Peds Exam 1 PDF

Swetha Week 1 ★ Freud [based on sex] ○ 3 components: ID Unconscious mind Pleasures Immediate gratification Ego Conscious mind Rational & realistic...

Swetha Week 1 ★ Freud [based on sex] ○ 3 components: ID Unconscious mind Pleasures Immediate gratification Ego Conscious mind Rational & realistic Superego Conscious mind Moral compass Keeps you in line ○ Oral stage : birth - 1 yr Pleasure centered on oral exploration Learning about world by putting in mouth Tasting, sucking, chewing ○ Anal stage : 1-3 yrs Interested in anal region Ability to control pee/poop Anal retentive Developed due to strict toilet training during this stage ○ Phallic stage : 3-6 yrs ↑ interest in genitals Recog of sex difference Oedipus Boy wants to marry mom Electro complex Girl wants to marry dad Penis envy Girl jelly of boys for having a penis ○ Latent stage : 6-12 yrs Focus on knowledge gaining & play ○ Genital stage : 12 yrs & ↑ Onset of puberty Focus on relationships Pleasured focus on genitals ★ Piaget [child ability & senses] ○ Sensorimotor : birth - 2 yrs Reflexes to purposeful mvmt Sep anxiety Object permanence Mental representation (symbol recog) ○ Preoperational stage : 2-7 yrs Egocentrism (ALL ABOUT MEEEE) Unable to understand others feelings Understand envmt in relation to themselves  Swetha Concrete thinking (you’re killin me) Cannot engage in deductive reasoning yet Lang growth ○ Concrete operations : 7-11 yrs Logical thought Raining outside then everything outside is wet Understand convos Start to multitask Unable to understand abstract thoughts ○ Formal operations : 11-15 yrs Able to understand abstract thoughts Understanding of things that are not visible or unavailable Form & test hypothesis ★ Erikson [self & social orientation] ○ Trust vs. mistrust : birth - 1 yr Infants experience world thru senses & caretakers Basic needs not met? Mistrust develops. Lead to perm lang & emotional delays Ex → russian orphanage: kids crying and crying waiting for someone to come & then realized no one was coming so they stopped crying ○ Autonomy vs shame/doubt : 1-3 yrs Learn independence Control of some of their world “Do it myself” Imitation learning Toilet training If discourage? Self esteem ↓ ○ Initiative vs guilt : 3-6 yrs Imagination grows Develop sense of right & wrong Exploring & intrusive behavior If encourage? Develop sense of confidence & purpose If discourage? Develop guilt ○ Industry vs. inferiority : 6-12 yrs Seek achievement Wish to do things that they can be proud of Learn competition & rules If expectations are too high? Inferiority can develop ○ Identity vs. role confusion : 12 - 18 yrs Physical changes of teens Growth? Awk Peers = important Learn conflict resolution Seek self identity & how to fit in ★ Kohlberg [morality & moral reasoning] ○ Preconventional lvl Good and bad/right and wrong → based on physical consequences of actions Avoidance of punishment  Swetha ○Conventional lvl Conformity & loyalty Self interest Seeking approval & pleasing others ○ Postconventional & principle lvl Principles & society May get in trouble for a good cause ★ Family health & promotion ○ Family = patient ○ Kids must be considered w/n family context ○ Consider developmental stage, primary caregivers, peer influences ○ SDOH ○ Are parents/guardians in need of resources? ○ Interprofessional = vital ○ Fam health = imp as kid health ○ Assess family ○ Health belief systems ○ Promote health education ○ Examples Healthy eating Obesity Smoking Vaccines ○ Note + influences ★ Ped assessment ○ Infancy : birth - 1 yr Nonverbal Sleep frequently (ask parents for norms) Flexed position Some droolin = nml Able to lift head midline Unable to protect by turning head to side Back to sleep Fontanelles Posterior = closes in first months Anterior = closes by age 2 Reflexes Moro / babinski Identification of hip dysplasia Ortolani & barlow tests Infants = not able to shiver → KEEP THEM WARM!!! Birth wt doubles by 4-7 months of age & triples by age 1 Allow parents to hold for warmth & comfort Listen for murmurs PDA & CHD Obligate nose breathers Approach quietly due to sensitive startle reflex, talk in soothing tones. ○ By 4 months:  Swetha Smiling Making sounds → cooing in response to speech Able to hold head up steadily Hold objects in hands Looks @ u when talkin ○ By 6 months: Laughs Looks at self in mirror Rolls from tummy → back Reaches for toy Pushes self up when on tummy Blows raspberries ○ By 9 months: Stranger anxiety Makes repetitive sounds Mama or dada Peek-a-boo Lifts arms to be picked up Object permanence Sits & moves to sitting from lying down Transfer objects from one hand to other ○ By 1 yr Pat-a-cake Waves BYEE Understand “no” Places objects in container Looks for hidden toy Pulls to stand Furniture walk Pincer grasp ○ Toddlers : 1-3 yrs Curious af Reach for everything & put in mouth Comfort objects = IMP Talk to parents first & let ‘em look at you from a far Least invasive → most invasive Observe, assess, do vitals, shots and all that shit towards the end, but first look with your eyes, let ‘em