peds exam 2

object permanence

9-10months, just because something is not visible does not mean it does not exist

separation anxiety in infants

protest caregiver leaving, starts between 4-8m, 11-12m they can predict departure and try to prevent leaving

discipline for infants

protects them, put away breakables and things that can hurt them, do not understand cause and effect yet, do not punish they do not understand it yet, use timeout, avoid negative reinforcement only use positive, do not let environment put them at risk, need to explore or they will regress

teething

6-10m lower central incisors, drooling, biting on hard objects, finger sucking, irritable, difficulty sleeping

abnormal symptoms for teething

fever, vomiting, diarrhea, seek care

Tx for teething

cold, Tylenol <3d, topical analgesics (not as recommended anymore due to numbing airway), no aspirin due to RYES syndrome or cutting gums

nutrition/feeding requirements for first 6m of life

human milk, daily vitamin D supplement, iron (after 4m) if exclusively breastfed because iron stores start getting used up at 5m, no animals milk

nutrition/feeding requirement for second 6m of life

human milk or formula still primary source of calories just experimenting with solids GI tract less sensitive to potentially allergenic foods more mature so start solid foods, tongue lets them keep food in, no honey or cows milk before 1y

contraindications and precautions with vaccines for infants

severe febrile illness NOT minor illness (cold), MMR, V postponed 3m after IVIG or blood transfusion, anaphylaxis from previous vaccine, if immunocompromised do not give live vaccine

vaccine reactions for infants

redness, swelling, tenderness, low grade fever, fussy, shows our body is actively fighting vaccine does not mean allergic reaction

vaccine admin for infants

longer needle=less pain receptors, vaccine information statement (VIS) given to parent before vaccine admin, get consent at this time, record date, manufacturer, lot #, name of who administered it, site, VIS publication date, consent, parents should keep immunization record

VAERS

vaccine adverse event reporting system, when child gets adverse reaction from vaccine parents should be educated to report it VAERS, makes sure vaccines are safe and keep track of their reactions, helps them make changes to vaccines to help keep children safe and decrease adverse effects

colic

paroxysmal abdominal pain, crying and fussing more than 3 hours a day, more than 3 days per week, and more than 3 weeks in an otherwise healthy infant, more common in <3m, evening time, growing just fine just crying

colic management

supportive, make sure nothing else is going wrong in infant, educate parents to keep them safe even though they are crying, massage belly, swaddle, put in car/swing, remind parents they are not doing anything wrong, just support infant through this and hopefully colic will resolve on its own

failure to thrive

inadequate growth and development resulting from inability to obtain or use calories required for growth, commonly weigh or height <5th percentile

interprofessional care and management for FTT

daily weight, strict I/O, written feeding plans, recipe, schedule, may need foster home to get care they need, develop mistrust from impaired parent-child interaction, may be getting wrong formula, not breastfeeding properly, enough, right time, may be throwing up or just spending too many calories

SIDS

sudden infant death syndrome younger than 1y that remains unexplained after complete autopsy

risks for SIDS

maternal smoking/ secondhand smoke, preterm, lack of prenatal care, race (AA, NA), males, bed sharing, soft items in or on sleep surface, prone positioning, inclined sleep position, recent viral illness, may have none of these and still die from SIDS

protective factors for SIDS

breastfeeding, pacifier, supine sleeping, room sharing (6m), immunizations, alone, back, crib

nutrition for toddlers

psychologic anorexia: some days eat 7 meals the next eat nothing, normal, do not need amount of calories that infants do, growing in spurts, do not give food as reward, what is eaten is more important than how much, do not want toddlers grazing, choking: hotdogs, grapes, peas, carrots, fruit snacks, popcorn, resins, if they want a snack give them their dinner they did not finish, does not always have to be candy

milk and juice for toddlers

milk makes toddlers full so they are not hungry, iron deficient, limit milk intake to make sure they are getting good food intake, juice has to be 100% fruit juice, helps iron get absorbed better, cannot be fruit colored and fake

discipline for toddlers

time out=1min per age, best positive reinforcement, do not give bad behavior negative attention, give positive reinforcement for good behavior, ignore regressions, same discipline with all caregivers

play for toddlers

enhances development, interaction with others becomes more important, parallel play, less focus on own body more focus on toys

