Pediatrics I Comprehensive Practice Flashcards

Introduction to Paediatric Nursing and Pediatrics I

Course Information and Overview

Course Title: Pediatrics I
Course Code: Code BSc.N26
Instructor: RN. Mohamed-hanfi A. Rahman, MSc in Pediatrics and Child Health Nursing.
Course Description: Provides a comprehensive understanding of child health, growth, and development from before birth through adolescence. It explores physical, cognitive, emotional, and social aspects, including milestones and growth deviations. It also covers nutritional needs, immunization programs, and the nurse's role in promoting child health and collaborating with families/communities.

Course Objectives

By the end of the course, students should be able to:

Demonstrate safe nursing psychomotor skills.
Apply therapeutic communication in clinical areas.
Utilize organizational and time management skills to prioritize clinical performance.
Demonstrate critical thinking and decision-making skills based on practice standards, theory, and research.
Apply theoretical content to nursing care in clinical settings.
Implement care plans reflecting legal and ethical nurse responsibilities.
Perform nursing interventions reflecting caring behaviors for biopsychosocial, cultural, and spiritual needs.
Utilize the nursing process for all clients.
Demonstrate responsibility for personal professional growth as an adult learner.
Provide safe care through dependent, independent, and collaborative interventions.
Support family and community involvement: Collaborate with families and educate caregivers on hygiene and safety.
Demonstrate ethics: Respect children's rights and involve guardians in decisions.
Provide communication/counseling: Educate caregivers on health promotion.
Promote child welfare: Identify vulnerable children and refer them to social services.
Emergency Care: Provide basic care for emergencies like dehydration and respiratory distress.

Definitions and Classifications in Pediatrics

Paediatric Nursing: A specialized branch of nursing focusing on healthcare for infants, children, and adolescents from birth to $18$ years of age.
Childhood Age Limit (UNICEF): From birth up to $18$ years.

