Pediatrics

Pediatrics DEVELOPMENT Infant (birth-1 year) Toddlerhood (1-3) Preschooler (3-5) School age (6-12) Adolescent (13-18) Biological: Biological: Biological: Biological: Weight: doubles @ 6 mos, triples @ 1 year Growth slows Growth slows + stabilizes Weight: birth weight quadrupled @ 2.5 yrs Weight: 2-3kg/yr Weight gain is slower: 2-3 kg/yr Predictable sexual maturation + physical growth but highly variable  Length: 2.5cm/month until 6 mos, @ 1 year length by 50% Fontanelles: posterior close @ 6-8 wks, anterior @ 12-18 mos Vision: can focus @ 4 wks Fine motor: grasp Height: 7.5cm/yr Height:  Biological: by 6-9cm Slender and erect posture Vision: 20/40 is acceptable Fine motor: improved manual dexterity @ 12-15 mos, throw ball @ 18 mos Gross motor: skip + hop on 1 foot @ 4, skip on alternative feet, jump rope, swim, and skate @ 5 Height: 5cm/yr Loss of temporary teeth! *dental health is important bc permanent teeth are now growing Growth spurt; begins earlier in girls *Tanner stages Gross motor: walk @ 12 mos, run @ 18 mos, walk upstairs @ 2 yrs, jump @ 2.5 yrs Gross to fine motor refinement: tricycle → bicycle, jumping → skipping, catching ball more consistently, refined drawing Psychosocial: Psychosocial: Psychosocial: Psychosocial: Psychosocial: Trust v Mistrust: having needs met (when hungry get fed, when dirty get changed) Autonomy v Shame/Doubt: giving autonomy leads to no shame Initiative v Guilt: pt wants to be independent and be praised for this Identity v Confusion: developing sense of self and personal identity As nurse: offer comfort after needles Ritualization provides comfort Industry v Inferiority: pts want to gain new skills and knowledge to feel confident; competition  Differentiate self from others, withstand delayed gratification, control bodily fx, communication, and negativism (say no to everything)  Gross motor: head control, sitting, crawling Development of conscience Appreciate right v wrong d/t parent’s reaction (rewards or punishment), not d/t moral thinking Growing sense of independence (take on new responsibilities) Developing autonomy (emotional, cognitive, behavioural) Peer support is very important Peer approval is strong motivator Sexual identity Magical thinking* As nurse: give choices and be assertive As nurse: ensure pt knows they didn’t cause sickness on themselves or sibling Cognitive: Cognitive: Cognitive: Cognitive: Cognitive: Sensorimotor (birth2yrs) Pre-operational (2-7 yrs); pre conceptual phase (2-4 yrs) Pre-operational (2-7 yrs): intuitive thought phase (4-7 yrs) Concrete operational (7-11 yrs): Formal operational: Symbolic thought, cant perform mental operations (no More reasoning, but not quite logical Uses reflexes and moves voluntarily using senses to interact with env Conservation + decentration (understand multiple Abstract thinking (can think of past experiences + future consequences) symbolism, and formal logic 34 conservation skill), egocentric, intuitive *object permanence = acquiring memory* @ 6-8mos Centration (focus on 1 aspect of situation), time is abstract, magical thinking (ghosts), social awareness No conservation understanding perspective and parts of problem) Know right v wrong d/t understanding standards of acceptable behaviour  Reflexive beh→ simple repetitive acts →imitate activity decision making skills egocentric (look deeper into themselves and see what they desire + how to achieve it) Use numerical pain scale @ 7 Language: Nutrition: Social Development: Social Development: Milk for first 6 mos 1 yr = 4 words Solids @ 6 mos (iron fortified cereals – rice, barley, oatmeal, multigrain) 2 yrs = 300 words 90 kcal/kg, fluid 100 ml/kg, begin proper diet Peer pressure (can be + or -) Family and parental relationship Stress w extracurricular activites Peer groups Social media Social env (school, work, community) Veggies and fruits introduced 1 at a time 3 yrs = simple sentances Play is more social = chance of abduction  Nutrition: Awareness of racial identity Romantic relationships 400 IU of Vit D (prevents rickets) Toilet training: sphincter control @ 18-24 mos. Ensure motor readiness (undoing button/zipper) Injuries: Injuries: Choking, MVA d/t car seat, drowning (bathtub and pool), mechanical