pediatrics final

definitions - maturation, development, growth

• maturation

  • total way a person grows and develops; as dictated by genetics

• growth

  • is a measurement in numbers ie

    • HEIGHTandWEIGHT

    • shoe size

    • teeth

    • head circumference

    • bmi

• development

  • is a progression increase in body functions ie

    • baby learning to sit, walk, run

growth patterns

1. cephalocaudal: is the first one, upper part grows faster than the rest of body-quicker in M than F

2. secondary is proximodistal - body grows middle outward - physically and motor like writing in children

growth: weight

birth 3-4kg (6.5-9lbs)

double that by 6 months

triple by a year

2lbs for the first 6 mo then 1lbs til a year

development:: major milestones

*infancy is dob-1 year for reference

0-3 mo: smile babble rolling, interacting w caregiver

6 mo: core development, sitting

8/9mo crawling

12 mo walking

developmental: stages and ages

• neonatal: DOB-28 days

• infancy til one year

• toddler = 1-3 years (parallel play, ID, NO, tantrums)

• preschool = 3-5 years (immersive play, creative and concrete thinking)

• school age 6-12 year (abstract thinking)

• adolescents 13-28/25

developmental theories - which is which

erikson’s - psychosocial

• trust vs mistrust = infancy

• autonomy vs shame = toddler

• initiative vs guilt = preschool

• industry vs inferiority = school age

• identity vs role = adolescent

piaget - cognitive

• 4 stages from simple to complex thinking

• sensorimotor 0-2

• preoperative 2-7

• concrete operative 7-11

• formal operative 12-15

other factors influencing development

• genetics

• resiliency

• environment

• temperament

infancy and development

• smile babbles

• poor balances

• reaches for mouth

• lack of body control

toddlers and development + major safety risks

• NO / independence

• parallel play

• simple directions

• walking and running

safety risks

• tripping falling

• don’t leave unsupervised

• regression with a stressor; remove the stressor

preschool and development

• creativity

• immersive play’

• why

• concrete thinking

• curious

school age and development

• abstract thinking

• logical

• sports

• injuries

adolescents and development

• puberty

• ID

• coming into the world

child health indicators

• pre mature baby most important

• infant mortality

• low birth weight

• injury hospitalization and mortality

hospitalization/illness response

child - fear, anxiety, behavioural distress developmental regression

patient family

• fear anxiety

• siblings - behavioural disruptions

fears: infants, toddler/preschool, school age, adolescents

fever for pediatrics

• normal for children

• normal temp is 37.5 to 37.9

  • 38> is febrile

• route: temporal, tympanic, axillary, oral

• why treat?

  • febrile seizures

  • comfort

  • decrease physical demands

• treat:

  • antipyretics - acet and ibu

  • warm bath

  • cold cloth

  • remove some layers

IF BABY IS UNDER 3 MO

• this is an emergency- worse if they are less than 28 days - sepsis

• no advil for less than 4-6 mo unless prescribed

• tylenol q3h

pediatric differences In respiratory system

infants

• abdominal breathing - diaphragm Is higher

• dependant on accessory muscles

• smaller air way

• fewer alveoli

• soft tissue around lungs fewer mucous

• under developed smooth muscle

• less developed intercostals-tire out faster

• brief periods of apnea

• obligatory nose breathers

respiratory assessment

• nasal discharge

• cough w sputum - seldom

  • dont spit out

  • dont produce mucous dt soft tissues, smaller airways

• rate - always count for one minute

• most arrests in kids are respiratory

• 0-28 days 31-60 rr

• 1 mo - 3 mo 31-60

• 4-11 mo 29-53

signs of respiratory distress

• grimacing

• wheezing

• nasal flaring

• retractions

• tachypnea

• neck extended

• frantic / panic

• lethargic

• o2 <92

late signs

• see saw belly

• head bobbing

• decreased cap refill

• cyanosis

• agitation

• desat

ARI - a cold

• responsible for 20% (<5 years) of child death - 90% is pneumonia

• ARI most common in

  • malnourished

  • infants toddlers <2 years of age

  • weaned off bf early/formula fed

  • low sdoh

  • immunocompromised

  • HIV positive

• 20-60% outpatient

• 12-45 are admitted

asthma ( 4 components and RF)