Developmental Age Groups

Neonate: First $4$ weeks ( $0 - 28$ days) of life.
Infancy: Up to $1$ year of age ( $1$ month to $1$ year).
Toddler: $1 - 3$ years of age.
Preschool: $3 - 6$ years of age.
School Age Children: $6 - 12$ years of age.
Adolescents: $12 -$ 18 years of age.\n\n## Scope and Role of the Paediatric Nurse\n* **Health Promotion and Prevention:** Immunizations, growth monitoring, and nutrition education.\n* **Acute Care:** Managing infections, emergency care, and post-surgical management.\n* **Chronic Conditions:** Diabetes, asthma, and congenital heart diseases.\n* **Mental Health:** Psychological support for anxiety and depression.\n* **Family-Centered Care:** Emotional support and education for parents.\n* **Ethical/Legal Considerations:** Child's consent, confidentiality, and protection of rights.\n* **Specific Roles:** Direct caregiver, educator, advocate, and collaborator with healthcare teams.\n\n## Rights of the Child\nUnder the UN Convention on the Rights of the Child:\n* Access to healthcare and medical care.\n* Protection from harm and abuse.\n* Education and play.\n* Freedom to express views and be heard.\n* Participation in decisions affecting them.\n\n## Growth and Development Concepts\n\n### Growth\n* **Definition:** Quantitative change referring to an increase in physical size of the whole body or its parts. Measured in kg, pounds, meters, or inches.\n* **Types of Growth:**\n * **Physical Growth:** Includes height, weight, and circumferences.\n * **Physiological Growth:** Refers to vital signs.\n\n### Growth Parameters and Formulas\n* **Average Height at Birth:** Boys (50\,\text{cm} $), Girls ($ 49\,\text{cm} $). Normal range:$ 47.5 - 53.75\,\text{cm}.\n* **Weight at Birth:** 2.7 - 4\,\text{kg}.\n * Weight loss of 5\% - 10\% $occurs by day$ 3 - 4 after birth.\n * Weight gain resumes by day 10 of life.\n * Gain of \frac{3}{4}\,\text{kg} by the end of the first month.\n* **Head Circumference (HC):** 33 - 35\,\text{cm} $at birth. Head is$ \frac{1}{4} of total body length.\n* **Chest Circumference (CC):** 30.5 - 33\,\text{cm} $(usually$ 2 - 3\,\text{cm} less than HC).\n* **Physiological Normal (Growth):**\n * Temperature: 36.3\,^\circ\text{C} $to$ 37.2\,^\circ\text{C}.\n * Pulse: 120 - 160\,\text{b/min}.\n * Respiration: 35 - 50\,\text{b/min}.\n\n### Development\n* **Definition:** Qualitative change referring to a progressive increase in skill and functional capacity (e.g., sitting, walking, talking). Measured through observation of milestones.\n\n### Principles of Growth and Development\n1. **Cephalocaudal Principle:** Proceeds from head downward (head control first, then arms, then legs).\n2. **Proximodistal Principle:** Proceeds from center of body outward (spinal cord before outer parts, arms before hands).\n3. **Maturation and Learning:** Biological growth occurs in sequential order (maturation). stimulating environments allow full potential.\n4. **Simple to Complex:** Thought processes move from concrete (e.g., identifying colors) to abstract (e.g., classification of fruits).\n5. **Continuous Process:** New skills build upon previously acquired ones.\n6. **General to Specific:** Progress from large muscle movements to refined, smaller muscle movements.\n7. **Individual Rates:** Rates varies by child; passive children aren't necessarily less intelligent.\n8. **Gradual Process:** Changes occur over weeks, months, or years.\n\n## Developmental Milestones\n\n### Fine Motor Skills\n* **1–4 Months:** Hands closed; brings hands to eyes/mouth.\n* **5 Months:** Voluntary grasping of objects.\n* **6 Months:** Holds bottle; grasps feet and pulls to mouth.\n* **7 Months:** Transfers objects between hands.\n* **6–12 Months:** Palmar grasp replaced by pincer grasp; claps and waves.\n* **12 Months:** Turns pages.\n* **15 Months:** Tower of 2 cubes; scribbles.\n* **18 Months:** Tower of 4 $cubes; imitates vertical lines; turns$ 2 - 3 pages at a time.\n* **21 Months:** 6 cubes.\n* **24 Months:** Tower of 7 cubes; imitates horizontal lines; turns pages one by one; circular scribbles.\n* **30 Months:** 9 cubes; makes horizontal/vertical lines separately.\n* **36 Months:** Hand preference (handedness); 10 cubes (imitates "bridge"); copies circles; draws person with head and one body part.\n* **48 Months:** Copies triangle, cross, and square; imitates gate (5 $cubes) and step ($ 6 cubes).