypothermia or cold stress A. factors leading to dev’t of HYPOTHERMIA 1. preterms are born poi kilo thermic- cold blooded - babies easily adapt to temp of environment due to immaturity of thermo regulating system of body. Hypothalamus 2. inadequate SQ tissue 3. baby is not capable of shivering 4. babies are born wet 14 content: inc lactose, inc water soluble vit., inc minerals 3. Mature milk- 14 & up content: inc fats (linoleic acid) – resp for devt of brain & integrity of skin inc CHO- lactose – easily digested, baby not constipated. - resp of sour milk smelling odor of stool. Lactose intolerance- deficiency of enzyme LACTASE that digest LACTOSE Decrease CHON- lactalbumin Cows milk – inc fatsDec CHO Inc CHON – casing- has curd that’s hard to digest. Inc minerals–traumatic effect on kidneys of babies. Can trigger stone formation. Inc phosphorus Health Teachings: 1. Proper hygiene- proper hand washing Care of breast - cotton balls with lukewarm water Caked colostrum- dry milk on breast 2. Best position in breastfeeding – upright sitting -avoid tension! 3. Stimulate & evaluate feeding reflexes a.) Rooting reflex- by touching the side of lips/cheeks then baby will turn to stimulus. Disappear by 6 weeks- by 6 weeks baby can focus. Reflex will be gone - Purpose rooting- to look for food. b.) Sucking – when you touch middle of lips then baby will suck - Disappears by 6 months - When not stimulated sucking will stop. c.) Swallowing- when food touches posterior of tongue then it will be automatically swallowed d.) Extrusion/ Protrusion reflex -when food touches anterior portion of tongue then food will be extruded. Purpose: to prevent from poisoning Disappear by 4 months & baby can already spit out by 4 months. Criteria Effective Sucking a.) Baby’s mouth is hiked up to areola b.) Mom experiences after pain. c.) Other nipple is also flowing with milk. To prevent from crack nipples & initiate proper production of oxytocin. - begin 2-3 min at @ breast ( 5 – 7 min other authors) to initiate production of oxytocin - increase 1 min/ day – until reaching 10 mins @ breast or 20 mins/ feeding. For proper emptying & continuous milk production / feeding -feed baby on last breast that you feed her with, alternately ( if not emptied - mastitis) Problems experienced in Breastfeeding : 3RD day changes in breast post partum a.)Engorged- feeling of fullness & tension in breast. - sometimes accompanied by fever known as MILK FEVER. Mgt: Warm compress- for breastfeeding mom Cold compress – for bottle feeding & wear supportive bra. When is involution of breast- 4 weeks b.) Sore nipple – cracked with painful nipple Mgt: 1.) exposure to air – remove bra & wear dress, if not, expose to 20 Watt bulb 16 avoid wearing plastic liner bra - will create moisture, cotton only c.) Mastitis- inflammation of breast : staphylococcus aureus Factors: 1. Improper breast emptying 2. Unhealthy sexual practices -contraindicated for breast feeding - manually express inflamed breast feed on unaffected breast - give antibiotics – can still feed on unaffected breast Contra Indications in Breast Feeding: Maternal Conditions: 1. HIV CMV Hepa B Coumadin Newborn Condition - Inborn errors of metabolism Erythrobastosis Fetalis – Rh incompatibility Hydrops Fetalis Phenylketonuria Galactosemia Tay Sachs disease 5. Establish of waste elimination A. Diff stools 1. Meconium - physiologic stool - black green, sticky, tar like, odorless (Sterile intestine) will pass with in 24 – 36 hrs failure to pass mecomium after 24h- GIT obstruction ex. Hirschsprungs disease imperforate anus mecomium ileus – due to Cystic Fibrosis 2. Transitional stool - green loose & shiny, like diarrhea to the untrained eye 3. Breastfed stool - golden yellow, soft, mushy with sour milk smell, frequently passed - recur every feeding 4. Bottlefed stool – - pale yellow, formed hard with typical offensive odor, seldom passed, 2–3 x/day - with food added -brown & odorous Jaundice baby – Under phototherapy – Mucus mixed with stool Clay colored stool – Chalk clay stool – Black stool – Blood flecked stool Currant jelly stool – Ribbon like stool – Steatorrhea stool – Cult blood – light stool bright green milk allergy obstruction to bile duct after barium enema GIT bleeding (melena) anal fissure. instussusection hirschsprung disease fatty, bulky foul smelling odor stool - malabasorption syndrome ( celiac disease or cystic fibrosis) stool exam III Assessment for Well–being APGAR SCORE – Dr. Virginia Apgar Special Considerations: 1st 1 min – determine general condition of baby Next 5 min- determine baby’s capabilities to adjust extra uterinely 17 Circulation Check for pulslessness :carotid- adult Brachial – infants CPR – breathless/pulseless Compression – inf – 1 finger breath below nipple line or 2 finger breaths or thumb CPR inf 1:5 Adults 2:15 Assessment tool determines respiration of baby Silvermann Anderson Index Respiration Evaluation – lowest score – best Criteria 0 1 Chest movement synchronized Lag on respiration Intercostal No Just visible retraction retraction Xiphoid retraction None Just visible Nares dilatation None Minimal Expiratory grunt None Heard on stet only 2 See - saw Marked Marked Marked Heard on naked ear Interpretation result: 0 -3 – normal, no RDS 4 – 6 – moderate RDS 7 – 10 – severe RDS Assessment of Gestational Age -Ballards & Dobowitz Findings Less 36 weeks (Preterm) Sole creases Anterior transverse crease only Breast nodules 2mm Scalp hair Fine & fuzzy Ear lobe Pliable Testes and testes in lower canal Scrotum Scrotum – small few rugae 37 - 38 Occasional creases 2/3 in 4mm or 3 mm Fine & fuzzy Some cartilage Some intermediate 39 and up Covered with creases > 5 or 7mm Coarse & silky Thick cartilage Testes pendulus Scrotum full extensive rugae Signs of Preterm Babies Born after 20 weeks, after 37 weeks -frog leg or laxed positon -hypotonic muscle tone- prone resp problem -scarf sign – elbow passes midline pos. - square window wrist – 90 degree angle of wrist - heal to ear signabundant lanugoSigns of Post term babies: > 42 weeks - classic sign – old man’s face - desquamation – peeling of skin - long brittle finger nails - wide & alert eyes Neonates in Nursery Nsg responsibility upon receiving baby- proper identification 19
PEDS Final 1
Course: PEDIATRICS (ss)
University: Kentucky State University
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