Ped- 244 final
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. What would you like to do?
What info do you collect in a pediatric health history?
Maternal history, biographic data, labor and delivery, present health status, and family history
What does anxitey indicate?
What is the approach you should take to the peds assessment?
- developmetnal readiness
- get acquainted time
- determine best exam place
- be systematic, yet flexible
- examine intrusive or painful areas last
What is a newborn?
- Newborn- birth to 28 days
- Pre- term: <37 weeks
- term: 37-42 weeks
- Post-term- >42 weeks
What are infants?
- Birth- 6 months: Immoblie, safety, comfort, sensory stimulation
- 6 months-12 months: Separation/stranger anxity, warm up play techniques, examine infant on parents lap if appropriate
What is a toddler?
age 1-3 years, parent's lap provide security, play, least inrusive assessment first, avoid no responses, offer choices, and let touch equipment
What is a pre-school age child?
age 3- 5/6, keep parent close, exam table, protect modesty, consider magical thinking, use safe words, let touch equipment
What is a school age child?
age 6-10/12: Head to toe exam , address questions directly to child, give concrete explanations, answer questions honestly
What is pre adolescent and adolescent?
- Pre- 10-12 years
- Adolescent: 13-18/21
- privacy (exam alone)
- Preventive services
- Issues: body issues, eating disorders, pregnancy, STD, violence
What do you look for in the lungs and thorax for pediatrics?
- Tachypnea: rapid breathing
- Retractions: intercostal retractions- trouble breathing
- Dyspnea: SOB
- Anxiety & air hunger
- Inspriatory stridor
- Second hand smoke
What is the difference in a child's trachea?
It is higher and shorter so more respiratory problems
What are signs of airway obstruction?
Restlessness, anxiety or agitation indicate hypoxia, increased HR and RR, stridor/retractions, pallor/xyanosis, avoid sedatives that deress repirations
What are the differences in RR in children?
- Higher than adults go to 12-20 a min b/w 10-18 years
- Respirations should be counted for a full minute
- Assess when child is calm
- Infants/children under 7 are abdominal breathers
- BV in lungs when younger
What is croup?
- Acute spasm of larynx resulting in partial airway obstruction
- Peak: 6 months-2 years, grow out of
- Cause: Viral
- Mild fever, inspiratory stridor, barking cough
- Give plenty of fluids
What is epiglottitis?
- Medical emergency
- Severe inflammation of eiglottis that progresses rapidly
- peak: 3-8 years
- High fever, trouble swallowing, cherry red color, severe distress, upper airway obstruction, DO NOT examine throat
What is laryngotracheobronchitis?
- Inflammation of larynx, trachea, and bronchi.
- Predominately in infacts and toddlers
- Gradual onset
- Labored inspirations
What is pneumonia?
- Inflammation of bronchioles and alveoli
- Retractions, tachypnea, labored resps
- percussion: dullness
- vesicular BS change to Bronchial or BV
What is the difference in HR of children?
- Higher HR than an adult
- In infants under 1 year take aprical pulse because radial pulse is difficult to palpate, count for a full minute
What are normal BP in children?
- Birth to 1 year: 80/50
- 1 to 5 years: 90/60
- 5 to 10 years: 100-110/60-70
- 10 to 16 years: 110-120/70-80
- Measure annaully at age 3 and up
- use dynamap in infants
- use appropraite pediatric cuff
What do you assess in a CV/PV assessment?
- -Apical impulse at 4th ICS left of MCL, by age 7 reaches 5th ICS at MCL
- -Heart sounds louder and more high pitched
- -Some children have physiologic murmurs, does not indicate disease
- -Assess peripheral pulse, especially newborns
What do you look for in CV/PV history?
Growth patterns, clubbing, SOB, fatigue, suck reflex, having trouble keeping up with activity, murmurs, chest pain
What do you look for in an abdominal assessment in an infant?
- Infant history: breast or bottle fed, spitting up, response to new foods, bowel movements, food allergies.
- Infants have a soft, round abdoment with slight protrusion- bowel sounds in center of abdomen
- -Diastatis recti- when crying, muscle seperation
- -Umbilical cord: 2 arteries, 1 vein
- -Liver palpable .5-2.5 cm below right costal margin for newborns, 1-2 cm below for infants
What do you look for in an abdominal assessment in children?
- -24 hr diet recall, likes, dislikes, Pica- eating non-nutritional foods like stuffed animals
- -liver palpable 1-2 cm below right costal margin
- -Spleen 1-2 cm below left costal margin
- -Less palpable with age
What do you look for in an abdominal assessment for an adolescent?
