Exam one notes.pdf

NURS 643 Peds Exam One Week One Pediatric Maintenance Exam Pearls Developmental Milestone Red Flags ○ 3m- no raise head prone ○ 6m- no sit w/support No smile ○ 9m- no respond to name...

NURS 643 Peds Exam One Week One Pediatric Maintenance Exam Pearls Developmental Milestone Red Flags ○ 3m- no raise head prone ○ 6m- no sit w/support No smile ○ 9m- no respond to name ○ 12m- no gestures, pull to stand ○ 16m- no words 1  ○ 18m- not walking ○ 2y- no 2-word phrase ○ 3y- speech not understandable ○ 4y- unable to dress self ○ 5y- unable draw person w/body Newborn Health Promotion and Maintenence Birth until one month of age Review maternal history ○ OB history ○ Preganncy history Social history ○ Pets/smoking ○ Homes older than 1980 likely contain lead paint ○ Financial and emotion supports Newborn primary care visits ○ Wait 24 hours for screening tests after birth ○ Assess bonding/mom for PPD ○ Repeat bili if needed Infant head assessment ○ Head Circumference Fontanels- anterior 2-3cm, posterior 1cm Cephalohematoma- deep collection of blood, less common, forcep assisted birth Does not cross suture lines Resolve weeks to months Caput succedaneum- superficial swelling crosses suture linesCephalohematoma- deep collection of blood Newborn HEENT assessment ○ Facial symmetry Facial nerve damage from forcep birth ○ Eyes - symmetry, size, & angle of palpebral fissures ○ Ears - size, shape, position, skin tags, pits 2  Kidney eval if abnormalities d/t ears and kidneys developing inutero at the same time ○ Nose patency - infants are obligate nose breathers ○ Mouth Lip size & symmetry, palate, lip & tongue frenulu Newborn chest and respiratory assessment ○ Rate 30-60 breaths per minute ○ Thorax- shape, size, expansion ○ Nipples- white discharge, supernumerary ○ Respirations First 12 hours - cough, rales are common Clears after 12 hours ○ Cyanosis Peripheral - normal in first weeks in hands and feet Central - normal first 5-10 minutes Newborn cardiac assessment ○ Heart rate 100-190 ○ PMI - 4th left intercostal space ○ Murmurs common in first hours-days Newborn abdominal assessment ○ Umbilical cord - 2 arteries, 1 vein ○ Umbilical hernia is normal ○ Linea nigra is normal Newborn GU assessment ○ Circumcised - clean with wet cotton ball, apply petroleum jelly After healed- pull back loose skin and clean ○ Uncircumcised- do not retract foreskin 3  ○ Newborn females - may have small amount of discharge/vaginal bleeding postpartum Newborn extremities assessment ○ Fractures - clavicle is common ○ Barlow and Ortolani test for hip dysplasia Newborn neuro assessment ○ Tone, symmetry and movement ○ Reflexes Newborn skin assessment ○ Port wine stain - if near the eye needs ophthalmology referral ○ Hemangioma - if over a fontannel or airway need referrals When to call provider ○ Temperature greater than 100 F rectal (99.5 if mom GBS positive) ○ Poor feeding, decrease wet diapers, 8-10 per day is normal ○ Irritability not able to resolve ○ Difficulty breathing 1-12 Month Health Promotion and Maintenence Fontanel closure ○ Posterior 6-8 weeks ○ Anterior 12-18 weeks Monitor percentile for growth charts - weight, length, head circumference ○ Want it to be consistent (always around the same percentile) One Month Visit ○ Development Turn head side to side Focus on face Consoles when talked to ○ Start tummy time Two Month Visit ○ Development Lift head & chest prone Vocalize more than cry Turn head to sounds Smile spontaneously ○ Immunizations- DTaP, IPV, Hib, PCV, HBV, rotavirus 4  Four Month Visit ○ Development Roll over front to back Head midline; minimal to no head lag Aware of hands; reaches for items Vocalize & laugh ○ Immunizations- DTaP, IPV, HiB, PCV, rotavirus Six Month Visit ○ Double birth weight ○ Development sit unsupported transfer object hand to hand; pincer grasp bear weight on feet ○ Start solid food ○ Immunization- DTaP, HiB, PCV, IPV, HepB, influenza Nine Month Visit ○ Development pull to stand ○ Nutrition - table food cut in swallowable sizes ○ Screening- anemia and lead One Year VIsit ○ Triple birth weight ○ Development Walks, holding on to furniture Mama & dada specific ○ Immunizations- MMR, Varicella, Hepatitis A, HiB, PCV (can wait 15m) Seasonal influenza- delay Hep A Health Maintenance Early Childhood 1-4yrs 15 month visit ○ Development Walk forward Squat and recover 3-5 words ○ Immunizations- PCV (if not given)& DTaP Influenza first dose or booster for first dose 18 Month Visit ○ Development Runs Aims while throwing 15-20 words ○ Immunizations- Hep A #2 must be 6 months from the first dose 2 year visit ○ Development Kick ball forward; throw overhand Parallel play Combines words 5  ○ First dental visit 30 Month Visit ○ Development Jump both feet ½ intelligible speech ○ discussions of potty training 3 Year Visit ○ Development Catch a ball Speech understandable ○ Start BP reading 4 Year Visit ○ Development stand on one foot 5 seconds Ask “how” & “why” ○ Screen vision- normal 20/40 ○ Immunizations- MMR, Varicella, DTaP, IPV Health Maintenance Middle Childhood (5-10yrs) Grow 2-3 inches per year Tanners development (puberty) at each visit Booster seat until age 8 or 4’9” Screening ○ Anemia (iron w/meat), BP, BMI, development, vison should be 20/20 (ages 6,8,10,12), hearing, dyslipidemia (lipoprotein 1x age 9-11), psychosocial/behavior Adolescent Health Maintenance Growth & development Female ○ Pubarche: 11yrs, Menarche: 9-15yrs, Breast asymmetry is normal Growth & development Male ○ Muscle mass increase, Gynecomastia in up to 50% of boys, usually decreases in 6 months-1 year Early adolescent (11-14yrs) ○ Cognitive: daydreaming, goals change, personal values ○ Social: lonely, wide mood swings, body conscious, privacy & friends ○ Guidance: physical changes, emotional coping, sexual responsibility ○ Immunizations: TDaP, MCV4, HPV (2 injections 6 mo apart) Middle adolescent (15-17yrs): interest in attractiveness —> diet, muscle build ○ School & friend focused, sexual drive, parental conflict ○ Screening: school performance, depression, driving, STI ○ Guidance: nutrition (iron, Ca), technology use, sleep (8-9hr), sex ○ Immunizations: MCV4, meningitis B Late adolescent (18-21yrs) ○ adult reasoning, understand consequences, future planning ○ Screening: STI, cervical CA (pap age 21), high risk behaviors, menstrual hx (anemia) 6 Sexuality and Gender Identity Early childhood (toddlers 2-3 years) ○ confuse gender, self-pleasuring, lack of personal space ○ Start teaching “private parts” Preschoolers ○ Use appropriate words for body parts, explain gender differences, potty training, hygiene Middle childhood ○ Plays house, potty language ○ NOT NORMAL: not age appropriate, prolonged behavior, child anxious or extremely aroused, child forced, knows more about sexual acts ○ Sex talk around 9 years old Early adolescence : menarche (discuss before start) & spermarche ○ Sexual pleasure, body image, same sex friends, intimacy limited, sex education Middle adolescence (15-17 years old): test ability to attract a partner ○ Exploration of sexual identity, moral significance of sexuality ○ 65% of children have intercourse before 18 Late adolescence (18-21 years old): expression w/sexual expressions, responsibility Week Two Prescribing Medications in Pediatrics Prescribing Absorption: SQ & IM are effected by blood flow, GI, topical (infant decreased absorption, young child increased absorption) Script needs: medication name, amount in ml (not mg), how often, route, duration, and how many pills/ml to dispense ADHD Criteria 1: inattention, 6 or more symptoms Criteria 2: hyperactivity - impulsivity, 6 or more symptoms Prevalence: 11.4% of population, boys > girls ○ Co-dx w/behavioral disorders (conduct, anxiety, autism, Tourettes) Screen for sleep apnea Red and yellow dyes may exacerbate ADHD symptoms Follow-up one month when starting or changing med doses (every three months following) SE = GI upset w/decreased appetite, BP/CP/Tachy arrythmia, insomnia Autsim and Behavior disorders Autism ○ 1:59 children ○ Typically have symptoms before age 2 ○ Deficit in social communication & interaction 7  ○ Restricted, repetitive, patterns of behavior, interest, or activities (motor movements, use of objects, or speech), insistence on sameness; highly restricted, fixed interests with abnormal intensity or focus, hyper/hypo reactivity to sensory input ○ Screening: MCHAT for all age 18mo-24mo old Aggression ○ Irritability, emotional dysregulation (“big emotions”), impulsivity, overt (physical, common in males), covert (threat, “mean girls”, common in females) ○ Risks: neurodivergent, stress, genetic maltreatment, inconsistent/harsh discipline, bullying, parental rejection Conduct Disorder (CD): violation of rights of others and societal norms ○ Management: + parenting, social-cognitive skill training, teacher classroom management strategies, group & family therapy, CPS if abuse is sucpected Oppositional Defiant