• characterized by s/s and an increased response of tracheobronchial stimuli leading to the constriction of airway

• over 2 years

• manifested by 1 of 4 components

  • bronchospasms / irritable airway

  • edema and mucous

  • inflammation

  • airway reactivity

• risk factors

  • family hx and genetics

  • smoke / pollen

  • frequent ARI *

  • * pre mature baby, low birth weight and c section

signs and symptoms of asthma

• nasal flaring *

• decreased O2

• itching and eczema

• in and ex wheezing

diagnosis/orders and treatment for asthma

dx/orders

• pulmonary function test and spirometry

• chest xray

• resp panels and swabs

• labs and abg if severe

treatment

• fluid to thin the secretions

• corticosteroids

• bronchodilators - salbutamol

  • nebulizers

  • mdi

• hob up

• maintain airway

pram score for asthma

acute croup + s/s

laryngotracheobronchitis (LTB)

• inflammation of the larynx, trachea and bronchi

• viral

• upper respiratory

way to differ:

• starts off with mild upper respiratory infection / cold - BARKY COUGH

• worsens with stridor - inspiratory upper constriction

signs and symptoms

• pale

• blue

• restless

• hypoxic

• needing to sit upright

orders/dx + tmt for croup

• chest xray

• assessment

treatment

• inhalers wont help

• antipyretics for comfort

• racemic epinephrines *

• steroids

• fluids

• humidified o2

• seldom abx

Epiglottitis = emergency

• inflammation of the epiglottis - above vocal cords - supraglottic

• bacterial

• medical emergency

• constriction and obstruction of the airway

• onset sudden abrupt and rapid progressive

• 3-6 years of age rare but possible in older children

epiglottitis s/s

• 4 D’s

  • drooling

  • dysphagia

  • dysphonic

  • distress

• blue

• decreased o2

• tachycardic

• high fever

• croak/stridor on inspiration

• agitation and anxious

epiglottitis dx and tmt

• don’t leave alone without medical emergency

• don’t use tongue depressor to examine

• ax/xray

iv fluid abx

intubate and trach for 24-48 hours

steroids

fluids

o2

1;1 care

bronchiolitis + RSV

bronchiolitis

• inflammation and swelling of the bronchioles - no response to inhalers

• viral

• 60 mo - years

• may lead to asthma

• main cause 50% rsv and influenza

  • RSV - respiratory syncytial virus

  • all children affected by 3

  • highly contagious

  • wash hands and vaccinate flu

  • immunocompromised, premies maltips - rsv synagis not a vaccine

LATE signs of respiratory distress

• head bobbing

• desat

• agitation

• cyanosis

• seesaw breathing

• tachycardia/delayed cap refill

fluid and electrolytes compared to adults

in comparison to adults, children have more icf and ecf (interstitial, intravascular and transcellular)

key cations

• sodium (Na+) - for osmosis and fluid exchange

• potassium (K+) - Action potential and electrical potential

• Calcium (Ca++) - action potential

• Magnesium (Mg+) - metabolizing K and Ca

conditions that increase / decrease fluid needs

• Increase

  • gi losses

  • bleeding

  • fever

  • respiratory illness

  • infection/sepsis

• decrease

  • kidney condition

  • metabolic condition

  • cardiac - HF

  • lymphatic

3 types of dehyration

• isotonic= same na and water loss

• hypertonic=more water than na loss

• hypotonic=more na loss than h20

(4) acid base balances

respiratory ACIDosis

= increase CO2 ; decrease PH

• asthma, opioid OD, anything causing HYPOventilation

respiratory ALKalosis

= decrease CO2 ; increase PH

• pain, fever/some resp conditions, hyPERventilation

metabolic ACIDosis

• decrease hco3; decreased PH

  • DKA and sepsis

metabolic ALKalosis

• increased hco3 increased ph

• loss of gi, ng suction

rehydration and electrolyte replacement

mild / moderate

• healthy lytes and broth

• anything that they’re getting in

severe

• iv fluids; ensure the right one

GER - gastroesophageal reflux

• when the lower esophageal (cardiac) sphincter is open or relaxed

• symptoms: regurgitation, vomiting, pain, poor weight gain

• usually common in 3 mo to one year * with extent:

  • lead to malnourished failure to thrive

  • vomiting

  • bleeding

• treatment:

  • positioned and slow feeding

  • PPI

pyloric stenosis

• narrowing of the lower stomach sphincter aka the pyloric sphincter

• common in infants - 2-5 wks, full term W, M

• similar symptoms of gerd but

  • projectile vomiting right after eating

tmt= surgery

intussusception

• intestine scoping into another part

• more common in boys 2mo - 2 years

• symptoms

  • sudden onset

  • high pitches screaming/indrawing/kicking

  • vomiting - yellow green

  • palpable mass

• tmt

  • spontaneous reduction

  • air enema / or no saline

  • surgery if necrotic bowels

appendicitis

most common surgery for pedes

symptoms

• rlq pain localized

dx = ultrasound and wbc

ruptured=surgery abx and ng suction

non ruptured = surgery

type 1 diabetes ( what is it, characterized by, presenting symptoms, assessment @ diagnosis, diagnostic tests)

what is it?

• type I diabetes is an autoimmune disorder occurring in genetically susceptible individuals who were exposed to toxins or environmental factors

characterized by

• autoimmune destruction of the pancreatic beta cells that produce insulin - so no insulin at all

• insulin is needed to metabolize proteins fat and carbohydrates

• also important for insulin glucose metabolism = wound healing and growth

peak is between children 10-14

seasonal variation of dx ; more in the winter

family hx

presenting symptoms

• hyperglycemia

• glucosuria

• polyuria

• polydipsia

• polyphagia

• dka

diagnostic tests

• elevated bs levels

• urine sample

assessment @ diagnosis

• weight loss 30%

• fatigue

• glucosuria

• elevated blood sugar leads to osmotic diuresis

• ketones decrease the ph so metabolic acidosis

diabetic ketoacidosis and signs/symptoms

s/s

• polyuria

• polyphagia

• polydipsia

• fatigue

• altered loc

• weight loss

• shock

• vascular collapse

• dysrhythmias

• dehydration

• fruity smelling breath*

management of severe DKA - 3 Phases * and the general care

1. resuscitation - airway and fluids - may be dehydrated

2. fix the acid base, then the electrolytes and then insulin

3. return to routine

bgm q30-60 mins

kabwork

vs and neuro til stable

strict I/o

education

kids w chronic disease

• can be congenital or acquired

• more than 6 mo of age

• fixed, remission, exacerbation

• requires supportive care;

  • respite

  • physical financial and educational support

• types

  • physical - cystic fibrosis

  • psychological - ADHD

  • social - autism

  • cognitive - cerebral palsy

childrens conceptualization of death

infants - mimic caregiver no understanding

toddler - see it as temporary

preschool- think its a punishment*

school age - see it more concrete

adolescants - realize death is final

myths about pain

• infants don’t feel pain

• children forget pain

• distraction = no pain

• become used to pain

• opioid = quick addiction

addiction concepts

• tolerance=increase dose for effort

• physical dependance=withdrawal if symptoms stopped

• addiction = maladaptive drug seeking behaviour

consequences of poorly controlled - post op - management

• delayed healing ; increase length of stay

• more hospital visits

• decreased immune ; increase tumour growth

• increased risk of complication and anxiety

pain assessment tools

• infants / newborns

  • cries

  • nips

  • premature infant pain scale

• toddler

  • faces

  • oucher

  • flacc

• preschool

  • faces

  • oucher

  • flacc

  • body outline

• school age

  • faces oucher

  • word graphic

• adolescents

  • faces oucher and numerics

adhd (what it is, manifestations, and tmt)

• most common neurodevelopment

• dx by 7

• genetic play a big part

• many children have a learning disorder along side

• manifestations

  • decreased attention

  • increased distract

  • poor impulsivity

  • motor restlessness

• tmt

  • meds - aderall and ritalin

  • cbt

  • therapy

odd

• develops gradually - increased defiance, negativism, argumentative, temper, hostility

• rf

  • low iq

  • child trauma

  • antisocial parents

  • over or under child rearing

• commonly comorbid with mood disorder, adhd and anxiety

• tmt

  • ssri - zoloft, prozac, paxil
    

anxiety

intense worry

manifestations

• interferes with daily life and adl

• reason why worry unclear

• logic doesnt calm worry

• can be treated w meds