suffocation* Falls*, choking, playing Drowning, MVA* (d/t with electrical outlets running on street, and reversing) Sporting injuries* (concussion), head injuries d/t not wearing helmet; big risk taking group Nursing Interventions: Nursing Interventions: Nursing Interventions: Nursing Interventions: Nursing Interventions: Encourage parents to hold + remain with pt Maintain toilet training procedure Encourage parent involvement in care of pt Provide privacy Privacy + confidentiality Provide opportunities for non-nutritive sucking Encourage independent beh Give clear explanations to relieve fears Explain treatments clearly Quiet + nonthreatening env (use toys to make explanations clear) Encourage continuation of school work HEADSSS (health risk Qs) Short explanations Honey delayed until 1 yr (d/t botulism) Provide pt with toys (comfort + stimulation) Provide rewards for good beh Stutter is normal for < 6 mos Speech delay is not normal Injuries: Cyberbullying Efficient language skills *MH: eating disorders, = nurse can use ADHD, anger, suicide detailed explanations Injuries: SAFE TIMES (health screening interview) Encourage participation in making treatment decisions 35 Age 3 4 5 Gross Motor Walk up stairs with alt. feet Pedals tricycle Jumps forward Walks down stairs with alt. feet Balances on 1 food Catches ball Skips Walks backwards Jumps rope Developmental Skills Fine Motor Language Draws circle 3-4 word sentences Feeds self Asks why Qs Grips crayon Says own age Draws square Names 2+ colour Cuts with scissors Tells stories Ties knot Draws triangle Ties shoelaces Prints letter + numbers Counts to 10 Full sentences Knows days of week Social Associative play Toilet trained Imaginative + group play Focused on self Dresses independently Differentiates real from pretend INTEGUMENTARY Impetigo: Bacterial infx of skin due to poor hygiene or infected bite/rash. Mostly occurring during hot/humid months and will appear most commonly on face/mouth, neck, and extremities S/S: vesicle/pustule that progresses to an exudative lesion with honey-coloured crusts, burning, pruritis Priority: 1. Contact precautions (*highly contagious) 2. Keep lesion open to air; let it dry out 3. Daily bathing 4. Warm saline compress to lesion 2-3/day 5. Topic and oral ABX 6. Proper hand hygiene 7. Use separate towels/linens for pt Lice: S/S: scratching scalp, nits in hair Priority: 1. Pediculicide 2. Fine tooth comb to remove nits 3. Change + clean clothing and linen daily 4. No sharing of clothing, hats, or brushes HEMATOLOGY Iron Deficiency Anemia: Low iron = low supply of hemoglobin S/S: pale, weakness, low hgb + hct, microcytic + hypochromic RBC Priority: 1. Oral iron intake 2. Iron supplements (give between meals and with fruit juice for max absorption; avoid giving with milk or antacids – decreases absorption) 3. Teach parents about expected dark stool colour + constipation Hemophilia: X linked recessive disorder; Bleeding due to deficiency in coagulation protein Hemophilia A – due to deficiency in Factor 8; Hemophilia B – due to deficiency in factor 9 S/S: abnormal bleeding, epistaxis, joint bleeding, easily bruised Priority: 1. Monitor for bleeding 2. Replace missing clothing factor 3. Assess LOC (increased risk of intracranial hemorrhage) 4. Avoid contact sports Von Willebrand’s Disease: Bleeding due to deficiency of protein von Willebrand factor, causing bleeding of mucous membranes S/S: epistaxis, gums bleed + bruise, ++ menstrual bleeding GASTROINTESTINAL Vomiting: Puts pt @ risk of dehydration, electrolyte imbalance, metabolic alkalosis, aspiration, and pneumonia Projectile vomiting = pyloric stenosis or increased ICP Priority: 1. NPO 2. IV fluids 36 Diarrhea: Puts pt @ risk of dehydration, electrolyte imbalance, and metabolic acidosis Constipation: Priority: 1. High fiber and fluid intake 2. Enema, stool softeners, or laxatives as needed Cleft Lip/Palate Congenital anomalies due to failure of soft tissue or bone to fuse Cleft lip will close earlier than a cleft palate; cleft lip repair = 3-6 mos, cleft palate repair = 6-24 mos Cleft palate can lead to speech impairment and otitis media Priority: 1. Assess ability to suck/swallow/breathe 2. Monitor fluid intake and daily weight 3. Hold infant upright and direct milk