pedi midterm 2

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  1. emancipated minor
    one who is legally under the age of majority but is recognized as having the legal capacity of an adult under circumstances prescribed by state law such as pregnancy,marriage, high school graduation,independent living, or military service
  2. treatment w/o parental consent
    exception to requiring parental consent occur in situations where urgent medical treatment  is needed and the parent is not available to give consent or refuse consent

    any child brought to a emergency department accompanied by a caregiver the caregiver who was given permission by the parent is able to give informed consent by proxy

    in emergencies including danger to life  or the possibility to permanent injury appropriate care should not withheld or delayed because of problems obtaining consent

    the nurse should document any effort made to obtain consent

    parental refusal to give consent for life saving treatment or prevent serious harm can occur and require notification to child protective services to render emergency treatment. evauluation for child abuse or neglect can occur w/o parental consent and w/o notification to the state before evauluation in most states
  3. adolescent, consent and confidentiality
    all 50 states have enacted legislation  that entitles adolescents to consent to treatment without parents knowledge to one or more medically emancipated conditions such as std's mental health services, drug addiction and pregnancy and contraceptive advice

    • consent to abortion is controversy and states vary widely by state 
    • state law preempts HIPAA regardless of whether that law prohibits mandates or allows discretion about a disclosure
  4. preparing children for procedure
    • determine details of exact procedure to be performed
    • review child and parent understanding
    • base teaching on developmental age and existing knowledge
    • incorporate  parents in teaching, especially if they plan to participate in care
    • inform parents of their supportive role during the procedure,as well as typical responses of children under going procedure
    • allow for ample discussion to prevent information overload and ensure adequate feedback
    • use concrete not abstract terms and visual aids to describe procedure
    • emphasize that no other body part willl be involved
    • if body part is associcated w/specific function, stress the change or noninvolvement of that ability
    • use words and sentence length appropiate to child's level of understanding
    • avoid word and phrases with dual meanings 
    • clarify allunfamiliar words
    • emphasize sensory aspects of procedure-what child will feel see hear touch and what child can do during procedure
    • allow child to practice procedure that will require cooperation
    • introduce anti-anxiety information last like starting an IV
    • be honest with child about unpleasant aspects of procedure but avoid creating undue concern 
    • emphasize end of procedure and any pleasurable event afterward
    • stress positive benefits of procedure
    • provide a positive ending,praising efforts at cooperation and coping
  5. age specific preparation for procedure infant
    • developing trust and senssorimotor thought
    • attachment to parent- involve parent in procedure if possible place familiar object w/infant
    • stranger anxiety-have usual caregiver w/pt make advances slowly, limit # of strangers entering room during procedure
    • sensorimotor phase of learning-use sensory soothing measures, use analgesics encourage parent to comfort after procedure 
    • increased muscle control-expect older infants to resist,
    • restrain adequately
    • memory for past experience-may associate objects with past painful experience
    • keep frightening objects out of view
    • perform painful procedure in separate room
    • imitation of gestures-model desired behavior
  6. age specific preparation for procedure toddler
    • develooping autonomy  and sensorimotor to preoperational thought
    • preoperational thought-use same approach as infants
    • egocentric thought- explain procedure inrealtion to what child will thats see,feel and hear, emphasize aspects of procedure that will require cooperation
    • tell child it is ok to cry or yell to express discomfort
    • designate one provider to speak during procedure
    • negative behavior-expect treatment to be resisted use firm direct approach
    • ignore temper tantrums
    • use distraction techniques
    • restrain adequatly
    • animism-keep freightening object out of view
    • limited language skills- communicate using gestures or demonstrations
    • use simple terms familiar to child
    • give child one direction at a time
    • use small replicas of equipment allow child to handle equipment
    • use play
    • prepare parents seperatly to avoid child misinterpriutation of words
    • limited concept of time- prepare child shortly or immediately before procedure
    • keep teaching sessions short
    • have preparations complete before involving child in procedure
    • have extra equipment near by
