1

Family Centered Care It sees family as central to childs world and to nursing plan of care It provides support for childs emotional and developmental needs It supports honest and open exchange of information Characteristics of family centered care includes: Respect for family expertise Respect for parental roles Empowerment of parents Care for all family members Flexibility If visiting hours are limited, the schedule should be flexible to accommodate parental needs Negotiation and communication Collaboration o LEARN to communicate with families L = listen empathetically to familys perception of the situation E = explain your perception of the situation A = acknowledge and discuss similarities and differences in perceptions R = recommend strategies N = negotiate agreement on strategies o o o o
Hospitalization of Children and Pediatric-specific nursing care/ procedures

Separation Anxiety AKA Anaclitic Depression o By age 6 months infants respond to facial expressions and can distinguish between familiar and strange faces. This is the time that Separation Anxiety begins to occur o Object Permanence is when the object continues to be remembered even though it is beyonf the range of perception. This is seen in the development of separation anxiety at 6-8months of age o Occurs between the ages of 4-8 months o The nurse should encourage parents to discuss their feelings regarding the childs separation o Ways of alleviating anxiety Include planning a household schedule that divides major chores into smaller ones Combining household duties with a childcare activity such as cleaning the bathroom while the child is bathing Providing time for relaxation and activity with the child Parents can provide the school with detailed information about the childs home environment, such as familiar routines, favorite activities, food preferences, names of siblings or pets, and personal habits o Some kids with severe separation anxiety disorder and school refusal may be treated with tricyclic antidepressant o It is the major stress from middle infancy throughout the preschool years, especially for children ages 16 30 months o Protest Phase : Children cry loudly and are inconsolable in their grief for the parent

During later infancy : cry, Screams, searches for parent with eyes, clings to parent, avoid and rejects contact with strangers During toddlerhood: verbally attacks strangers (eg: Go away), physically attacks strangers (eg. Kicks, bites, hits, pinches), attempts to escape to find parent to stay, behavior lasting from hours to days, protests, such as crying, often with continuous, ceasing only with physical exhaustion, increased protests precipitated by approach of stranger Despair Phase: crying stops children are sad, lonely, and uninterested in play or food Inactive, withdrawn from others, depressed, uninterested in environment, uncommunicative, regresses to earlier behavior (eg. Thumb sucking, bed wetting, use of pacifier, use of bottle), childs physical condition deteriorating from refusal to eat, drink, or move Detachment Phase: Shows increased interest in surrounding, interacts with strangers or familiar caregivers, forms new but superficial relationships, appears happy, detachment occurring usually after prolonged separation from parents; rarely seen in hospitalization children, behaviors representative of a superficial adjustment to loss Health care professional often think the child has adjusted to hospitalization. However, this behavior is a result of resignation is not a sign of contentment The child detached from the parent in an effort to escape the emotional pain for desiring the parents presence Separation Anxiety during Early Childhood Greatest stress imposed by hospitalization during early childhood If separation is avoided or decrease, young children have a tremendous capacity to withstand any other stress They demonstrate more goal-directed behaviors For example, they may verbally plead for their parents to stay and physically attempt to secure or find them. They may demonstrate displeasure on the parents return or departure by having temper tantrums refusing to comply with the usual routines of mealtime, bedtime, or toileting or regressing to more primitive levels of development preschoolers can tolerate brief periods of separation, however the stress of illness, renders them less able to cope with separation as a result they manifest many of the separation anxiety behaviors by refusing to eat, having difficulty sleeping, crying quietly for their parents, continually asking when they will visit, or withdrawing from others They may express anger indirectly by breaking their toys, hitting other children, or refusing to cooperate during usual self-care activities. Separation Anxiety during Later Childhood School-age children Children ages 5-9 described hospitalization in stories that focused on being alone and feeling scared, mad, or sad. These children also described the need for protection and companionship while hospitalized Middle and late school-age children may react more to the separation from their usual activities and peers than to absence of their parents They have a high level of physical and mental activity that frequently finds no suitable outlets in the hospital environment

Even when they dislike school, they admit to missing its routine and associated activities and worry that they will not be able to compete or fit in with their classmates on returning to school. Feelings of loneliness, boredom, isolation, and depression are common Because the goal of attaining independence is so important in this age-group, they are reluctant to seek help directly for fear that they will appear weak, childish, or dependent Cultural expectations to act like a man or to be brave and strong bear heavily on these children, especially boys, who tend to react to stress with stoicism, withdrawal, or passive acceptance For adolescents, separation from home and parents may be difficult. However, loss of peer-group contact may be a severe emotional threat because of loss of group status, inability to exert group control or leadership, and loss of group acceptance. the best approach for the stranger (including the nurse) is: to talk softly; meet the child at eye level (to appear smaller); maintain a safe distance from the infant; and avoid sudden, intrusive gestures, such as holding the arms out and smiling broadly.

