Exam 1: Pediatric Assessment

Temperature ranges

Infants (birth to 1 year old)= 98-99.F

2 to 12 years old= 98-99F

12 to 18 years old= 97.8-98.9F

Pulse Range

Infants-2 years old= 80-130

2 to 10 years old= 70-115

10 to 18 years old= 60-100

Respiration Range

Infants= 30-50

1 to 3 years old= 20-30

4 to 12 years old= 19-25

12 to 18 years old= 12-20

Blood pressure Range for Systolic Range

Age in years x2 +70

Age in years x2 +90

Pediatric vs Adult

Increased HR- cardiac output, as get older HR decreases, heart muscles become more efficient in pumping. Count HR for full min.

Respirations- Periodic breathing is expected in infants. Up until 6 months of age are nose breathers. Respiratory illness-section to help with breathing and help eat.

-Trachea smaller- minimal swelling before an obstruction occurs.

Children at increased risk for hypothermia, liver underdeveloped, decreased glycogen.

Bones not fully calcified, bones more flexable, harder to break- red flag for abuse.

Metabolic rate- increased metabolic rate puts at risk for hypoglycemia when stressed, everything weight based.

Effective Communication

Always talk to child or include, Don’t lie, be truthful, Don’t give opportunity to say no, but give choices, choose words carefully, give options not opportunity to say no.

-Introduce yourself

-Explain yourself- tell them everything your doing.

-Privacy

-Open-ended questions (one at a time)

-Involve the child, Be honest

-Choose appropriate language (less “medical terms”)- use words the parent or child understands.

-Use an interpreter if needed

-Always listen carefully.

What questions to ask to get a History?

Ask patient quickly in emergent situation

-What prompted the parent to bring the child for examination?

-Does the child have any chronic medical conditions?

-Is the child on any routine medications? When was the last time the child took any medications?

-Does the child have any allergies? What type of allergic reaction do they have?- rash?, Stop breathing?

Detailed History

Make sure patient primary care provider that can watch their development closely and follow patterns, Ensure immunizations are up to date to be able to start school.

Ask who lives at home, if any changes; marriage, divorce, new family member, death, finacial changes, adolesence ask privarcy questions- without family present.

-Chief complaint, History of present illness, birth (past) history, current health status, family history, review of systems, psychosocial data, developmental data, daily living patterns.

Safety

Always look at the environment the child is in. See where family is; involved, or ignoring child. Safe in bed. Where child at.

Identification/HALO band- alarm/security band. Make sure id band on and on right patient, check child to make sure id band on.

Siderails- up and higher for older ones, make sure up to prevent fall.

Parental involvement, caregiver. Look at caregiver how involved and it they are paying attentions to kid.

Sequence

Infant, toddlers, preschoolers start outward and work in- start at extremities. If not calming down include caregiver to hold, or do in bits and places.

Sleeping vs Awake- get HR, listen to heart and lung sounds, bowel sounds, How IV looks, and how skin looks before wakes up.

-If baby is sleeping or quiet in parents arms start with auscultation- HR, Lung sounds, part of assessment that requires only looking.

DO NOT WAKE A SLEEPING BABY UNLESS ABSOLUTELY NECESSARY!

Baby and caregiver need sleep

ALWAYS ASSESS IV SITE

Infant and Toddler Vital Sign measurement

1. Assess comfort level

2. Count respirations first (before disturbing the child)- for full min

3. Count the apical heart rate second- for full min

4. Measure the blood pressure (if applicable) third

5. Measure the temperature last, Axillary- kids don’t like it.

Measurements

Younger than 1 year old- infants n admission and welfare checks- head, chest, abdomen circumferance, height, and weight.

Need to be naked to weight- weigh diper, needs to be dry, weigh everyday for daily weights, and before they eat.

Ages 1 to 2= head circumference, height, and weight.

Plagiocephaly

See flattened area of head, children laying on same place/side all the time. Should correct itself overtime once mobile not laying on same spot all time. Encourage caregivers to re-position.