\n* **60 Months:** Step of 10 $cubes; copies diamond; writes name; draws person with$ 6 body parts.\n\n### Gross Motor Skills\n* **Birth:** Much sleep, sucking reflex.\n* **1 Month:** Social smile; lies flat; head lag present.\n* **2 Months:** Socialization and cooing.\n* **3 Months:** Head control (holds steady); raises head 45^\circ on stomach; pushes down on feet.\n* **4 Months:** Hand control.\n* **5 Months:** Sits with support; rolls stomach to back.\n* **7 Months:** Sits without support; bears weight on legs; crawling.\n* **8 Months:** Stands with support; prehension uses thumb and forefinger.\n* **9 Months:** Sits well; crawls; pulls to stand; gets toy out of reach.\n* **10 Months:** Stands alone.\n* **11 Months:** Walks with support ("cruising").\n* **12 Months:** Walks alone (1 $or$ 2 steps).\n* **15 Months:** Broad base gait; crawls up stairs.\n* **18 Months:** Runs stiffly; walks up stairs with one hand held.\n* **24 Months:** Runs well; jumps; kicks ball; opens doors.\n* **36 Months:** Mature gait; stands on one foot for 3 seconds; rides tricycle; alternates feet going up stairs.\n* **48 Months:** Hops on one foot (2 - 3 times); alternates feet going down stairs.\n* **60 Months:** Skips with both feet.\n* **72 Months:** Catches ball; rides bicycle; walks heel-to-toe in straight line.\n\n### Speech and Language Skills\n* **Birth:** Crying.\n* **5–6 Weeks:** Vocalizes; smiles when spoken to.\n* **7 Months:** Responds to own name and "no"; combines vowels/consonants in babbling.\n* **9 Months:** Says "Mama" or "Dada" indiscriminately.\n* **12 Months:** Says 6 - 8 words; uses "Mama/Dada" appropriately.\n* **18 Months:** Speaks 10 words; names pictures.\n* **24–30 Months:** 2 - 3 word sentences; uses "I"; verbalizes toilet needs.\n* **36 Months:** Repeats 6 $-syllable sentences; counts to$ 3 $; recognizes$ 3 colors.\n* **60 Months:** Repeats 10 $-syllable sentences; counts to$ 10 $; names$ 4 colors.\n\n### Emotional and Social Skills\n* **Separation Anxiety:** Becomes common at 8 months; bedtime/childcare transitions are difficult. Transitional objects (blankets/stuffed animals) provide security.\n* **Tantrums:** Common at 2 - 3 years due to a struggle for independence and inability to verbalize frustration.\n* **Gender Identity:** Established between 18 $months and$ 2 years.\n* **Interactive Play:** Begins at 2 - 3 $years; children share and take turns. Fantasy play emerges at$ 3 - 5 years.\n* **Crying Patterns:** Infants cry average 3\,\text{hours/day} $at$ 6 $weeks, decreasing to$ 1\,\text{hour/day} $by$ 3 months.\n\n### Cognitive Skills\n* **Object Permanence:** Realization that objects exist even when unseen.\n* **Time Perception:** At 2 - 3 $years, yesterday is "past" and tomorrow is "future." By$ 4 years, they understand morning/afternoon/night and seasons.\n* **Complex Logic (Age 7):** Appreciation of conservation (liquid volume in different containers); understanding multiple perspectives (a mother can be angry but still loving).\n\n## Dentition\n1. **Primary (Deciduous/Milk) Teeth:** Total = 20 $($ 8 $incisors,$ 4 $canines,$ 8 molars).\n * **Timeline:** Eruption starts at 6 - 10 $months (lower central incisors first). All usually erupted by$ 31 $months. Exfoliation (loss) occurs$ 6 - 12 years.\n2. **Permanent (Adult) Teeth:** Total = 32 $($ 8 $incisors,$ 4 $canines,$ 8 $premolars,$ 12 molars).\n * **Timeline:** First molars appear at 6 - 7 $years. Wisdom teeth (third molars) appear at$ 17 - 25 years.\n\n## Factors Affecting Growth and Development\n* **Hereditary:** Genetic traits.\n* **Environmental Factors:**\n * **Pre-natal:** Maternal nutrition, diabetes, radiation, infections (German measles), smoking, drugs, and fetal growth factors.\n * **Post-natal External:** Socio-economic status, nutrition, climate, siblings/ordinal position, family structure, culture, and trauma.\n * **Post-natal Internal:** Hormones, emotions, and genetic factors.\n\n## Developmental Assessment Tools\n* **Anthropometric Measurements:**\n * **Weight Calculation Formulas:**\n * Infant: \text{Wt} = \frac{\text{Age in months} + 9}{2}\n * 1 - 6 $years:$ \text{Wt} = \text{Age in years} \times 2 + 8\n * 6 - 12 $years:$ \text{Wt} = \frac{\text{Age in years} \times 7 - 5}{2}\n * **Height Calculation Formula:**\n * \text{Height (cm)} = \text{Age in years} \times 6 + 77\n* **Weight Guidelines:** Birth weight doubles by 5 - 6 $months, trebles by$ 1 $year, and quadruples by$ 2.5 years.