Disorder (ODD): negative, defiant, hostile, disobedient ○ Easily annoyed, do not see that they have a problem ○ Manage: refer for behavioral therapy, + parenting, consistent healthy discipline, school collab Disruptive mood dysregulation disorder (DMDD) ○ Irritability w/verbal/physical outburst, onset < 10yo (2 different settings, 3x/wk for > 1yr) ○ Manage: refer to behavioral therapy, parent skills, socioemotional skills Behavioral Health Disorders Anxiety ○ 7% of youth ○ Separation anxiety: most common in pediatrics, abnormal reaction Management - family therapy ○ Generalized anxiety disorder: cognitive and obsessive, no direct cause, irrational Management - CBT, SSRIs, hydroxizine ○ OCD: obsession (persistent), compulsion (repetitive behavior) Severe distress, time consuming, interfere w/function Manage: individual, developmental, CBT, meds – SSRI ○ Tic Disorders: sudden, repetitive, unconscious, Motor or vocal, male > female Tourette’s multiple motor w/1 verbal before age 18, last 1 yr Manage: comprehensive intervention = extinguish tic, awareness of behavior, teach another behavior (snapping rubber band), + reinforcement, meds = alpha adrenergic ○ Depression Major (2 wks), persistent (>2 yrs), adjustment (w/in 3mo of life stressor) Manage: Establish safety (guns, knives, meds), follow-up, referral to community resources, family emergency plan if the child puts themselves into danger Child Maltreatment Types: Neglect (most common), physical abuse, sexual abuse, medical neglect Neglect ○ Fail to provide: Physical (nutrition, hygiene, shelter, clothing), emotional (ignore child), Medical/dental (Æ care, delay in screening/care), educational (miss 25 or more days, Æ enroll child in school, inattentive to special ed) Physical abuse: intentional force which result in injury 8  ○ RED FLAGS: ∆ providers frequently, story ∆s, inconsistency among caregivers, describe the injury to be less than it is, story doesn’t match injury, Æ hx of trauma offered, described as self-inflicted ○ Fractures: ANY in non-ambulatory infant w/out clear accident should be reported ○ Abdominal trauma - 2nd leading cause of death by abuse LFTs (if elevated the do an abd CT) ○ Head CT w/o (anyone movements in 1 hr of sleep, ferritin/iron levels ○ Tx: avoid nicotine & caffeine, iron replacement, ∆ meds Sleep disroder breathing ○ Signs- snoring, gasping, apnea, paradox respirations, neck hyperextension, night sweating, tachycardia, parasomnias 10  Diagnosis- sleep study Apnea/hypopnea >1.5x per hour ○ Treatment T&A surgery Positive airway pressure Nasal steroids Montelukast Week Three Fever in Children Fevers above 105 are usually not infectious caused Infections in 10 days 14  ○ TX: amoxicillin Chronic Rhinosinusitis: Inflammatory process that persists for 12wks or longer Rhinosinusitis Emergency: intracranial or orbital infections Allergic Rhinitis: inflammation of the nasal membranes ○ Triggered by an immunoglobulin E mediated response ○ S&S: nasal crease, pale mucosa ○ TX: 2nd gen antihistamines: cetirizine (Zytec), Loratadine (Claritin), Fexofeadine (allegra) Foreign body ○ unilateral purulent drainage, odor Epistaxis ○ Tx: sit up/lean forward w/pressure for 5 min, cool mist humidifier or nasal saline, Afrin, nasal packing w/urgent referral, prevent w/humidification & nasal corticosteroids Throat Pharyngitis: infection or irritation of the pharynx or tonsils GAS ○ PE: airway patency, temp, hydration status (eat/drink, UO) ○ Skin: Sandpaper rash (scarlet fever), maculopapular rash ○ Tx: amoxicillin, cephalexin, Macrolide (high resistance rate), ∆ toothbrush after a few days of ABX Infectious mononucleosis ○ S/S: hepatosplenomegaly, petechiae, pharyngitis w/fatigue, HA, nausea, abd pain Tonsillolith (tonsil stones): white or yellow concretions in tonsillar crypts ○ s/s: hallitosis Peritonsillar abscess ○ S/S: unilateral swelling, muffled voice, reffered ear pain Week Five Dermatology Disorders Impetigo ○ Bacterial ○ Gold colored crust 15  ○ Tx: topical mupirocin or oral abx with fever or fatigue ○ Educate: handwashing, no daycare for 1 day Staphylococcal scalded skin syndrome: not common ○ S&S: abrupt inset, peeling skin that looks like burns ○ Tx: hospitalization for IV abx, topical mupirocin Cellulitis ○ Typically localized ○ Erythematous poorly demarcated, tender & warm, reginal lymphadenopathy ○ Tx Hospitalization neonate or febrile infant or periorbital All others tx outpatient with abx Neonatal skin disorders Acne 16