appropriate toys for toddlers

safety, push pull toys, tricycles, slides, crayons, large puzzles, creativity (push buttons, Ms. Rachel) vs passive (watching TV), imitation, tactile play: mud, sand, Plato, squishy

negativism for toddlers

assertion of self control, constantly expressing no, throwing tantrums, avoid by giving them choices

ritualism for toddlers

routine, something expected, after nap I get a snack, when we eat we sit at the table, make sure every caregiver knows ritual or toddler will try to take control

temper tantrums for toddlers

Breath holding, consistency between ALL caregivers or else they will know what they can get away with and will push boundaries, positively reinforce appropriate behavior, cannot express words so they throw tantrums, do not give negative attention that is rewarding negative behavior, ignore tantrum

injury prevention choking for toddlers

keep environment clean, cut up food small, constant supervision while eating, popcorn kernel and balloon fragments hardest to dislodge, avoid choking hazard foods

car seat recommendations

rear facing for as long as possible, manufacturer recommendations for height/weight, check expiration dates, car seats need to be destroyed if they are ever in a crash

injury prevention poisoning for toddlers

locks, child resistant caps: slow children down, not prevent them

management for poisoning

call poison control center first, assess child not poison, then circulation, airway, breathing, inducing vomit not permitted can scar esophagus and aspirate, gastric decontamination trying to suck everything out of stomach will not get much poison out, already mostly absorbed

antidotes for poisoning

narcan, flumazenil, nactylcestein=mucomyst (protects liver)

lead poisoning causes

lead based paint, dust in urban areas, iron deficiency makes it easier to absorb lead, cant bind to heme=anemia

s/s of lead poisoning

aggression, developmental delays, hyperactivity, impulsivity, withdrawal, lower IQ, visual motor problems, physical growth, reproductive efficiency

education and treatment for poisoning

Anticipatory guidance, screening for lead poisoning (BLL) at 1-2yrs, Therapeutic management depends on BLL: chelation therapy IM, binds to iron then excrete it through pee, damage kidneys so increase fluid in child

transitional objects for toddlers

Object permanence allows for longer separations from parents, these objects used for Security, especially when lonely, teddy bear from home

psychosocial developmental milestones for preschoolers

Eriksons initiative vs guilt, period of energetic learning (love to learn), when they overstep limits, feel guilty for not behaving properly, also feel guilty when their THOUGHTS differ from expected behavior, learning right from wrong/moral development: little, if any, concern about WHY something is wrong, know that bad things get punished and things that are not punished must be okay

cognitive developmental milestones for preschoolers

Piagets preoperational phase 2-7, fully in preoperational phase: shifting from totally egocentric thought to social awareness and ability to consider other viewpoints, limited ability to reason or use logic, getting ready for (pre) school/scholastic learning (5-6), language continues to develop, understanding cause/effect begins, time still not entirely understood, magical thinking, can consider how a situation appears to others

magical thinking for preschoolers

all powerful, believe if they think something will happen it will happen, their thinking can cause events

animism for preschoolers

Believe inanimate objects are alive and have feelings, lifelike qualities to inanimate objects

imaginary friends for preschoolers

Important because they become their friends when they are lonely, to them it is real, okay to do small things like set up cups but not for them to do bad things and say George made me do it, parents should say well I do not see George not George is not real, normal to have imaginary friends not bad

abusive head trauma

aka shaken baby syndrome shaking of infants/young children: large body to head ratio, weak neck muscles, large amount of water in brain, shaking= brain rotation, shearing forces tear blood vessels and neurons, causes subdural hematoma and retinal hemorrhages, can be fatal or lead to lifelong complications (neurologic, visual, cognitive, behavioral), often present with other symptoms and no external injuries

munchausen syndrome by proxy

caregivers exaggerate or fabricate histories or symptoms OR induce symptoms in children that lead to painful, unnecessary procedures

child abuse indications

intentional physical abuse, neglect (most common), emotional abuse or neglect, sexual abuse, inconsistent stories or stories about injuries happening that are inconsistent with the child’s age, response from or to caregiver (overly clingy or avoids parent)

child abuse pattern

NO SINGLE FACTOR IS PREDICTIVE OF ABUSE, caregiver-child interaction used as one factor in overall evaluation, children younger than 1 have highest rate of abuse