to side/back of mouth 4. Provide feeds in small amounts 5. Suction and bulb syringe @ bedside 6. ESSR feeding – enlarge nipple, simulate sucking reflex, swallow, rest Esophageal Atresia: Congenital defect; food/fluids enter lungs or air enters stomach (issue is with the esophagus) S/S: 3 Cs (coughing, choking, cyanosis), frothy saliva, vomiting, abdo distention, resp distress Priority: 1. NPO 2. IV fluids 3. Suction as needed 4. Supine 5. ABX for potential pneumonia Hirschsprung’s Disease: No ganglion cells in rectum = mechanical obstruction due to low motility S/S: no meconium, refusing to suck, abdo distention, delayed growth, vomiting, constipation, ribbon like stools Priority: 1. Monitor for enterocolitis (fever, GI bleed, diarrhea) 2. Low fiber, high cal, high protein diet 3. Stool softeners 4. Rectal irrigations 5. NPO 6. Monitor weight Intussusception: Results in obstruction of GI content S/S: abdo pain (pt has knees up to abdo), vomiting up bile stained emesis, currant jelly like stool, distended abdo with sausage shaped mass in RUQ Passing of normal stool = intussusception has resolved Priority: 1. Monitor for perforation (fever, tachycardia, resp distress) 2. ABX and IV fluids 3. NGT for decompression Umbilical Hernia: Bowel protrudes through opening in abdo wall (usually through umbilicus or inguinal canal) Incarcerated hernia = medical emergency due to compromising blood supply EYE + EAR Conjunctivitis: Bacterial + viral conjunctivitis is very contagious S/S: redness, edema, discharge, burning Priority: 1. Hand hygiene 2. ABX or antiviral eye drops 3. No sharing of towels 4. No school or daycare until 24 hrs post ABX administration 5. Avoid rubbing eyes and wearing eye makeup Otitis Media: Common after a respiratory infection. Common in children due to shorter, wider, and straighter eustachian tubes To prevent: feed infant upright, breast feed for first 6 mos, avoid smoking, maintain immunizations S/S: fever, ear pain, crying, no appetite, head rolling side to side, pulling on ear, ear drainage, red + opaque tympanic membrane *remember to pull child under 3 yr pinna down + back when giving meds (older than 3 y = pinna up and back) 37 Nosebleed: Do not put pt in laying down position = risk of aspiration RESPIRATORY Epiglottitis: Bacterial form of croup Emergency due to possibility of severe resp distress S/S: fever, red/inflamed throat, painful swallowing, no cough, muffled voice + drooling, agitation, stridor, tachycardia, tachypnea, tripod position Priority: 1. Patent airway 2. Do not measure oral temp 3. NPO 4. Do not leave child unattended 5. Avoid supine position 6. IV ABX, analgesics, and antipyretics 7. Cool mist O2 8. Do not attempt to visualize pharynx or take a throat culture (can lead to spasm → airway occlusion) RSV: Acute viral infx that is highly communicable by direct contact with resp secretions Common cause of respiratory infection and bronchiolitis Affects ciliated cells = bronchiolar swelling = increased mucous production Mostly occurs in winter + spring S/S: rhinorrhea, cough, wheezing, fever, tachypnea, retractions, cyanosis, apneic episodes Priority: 1 Contact precautions 2. Maintain patent airway with HOB @ 30-40 degrees 3. Cool humidified O2 4. Suction if needed 5. Antiviral and antipyretic medication 6. IV fluids for dehydration 7. Palivizumab given to high risk infants Cystic Fibrosis: Autosomal recessive trait; no cure; protein responsible for transporting Na and Cl is defective = secretions are thicker and stickier Mucus production is thick and copious, causing obstruction in small passageways of respiratory, GI, and reproductive systems → pancreatic fibrosis, chronic lung disease, sweat gland dysfunction S/S: emphysema, hypoxemia, wheezing, cough, dyspnea, cyanosis, barrel chest, meconium ileus, frothy stools, rectal prolapse, very high concentration of Na + Cl in sweat, delay in female puberty, sterility in males Priority: 1. ABX 2. Chest physiotherapy daily (do not perform after a meal) 3. Mucous removal 4. Huff cough 5. Bronchodilators 6. High cal, high protein, high fat diet 7. Monitor stools 8. Pancreatic enzyme replacement within 30 mins of eating + with all snacks 9. Salt replacement Sudden Infant Death Syndrome (SIDS): Most