Growth & development principles, theories, patterns and milestones o Factors affecting growth in infants and children Heredity, prenatal life, envirnonemtn, socioeconomic status, nutrition, general health, relationships with others, physiological factors There are a lot of things that can influence weight as well, such as fluid Prenatal life can affect fetals growth such as moms nutrition intake, like if mom has HTN or diabetes (babies are either small or big), or mom drinking, smoking o Development It is an increase complexity in thought, behavior, and skill Occurs gradually, and influenced by experience, learning, maturation, and growth it also involves act of readiness meaning your nervous system has to be ready for the development, the neurological measure has to be ready fior the maturity o Maturation It is a physiologically determined pattern for growth and development Individual pattern Internally controlled, and influences when developmental milestones occur Everybodys development SEQUENCE (sitting, then standing, and then finally walking) is similar. [crawling is not considered a development mileston] but the pace of this sequence is determined by the genetic pattern {in one family there will be a kid who will walk at 14 months and the other kid in another family will walk at 8 months <<< this has nothing to do with IQ level} o Growth & Development Patterns: Spurts Cephalocaudal (from head to toe) Proximodistal (from inner to outer) Differentiated from simple to complex o Assessing growth Linear growth reflects skeletal growth (assessed by recumbent length or height) Use measuring board for lenfth Use stadiometer for height (stature) Precision is essential

Measure at least twice Should not lose over time Follow trends Recent research: measurement, growth spurts Weight reflects growth, nutrition, fluid balance Length is more stable than weight Head circumference reflects brain growth When a kids head circumference is within the normal brain growth range, it doesnt say anything about the normality of the inside of the breain Measure head circumference 3 times because you want to measure the widest (across the frontal bone over occipital bone) of the head Measure with paper and not cloth but paper does not stretch Measure until 36 months or if head size is questionable because up until 36 months the cranial features are completely ossified Over brow and occipital prominence Use Nonstretchable tape measures Ratio of Newbron : Headcircumference should have 1 difference Around 1-2 years: HC = CC Children HC < CC (2-3 difference) Plot on growth chart Plot on growth chart 50th percentile does not mean its the average Above 85th percentile is considered overweight Monitor trends By age 2. The child has attained 50% of adult height o Physical differences between adults and infants Vital signs are age specific Hematology value age specific Infant head size larger in proportion to body Cranial suture not fused/fontanels Smaller respiratory structures Rapid GI transit Infant liver and renal immaturity Higher body water content o Preterm Infants Use corrected age until 24 months Corrected age = chronological age time premature Ex: child was 8 weeks premature and is now 5 months old. Corrected age is 5 months 2 months = 3 months. So, you want to assess child based on parameter for 3 month old infant, not 5 month old. Immunization is given during the chronological age not the corrected age - we dont immunize kids until they are going home because some immunization are attenuated to virus, and we dont want these viruses in neonates ICU o Physical Growth Patterns for Infant 0-6 months Weight increases 6-8 oz/week Length increases 1/month HC increases 0.5/month Posterior fontanel closes at 2 months

Stage 1

Double birth weight by 6 months ** There are 3X as growth spurts that occur at this age First during Prenatal period Second occurs between 1st and 6th months of life Third during Puberty Physical Growth Patterns in Infant 6-12 months Weight increases by 3-4 oz/week Length increases by 0.5/month HC increases by 0.25/month Teething begins 6-8 months Triple birth weight by 12 months Height increased by 50% by 12 months ** Physical Growth Patterns in Young Child 1-4 years Weight increases 4-6 lbs/year Height increases 3/year Head circumference increases 1/year Anterior fontanel nonpalpable at 12 months --- closed completely at 18 months Toddler slightly bowlegged Physical Growth Patterns in School-Aged Child 5-12 years Height increases 2.5/year Weight increases 5-7 lb/year Organ development complete Tonsils/adenoids largest at 6 years Permanent teeth erupt at 6 years Loss of 4 teeth/year Puberty onset 10-13 in girls Puberty onset 11-14 in boys Abnormal if <age 8 Puberty Growth Patterns in Puberty and Adolescence in Girls First pubertal change: enlargement of ovaries First visible change: breast bud (thelarche) >> 9-13 years Growth spurt begins after onset of breast development Peak height velocity 11-12 years Fastest growth in height at this age nutrition comes very important Onset of menses 10.5 14.5 years (menarche average 12.5 years) Puberty Growth Patterns in Puberty and Adolescence in Boys First pubertal change: testicular enlargement First release of sperm 13.5 14.5 years Peak height velocity 10.5 16 years --- girls start earlier and lasts only a year but boys start later and lasts longer Voice changes coincides with Peak High Velocity (PHV) Gynecommastia in 50% adolescent males Lasts 12-18 months Resolves spontaneously Assessment of Sexual Maturity 5 stages of development of sexual maturity : they are sequential and time variable Staging of Sexual Maturity in Girls Breast Pubic Hair Prepubertal None