\n* **Head Circumference Monitoring:** Measured over the occiput and supraorbital edges. HC and CC approximate at 1 year.\n* **Mid-Arm Circumference (MAC):** Normal is 13 - 16\,\text{cm}; used for toddlers and preschoolers.\n* **Fontanelle Closure:**\n * **Anterior (Bregma):** Diamond shape; closes by 18 $months ($ 1.5 years).\n * **Posterior (Lambda):** Triangular shape; closes by bitth to 6 $weeks ($ 1 month).\n* **Bone Age:** Assessed via X-ray of the left hand/wrist carpal bones. Ossification centers for femur/tibia appear at birth.\n* **Growth Charts:** WHO Child Growth Standards for children 0 - 5 years measure weight-for-age, height-for-age, weight-for-height (wasting/overweight), and BMI.\n\n## Theories of Child Development\n\n### 1. Psychoanalytic Theory (Sigmund Freud)\n* **Structure of Mind:**\n * **Id:** Primitive, pleasure principle, demands immediate gratification (hunger, thirst).\n * **Ego:** Reality principle, develops in first 3 years, rational/socially appropriate mediator.\n * **Superego:** Moral principle, develops around age 5, context of "conscience."\n* **Psychosexual Stages:**\n 1. **Oral (0 - 18 months):** Mouth (sucking, biting).\n 2. **Anal (18 - 38 months):** Bowel and bladder control; conflict between Id and societal pressure.\n 3. **Phallic (3 - 6 years):** Genitals; Oedipus (boys) and Electra (girls) complexes.\n 4. **Latent (6 to puberty):** Libido inactive; social skills and values focus.\n 5. **Genital (Puberty onwards):** Maturing sexual interests.\n* **Defense Mechanisms:**\n * **Positive:** Sublimation (channeling energy into acceptable activities).\n * **Negative:** Denial, Projection, Displacement, Regression, Repression, Reaction Formation.\n * **Mixed:** Rationalization (substituting acceptable reasons for real ones).\n\n### 2. Cognitive Theory (Jean Piaget)\n* **Sensorimotor (0 - 2 years):** Learning through sensations and basic actions (sucking, grasping). Goal: Object permanence.\n* **Preoperational (2 - 7 years):** Symbolic thought and language. Traits: Egocentrism.\n* **Concrete Operational (7 - 11 years):** Logical thought about concrete events. Concept: Conservation.\n* **Formal Operational (11+ years):** Scientific reasoning and abstract logic.\n\n### 3. Psychosocial Theory (Erik Erikson)\nFocuses on social/cultural crises across the lifespan:\n1. **Trust vs. Mistrust (0 - 1.5 years):** Virtue: Hope.\n2. **Autonomy vs. Shame/Doubt (1.5 - 3 years):** Virtue: Will.\n3. **Initiative vs. Guilt (3 - 5 years):** Virtue: Purpose.\n4. **Industry vs. Inferiority (6 - 11 years):** Virtue: Competence.\n5. **Identity vs. Role Confusion (12 - 18 years):** Virtue: Fidelity.\n6. **Intimacy vs. Isolation (19 - 40 years):** Virtue: Love.\n7. **Generativity vs. Stagnation (40 - 65 years):** Virtue: Care.\n8. **Integrity vs. Despair (65+ years):** Virtue: Wisdom.\n\n### 4. Moral Theory (Lawrence Kohlberg)\n* **Level 1: Pre-conventional Morality (0 - 9 years):**\n * Stage 1: Obedience and Punishment.\n * Stage 2: Individualism and Exchange.\n* **Level 2: Conventional Morality (Adolescence):**\n * Stage 3: Good Interpersonal Relationships.\n * Stage 4: Maintaining Social Order.\n* **Level 3: Post-conventional Morality (Rare in adults):**\n * Stage 5: Social Contract and Individual Rights.\n * Stage 6: Universal Principles (justice, human rights).\n\n### 5. Language Theory (Noam Chomsky)\n* **Nativist Theory:** Language is innate. All humans have a Language Acquisition Device (LAD).\n* **Universal Grammar:** Inborn rules shared by all languages.\n* **Poverty of Stimulus:** Input is insufficient; mastery occurs due to inherent cogitative structures.\n\n## Pediatric Nutrition\n\n### Stages of Nutritional Needs\n* **Infants (0–12 $Months):** Exclusive breastfeeding for$ 6 $months. Supplement Vitamin D ($ 400\,\text{IU/day} $). Introduce iron-fortified cereals at$ 6 $months. Avoid honey ($ botulism).\n* **Toddlers (1–3 $Years):** Higher protein for muscle; calcium ($ 700\,\text{mg/day} $). Limit juice ($ < 4\,\text{oz/day}).\n* **Children (4–12 $Years):** Complex carbs; calcium ($ 1000\,\text{mg/day}); Omega-3s.\n* **Adolescents (13–19 $Years):** Protein ($ 0.85\,g/kg/day $); girls need extra iron due to menstruation; calcium ($ 1300\,\text{mg/day}).\n\n### Malnutrition Classifications\n* **Gomez Classification (Weight-for-age):**\n * Grade 1 (Mild): 90 - 75\%.\n * Grade 2 (Moderate): 75 - 60\%.