-Wear helmet to correct.

Head-To-Toe

Talk to child to get them to become more comfortable, start outward and work way in. Include all these aspects:

Head:

-Hair= not pulling, no lice, nutrition will effect hair, look for balding due to stress.

-Fontanel= soft and flat- normal, Sunken- dehydrated, Bounding/protruting-infections, meningitis. Assess anterior (closes 12-18 months) and Posterior (closes 2-3 months).

-Eyes= no drainage, symmetric, check pupils

-Ears= No foreign bodies, symmetric, no drainage

-Nose= No foreign bodies, symmetric midline, check palete

-Mouth= look at teeth, loose them or getting them by 2-3 months, no cleft palet, intact, No foreign bodies.

Trunk:

-Cardiac= HR increases on inspiration, could have S3- could be normal, count 1 min, murmurs can be seen.

-Respiratory= count 1 min, periodic breathing for infants

-GI/GU= tell caregiver change diaper or change to gown, measure abdomen.

Infants 2-4-6 months old Vaccines

Harry Rodents Don’t Have Pretty Pets

H- Hepatits B

R- Rotavirus

D- Dtap

H- Hib

P- Pneumococcal

P- Polio

Infants 12-18 months old Vaccines

Very Merry Pretty Dancers

V- Varicella

M- MMR

P- Pneumincoccal

D- Dtap

Vaccines for 4 to 6 years of age

Very Merry Pretty Dancers

Varicella

MMR

Polio

Dtap

Difference between Periodic breathing and Apnea?

Periodic breathing is a normal pattern in infants (up to 6 months) and some adults, characterized by short (5-10 second) pauses followed by rapid breaths. Conversely, apnea is a pathologic, sustained pause in breathing (usually >20 seconds in infants or >10 seconds in adults) that causes low oxygen/heart rate, requiring medical evaluation

Calculate Output to measure adequate nutrition?

When assessing your patient, you need to look at their intake and output.

Output should be calculated as a minimum of 1ml/kg/hour. If your patient is in diapers, then you aregoing to weigh them. The scales to weigh the diapers are generally in grams and when converted1ml=roughly 1 gram (you can’t be exact going from liquid to solid).

-Once they reach about 7 years of age then the calculation changes to at least 0.5ml/kg/hour and whenthey are adolescents (12 years and older) then you can use the adult range which is at least 30ml/hour.

Calculate Intake to measure adequate nutrition?

Intake: Infants need at least 100-115 calories/kg/day. Regular formula and breastmilk has 20 calories/ounce.

Fluid Intake (Maintenance)= 100ml/kg/day for the first 10 kg of weight. For a child weighing 11-20kg is1000ml plus 50 ml/kg for every kg above 10. For a child that weighs more than 20kg, it is 1500ml plus 20ml/kg for every kg above 20.

Hydrocephalus

abnormal accumulation of cerebrospinal fluid (CSF) within the brain's ventricles, causing increased pressure and potential brain damage.

Cornelia de lange syndrome facial features

Significant brows, nose pointed, enlarged area between lip and nose.

Pierre-Robin Sequence facial features

Absent jaw, upper respiratory support- need trach, Abnormal upper extremities webbed.

Head-To-Toe- Extremities

Play with patient, walk around to help assess. Equal movements, if favor one side, check for scoliosis.

Extremities→ Movement- when playing or walking. Temperature- check temp of extermities. Assess fine motor skills.

Integumentary/Hydration→ Bruises/wounds, can have mangolian spots (normal)- sometimes confused for bruises.

Genital/Perineal Areas

Head-To-Toe= Nervous system/cognitive function

-Milestones→ children have certain milestones that should be met at certain age.

-Cranial Nerves→ smell, see, able to walk.

-Sensory

-Reflexes- Rooting= disappears 3-4 months, Sucking= test cranial nerve 5. Babiski- apply pressure along bottom of foot hyperextends toes (positive) disappears at 12-24 months. Tonic neck (fencing reflex) 4-6 months doesn’t go away then could indicate neuro impairment.