    • tell child when procedure is complete
    • striving for independence- allow choices whenever possible
    • allow child to participate in care and help whenever possible
  7. age specific preparation for procedure -preschooler
    • developing initiative and pre operational thought
    • egocentric- explain procedure in simple terms and in relation to how if affects child
    • demonstrate use of equipment
    • allow child to play with miniature or actual equipment
    • encourage play out experience
    • use neutral words to describe procedure
    • increased language skills-use verbal explanations but avoid over estimating child's comprehension words
    • encourage child to verbalize ideas and feelings
    • limit concept of time and frustration tolerance- implement same approach as toddler
    • plan longer teaching sessions may provide information in more than one session
    • illness and hospitalization viewed as punishment- clarify why each procedure is done
    • ask child's thoughts regarding why procedure is preformed
    • state directly that procedures are never a part of punishment
    • animism-keep equipment out of site except when shown or used
    • fears bodily harm, intrusion, and castration- point out of drawing or doll where procedure will be performed
    • emphasize that not all body parts will be harmed
    • use non-intrusive procedures when possible
    • apply any adhesive bandages over puncture sites
    • encourage parental presence
    • realize that procedure involving genitalia provoke anxiety
    • allow child to wear underwear with gown
    • explain unfamiliar situations
    • strive for initiative- involve child in care whenever possible
    • give choices whenever possible
    • praise child for helping and attempting to cooperate
  8. age specific preparation of children procedure - school-age child
    • developing industry and concrete thought
    • increased language skills interest in acquiring knowledge-
    • explain procedure using correct scientific terminology
    • explain procedure using dimple diagrams and photos
    • discuss why procedure is necessary
    • explain function and operation of eqipment in concrete terms
    • allow child to manipulate equipment
    • allow before and after procedure for questions and discusiions
    • improved concept of time- 
    • plan for longer teaching session 
    • prepare up to 1 day in advance of procedure  to allow for processing of information
    • increased self control-gain child's cooperation
    • tell child what is to be expected
    • suggest several ways to maintain control the child may select from deep breathing counting etc
    • striving for industry- allow resposibilty for simple task
    • include child in decsion making
    • encourage active participation
    • developing relationship with peers- prepare 2 or more children for same procedure or encourage one to help another
    • provide privacy from peers during procedure to maintain self esteem
    • -
  9. age specific preparation of children procedures adolescent
    • developing identity and abstract thought, increasing abstract thought and reasoning- discuss why procedure is necessary
    • explain long term consequences of procedure
    • realize adolescents may fear death,disability or other risk
    • encourage questioning regarding fears options and alternative
    • consciousness of appearance -provide privacy
    • discuss how procedure may affect appearance and what can be done to minimize it
    • emphasize onphysical benefits of procedure
    • concern more with presence than future -realize the immediate effectsof procedure are more significant than future benefits
    • striving for independence involve in decision making and planning
    • impose as few restrictions as possible
    • explore what coping strategies have worked in the past and suggest various techniques
    • accept regression to more childish methods of coping
    • realize adolescents have difficulty accepting new authority figures and may resist complying with procedures
    • developing peer relationships and group identity- same as with school age children but assume even greater significance
    • allow adolescents to talk with other adolescents who have had the same procedure
  10. fasting recommendation to reduce risk of pulmonary aspiration
    • clear liquids- more than 2 hours
    • breast milk-   4 hours
    • infant formula-  6 hours
    • non-human milk- 6 hours
    • light meal -  6 hours
  11. child with fever
    • call office immediatly: 
    • child w/ fever is younger than 2 mths old
    • fever is over 105F
    • the child looks or acts very sick, including stiff neck, persistent vomiting,purplish spots on skin, confusion trouble breathing, inability to be comforted

    • call within 24 hours
    • fever between 104-105
    • fever longer than 24 w/o obvious cause or location
    • fever longer than 3 days
    • burning pain with urination
    • hx of febrile seizures
    • fever went away for more than 24 hours and than returned
  12. types of precautions
    airborne- transported by airborne droplet nuclei (measles,varicella,tuberculosis)