frequent in winter, during sleep, and in male infants 2-3 months of age. Incidence is lower in breastfed infants High risk for SIDS: prone sleep position, soft bed, overheating, cosleeping, mother who smoked/abused substances while pregnant, excessive sheets in bed, exposure to smoke CARDIOVASCULAR Atrial Septal Defect Atrioventricular canal defect Patent Ductus Arteriosus Heart Defects Opening b/w atria = oxygenated blood goes to R side = increased pulmonary blood flow = R atrial + vent enlargement Incomplete fusion of endocardial cushions. Seen in Down Syndrome Shunt connecting aorta + pulmonary artery does not close S/S: decreased peripheral pulses, feeding difficulty, hypotension, restless, oliguria, pale/cool, tachycardia S/S: murmur, cyanosis increases with crying, S/S of low cardiac output S/S: murmur, wide pulse pressure, S/S of decreased cardiac output 38 Ventricular Septal Defect Aortic stenosis Coarction of aorta Pulmonary stenosis Tetralogy of Fallot Tricuspid atresia Transposition of great arteries Opening between L and R ventricles. Most close spontaneously Narrowing of aortic valve = resistance to blood flow from L ventricle to aorta = L ventricular hypertrophy + pulmonary congestion Narrowing near ductus arteriosus Narrowing at pulmonary artery = causes R ventricular hypertrophy (can lead to pulmonary atresia = no blood flow to lungs) VSD + pulmonary stenosis + overriding aorta + R ventricular hypertrophy Tricuspid valve fails to develop = no communication b/w R atrium and R ventricle = blood will flow through ASD or patent foramen ovale = complete mixing of unoxygenated + oxygenated blood. Usually associated with pulmonic stenosis Pulmonary artery leaves the L ventricle and aorta leaves the R ventricle S/S: murmur, S/S of heart failure S/S: murmur, decreased cardiac output, exercise intolerance, chest pain, dizziness S/S: BP is higher in upper extremity than lower extremity, bounding pulses in arms, cool lower extremities, signs of heart failure, decreased cardiac output, headaches, dizziness S/S: murmur, cyanosis @ birth, decreased cardiac output S/S: cyanosis @ birth, murmur, episodes of hypoxia + cyanosis (tet spells), clubbing, poor growth S/S: cyanosis, tachycardia, SOB, clubbing Clubbing = chronic hypoxia S/S: severe cyanosis @ birth, cardiomegaly Rheumatic Fever Inflammatory autoimmune disease affecting connective tissue of heart, joints, skin, blood vessels, and CNS Most serious complication = rheumatic heart disease RF occurs after untreated streptococcal infx of upper respiratory tract (ask about recent sore throat) S/S: chorea (involuntary movement of extremities + face, can affect speech), fever, carditis (inflammation of mitral valve), abdo pain, erythema marginatum (red lesions on trunk), subcutaneous nodules, polyarthritis Priority: 1. Bed rest 2. Limit activity 3. ABX, analgesics, anti-inflammatories 4. Seizure precautions if pt has chorea Kawasaki Disease Acute systemic inflammatory illness; no known cause Most serious complication = aneurysms S/S: fever, red throat, swollen hands with rash, cracked lips, peeling of skin on fingers + toes, joint pain, thrombocytosis Priority: 1. Monitor for fever 2. Asses for edema, redness, and peeling 3. Soft food diet 4. ROM exercises 5. Aspirin RENAL Nephrotic Syndrome: Proteinuria, hypoalbuminemia, edema S/S: weight gain, edema (most prominent in morning), low urine output, ascites, HTN, lethargy Enuresis: Pt unable to control bladder function 39 Cryptorchidism: Teste(s) fail to descend into scrotum (cannot palpate or easily guide testes into scrotum) Epispadias + Hypospadias: Epi = dorsal urethral opening, hypo = ventral urethral opening; can lead to bacteria entering urine Circumcision is not performed (foreskin needs to be used for reconstruction) NEUROLOGICAL Cerebral Palsy: Abnormality in extrapyramidal + pyramidal motor system = impaired movement + posture S/S: irritability, difficulty feeding, stiff + rigid muscle tone, delayed milestones, abnormal posture, seizures Priority: 1. PT, OT, speech therapy 2. Mobilizing devices 3. Interact with child based on developmental level rather than chronological age 4. Safe environment with seizure precautions 5. Upright position after meals Increased ICP: S/S: high