- -Eatting patterns, 24 diet recall, weight loss or gain, level of activity
- -laxative use, vomiting
- -View self as thin or overweight
- -Same assessment as the adult
- -Privacy issues with exam
What are some eating disorders?
- OBessesd with food, weight, distorted body image
- Control issue
- Tooth decay, anemia, dry skin, hypotension, etc
What do you look for in musculoskeletal in infants?
- Cranial bones soft at birth (soft sport)
- Sutures ossify around age 6
- assess for congenital birth defects
- Bones arent fused at birth
What do you look for in musculoskeletal in children and adolescents?
- Children: Height, weight each visit, look at percentiles
- Assess gait, knees for alignment
- Toddlers have a wide stance which ends after 2.5 years
- Screen for scoliosis
- Injuries due to sports or trauma
What do you look for in an infants lymphatic assessment?
- System develops at 20 weeks, very susceptible to infection due to inability to produce immunoglobulins
- Receive IgG from Mother through passive immunity
What do you look for in a child lymphatic assessment?
increase b/w ages 6-9, larger than adults, shotty nodes 3mm to 1 cm in cervical and inguinal areas, small nontender nodes
What to look for in a infant & pediatric HEENT
- Head: Symmetry of skull and face
- Neck: Structure, movment, trachea, thyroid, vessels, lymph nodes
- Eyes: vision, placement
- Ears: hearing, external ear, ear canal, and otoscopic exam of tympanic membrane
- Nose: nose and sinuses
- Mouth: Structures of mouth, teeth and phaynx
Assessment of head: Infant
Head circumference: asses each visit for first 2 years of life Measure just above eyebrows, rapid increase in HC during first 3 months of life 34-35 cm at birth
Fontanels: Anterior 2.5-4 cm, close by 24 months. Sunken- dehydration, bulging: increased hemorrhage
Molding: cone head, overlapping of sutures due to pressure from birth. Resolves in a week
What is caput succedaneum?
- Accumulation of fluid beneath scalp
- crosses the suture line
- Normal findings: resolves in 3-4 days after birth
What is cephalhematoma?
- -Collection of blood and fluid beneath scalp, localized over one cranial bone, does not cross suture line
- Normal finding: take 3-4 weeks to resolve
Assessment of the Face
- Assess for symmetry, twitching-should be none, tics, edema
- Assess expression
Assessmentof the eyes
- Symmetry: outer canthus should align with pinna of ear
- Wide set or close eyes can indicate chromosomal problems
- Assess conjunctive for drainage
- 2-4 weeks: can focus on objects
- 3-4 months: coodination of EOM and follow objects
- 5-6 months: Follows peoples movements, plays with hands
Visual acuity in children
- Gets to 20/20 at age 6
- Use E on snellen chart to assess vision until age 6
- Color vision age 4-8
Assessment of the Neck
- Turns head side to side by 2 weeks of age
- Steady head control at 3-5 months
- Assess for short neck (Down Syndrome) or webbing (turners Syndrome)
- Head lag (poor neck control) after 6 months may indicate CP
- Assess shape and size of thyroid
Oral Pharynx assessment
- Assess color, drainage, uvula size
- Bed breath can indicate chronic sinusitis, infected tonsils
- Tonsils grow to maximum size between 2-6 years, can obstruct airway
- Assess nasal patency
- Infants are nose breathers
- Nasal flaring is respiratory distress
- watery discharge with allergies
- Yellor or green discharge: infection
- Maxillary and Ethmoid sinuses present at birth
- Frontal sinuse develops around age 7
- palpate and transilluminate
- Inspect mucosa, gingivae, tongue
- Assess for cleft palate
- Tongue movement
- Lips for color
- Salivary glands developed by 3 months
- 4-6 months- infant turns head to sound
- 6-10 months- responds to name and follows sounds
- Assess for hearing loss if decreased vocabulary
- Assess ears for abnormalities of auricle
- Low set ears- mental retardation
- Tragus and auricle pain: otitis externa
- To examine pull pinna down and back to straighten out until age 3
- hearing screenings at birth
- Primary concerns: Reflex, posture, tone
- closely tied with developmental tasks
- voluntary control will take over as brain develops
- Functions develop in orderly process
What are the soft signs in school-age children
- Signs are vague and conroversial
- Clumsiness, language distrubances
- delay in child to perform age specific activites
- continued presnce is a developmental delay or lag
What are infant reflexes?