Can incorporate cranial nerves and reflexes together.

Fine Motor Development

Grasping object at 2-3 months.

Transfer objects between hands at 7 months

Pincer grasp at 10 months

Remove objects from container at 11 months

Build tower of two blocks at 12 months.

Gross Motor Development

Head lag in first 2 months (hold up and head leans back)

Head control at 4 months- should be able to hold head up right on own

Rolling over (from abdomen to back) at 5 to 6 months

Parachute reflex by 7 months

Move from prone to sitting position by 10 months

Head Lag

Head control while pulled to sitting position. Complete head _ at 1 month. Partial head _ at 2 months. Almost no head _ at 4 months.

In first 2 months.D

Development of sitting

Infant has no ability to sit upright at 1 months. At 2 months the infant has more control the back us still rounded but can try pull up with some head control.

The back is rounded only in lumbar area, infant is able to sit erect with good head control at 4 months.

The infant can sit alone at 7 months. Infant sits without support at 8 months.

Locomotion

Infant bears full weight on feet by 7 months. The infant can maneuver from sitting to kneeling position. Infant can stand holding on furniture at 9 months.

While standing infant takes steps at 10 months. Infant crawls with abdomen on floor and pulls self forward at about 7 months and then creeps on hands and knees at 9 months.

Tone

Can be from vigorous to limp. Every child including newborns should have good muscle _.

Interactive

Infant normally should be interested in his or her surroundings.

Consolability

The normal infant should be able to be consoled by parents

Look (gaze)

The normal infant should follow with his or her eyes interesting objects, A glassy eyed stare is abnormal.

Speech (cry)

The normal infant should have a normal cry; not a weak cry or absent of sound.

Early Behavioral signs of cognitive impairment

Encourage caregivers to feed infant when feeding- allows for bonding, babies can aspirate.

Allows us to assess for; No response to contact, voice or movement. Irritability. Poor or slow feeding- no more than 30 min.

-Poor eye contact during feeding, Diminished spontaneous activity.

Causes of cognitive impairment

Intrauterine infection and intoxication- can lead to deficts early on.

Trauma (pre, peri, or post-natal)- menigitis lead to encephlolitis.

Metabolic or endocrine disorders

Inadequate nutrition

Postnatal brain disease

Chromosomal anomalies- down syndrome, fragile x syndrome

Premaurity, low birth weight, postmaturity.

Environmental influences- history of cognitive impairment among parents and siblings.

Unknown prenatal influences- microcephaly, hydrocephaly, mengiomyecelpe.

Psychiatric disorders with onset in childhood- Autism.

Primary prevention of cognitive impairment

Support for preterm and high-risk infants

Rubella immunization (german measules)= put unborn baby at high risk for birth defect if exposed during pregnancy, transmitted droplet.

Genetic counseling

Maternal counseling

-Use of folic acid supplements

-Education about fetal alcohol syndrome

-Education about lead exposure.

Autism Spectrum disorders (ASDS)

Are complex neurodevelopmental disorders of brain function. Autistic disorder, Asperger syndrome, and Pervasive development disorder not otherwise specific.

Impairment with social interaction, not able to pick up on social cues.

Range from mild to severe.

Screening tool= M-CHAT-R

Diagnostic criteria for ASD

Qualitative impairment in social interaction

Qualitative impairment in communication- saying half words, communication devices.

Restricted repetitive and stereotyped patterns of behavior, interests and activities.

Delays or abnormal functioning with onset before 3 years of age.

American psychiatric association

Nursing considerations for ASD

Be aware of routines that they follow. Don’t like to change their routine.

Wide variation in the individual client response to treatment efforts.

No cure for ASD, but many therapies are used

Most promising results seem to be obtained with the use of highly structured routines and intensive behavior modification programs.

Family support for ASD

Help with some type of counsling or have someone to talk to. Often becomes a “family disease”. Help alleviate parents unwarranted feelings of guilt and shame.