    • droplet-transmitted by large-particle droplets (meningitis,pneumonia,epiglottis,sepsis,) bacterial respiratory tract infections spread by droplet transmission
    • serious viral infections (adenovirus,influenza,mumps,parvo,and rubella)

    • contact precautions: transmitted by direct pt contact or contact with items in the pts enviroment
    • gastrointestinal,respiratory, skin or wound infections of staph
    • enteric infections ex c-diff shigella,hep a rotavirus
    • respiratory viruses or enteroviral infections in infants and young children
    • skin infections are highly contagious ex diphtheria,herpes impetigo,abscesses cellulitis
    • viral or hemorrhagic conjunctivitis
    • viral hemorrhagic infections
  13. fluid and electrolyte balance
    • the fetus is composed of almost entirely water early in gestation and at term is 73% FLUID COMPARED WITH 58%in the adult
    • fetus has more extracellcular fluid but this shift progressively throughout postnatal life ,because of the growth of cells at the expense of the extracellcular fluid

    • infants rate of metabolism is twice that of an adult in relation to body weight as a results more acid is formed  leading to more rapid development of acidema
    • immature kidneys can not sufficiently concentrate urine to conserve body water, theses factors make the infant more prone to dehydration, acidosis and overhydration
  14. gastrointestinal system
    • newborns ability to digest absorb and metabolize food is adequate but limited in certain functions
    • enzymes are available to catalyze proteins and simple carbs but deficient production of pancreatic amylase impairs utilization of complex carbs
    • a deficiency of pancreatic lipase limits the absorption of fats , especially w/ingestion of food that have high saturated fatty acid content,such as cow's milk
    • human milk despite its high fat content is easy to digest because it has lipase in it 
    • the liver is the most immature of the gastro organs
    • the activity of the enzyme glucuronyl transferase is reduced affecting the conjugation of bilirubin w/glucuronic acid which contributes to physiologic jaundice in newborns
    • the liver is also deficient in forming plasma protein which plays a role in the edema seen at birth
    • the liver stores less glycogen at birth 
    • newborn is prone to hypoglycemia which can be prevented by early effective breastfeeding
    • do not began to secrete saliva until 2-3 mths
    • stomach capacity 5 ml on day 1 to 60 ml on day 3
    • intestines are larger in reference to body size therefore has larger # of secretory glands and larger surface area for absorption
    • rapid peristaltic waves simultaneous non-peristaltic waves occur along the entire intestine, theses waves called migrating motor complex prople nutrients forward
  15. renal system
    • all structural component are present
    • kidneys have functional deficiency in its ability to concrete urine and to cope with fluid and electrolyte fluctuations such as dehydration or concentrated solute load
    • total volume of urinary output per 24 hours is about 200to 300 ml by the end of the first week 
    • the bladder empties when stretched to a volume of about 15 ml resulting in as much as 20 voidings daily
    • urine has a specific gravity of about 1.020
  16. integumentary system
    • many functions are immature.
    • epidermis and dermis are loosely bounded and are very thin
    • rete pegs which anchors the skin is not developed
    • slight friction such taking tape off can separate the layers and cause blister or loss of epidermis
    • in full term infants the transitional zone between the cornified and living layer is effective in preventing fluid from reaching the skins surface
    • the sebaceous glands are active later in life they are densely located on the scalp face and genitalia and produce the greasy grayish white vernix caseosa that covers the infant at birth plugging of those glands cause milia 