- Moro or startle
- Tonic: Head to one side, other side arm and leg up disappears 4- 6 months
- Palmer grasp: Disappers 3-4 months
- Step in place
- Babinski- Disappears at 18 months
- Rooting: disappears at 3 months
- Newborn red in color-decreased fat, vasomotor instability
- Covered with white wazy coating (Vernix Caseosa)
- Immediately after birth lips, nail beds, and feet may be cyanotic
- Temp regulation not develop
- Sub-Q fa layer is poorly developed
- Apocrine glands not active until adolescense-mid perspiration odor
What are some infant skin conditions?
- Storkbites, Angelkiss- Vascular birthmarks
- Strawberry Mark- Immature hemangioma, slightly raised sharp demarcation 2-3 cm in diameter, disappear by age 5
- Cavernous Hemangiomas- reddish round mass blood vessels, may continue to grow until 10-15 months, regularly reassess
Infant hair and nails
- Lanuago- soft fine hair on ears, shoulds, and back-sheds 10-14 days after birth
- Postmature infants will have long nails
- Tufts of hair on back of spine- spina bifida
Children skin, hair and nails
- Bruising-inconsistent brusing with development= suspicion
- Common lesions associated with communicable diseases
- Rubella, Rubeola, Roseola
- Tinea corporis
What is diaper Rash?
- Result of prolonged contact with urine and feces
- Can be fungal with lesions
- Treatment: If dry, wet it. If wet, dry it!
- Caldesene medicated powder or desitin cream
What is Impetigo?
- Most common cause is Staphyloccus aureus, can be strptococcal.
- Predisposing factors; poor hygiene, antecednet lesions
- Occurs around the mouth and nose as oozing that becomes honey-crusted lesions
- Scratching will spread the infection
- Treatment: antiseptic soap/water, ATB
What is Tinea corporis?
- Ringworm: superficial fungal infection that is most prevalent in hot, humid climates and children
- Transmitted by direct or indirect contact and is communicable as long as lesion is present
- Treatment: fungal cream or griseofulvin for systemic treatment
- Keep skin dry, avoid tight clothing
What is scabies?
- Caued by mites that burrow under the skin to lay eggs
- Pruitus is caused by feces and ova
- Highly communicable and spread skin to skin
- Most common sites are the finger webs, wrists, and anticubial fossa
- Lesions are linear, threadlike, grayish burrows
- Treatment: Elimite cream applied and left on skin 8-14 hours head to toe
- Apocrine glands enlarge and become active
- Incresed sebaceous gland activity
- Have oiler skin
Adolescent hair and Nails:
- Increased andrgoen levels
- Axillae adn pubic areas will develop coarse terminal hair
- Nails: same as adults
- Tanner Stages- developmental assessment
- Asymmtrically-normal may resolve
- Gynexomastia- normal, resolves
Should children warm up before sports?
Yes, if not many injuries can occur
What is the most common disorder in babies?
What is the test used to assess development of a newborn/infant/child?
The Denver developmental Screening Test- tests approproiate milestones for a child's gross motor, language, fine motor, and personal social development
What are the developmental stages of infants/newborns?
- Cognitive and Language development (Piaget)- Sensorimotor stage
- Moral Development (Kolberg)- Love and affection of the parents, follows them
- Psychosocial Development (erikson)- Trust v. Mistrust
- Psychosexual Development (Freud)- Oral Stage
What is the APGAR scoring in Newborns.
- Check at 1 and 5 minutes after birth
- Score less than 8 may indicate poor transiton from intrauterine to extrauterine life
Female Breast Development Rating
- Stage 1-5 based on Tanner
- 1: none
- 5: highest
Male Genitalia and Public Hair Rating
- Stage 1-5, based on Tanner
- Stage 1: No hair
- Stage 5: Adult configuration, adult pattern hair
Female Pubic Hair Rating
- Stage 1-5, based on Tanner
- Stage 1: No hair
- Stage 5: Inverse Triangle
Developmental Stage based on Piaget from Toddler to Adolescents
- Toddler- Sensorimotor to Preoperational Stage
- Preschoolers- Preoperational
- School-age children: Operational
- Adolescents: Formal Operations Stage
Moral Development by Kolberg from Toddler to Adolescent
Toddler- precoventional stage, punishment and obedience
Preschooler- preconventional stage, 10 years, external control
School-age child- role conformity-please others
Adolscent- postconventional, individual conscience and defined set of moral values
Psychosocial Development by Erikson from Toddler to Adolescent
- Toddler- Autonomy versus shame and doubt
- Preschooler- initiative v. guilt
- School-age child- industry v. inferiority
- Adolescent- identity v. role diffusion
Psychosexual Development by Freud from Toddler to Adolescent
- Toddler: Anal stage
- Preschooler: Phallic Stage
- School-age chld: Latency period
- Adolescent: Genital Stage
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