Stress the importance of family counseling.

Autism Society of America is good source of information.

Encouraging home care for children; assisting with long-term placement later in life

Sucking/Rooting reflex

Touch infant’s lip, cheek, or corner of mouth with nipple and infant turns head toward stimulus, opens mouth, takes hold and sucks.

-Difficult or impossible to elicit after feeding. If weak or absent, consider prematurity or Neuro deficit. Response disappears within 3-4 months.

Swallowing Reflex

Feed infant; Swallowing usually follows sucking and obtaining fluids.

Swallowing is usually coordinated with sucking and usually occurs without gagging, coughing or vomiting.

If response is weak or absent, may indicate prematurity or neuro deficit.

Grasp palmar Reflex

Place fingers in palm of hands and infant’s fingers curl around examiner’s fingers. Reflex disappears by 5-6 months,

Plantar Reflex

Place fingers at base of toes and toes curl downward. Reflex disappears by 9-12 months.

Tonic Neck Reflex

With infant falling asleep or sleeping, turn head quickly to one side. With infant facing left side, arm and leg on that side extend and opposite arm and leg flex (turn head to right and extremities assume opposite postures).

-Responses in leg are more consistent. Complete response disappears by 5-7 months. Persistent response is a sign of possible CP.

Moro/Startle Reflex

Place infant on flat surface, strike surface to startle infant (best elicited if newborn is 24-36 hours or older). Symmetric abduction and extension of arms are seen, fingers fan out and form a “C” with thumb and forefinger, slight tremor may be noted, arms are adducted in embracing motion and return to relaxed flexion and movement.

-Response is present at birth and complete response may be seen until 8 weeks. Body jerk only is seen between 8-18 weeks. Response is absent by 6 months if neuro maturation is present. Incomplete response if asleep.

Stepping or Walking Reflex

Hold infant vertically, allowing one foot to touch table surface. Infant will simulate walking, alternating flexion and extension of feet. Term infants walk on soles. Preterm infants walk on toes.

Response is normally present for 3-4 weeks. Disappears by 2 months.

Babinski Sign Reflex

On sole of foot, beginning at heel, stroke upward along lateral aspect of sole, then move fingers across ball of foot. All toes hyper-extend, dorsiflexion of big toe. Absence requires neuro evaluation. Response should disappear after 1 year.

Glabellar (Myerson) Reflex

Tap over the forehead, bridge of nose, or maxilla of newborn whose eyes are open and newborn blinks for first 4-5 taps.

-Continued blinking with repeated taps is consistent with extra-pyramidal disorder.

Trunk Incurvation (Galant) Reflex

Place infant prone on flat surface, run finger down back about 4-5 cm lateral to spine, first on one side then on the other. Trunk is flexed and pelvis is swung toward stimulated side. Response disappears by 4 weeks.

Growth

Quantitative change or an increase in physical size

Maturation

An increase in competence and adaptability; A qualitative change; Functioning at a higher level

Percentile of growth

A statistical representation of 100 children and placement within the 100 members of a comparison group

Development

Qualitative change or an increase in capability or function.

A gradual change and expansion; Advancement from a lower to a more advanced stage of complexity

Increased capacity through growth, maturation, and learning

Infancy/Infant

•Birth to 1 year

Toddler

•1-3 years

Preschool

•3-6 years

School age

•6-12 years

Adolescence

•12-18 years

Factors Influencing Growth

•Heredity→ influences physical growth potential (e.g., height, weight, body shape, and features).

•Nutrition→ single largest influence on growth. Severe malnutrition during critical periods of development (e.g., from birth to age 6 months) is positively correlated with diminished height, weight, and IQ in later life.

•Gender→ bearing on growth rates; different growth charts; the onset of puberty and full adult size are attained earlier in girls.

•Disease→ skeletal disorders may affect growth. Chronic disease may lead to chronic (even subacute) hypoxia, resulting in small build, short stature, and poor growth patterns (e.g., cystic fibrosis, respiratory diseases, and cardiac lesions).