    • the eccrine glands which are in charge of producing sweat in response to heat  are functional at birth the sweat response is at hight temps tahn adults and retention of sweat cause milia
    • by 3 wks of age palmar sweating reaches thos of anxious adults
  17. defense against infection
    • first line of defense is the skin and mucous membrane which protect the body against invading organisms
    • 2nd line of defense is cellcular elements of the immunologic system which produce several types of cell  capable of attacking a pathogen
    • neutrophils and monocytes are phagocytes  cells that engulf,ingest  and destroy foreign agents
    • eosinophils also phagocytic property because in the presence of foreign protein they increase in number
    • lymphocytes t &b cells are capable of being converted to other cell types 
    • 3rd line of defense is formation of specific antibodies to an antigen this process requires exposure to various foreign agents for antibody production to occur
    • infants are not capable of producing their own immunoglobulins until the beginning of the 2nd month of life but they receive passive immunity igg from mother
    • infants are protected against major childhood disease including diphtheria,measles,poliomyelitis, rubella for about 3 months provided the mother has developed antibodies
  18. endocrine system
    • adequately developed
    • functions are immature
    • posterior lobe of the pituitary gland produces limited quantity of antidiuretic hormone or vasopressin which inhibit diuresis which makes infants prone to dehydration
    • breast in both sexes may be enlarged and secrete milk during first few days to 2 months of age
  19. neurologic system
    • nervous system is incompletely integrated but sufficiently developed to sustain extrauterine life
    • most neurologic functions are primitive reflexes
    • autonomic nervous system is crucial during transition because it stimulates initial respirations. help maintain acid-base balance and regulates temperature  control
    • myelination of the nervous system follows cephalocaudal proximodistal laws of development (head to toe center to periphery) and is closely related to the observed mastery of fine and gross motor skills.
    • tracts that develop myelin earliest are sensory,cerebellar and extrapyramidal.this accounts for the acute sense of taste smell and hearing and the perception of pain
    • all cranial nerves are myelinated except the optic and olfactory nerves
  20. vision
    • at birth the eye is structurally incomplete
    • the fovea centralis is not yet completely differentiated from the macula
    • the ciliary muscles are also immature, limited the eyes ability to accommodate and fixate on an object for any length of time
    • the pupils react to light, the blink test is responsive to minimum stimuli and the corneal reflex is activated by light touch
    • tear glands usually do not begin to function until 2-4 wks age
    • the newborn has the ability to momentarily fixate on a bright or moving object that is within 8 inches and is midline of the visual field
    • the infant's ability to fixate or coordinate movement is greater during the first hour of life than during succeeding several days
    • visual acuity is reported to be between 20/100 and 20/400
    • infants also demonstrate visual preference medium colors yellow green pink or dim or bright colors red orange blue, black and white contrasting patterns especially geometric shapes checkerboards large objects w/medium complexity
  21. hearing
    • once amniotic fluid has drained from the ears audible acuity is the same as adults
    • response to low and high frequency sounds differ
    • infants have an early sensitivity to the sound of human voices and specific speech sounds
    • the mastoid process and the bony part of the external ear have not yet been developed
    • the tympanic membrane and facial nerves are close to the surface and can be easily damaged
  22. smell
    • newborns react to strong odors 
    • breastfed babies are able to smell breast milk
    • infants are able to differentiate their mothers breast milk from another's breast milk by scent alone 
    • unnecessary washing of the breast between feeding can interfere with early breast feeding
  23. taste
    • can distinguish between taste and various solutions and elicit different facial reflexes
    • a tasteless solution elicits no face expression a sweet solution elicits an eager suck a sour solution elicits puckering of the lips and bitter taste elicits and angry upset exspression
  24. touch
    • can perceive tactile sensation in any part of the body 
    • face sole of feet and hands are most sensitive
    • touch and motion are essential in the attachment process and in normal growth and development 
    • gentle patting and rubbing of abdomen usually elicit a calming response painful stimuli elicit an upset response
  25. apgar scoring
    • based on observation of heart rate respiratory effort,muscle tone, reflex irritability and color
    • each item is given a score of 0,1,2
    • done 1 min and 5 min after birth and is repeated every 5 mins until newborn is stabalized