actions for child abuse

identify abusive situations as early as possible: assess risk factors and vulnerability, determine if child is safe and if not do not go any further until we identify they are safe, history and interview: avoid biasing by using non leading, open ended questions, record: date, time, what happened and when, location, witnesses to accident, chain of custody, witnesses: CPS, SW, provider, police

actions for child abuse continued

physical assessment: recognize that some situations/normal variants can be mistaken for abuse, identify all injuries: color, size, pattern, use body diagram chart, photograph with a measurement tool, height, weight, hygiene may be s/s of neglect, make sure we are looking in areas that are hard to see (scalp, frenulum in mouth)

care management for child abuse

protect child from further abuse, consult CPS + document it on the chart (who we talked to, referral number, when we called), if it is sexual abuse consult SANE nurse: sexual assault nurse examiner, expert in sexual abuse

characteristics of abusers

usually by adult, typically a male who the victim knows, often employed in positions that bring them in contact with kids, many commit multiple assaults before being caught, often spend time with victim, gain their trust before initiating sexual contact, play on childs fears, tell them its okay, often children do not tell for fear of retaliation, that they wont be believed or they will be blamed, told its a secret, some dont have ability/vocabulary to explain what happened

risk factors for abuser

drug or alc addicted parents, low SES, less education, parents abused as kids, kids with disabilities, no single factor for sure can tell us this child has been abused these factors just raise our suspicions

measles (rubeola) transmission and s/s for preschoolers

contact, droplet, airborne, fever, malaise, cough, koplik spots on buccal mucosa, rash on face that spreads downward, anorexia

mumps transmission and s/s for preschoolers

contact or droplets of saliva from infected person, fever, headache, malaise, earache aggravated by chewing, parotitis, can progress to deafness, hepatitis, meningitis, sterility

varicella (chickenpox) transmission and s/s for preschoolers

respiratory secretions + lesions of infected people spread the disease: contact, droplet, airborne precautions, infectious until all lesions have crusted, fever, malaise, anorexia, itchy rash- papule to vesicle to crust

rubella (german measles) transmission and s/s for preschoolers

nasopharyngeal secretions, blood, feces, urine, low grade fever, headache, malaise, rash starts on face then rapidly spreads down neck, arms, and trunk, discrete, fine

fifths disease (erythema infectiosum) transmission and s/s for preschoolers

human parvovirus B19, transmitted through respiratory secretions, blood, rash starts on cheeks (slapped face), then maculopapular red spots on upper and lower extremities, rash goes away unless irritated or in the sun, do not care for if pregnant

pertussis (whooping cough) transmission and s/s for preschoolers

respiratory contact or droplets, starts as URI- sneezing, cough, low grade fever for 1-2 weeks, then dry, hacking, severe cough, then goes into paroxysmal stage with coughing mostly at night, high pitched whoop sound, with rapid inhale, vomiting after coughing spell: for 4-6 weeks

injury prevention for preschoolers

Increase in pedestrian motor vehicle accidents: bike helmets, looking both ways, childcare focus shifts from protection to education: verbal explanations of how to avoid danger rather than implementing environmental safeguards: such energetic learners and own injury prevention will help protect our preschoolers

anticipatory guidance for preschoolers

very similar to adults, sleep when adults do, complications of not getting enough sleep are same as adults, not enough sleep: perform bad in school, diet is like adults, eat 3 meals a day, maybe some snacks, balance energy and calories they are taking in with calories they are putting out

conservation for school age

Master in this stage, Volume does not change just because the shape of the container changes

s/s of lice in school age

Itching usually only symptom, sometimes observable nits on hair shaft, observation of nits confirms diagnosis, lice bugs harder to find

treatment for lice in school age

apply pediculicides, permethrin 1% cream rinse can be obtained without prescription, advise 2^nd Tx at 7-10 days, if permethrin and pyrethrin not effective malathion can be used, Tx must stay on scalp for several minutes (shampoo), retreatment required, daily removal of nits from hair with comb

lice for school age

pediculus capitis, lice do not jump or fly, but can be transmitted from one person to another on personal items like combs, hair ornaments, hats, caps, scarves, coats, lice not carried or transmitted by pets