\n * Grade 3 (Severe): < 60\%.\n* **Waterlow Classification:**\n * Wasting (Weight-for-height): Acute malnutrition.\n * Stunting (Height-for-age): Chronic malnutrition.\n* **WHO Classification (Z-scores):**\n * Moderate: < -2 $to$ > -3\,SD.\n * Severe: < -3\,SD.\n* **Severe Acute Malnutrition (SAM):** Defined as bilateral pitting edema, or WFH < 70\% $, or MUAC$ < 11.5\,\text{cm}.\n\n### SAM Clinical Manifestations\n* **Kwashiorkor (Low protein):** Bilateral pitting edema, flaky paint dermatosis, moon-shaped face, and hepatomegaly (fatty liver).\n* **Marasmus (Low calories):** Severe wasting, "old man face", baggy pants (loose skin), and good appetite but irritable mood.\n* **Marasmic-Kwashiorkor:** Combined features; edema with severe muscle wasting.\n\n### Management of SAM\n1. **Phase 1 (Stabilization):** Uses F-75 (75\,kcal/100\,mL). Prevents hypoglycemia, hypothermia, and infection. No IV fluids unless in shock.\n2. **Transition Phase:** Introduction of RUTF (Ready-to-Use Therapeutic Food) or F-100 (100\,kcal/100\,mL $). Aim: controlled weight gain ($ 6\,g/kg/day). Avoid "refeeding syndrome."\n3. **Phase 2 (Rehabilitation):** Unlimited F-100 or RUTF. Catch-up growth. Discharged when weight/height > 85\% $and edema absent for$ 10 days.\n4. **Routine Meds:** Vitamin A (Day 1, 2, 14 $), Folic acid ($ 5\,\text{mg}), Amoxicillin, and iron (Phase 2).\n\n## Immunization\n\n### Types of Immunity\n* **Naturally Acquired Active:** Resistance after disease exposure.\n* **Artificial Acquired Active:** After vaccine administration.\n* **Naturally Acquired Passive:** Trans-placental maternal antibodies.\n* **Artificial Acquired Passive:** Administered antibodies.\n\n### Vaccination Schedule (WHO/National)\n* **At Birth:** BCG (0.05\,mL\,ID $, right arm) and OPV-0 ($ 2 drops).\n* **6 Weeks:** Penta-1 (DTP-HepB-Hib), PCV-1, Rota-1, OPV-1.\n* **10 Weeks:** Penta-2, PCV-2, Rota-2, OPV-2.\n* **14 Weeks:** Penta-3, PCV-3, IPV (injectable polio), OPV-3.\n* **9 Months:** Measles vaccine, Vitamin A (100,000\,IU).\n\n### Cold Chain and Storage\n* **Freezing Permissible:** OPV, Measles, BCG.\n* **Freezing Forbidden:** DPT, Hep-B, Hib (freeze-sensitive).\n* **Monitoring Tools:** VVM (inner square must be lighter than outer), Shake Test (identifies frozen damage for killed vaccines), and Refrigerator Graphs (2 - 8\,^\circ\text{C}).\n\n## Common Paediatric Conditions\n\n### 1. Spina Bifida (Neural Tube Defect)\n* **Occulta:** Hidden malformation, tuft of hair or lipoma over spine; non-disabling.\n* **Meningocele:** Meninges protrude but spinal cord remains inside; usually no neurological deficit.\n* **Myelomeningocele:** Severe; spinal cord/nerves protrude. Associated with hydrocephalus and Chiari II malformation. Prevention: Folic acid (400\,\mu g daily for women).\n\n### 2. Cerebral Palsy (CP)\n* **Definition:** Non-progressive neuromuscular disorder due to brain damage.\n* **Classifications:**\n * **Spastic (86\%):** Muscle stiffness; diplegia (legs), hemiplegia (one side), or quadriplegia.\n * **Dyskinetic:** Athetosis (slow writhing) or Dystonia (twisting).\n * **Ataxic:** Coordination failure; wide-based gait.\n* **Management:** SDR (Selective Dorsal Rhizotomy) surgery, Botulism toxin A injections, orthopedic braces, and walkers/standing frames.\n\n### 3. Autism Spectrum Disorder (ASD)\n* **Clinical Features:** Deficits in social communication, repetitive behaviors (hand flapping), and sensory hyper-reactivity.\n* **Interventions:** ESDM (Early Start Denver Model), TEACCH, Risperidone/Aripiprazole for irritability, and SSRIs for repetitive behaviors.\n\n### 4. ADHD\n* **Characteristics:** Inattention, hyperactivity, and impulsivity. Diagnosed via DSM-IV criteria before age 7.\n* **Meds:** Stimulants (Methylphenidate) or non-stimulants (Atomoxetine/Guanfacine).\n\n### 5. Hydrocephaly\n* **Pathophysiology:** Accumulation of CSF in brain ventricles.\n* **Symptoms:** Sunsetting eyes, increased head circumference, and papilledema.\n* **Surgical Management:** Shunts (VP is preferred) or Endoscopic Third Ventriculostomy (ETV).\n\n### 6. Muscular Dystrophy (MD)\n* **Duchenne (DMD):** X-linked recessive; onset 2 - 5$$ years; affecting pelvis/arms. Waddling gait and pseudo-hypertrophied calves. Death by late teens.
Becker's: Milder form; progress over decades.
Myotonic: Muscle stiffness; inability to relax muscles (Steinert’s disease).