    • sign             0           1                2
    • heart rate  absent       slow<100   >100
    • Respiratory  absent irregular slow  good strong
    • effort                           weak cry       cry
    • muscle tone  limp      some flexion   well flexed
    • reflex
    • irritabilty   no response   grimace    cry sneeze
    • color       blue pale     pink blue extrem   comp
    •                                                            pink
  26. assessment of attachment behaviors
    • bonding represents the development of emotional ties from parent to infant
    • attachment represents the emotional ties from infant to parent
  27. physical assessment of a newborn 
    vital signs
    • temperature 97.7-98
    • heart rate apica 120-140bpm
    • bradycardia 80-100
    • tachycardia 160-180
    • respiration 30-60/
    • crying increases rate
    • sleep decreases rate
    • blood pressure 65/41 in arm and calf
    • systolic greater than 90 considered hypertension
  28. newborn head assessment
    • anterior fontanel-diamond shaped
    • posterior fontanel-triangular
    • fontanels flat soft and firm
  29. lungs
    • respirations abdominal
    • cough reflex absent at birth present by 1-2 days
    • bilateral equal bronchial breath sounds
    • minor abnormal finding crackle shortly after birth

    • abnormal
    • inspiratory stridor,unequal breath soounds
    • expiratory grunting,wheezing,
    • retractions seesaw respirations
    • apnea,peristalsis bowel sounds on one side w/diminished breath sounds on the other
  30. heart
    • apex 4-5th intercostal space ,lateral to left sternal boarder
    • s2 slightly sharper and higher in pitch than s1

    sinus arrhythmia-heart rate increasing w/inspiration and decreasing with expiration

    abnormal

    • dextocardia- heart on right side
    • displacement of apex
    • thrill
  31. physical eye assessment
    • examine the cornea for any opacities or haziness
    • corneal reflex is present at birth but is generally not elicit unless cerebral or eye damage is suspected

    • pupils respond to light by restricting
    • absence of pupillary reflex by 3 wks suggest blindness
    • a fixed dilated or constricted pupil may indicate central nervous system damage 
    • a searching nystagmus is common after birth

    strabismus is a normal finding because of lack of binocularity
  32. vitamin K
    • administered shortly after birth to prevent hemorrhagic disease of the newborn
    • baby's body supply is not enough at least for the first 3-4 days 
    • major function of vitamin K is to catalyze the synthesis of prothrombin in the liver,which us needed for blood clotting 
    • vatus lateralis muscle is traditionally recommended injection site  but ventrogluteal can be used
    • given as a single intramuscular dose .5-1.0 mg
  33. hep b vaccine administration
    • first 3 doses vaccine recommended between birth and 2 months for all newborns born to hep b surface antigen negative mothers
    • injection given in the vatus lateralis  site is associated with better immune response
    • should be vaccinated as early as 30 days regardless of gestational age or birth weigh
    • infants born to hbsag-positive mothers should be vaccinated within 12 hours after birth with hbv vaccine and hep b immune globulin at separate sites regardless of gestational age or birth weight
  34. human milk
    • lysozyme is found in large quantities  in human milk with bacteriostatic functions against gram positive bacteria and enterobacteriaceae organisms
    • human milk also contains macrophages granulocytes t&B lymphocytes
    • casein in milk greatly enhances the absorption of iron thus preventing iron dependent bacteria from proliferating in the GI tract
    • secretory immunoglobulin that prevents viruses and bacteria from invading the intestinal mucosa in breastfed newborns is found in  high levels of colostrum
    • this whey protein is believed to prevent development of allergies
    • human milk is composed of lipids triglycerides and cholesteral
    • cholesterol is essential in brain growth
    • lipids contribute to 50% total calories in human milk
    • overall fat content is more than cows milk but is used more efficiently
    • primary source of carbohydrate in human milk is lactose
    • the oligosaccharides(prebiotic') in human milk stimulate the growth of lactobacillus ( a probiotic) and prevent bacteria from adhering to epithelial surface
    • human contains 2 proteins whey and casein ratio 60:40 
    • several digestive enzymes  include amylase,lipase,protease and ribonuclease which enhance digestion and absorption
    • the amount of liquid and water soluble vitamins  as well as electrolytes,minerals trace elements are sufficient for development and energy needs during the first 6 months of life 
    • the one possible missing vitamin is vit D
    • to prevent vitamin d deficiency rickets it is recommended that breast fed babies take 400 IU per day
  35. proportional changes
    • infants gain 1.5lb a month until age 5  mths
    • weight should double by 5 mths
    • weight should triple by 1 year
    • average weight for 6 mth old 16 lbs
    • average weight of 1 yr 21.5
    • height increases 1 inch per month during first 6 mths and half that amount during 2nd 6 mths
    • lenght occur in sudden spurts
    • by 1 year length has increased by 50% occurs main in trunk rather than in legs
    • head circumference increases 2 cm  per month from birth to 3 mths  1 cm per month 4-6 and .5 for 2nd 6 mth 
    • by age 1 head size is increased by 33%
    • closure of the cranial sutures occurs with the posterior fontanel  closing by 6-8 wks  and anterior fontanels closing at 12-18 mths
    • heart grows less rapidly than the rest of the body
    • weight of heart id doubled by 1 yr
    • heart is 55% of chest width
  36. neurologic reflexes that appear during infancy
    labyrinth righting- infant in prone or supine position is able to raise head; appears at 2 mths strongest at 10