ADHD in school age

Developmentally inappropriate degrees of inattention, impulsiveness, and hyperactivity, present in at least TWO settings (school, home), start to see in preschool age but diagnosed in school age because we have to see it at school too not just at home in 1 setting before we diagnose it

diagnostic evaluation for ADHD in school age

multidisciplinary, H&P, checklists, seen by more than 1 person, rule out physical things going on that can cause inattention, impulsiveness, and hyperactivity

therapeutic management (multimodal treatment) for ADHD in school age

behavioral therapy- break things down, schedule things they dislike in the morning, rewards, visual charts, task modification, pharmacotherapy: stimulants (Ritalin) in AM, biggest side effect is poor appetite, environmental manipulation: consistency is key, working with teacher and interdisciplinary team, place in front of classroom so others cannot distract them, give them regular breaks to discharge energy

sex education for school age

media and peers are often primary teacher: info is often unrealistic, assess by starting with confidentiality, discuss puberty, number of partners, methods of birth control: should include normal body functions using straightforward, correct terminology, teach how to reduce risk of STIs, exploitation, assault, and abuse

sex education communication for school age

ask are you having sex, are you using protection, how are you having sex, teach risks of sexual relationships, do not make assumptions

sex education confidentiality for school age

If parents will not leave educate why leaving is good for their child, say the child will tell the nurse more if they are gone, wouldn’t they rather tell someone that cares such as the nurse instead of telling friends, and if they still will not ask the questions in front of the parent

leading cause of death in adolescents

unintentional injuries (MVA), homicide, suicide, risk taking, firearm availability in home is strongly linked to unintentional injuries, increased suicide/homicide, store firearm separate from ammo, make sure they are locked away

disease and injury prevention for adolescents

emphasize and encourage safe pedestrian behavior, appropriate behavior while riding in motor vehicle, refuse to ride with drunk or reckless driver, provide competent driver education and wearing seatbelt, teach basic water safety and nonswimmers to swim, discourage smoking, reinforce proper behavior in areas with burn hazards, educate in hazards of drug use, including alcohol for poisoning, protective equipment with hazardous devices, firearm safety, access to safe sports and recreational facilities

puberty onset and sequencing for girls

starts at 10y, changes after 8 is normal though, should see it by 13 or it is abnormal, grow breast buds, then get taller, then develop pubic hair, then get period, last thing that happens is regular ovulation and periods

puberty onset and sequencing for boys

starts at 12y, after 8 is normal though, should see it by 14 or it is abnormal, start with testicular enlargement, then pubic hair, then voice changes, increase in muscles and facial hair, last thing that happens for them is increase in height

gynecomastia

temporary enlargement of male breasts during puberty, happens before they hit heigh increase, normal and resolves in about 2 years after puberty, very common

suicide in adolescents

A deliberate act of self injury with the intent to cause death

suicide cause in adolescents

multifactorial, most have active psychiatric disorder

care for suicide patients

no threat of suicide should ever be dismissed: plan is 1:1 observation any time they tell us they have a plan even if it is unrealistic they will realize and change their plan, all parasuicidal activity should be taken seriously, screen for depression, teach med adherence, methods

suicide importance

previous suicide attempt is indicator for suicide completion in the future, often peers are told, aware of suicidal ideation= REPORT!!!

Erikson’s psychosocial stages

Trust vs. mistrust

Autonomy vs. shame and doubt

Initiative vs. guilt

Industry vs. inferiority

Identity vs. role confusion

physical developmental milestones for infants

6m birth weight doubles, 1yr triples, growth in spurts not patterns, head increasing in size, posterior fontanel closes 6-8 weeks, anterior closes 12-18m, chest circumference=head circumference, brain at 1 is 2.5x heavier than at birth, most of head growth done by 2

psychosocial developmental milestones for infants

Eriksons trust vs. mistrust, trust of self, others, and world: infant relies on caregiver, feeding, comfort, caring, stimulation, mutual regulation of frustration, Mistrust: result of too much or too little frustration (crying crying crying and we do not get them or crying and we immediately get them), occurs when prolonged delay in gratification of needs, social modifications: crying to grasping to biting, negative feedback to biting, realize it changes the way people respond to them

cognitive developmental milestones for infants

Piaget’s sensorimotor stage, reflexes: separation from objects, 9-10 mo object permanence, separation anxiety (6-8 mo), voluntary acts: primary circular reactions (start recognizing when they do something, something happens as a response, ex: when I cry I get this), secondary circular reactions (when I cry I know mom gets me, what happens if I cry longer and louder, experimenting with sensory activities that get a response, ex: hold block in primary then shake the block in secondary)