2 3

Bud (small mound) Labial, sparse, downy Enlarging, separation of areola and Coarse, curled over middle of pubic breast boen 4 Projection of areola, nipple forms Adult like, not on thighs nd 2 mound 5 Adult like Extends to thighs Staging of Sexual Maturity in Boys Stage Genitals Pubic Hair 1 Childlike, testes <2.5cm None diameter 2 Enlarged scrotum and testes, Sparse, dowry skin reddening 3 Increased testes size, increased Coarse, curled, spread to penile size middle of pubic bone 4 Increased penile width and Adult like, not on thighs length 5 Adult-like Extends to thighs o Developmental Theories DEVELOPMENTAL THEORIES AGE ERICKSON: FREUD:Psychosexual PIAGET: Cognitive Psychosocial Infant 1 year Trust vs. Mistrust Oral Sensorimotor (infant 2yrs) Object Permanence Toddler 1-3 years Autonomy vs Shame Anal Sensorimotor (2-7yrs) & doubt Egocentricism Preschooler 3-6 Initiative vs. Guilt Phallic Preoperational years School aged 6-12 Industry vs. Latency Concrete operations years Inferiority (7-11 years) Conservation Adolescent 12-18 Identity vs Role Genital Formal operations years Confusion Abstract reasoning, deductions, hypothesis o Characteristics of infant in sensorimotor stage Reflex activity evolves to repetition to imitation Develop understand of cause & effect Trial & error problem solving Curiosity, experimentation, novelty Object permanence at 7-8months When something disappears and the child thinks its permanent. At this stage separation anxiety occurs Development of stranger anxiety and intense attachment to primary caretaker/mother o Characteristics of Young Children in Preoperational Stage *** CHARACTERISTICS OF YOUNG CHILDREN (about 3-6 years) IN PREOPERATIONAL STAGE Egocentrism Only on perspective Avoid why answers give rules Transductive Reasoning Not logical, from particular to Accept childs reasons, avoid

particular complex answers Gives lifelike attributes to Recognize potentially inanimate objects frightening objects Irreversibility Unable to conceive of reversing Avoid stop talking, give action instructions Be quiet now Magical Thinking Believe thoughts are powerful, Clarify child is not the cause, can cause events avoid bad Absence of conservation No understanding that sam mass Cutting food into pieces, transfer can take differenct shape, size, liquids to difference size cups volume Literal Dont understand that words can dye stick your arm take a have multiple meanings little blood KISS Keep It Simple Silly for kids in Preoperational Stage o Characteristics of children in Concrete Operations Stage (7-11 years) They can perform mental operations More flexible thinking Less egocentric : they are able to take anothers perspective Inductive Logic Conservation Reversibility Classification Nursing Implication o Characteristics of Adolescents in the Formal Operations Stage Abstract thinking Hypothetical reasoning Conceives of possibilities Future orientation o Factors influencing development Temperament Health Oppurtunities for exploration and practice Neurological competence Motor skills Language skills Relationships with others o MILESTONES in NEONATES Flexed posture Reflexes* Grasp, rooting, sucking, tonic neck, moro reflex dance/step, Babinski, extrusion, spinal incurvation Cry becomes differentiated Visual preference for human face * + head lag is present o MILESTONES in 2 MONTHS Closure of posterior fontanel * Social smile* Vocalizes by 6 weeks* Fixes on visual stimuli Sleeps 15-16 hours/day Animism

Lifts head when prone +head lag MILESTONES in 3 MONTHS Landau Reflex : a postural reflex that shows a babys ability to hold his head up Drooling: newborns do not drool but if babys drool then that means they are ready for ..? Lifts head and chest from mattress by 3 months Head even with chest (no lag) by 4 months* Hands held open* Hand regard* Holds object Coos, gurgles, laughs* Squeals at 4 months Recognizes mother Social MILESTONES in 5-6 MONTHS Double birthweight by 6 motnhs Primitive reflexes gone* - except Bibinski Head leads when pulled* Rolls over* Voluntary grasp* Rakes objects Chewing, mouthing Tripod sit Bears weight on legs* Anticipates food MILESTONES in 7-8 months Sits without support by 8 months* Parachute reflex Crude pincer grasp Object permanence Stranger anxiety Transfers hand-hand by 7 months* Bangs objects together Imitates sounds Cup with assistances Combines syllables (da-dad, ma-ma) MILESTONES in 9-12 months Pulls to stand at 9 months * Cruises at 11 months* - walking around while holding on to something Walks with 1 hands held at 12 months* Crawling advancing to creeping (these are not developmental milestones) Fine pincer grasp by 11 months* Releases/drops objects at 11 months Plays peek-a-boo, claps at 9 months* Waves bye-bye at 10 months Says 1-2 words with meaning Attempts 2 block tower

Joint attention: ability to share interest in something if kids who doesnt have that then may be autistic; ex: when they see something and they want others to look at it so they point at that thing or person. MILESTONES by 13-18 MONTHS Average of walking is 13 months Babinski fading and disappears with walking by 18months Imitation 10 words at 18 months Removes clothing* Runs at 18 months Less separation anxiety Decreasing appetite, decreasing rate of growth MILESTONES in 2 years old Tiptoes Stands on one foot by 30 months Jumps Climbs Puts on clothing Holds on crayon Self-feeding Stacks blocks Stubborn no, me do it Ritualistic Temper tantrums Parallel play Stacks blocks Decreased appetite MILESTONES by 3 YEARS Night bowel and bladder control Rides tricyle Up and down stairs alternating feet* Dresses with supervision Copies circles and + 9-10 bock tower 3-4 words sentences, uses I Parallel to associative play Imaginary playmates MILESTONES by 4 YEARS Downstairs alternating feet Skips and hops Balances on 1 foot for 5 seconds Washes face and hands Use scissors Copies square, draws stick figure 4-5 words sentences Peak of questioning associative play MILESTONES by 5 YEARS Handedness firmly established Hops with alternating feet