pitch cry, buldging fontanel, increased head circumference, Macewen’s sign (cracked pot sound on head), setting sun sign (sclera shows above iris), dilated scalp veins, late S/S (change in LOC, decorticate or decerebrate posture, Cheyne stokes, coma) Priority: 1. Patent airway, O2 PRN 2. Head and body midline 3. Calm and quiet environment 4. Seizure precautions 5. NPO 6. Administer Tylenol, anticonvulsants, osmotic diuretic and ABX 7. Monitor for nose + ear drainage (test for CSF) Brainstem Injury: S/S: deep + rapid respirations, bradycardia, wide pulse pressure, dilated + unequal pupils Hydrocephalus: Increased CSF due to tumour, hemorrhage, infx, trauma = head enlargement S/S: high shrill cry, increased head circumference, Macewen’s sign, buldging anterior fontanel, dilated veins, setting sun eyes Priority: 1. Ventriculoperitoneal or ventriculoarterial shunt to drain CSF accumulation Neural Tube Defects: Neural tubes fail to close = sensorimotor deficits, dislocated hips, clubfoot, and hydrocephalus Types of neural tube defects = spina bifida, meningocele, myelomeningocele Priority: 1. Protect the exposed sac (cover with sterile moist dressing) 2. Change sac dressing regularly 3. Monitor neuro status and ICP 4. Aseptic technique 5. Monitor for infx, give pt ABX 6. Place pt in prone position 7. Prep for surgery Autism: S/S: impaired social interaction, verbal impairment, intellectual deficit, altered behaviour (attachment to objects, selfinjuries, repetitive routine or body movements) Priority: 1. Safe environment 2. Maintain a consistent routine 3. Avoid placing demands on pt MUSCULOSKELETAL Developmental Dysplasia of the Hip: Head of femur not in proper placement Signs of dysplasia: asymmetry of gluteal + thigh folds, limited hip abduction, shortening of limb on affected side, Ortolani click (in pt < 4 wks) Priority: 1. Pavlik harness continuously (maintains flexion, abduction, and external rotation) 40 INFECTIOUS DISEASE Rubeola/Measles: Spread by respiratory secretion, blood, and infected urine (droplet + direct contact) S/S: fever, weakness, 3 C’s (coryza, cough, conjunctivitis), rash on face turns red to brown over time, Koplik’s spots Priority: 1. Airborne, droplet + contact precautions 2. Bed rest + quiet environment 3. Cool mist for cough + coryza 4. Antipyretics Rubella/German Measles: Spread by nasopharyngeal secretion, blood, stool, and urine (droplet + direct contact) S/S: fever, weakness, pink/red maculopapular rash over entire body, petechiae on soft palate Priority: 1. Airborne, droplet + contact precautions 2. Keep away from pregnant women Varicella (Chickenpox): Spread by respiratory secretions and direct contact with skin lesions (droplet + direct contact) S/S: fever, weakness, macular rash (lesions will pus, dry, and crust) Priority: 1. Airborne, droplet + contact precautions 2. Acyclovir Pertussis (Whooping cough): Spread by respiratory secretions (droplet + contact precautions) S/S: cough (with whooping inspiration), cyanosis, respiratory distress, listlessness Priority: 1. Airborne, droplet + contact precautions 2. Antimicrobials 3. Reduce irritants (smoke, dust, etc.) 4. Suction and humidified O2 if needed 5. *Infants don’t receive maternal immunity to pertussis Age 1 month 2 months Immunizations Immunization Hep B Inactivated polio (PIV), diphtheria + tetanus + acellular pertussis (DTaP), Haemophilus influenzae Type B (HiB), pneumococcal (PCV), rotavirus (RV) 4 months IPV, DTaP, HiB, PCV, RV (same as 2 months) 6 months IPV, DTaP, HiB, PCV, RV, Hep B 12-15 months HiB, PCV, MMR, Hep A 15-18 months DTaP 18-33 months Hep A 4-6 yrs IPV, DTaP, MMR, varicella 11-12 yrs MMR, diphtheria + tetanus + acellular pertussis adolescent (Tdap), meningococcal, HPV Normal reactions to a vaccine: tenderness, redness, swelling, low grade fever, drowsiness, decreased appetite NUTRITION Honey: Don’t give to pt < 1 yr due to risk of infant botulism (produces muscle paralysis) S/S: constipation, decreased reflexes, weakness, respiratory failure Infant Nutrition: Birth-6 mos: exclusive breastfeeding Start introducing solid food between 4-6 mos (start off with iron fortified cereal) Give 5-7 days between food introductions to observe for allergies 1 year: introduce cow’s milk 41