    neck righting- head is turned to one side , shoulder trunk and finally pelvis  will tun toward the sun  appears at 3 mths until 24 to 36 mths

    body righting-turning hips and shoulders to one side causes all body parts to follow appears at 6 mths, until 24-36months

    otolith righting-when body of a erect infant is tilted, head is retrned to upright,erect position;appears at 7 to 12 mths persists indefinitley

    landau- when infant is suspended in a horizontal prone position , the head is raised and legs and spine are extended appears at 6 to 8 mths last until 12-24 mths

    parachute- when infant is suspended in a horizontal prone position and suddenly thrust downward, hands and fingers extend forward as if to protect against falling appears at 7-9 mths persist indefinitley
  37. maturation of systems
    • the immunes systems inability to produce immunoglobulin in the mucosal lining provides less protection against infection in infancy than in later childhood.
    • the entire respiratory tract's ability to produce mucus is diminished, decreasing the humidification of the large volume of inspired air 
    • the pliant rib cage has less elastic recoil,and during respiratory distress, the work of breathing is increased
    • infant has to breath approx twice as hard as an adult to provide the body it's needed amount of oxygen
    • systolic rises during the first 2 mths as a result of left ventricular increasing ability to pump blood into the systemic circulation
    • diastolic pressure decreases during the first 3 mths than rises to value closer to birth
  38. sinus arrhythmia
    rate increases with inspiration and decreases with exspiration
  39. physiologic anemia
    • fetal hemoglobin is present in the first 5 months
    • hgbF results in shortened survival of red blood cells and decrease # RBC a common result at 3-6 months is physiologic anemia
    • high levels of hgb F depress the production of erythropoietin a hormone release by the kidney that stimulates RBC production
  40. sucking
    • can occur in  utero 15-18 weeks of gestation
    • 27-28 weak disorganized mouthing movements may be noted
    • 36-38 complete maturation sucking, swallowing, and breathing patterns
  41. vernix caseosa
    • white, oily substance that coats infant's body
    • serves to protect the newborn from infection
    • maintains the integrity of the stratum corneum and facilitating acid mantle development
  42. grasp
    • 1-hands are predomitaley closed
    • 2-3 mths grasping occur
    • 3 mth hands are mostly open
    • 4 mth can hold object in hand and look at it
    • 5 mth voluntariy grasp an object
    • 7 mth transfer from one hand to another
    • 8-9 pincher grasp
    • 10 mth can let go of an object and give it to someone 
    • 11 neat pincher grasp
  43. caput succeda
    • scalp lesion
    • outlined are of edematous tissue situated over the portion of scap that presents in vertex delivery
  44. cephalhematoma
    • forms when blood vessels rupture during labor and delivery to preduce bleeding into the area between the bone and its periosteum
    • associated with forcep delivery
  45. erythema toxicum neonatorum
    • known as flea bite dematitis
    • begnin self-limiting  eruption tha appears within first days of life
    • 1-3 mm lesions are firm pale yellow or white papules or pustulates of erythema base that resemble flea bites
    • last 5-7 days

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Filename:
pedi midterm 2
Updated:
2016-10-18 11:54:37
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