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Balances on 1 foot for 10 seconds Copies diamond, triangle Draws person with head,trunk, arms, legs Knows days of the week Cooperative, wants to please May cheat to win at games o MILESTONES by 6-12 YEAS Increasingly coordinated Rides bike Organized sports and activities Collections, hobbies Same sex friends Develops conscience o MILESTONES by EARLY ADOLESCENT Final 20-25% of adult heigh Increased muscle strength Boys gain muscle, girls move from 80% leans, 20% fat tissue to 75/25 Peer relationships increasingly important Sexual curiosity o MILESTONES in MID & LATER ADOLESCENCE Need for privacy Risk taking More accepting of selves and differences of others Concerned with society Opinionated Myth of indestructibility Preparation for career Physical assessment/health assessment (assessment/intervention) o Social and health factors include: family structure, school or child care, substance use/abuse, psychosocial issue o Components of health history should include: Developmental history/milestones Medications Immunizations Pain history Sexual history Review of systems Sleep history o Structured developmental assessment should be done at 9, 18, and 24 months o Autism screening should be done at 18 and 24 months o Developmental Screening Tools address cognitive (especially language), social, and physical milestones and can identify children who may benefit from further diagnostic testing o Autism specific tools M-CHAT : Modified Checklist for Autism in Toddlers : it combines observation of 18-24 month old toddlers, with parent questionnaire evaluating the 16-48 months old o If the screening are negative, make an additional appointment within a month to monitor the child;s progress and to address any parental or provider concern o Denver II Developmental Screening Test (DDST)

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Birth to 6 years Designed to identify quickly and reliably those children whose developmental level is below normal for their age and require further investigation Correlations between DDST and later development of school problems, despite adequate intelligence Identify high-risk children and refer them for further testing 4 major categories Personal Social: getting along with people and caring for personal needs Fine motor adaptive : eye-hand coordination, manipulation of small objects, and problem-solving Language : hearing, understanding, and using language Gross Motor: sitting, walking, jumping, and overall large muscle movement o Goals of Pediatric Assessment To minimize stress and anxiety associated with assessment of various body parts Foster trusting nurse-child parent relationships Allow for maximum preparation of the child Preserve the security of parent-child relationship Maximize accuracy of assessment findings Overall approach Growth measurements Modifications of adult approach Allow to handle equipment Integrate developmental assessment Save intrusive procesures until last Use games Ask child Provide regards Nursing Care Guidelines for pediatric assessment Have room well lit and decorated with neutral colors Provide time for play and becoming acquainted If signs of readiness are not observed, use the following techniques: o Talk to parent while essentially ignoring child; gradually focus on child or a favorite object, such as a doll o Make complimentary remarks about child such as appearance, dress, or a favorite object o Tell a funny story or play a simple magic trick o Have a nonthreatening friend available, such as a hand puppet to talk to child for the nurse If child refuses to cooperate, use the following techniques o Assess reason fro uncooperative behavior; consider that a child who is unduly afraid may have had a traumatic experience o Try to involve child and parent in process o Avoid prolonged explanations about examining procedure o Use a firm, direct approach regarding expected behavior o Perform examination as quickly as possible o Have attendant gently restrain child o Minimize any disruptions or stimulation o Limit number of people in room

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o Use isolate room o Use quiet, calm, confident voice o Newborn Gestational age BP on 4 extermities at first exam Reflexes o Infant Examine on parents lap or flat surface Save intrusive exams until last VS and cardiopulmonary auscultation while quiet Developmental milestones Observe gait when able to walk o Toddler On parents lap Wait until acquainted Allow to handle equipment Lying down position last o Preschooler Encourage participation Games Handle equipment Show off skills Keep parent close by Leave underwear and socks on Rewards (stickers) Paper-Doll Technique Lay child supine on an examining table or floor that is covered with a large sheet of paper Trace around childs body outline Use body outline to demonstrate what will be examined, such as a heart and listening with stethoscope before performing activity on child o School-Age child Talk to child : include questions to child for history and ROS School history and performance Friends Free tiem Privacy Parents (choice for tweens) Explain exam Games Reward o Adolescent Choice for parental presence Explain exam Reinforce normalcy Immediate feedback Encourage/address questions HEADSS : home life, education, alcohol, drugs, sexual activity/suicide