cognitive developmental milestones for infants continued

6mo imitation (play), mental representation (symbols) and coordination of second schemas: apply new skills, associate symbols with events (know waving goodbye means mom is going to leave), intentionality (purposely choose to do something, happens after 9-10 months) 

physical developmental milestones for toddlers

terrible twos, 12-36 months, intense period of environmental exploration, searching for autonomy, want to do everything themselves, temper tantrums, negativism, favorite word is no, weight gain and height increase slows, ½ adult height by 2, growth in spurts, OFC slows, 75% of brain growth done by 2, depth perception immature, hearing, smell, taste, and touch continue developing, become associated with experiences, all senses are used to explore environment, lots of injuries

cognitive development for toddlers

sensorimotor ends, cognition develops rapidly but reasoning limited, tertiary circular reactions (active experimentation, applying knowledge to new situations to categorize data, ex: see light switch flip it and lights turn on, then go to bathroom and push a button and also realize this turns the lights on, can categorize what light switches can do and what they look like) learning spatial relationships

cognitive development for toddlers continued

appearance = function, domestic mimicry: imitation of behaviors, imitate everything they see, concept of time- 1min=1hr, explain time like Christmas is in 4 sleeps, we will be there in 2 blueys, preconceptual phase (early preoperational): egocentrism, animism, magical thinking

psychosocial developmental milestones for toddlers

Erikson’s autonomy vs. shame and doubt: independence, control, holding on and letting go (holding hand, letting go), negativism: constantly expressing no, throwing fits to fend for themselves, avoid by giving them choices with no option to say no, ritualism

cognitive development for school age

Piaget concrete operational stage, can relate series of events to mental representations that can be expressed verbally and symbolically= concrete operations, understand relationship between things and ideas/ cause and effect, not egocentric, able to make judgements on reason rather than only on what they see “conceptual thinking”, master conservation

cognitive development for school age continued

understand relational terms (bigger/smaller, more than, to the rt of), can tell time, develop classification skills: sort based on logical order and love to do this because of conservation being mastered, can conserve numbers= start numeric pain scale at 8y, learn to read which enhances all knowledge and understanding

reasoning for school age

helps them stay safe, they can learn and remember things based on what they have seen others do, if they hit brother even if no one sees they think that was a bad idea and can reason with their brothers perspective

psychosocial development school age

erikson’s industry vs. inferiority, social skills extend beyond family, stage of accomplishment: eager to develop skills and participate in useful work, reinforced by grades, material rewards (candy), privileges, recognitions, learning cooperation and competition with others: peer approval = a strong motivator, desire to become useful in their social communities, have to learn how to apply social skills to peers

industry vs. inferiority hint for school age

industry think of factories: build things, make things, want to be productive, show their worth, that they are valuable and can do things

cognitive development for adolescents

Piaget’s formal operations, abstract thinking: can think beyond the present, what is possible with influences, scientific reasoning and logic: mental manipulation of multiple variables, can detect inconsistencies, concern about others thoughts and needs: imagine the thoughts of others= self conscious, think others are right, cultural considerations, justice: can think about multiple peoples perspectives makes them aware of everyone’s perspective and how they feel when they make these decisions, risk taking and invulnerability- can consider long term consequences but often do not do so (form of regression?)

psychosocial development for adolescents

Eriksons identity vs. role confusion, group identity: peers> parents, pressure to belong to a group; reject parental qualities, individual identity: changes to body threaten self concept, development of self-concept and body image: defects or deviations are detrimental, sexual identity: shift from close friendships with same sex peers to intimate relationships with members of the opposite sex, often sexually active, have to form own identity or will be confused about their role and where they fit into the world, group identity puts them at risk for a lot of injuries in this age group, going to parties they know they should not, trying to do anything to fit in

2-3m

palmar grasping reflex

4-6m

head control well established, tummy time 30-60min a day helps develop head and neck control

5m

voluntary palmar grasp, roll belly to back

6m

roll back to belly

6-7m

crawling

7m

transfer objects between hands, sitting and leaning on hands for support

9m

creeping + pulling up on furniture