•Environment- Hazards, Socioeconomic influences, Season, climate, and oxygen concentration, Prenatal influences, Socioeconomic status, Interpersonal relationships, Stress, Television and mass media

Stages of Nutrition/Growth

•Infants start with breast milk or formula and then slowly graduate to soft table foods.

•Toddlers may exhibit “physiologic anorexia”

•Preschoolers may have “food jags”

•School-age can prepare simple meals and should learn how to choose healthy foods.

•Adolescents grow rapidly

Who can exhibit “physiologic anorexia”

Toddlers

-Don’t need as many calories, pick at foods

Who can exhibit “food jags”

Preschoolers

-1 or 2 food items all the time, incorporate in meal

Who can prepare simple meals and should learn how to choose healthy foods?

School-Age

___the birth weight by age 6 months

Double

___the birth weight by age 1 year

Triple

Promoting Optimum Health during Infancy

Nutrition: Breast milk is the first choice only for the first 6 months of life

NO need for additional fluids in the first 4 months

NO honey in the first year of life

Introduction of solid foods after age 6 months

-Introduce foods at intervals of 4 to 7 days to allow for identification of food allergies

May need fluoride supplements

Finger foods at 9 months

Weaning from breast or bottle to cup after 1 year

Physical Growth of the Toddler

__gain about 8 to 10 pounds between the ages of 12 months and 3 years

-Toddlers also grow about 7 or 8 inches. Want them to stay in steady growth pattern. If under then assess family history, and dairy of intake to prevent malnutrition.

Biologic Development- Preschool

•Physical growth slows and stabilizes

•Average weight gain remains about 5 pounds per year

•Average height increases 2½ to 3 inches per year

•Body systems mature and stabilize; can adjust to moderate stress and change

Promoting Optimum Health during the Preschool Years

•Caloric requirements are approximately
90 kcal/kg

•Fluid requirements are approximately
100 mL/kg, depending on activity and climate

•Food fads and strong tastes are common

Biologic Development -School-age

•Height increases by 2 inches per year

•Weight increases by 2 to 3 kilograms (5lbs) per year

•Males and females differ little in size

Sexual Maturation for Females

•Thelarche (8 to 13 years): Breast buds

•Adrenarche (8 to 13 years): Pubic hair growth

•Menarche: About 2 years after thelarche, menstruation begins

•Puberty “delay”: No thelarche by age 13 years

Nutritional Concerns

Account for lifespan;

•Food Insecurities

•Childhood Obesity→ Can lead to many complications, sleep apnea, HTN, depression, low self esteem.

•Food Safety→ teach prepare food adequatly, keep up with recalls, food poisening.

•Deficiencies→ adequate food intake. Head-to-toe may show signs- brittle hair, dry skin.

•Celiac Disease

Eating Disorders

Patient must be medically stable before transferred, Have to be watched when eating

•Anorexia Nervosa

•Bulimia→ Watch patients to prevent them from vomiting or taking laxiatives, look at nuckles- scrap on teeth when make them throw up.

•Failure to Thrive

•Pica→ eating non-food items.

•Food allergies→ educate on epipen.

Clinical Manifestations of Anorexia Nervosa or Bullimia

Severe weight loss, have to be medically stable before moving.

Altered metabolic activity, watch cardiac activity

•Amenorrhea

•Bradycardia, decreased blood pressure

•Hypothermia, cold intolerance

•Dry skin, brittle hair and nails

•Appearance of lanugo

Freud’s Theory of Psychomotor Development- Oral

Infant- birth to 1 year

Freud’s Theory of Psychomotor Development- Anal

Toddler

Start to control over body secretions, work on potty training, teach to wash hands.

Freud’s Theory of Psychomotor Development- Phallic

Preschool

Works out relationships with parents, closer to parent of opposite sex then become close with other parent.