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o Physical assessment Skin : Mottling, Acrocyanosis, Thicking, Keloids, Exantha and Enantha, Turgor Keloids excess growth of scar tissue at the site of a healed skin injury Head : HC, molding of cranium fontanels & sutures o abnormal closure (caniosyntosis) o PLagiocephaly and scaphrocephaly Scalp & Hair distribution Eyes Infant : red reflex the intensity of the color increases in darkly pigmented individuals [it refers to the reddish-orange reflection from the eyes retina that is observed] o To elicit a red reflex , place the infant in a dark room. In an alert state many newborns will open eyes in a supported sitting position o Always record and report absence of the red reflex it may indicate the presence of glaucoma, retinal abnormality, retinoblastoma, cataracts, or a systemic disease Brushfield spots speckling of iris [small white or grayish/brown spots on the periphery of the iris] Epicanthal folds excess folds of skin that extend from the rood of those nose to the inner termination of the eyebrow and that partially or completely overlap the inner canthus of the eye, may give false impression of misalignment o Often found in Asian Children Strabismus screen cross-eye one eye deviates from the point fo fixation o If the misalignment is constant, the weak eye becomes lazy and the rbain eventually suppresses the image produced by that eye o If strabismus is not detected and corrected by ages 4-6 years, blindness from disuse, known as Amblyopia, may result o Corneal Light reflex test or Hirschberg test is performed Shine a light directly into the pts eyes from a distance of about 16 minches if the eyes are orthophoric (normal), the light falls symmetrically within each pupil If the light falls off center in one eye, the eyes are misaligned Visual Acuity screen {Snellen, Tumble E, Blackbird} Ears Tympanometry membrane compliance, middle ear disease Hearing Screening Acoustic Evoked Potential (sensorineural loss), Audiometry (conductive and sensorineural) Rinne (bone vs air conduction) unreliable until late preschool Weber (symmetry of air conduction) unreliable in childhood Examining eardrum for an infant pull pinna down and back Examining eardrum on an older childs ear pull pinna up and back Mouth/ Pharynx Dentition it pertain development of teeth and their arrangement in the mouth Caries, bottle mouth syndrome Clefting Tonsils

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Chest Shape o Infant a-p and transverse diameter close to equal To measure size of the chest, take two measurements one during inspiration and the other during expiration and record the average Head and chest circumference o HC and chest circumferences are equal at about 1-2 years of age o During childhood, hest circumference exceeds head size by about 5-7 cm (2 2.75inches) chest wall compliance : chest wall should be symmetric bilaterally and coordinated with breathing symmetry to excursion o movement of the chest wall should be symmetric bilaterally and coordinated with breathing o during inspiration the chest rises and expands, the diaphragm descends, and the costal angle increases o during expiration, the chest falls and decreases in size, the diaphragm rises, and the coastal angle narrows abdominal breathing until age 7 neonates obligatory nose breathers respiratory effort breath sounds referred o breath sounds are best heard if the child inspires deeply o Vesicular Breath Sounds Heard over entire surface of lungs, with exception of upper inrtascapular are and area beneath manubrium

Tongue size Thrush Encouraging opening the mouth for examination o Perform the examination in front of a mirror o Let child first examine someone elses mouth, such as the parent, the nurse, or a puppet, and then examine childs mouth o Instruct child to tilt the head back slightly, breathe deeply through the mouth, and hold the breath; this action lowers the tongue to the floor of the mouth without the use of a tongue blade o lightly brushing the palate with a cotton also may open the mouth for assessment leave the inspection of the mouth for the end (along with the ears) or do it during episodes of crying use flavored tongue depressor place the tongue blade along the side of the tongue, not in the center back area where gag reflex is elicited Exam of Oropharynx o Note the size and color of the Palatine Tonsils They are same color as the surrounded muscosa, glandular, rather than smooth in appearance, and barely visible over the edge of the palatoglossal arches Report any swelling, redness, or white areas on the tonsils

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Inspiration is louder, longer, and higher pitched than expiration Sound if soft, swishing noise o Bronchovesicular Breath Sounds Heard over manubrium and in upper intrascapular regions where trachea and bronchi bifurcate Inspiration is louder and higher pitched than in vesicular breathing o Bronchial Breath Sounds Heard only over trachea near suprasternal notch Inspiratory phase is short, and expiratory phase is long signs of distress o infant o child Atraumatic Care - Encouraging Deep Breaths o Ask child to blow out the light on an otoscope or pocket flashlight; discreetly turn off the light off on the last try so that child feels successful o Place a cotton ball in childs pal,; ask child to blow the ball into the air and have parent catch it o Place a small tissue on the top of a pencil and ask child to blow the tissue off o Have child blow a pinwheel, a party horn, or bubble Cardiac Apical Pulse o 4th ICS and LMCL (Left midcalvicular line) <7 years just lateral to the LMCL in children less than 7 years of age o 5th ICS and LMCL >7 years o Pericordial Pulsation Point of maximum Intensity (PMI) it is the area of most intense pulsation o It can be found at the same site as AI, but it can occur elsewhere Physiological splitting of S2 (P-valve and AO-Valve) o S1 = closure of the tricuspid and mitral valves (aka Atrioventricular valves) Louder at apex o S2 = closure of the pulmonic and aortic valve (aka Semilunar Valves) Louder at base o Physiologic splitting the split of the two sounds in S2, which widens during inspiration o To distinguish between S1 and S2 heart sounds, simultaneously palpate the carotid pulse with the index and middle fingers and listen to the heart sounds; S1 is synchronous with the carotid pulse Fixed Splitting-the split in S2 does not change during inspiration a diagnostic sign of atrial septal defect S3 can be normal but S4 is not normal Sinus arrhythmia(increase with inspiration and decrease with expriation) o Common in children in which the heart rate increases with the inspiration and decreass with expiration

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o Cessation of breathing causes the heart rate to remain steady Murmurs it is produced by vibrations within the heart chambers or in the major arteries from the back-and-forth flow of blood o Reflects blood flow thorought t a narrow pathway, regurgitation, or increased blood flow through normal structures o Graded 1/6 6/6 o Description musical, vibratory, harsh, blowing o Can be functional (normal), but if associated with other sx, need investigation o Bruits Assess Capillary Refill Time a test for circulation and hydration, by pressing the skin lightly on a central site, such as the forehead, or a peripheral site, such as the top of the hand, to produce a slight blanching o The time it takes for the blanched area to return to its original color is the capillary refill time o Capillary refill should be brisk less than 2 seconds ~~~~~prolonged refill may be associated with poor systemic perfusion or a cool ambient temperature Inspection is easiest when the child is sitting in a semi-fowler position Auscultate the heart with the child in at least two positions : sitting and reclining Evaluate heart sounds for: Quality, Intensity, Rate, and Rhythm Abdomen Inspection inspect the contour of the abdomen with the child erect and supine o Rounded o Scaphoid o Diastisis recti a midline protrusion from the xiphoid to the umbilicus or symphysis pubis or failure of the rectus abdominis muscles to join in utero o Peristaltic waves (pyloric stenosis) they are observed by standing at eye level to and across from the abdomen o Hernias o In a healthy child a midline protrusion is usually a variation of normal muscular development o A tense, board-like abdomen is a serious sign of paralytic ileus and intestinal obstruction Auscultation o Listen for peristalsis, or bowel sounds record their frequency per minute (5 sounds/min) Palpation perform this last because it may distort the normal abdominal sounds o Liver edge 2cm below coastal margin palpation begins in the lower quadrants and proceeds upward to avoid missing the edge of an enlarged liver or spleen If the liver is palpable 3 cm (1.2 inc) below the right coastal margin or the spleen is palpable more than 2cm (0.8cm) below

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the left coastal margin, these organs are enlarged - a finding that is always reported for further medical investigation o Tip of pancreas can be palpated o Kidneys in newborn Percussion o Distention Umbilical Hernias common in fants, especially in African-American childrent o The umbilicus should be flat or only slightly protruding. o If herniation is present, palpate the sav for abdominal contents and estimate the approximate size of the opening Inguinal Hernias a protrusion of peritoneum through the abdominal wall in the inguinal canal - occurs mostly in males If the child is too young to cough,have the child blow up a balloon or laugh to raise the intraabdominal pressure sufficiently to demonstrate the presence of an inguinal hernia Genitilia Inspection o Appearance o Discharge/redness o Hernias/hydrocele o Urethral meatus (hypo/epispadias) o Sexual maturity (Tanner Stage) Palpation o Testes o Cremasteric reflex this reflex is stimulated by cold, touch, emotional excitement or exercise This reflex pulls the testes higher into the pelvic cavity To prevent this reflex, warm the hands, examine him in a tailor position, Musculoskeletal and Extermities Hips: infant Ortolani and Barlow maneuvers Bowleggedness until 2 years Knock knees 2-7 years old Appearance of flatfootedness in infants Tibial torsions (pigeon toes) Babinski normal until 18 months Muscle strength Gait Sole and palm creases PAIN ASSESSMENT o Physiological consequences of pain Elevation of VS Increase release of catecholamine, and hormone release Neurological, and GI changes Hyperglycemia and increased cortisol level Catabolic state Decreased energy stores Diaphragmatic splinting and subsequent increases ICP

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Change in sleep/wake cycles Atelectasis Alkalosis Increased risk of infection Ileus o Developmental and behavioral responses to pain Infants( less than 6 months) No apparent understand of pain Responds to parental anxiety Crying, grimacing, and thrashing Poor feeding More than 6 months By 6 months of age children demonstrate anticipatory fear of pain Changes in activity level Withdraw from stimulus Disturbed sleep pattern Toddlers Do not understand why they are experiencing pain Cannot describe the intensity or type of pain; use words such as boo boo Preschoolers Relate pain to an injury Can identify location and intensity of pain Toddlers and Preschoolers Crying and screaming Verbal expressions it hurts Moving and thrashing Uncooperative Asks to stop Clings Restlessness Irritability Anticipatory pain 4 years old and older can use symbol rating scales School-age child Can describe pain in relation to their body parts More descriptive of the experience of pain o Behaviors of younger children (7-9 years) stalling, rigidity, and emotional withdrawl o Behaviors of older children (10-12 years) withdrawl from stress and anxiety or aggressive behavior Project bravery Sleep disturbances and short attention spans Adolescent Want to behave in a socially acceptable manner Show control Gives a more sophisticated description of pain o Less protest