Freud’s Theory of Psychomotor Development- Latency

School-Age

Sexual energy is at rest, work on peer relationships, pull away from parents

Freud’s Theory of Psychomotor Development- Genital

Adolescence

Mature sexuality is achieved, work on relationships who attracted to.

Trust vs. Mistrust

Infant- Birth to 1 year

Achieved by providing basic needs, want to be taken care of, develop trust.

Autonomy vs. Shame & Doubt

Toddler- 1 to 3 years

Exhibits independence but if always criticized will not achieve, start to say “NO”

Initiative vs. Guilt

Preschoolers- 3 to 6 years

Likes to initiate play activities, start activity but not last long, short attention span.

Industry vs. Inferiority

School-Age- 6 to 12 years

Gains a sense of self worth from involvement in activities, have goals in mind, like to be challenged in school, gives self-esteem.

Identity vs. Role Confusion

Adolescents- 12 to 18 years

Search for self-identity leads to independence from parents and reliance on peers. Trying to figure out what they like.

Jean Piaget’s Cognitive (Intellectual) Development

Believed the child’s view of the world came mostly from; age, experience and maturational ability

•Sensorimotor (Birth to 2 years)- need stimulation to develop, nothing connects if not stimulates. Play is key, Infants and toddlers.

•Preoperational (2-7 years)- Preschool, ego-centric, only see from their point of view, no concept of time, very literal, choose words carefully.

•Concrete operational (7-11 years)- chroniological order

•Formal operational (11 years – adulthood)- think of concequences.

Kohlberg’s Moral Development

•Preconventional (4-7 years)

•Conventional (7-12 years)

•Postconventional (12 years and older)

Social Character of Play

Socialization and the type of play changes as the child advances in age. Play enhances: Socialization, Creativity, Self-awareness, Moral standards, Play is therapeutic at any age

•Onlooker→ watch

•Solitary→ more mobile

•Parallel→ Toddler, play someone but not interact.

•Associative→ Preschool, interacting, not doing same activity.

•Cooperative→ work together towards goal.

Health Promotion/Maintenance Infants

•Anticipatory Guidance- teaching keep child safe/healthy.

•Disease/Injury Prevention

•Assessment/Diagnosis

•Planning/Implementation

•Evaluation

Sudden infant death syndrome (SIDS)- to reduce the risk of SIDS recommendations; Place the infant in a supine position while sleeping, No co-sleeping or prone sleeping, Remove pillows, blankets, and moldable mattresses, Encourage breastfeeding, Nocturnal pattern of 9 to 11 hours by 3 to 4 months, Total daily sleep: 15 hours

Injury Prevention: Infant walkers, Aspiration of foreign objects, Suffocation, Motor vehicle injuries ,Falls, Poisoning, Burns, Drowning

Health Promotion/Maintenance Toddler, Preschooler and School-Age

•Anticipatory Guidance

•Disease/Injury Prevention

•Assessment/Diagnosis

•Planning/Implementation

Evaluation

-Avoidance of early childhood caries, Cleaning begins when primary teeth erupt, First dental visit at 6 months (eruption of first teeth), Water is preferred to toothpaste until after age 2 years, Consider need for fluoride supplements, Injury Prevention

Health Promotion/Maintenance Adolescent

•Anticipatory Guidance

•Disease/Injury Prevention

•Assessment/Diagnosis

•Planning/Implementation

Evaluation

Injury Prevention

RESPONSE TO INJURY OR ILLNESS- Infants

Varied by developmental stage 

-Developmental Issues= Separation anxiety, Stranger anxiety, Painful, invasive procedures, Immobilization, Sleep deprivation, Sensory overload

Response

•Sleep-awake cycle disrupted

•Feeding routines are disrupted

•Displays excessive irritability

RESPONSE TO INJURY OR ILLNESS- Toddlers

Developmental= Separation anxiety, Loss of self-control , Immobilization, Painful, invasive procedures, Bodily injury or mutilation, Fear of the Dark

Response-

•Frightened if forced to lie supine

•Associates pain with punishment

•Wonders why parents don’t come to their rescue