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o Less movement o More descriptive it hurt ache throbbing o Muscle tension, keeping still o Depressive or aggressive behaviors o Sleep disturbance o Pain Assessment Scale Infant Scale CRIES scale NIP PIPP Breathing patterns, oxygen saturations and VS Young and Infants FLACC Wonger-Baker Faces (for 3 years to adolescence) Oucher (Caucasian, African American and Latino versions) o Nonpharmacologic Management of Pain Relaxation Distraction Imagery Biofeedback Thought stopping Positive self-talk o Question of the child Use familiar terms: hurts, ouch, owie, boo-boo Point to or color area of pain on body drawing (4 years and older) use experience-based descriptions ask what will help (preschool and older) o take cause into account expected pain severity based on condition investigate when outside expected parameters contributing factors position swelling hunger, thirst, fatigue IV o Nursing Considerations with Pain management Opiods Respiratory depression Chest wal rigidity and bradycardia with fentanyl Benzodiazepines N/V, purities Paradoxical Reaction Enhance respiratory depression if administered with opoids Barbiturates Histamine release Hypotension Health Promotion o Signs of newborn illness

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o o o o o o o o o o o o o o o o o o o o

Rectal temp >100.9 Abdominal swelling and vomiting Signs of respiratory distress Persistent coughing and choking during feeds Lethargy/irritability Jaundice Newborn/infant sleep for 13-17 hours which includes naps Allow breast milk/formula for 12 months Exclusive BM/formula fro 406 months Should breast feed every 1.5-3 hr/formula or every 204 hours No whole milk until age 1 Initiate iron fortified solid around 4-6 months Finger foods by 6-8 months Pincer grasp 10 months Table foods by 12-15 months Fluoride is give 6 months of age if not in the water Cows milk should be avoided until 1 year of age First teeth erupt at 6 months Avoid bottles with sleep or bed First dental visit 12 months -30 months 12 month = TB screen in high-risk infants 18 and f24 months = autism screen During early childhood the average wt gain is 5 lbs/year School age is time where obesity may be a concern and place them at risk for type II DBM 6 years of age children loose their primary teeth and eruption of permanent teeth 32 permanent teeth by age 12 and remaining molars by the teenage years

Immunization o Current schedule includes 18-22 injections in the first year of life o Vaccine Preventable Infections Diphtheria Respiratory manifestations include respiratory nasopharyngitis or obstructive laryngotracheitis with upper airway obstruction This vaccine is commonly administered in combination with tetanus and pertussis vaccines (DTap)for children younder than 7 years of age It does not produce absolute immunity, protective antitoxin persists for 10 years -- and boosters are give every 10 years of life Pertussis whooping cough Recommended for all children 6 weeks through 6 years of age (up to the 7 th birthday) who have no neurologic contraindications Tetanus, diphtheria toxoids and acellular pertussis vaccine(Tdap) is now recommended at ages 11 and 12 for children who have completed eh DTap/DTP childhood series Tetanus 3 forms Tetanus Toxoid o Used for routine primary immunization, usually in one of the combo for diphtheria o Provides protective antitoxin levels for about 10 years

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Polio An all-IPV (inactivated polio virus vaccine) schedule for routine childhood polio vaccination is recommended for children in the US All children should receive four doses of IPV at 2 months, 4 months, 6-18 months, and booster gives an 4-6 years of age Pediatrix it is a combination of vaccine containing DTaP, Hepatitis B, and IPV o Can be used as the primary immunization beginning at 2 months of age Heaptitis B Synthetic Given at birth before hospital discharge Given IM Side effects : low grade fever Haemophilus Influenza Infection This vaccine protects against meningitis, epiglottis, bacterial pneumonia, septic arthiritis, and sepsis It is not associate with virus that causes flu Recommended for 5 years and older Generally given at 2,4,6 months and 12-18 months Measeles Given at 12-15 months of age During the course of measles outbreaks, the vaccine can be given any time after 6 months of age The second measles immunization is recommended at 4-6 years of age (at school entry) but may be given early Revaccination should occur by 11-12 years of age if tehmeasles vaccine was not administrered at school entry The MMRV vaccine (measls, mumps,rubella,and varicella) is a live virus vaccine and may be given to children 12 months 12 years of age Mumps Is recommended for children at 12-15 months of age and usually given in combo with measles and rubells It should not be administered to infants younger than 12 months because persisting maternal antibodies can interfere with the immune response Rubella Aim of rubella vaccination is to protect the unborn child rather the recipient of the immunization It is also recommended for children at 12-15 age MMR They are live virus vaccines Given at 12-15 months and then 4-6 years If older female child, document last period, investigate possibility of pregnancy, avoid pregnancy for 3 months

o Persons with a hx of two previous doses of tetanus toxoid can receive a booster dose of the toxoid Tetanus immunoglobulin (TIG) is used for human o For wound management Tetanus antitoxin no longer available in the US

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If allergic to eggs or neomycin --- dont use ! Varicella Recommended for any suspectible child (one who lacks proof of varicella vaccination or has a reliable history of varicella infection 1st dose is recommended for children ages 12-18 months, and to ensure adequate protection a second dose is recommended at 4-6 years If given after age 13, requires 2 doses, one month apart Keep the vaccine frozen and use it within 30 minutes of being reconstituted to ensure viral potency MMRV measles, mumps, rubella, varicella combination vaccine Risk for febrile seizure in 12-23 months olds vs receiving separate doses at the same visit Precaution : family hx of febrile seizures Recommended 1st dose as separate injections; 2nd dose can be in combination Pneumoccocal infection Causes infection such septicemia, and bacterial meningitis or localized infection of otitis media, sinusitis, and pneumonia Protects against streptococcus penumoniae meningitis Its an inactivated (killed) bacterial vaccine Given at 2,4,6, 12-15 months N.Meningititis it hyperendemic or epidemic should also receive one of the quadrivalent meningococcal vaccines High evidence that the risk of meningococcal infections is high in college freshmen living in dorms Meningococcal are also responsible for morbidities, including limb or digit amputation, skin scarring, hearing loss, and neurologic disabilities Influenza Children who have anaphylactic hypersensitivity to eggs should not receive the vaccine For 6 months and older Intranasal o Live virus for ages 5-49 years o Cannot be given if history of wheezing o Two doses the frist time a two months apart o Side effects : Runny nose and nasal congestion, low rgade fever HPV Administered in 3 separate doses via IM Routine schedule is 0,2,5 months IM injection in the deltoid Minimum intervals o 4 weeks between dose 1 and 2 o 12 weeks between doses 2 and 3 Minimum age is 9 years Maximum age is 26 years o some functions of Immunizations special vulnerability of newborns and young infants

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o o o

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because immune system is not fully mature at birth its protect from infectious disease it stimulates production of cellular or hormonal response it prevents sequelae of naturally occurring disease prevents transmission of infection Prinicples of Pediatric Immunization Preterm infants are immunized based on chronological age, not corrected age If a scheduled dose is missed, give at the next opportunity Active Immunity : antibody production is stimulated without clinical disease, an antigen is given in form of a vaccine Passive Immunity : induced with antibodies produced in another human or host IGg passed though the placenta to the fetus Types IGIV (immune globulin intravenous) IG (Immune Globulin) hep A, B, RSV (Synagis) Rabies given IM VZIG (Varicella Zoster Immune Globulin given IM Types of Vaccines Killed Virus Vaccines : vaccine that contains microorganism that are killed but capable of producing antibodies (IPV) Advantages : no risk of vaccine induced infection May be purified antigens Safe for immunocompromised individuals Safe for pregnant women Disadvantages: immunity less likely to permanent o Eg.inactivated poliovirus Toxoid : weak toxin treated by heat of chemicals but still retains its antigenicity (tetanus toxoid) Live Virus Vaccine : a vaccine that contains a live microorganism but in a weak state (MMR and Varicella) Recombinant Forms : an organisms that has been genetically altered for use in the vaccine Conjugated forms : an alered substance joined with another substance to increase the immune response Hib is conjugated with tetanus toixoid Live Attenuated(weakened) vaccines Advantages: produce controlled infections that emulate natural immunity More likely to produce long-lasting or permanent immunity than are killed vaccines Disadvantages : risk of vaccine induced disease Risk of vaccine strain spreading to another person E.g. varicella and measeles Children who have received Respigam, IVIG blood products, or chemotherapy should not receive MMR or Varicella for 6-9 months There must be 4 week interval between immunization Tuberculin testing should not be done with MMR, wait 4-6 weeks DtaP DT toxoids, acellular pertussis fraction IM injection

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o RSV

Given at 2,4,6, months Boosters at 15-18 months and 4-6 years 5 childhood disease Boosters required every 10 years Side effects : swelling ,soreness at injection site, restlessness, listlessness, seqizure, inconsolable crying Booster == are recommended fro 11-12 yrs old with additional pertussis coverage

Palivizumab (Synagis) Doesnt interfere with the vaccine schedule RSV IV immune globulin (Respigam) Interferes with immunization schedule-MMR delayed 9 months Both give during Oct Apr Given to children les than 2 years of age with chronic lung disease,significant congenital heart disease, or severe immunodeficiency Rotavirus A gastroenteritis virus causing severe dehydration Rota Teq (bovine-human recombinant) 3 doses of the oral vaccine at 2,4,6 months Meningococcal vaccines Menactra (MCV4) n.meningitidis Routine vaccination at 11-12 years of age New recommendation for booster dose at 16 years High risk young children : 9-54 uears (asplenic or otherwise immunocomprised) =2 doses Specific Vaccine Contraindications Varicella contraindicated fro immunocomprised children Receiving chemotherapy Receiving large doses of steroids HIV + DtaP contraindicated for children with hx of neurological reaction to prior DtaP MMR contraindicated for severe egg/neomycin allergy, caution in immunocompromised children HIV+ can receive MMR Vaccines not Contraindicated Local reactions Mild acute illness with or without fever Current antibiotic treatment Prematurity Recent exposure toa gent History of penicillin allergy Family hx of adverse reactions Breastfeeding

Calculation problems (weight conversions, basic dose calculation) 2-3 questions