trust ya ○ By 18 months Mimics Claps when excited Affectionate 1-2 clear wods Follow simple directions Points Stacks = 2 blocks Starts walking Self feed w/ fingers  Swetha Starts using spoon Drinks from cup ○ By 2 yrs Understand other feelings Puts atleast 2 words together Identify atleast 2 body parts Uses more gestures Blowing a kiss Nodding Runs Use both hands for sep tasks Kicks a ball Eats w/ spoon ○ Preschoolers : 3-5 yrs Concrete understanding Taking things literally (raining cats & dogs) Magical thinkers Concerned with body integrity = BANDAIDS! Offer choices when possible, ensure it’s realistic NO lying! Painful procedures = punishment (in their minds) Let em know, we’re helping not punishing Play dumb w/ assessment & let ‘em help Uses faces pain scale Due to hard time finding words to describe pain Give loads of praises EVEN when it is difficult ○ By 3 yrs Join other kids to play Tolerate being sep from parents Hold convo Draw circle String items together on string Fork ○ By 4 yrs Catch ball Unbutton easy buttons Multiple word sentences Recognize danger Hot stove Heights Change behavior w/ environment Library = quiet Pours H2O Lil helper ○ By 5 yrs understand/follow rules Do simple chores  Swetha Story telling w/ 2 events at the least Ans questions about book that was read to the, Simple rhymes Count to 10 Identify written #s Understand time of day Write some letters Hop on 1 foot Buttons ○ School age : 6-12 yrs More independent Understand time frames Talk to pt – not just parents They ask questions Choices Able to describe pain more accurately BE HONEST ○ Teens : 12-18 yrs Very private Ask personal questions w/o parents Gain trust - honesty Show respect & acknowledge feelings Keep judgemental shit to yourself Talk to them first Involve in care Capable of complex thought ○ Kids w/ special needs Listen to parents Assess cog lvl & interact accordingly Talk to child Tx with respect Assess for ↑ risks Seizure precautions GTs Trachs ★ Head - Toe assessment ○ Head: Alert & interactive? Size Microcephaly Hydrocephaly Fontanelles: Should be soft & flat Pupils: Equal & reactive Airway: Nasal secretions Drooling  Swetha Abnormalities Cleft lip Palate Ears: Low set? Mucous membranes: Color & moisture ○ Neck Short & fat in infants Keep it clean Look out for Nuchal rigidity (stiff neck) Torticollis JVD, tracheal deviation very unusual unless major trauma Usually carotid pulses are not used for palpation in infants & small children ○ Chest Normal structure? Pectus excavatum? Retractions inter/sub costal Aeration (lung sound) Signs of distress Wheezes Rales Crackles Grunting Tachypnea Children HAVE thin chest walls Should be easily heard w/ good aeration bilaterally Heart sounds Listen for ○ Murmurs ○ Arrhythmia Tachycardic or bradycardic? ○ Abdomen Rounded & full in infants & toddlers Look more flat in preschoolers Record abdominal circumference in infants Nml bowel sounds Soft, non-distended / non-tender Try to palpate when child is calm & while using distraction Liver more easily palpable in infants difficult/impossible to palpate in preschoolers & older children Should be at or slightly below margin ○ Extremities Should be warm & pink capillary refill Best to use palm of hand or sole of the foot Assess nail beds for clubbing Sign of chronic hypoxia  Swetha Peripheral pulses BP may be measured upper or lower extremities 4 pt BP to r/u CHD Infants normally flex their extremities ○ Pulses ○ GU / rectal exam Nml structure? Circumsized? Assess for infection Assess for rashes: Candida? Nml urine output Infants: 2mL/kg/hr Children: 1ml/kg/hr Regular bowel movements Or diarrhea / constipation? ○ Tanner stages ★ Normal VS  Swetha ★ Informed consent & assent ○ Informed consent Able to give consent Understand procedure, consequences & risks >18 yrs Voluntary & can be revoked at any time Kids require their legal guardian to consent to procedures ○ What requires consent? minor/major surgeries/procedures Dx tests w/ potential risks Med treatments Photographs Release of med info Post-mortem exam ○ Implied consent Emergency situation/no guardian available Assume they want to be treated Proxy may consent ○ Parental refuse Child custody can be medically taken for time-sensitive life saving tx Pregnant, parent, married, HS student, or in military State laws vary, be aware of your state Preg minor can consent herself until she gives birth, then may only consent for her child & not herself. ○ Mature minors Depending on the state 12-14 yrs & older Have the mental capacity to understand / make decisions for their own health Eg: cancer pt ○ Adolescents Parents have right to med records except in cases of med emancipation May seek & receive care regarding: Sex health ○ Contraceptives ○ STI’s ○ Preggers Substance use Psych services ★ Pediatric airway ○ Diameter smaller in children ○ Poiseuille’s law: If the radius of the airway is reduced by 1/2 , resistance is increased by 16 fold. ○ Kids have a large tongue & occiput (back of head/skull) Results in obstruction of airway Positioning = important ○ Kids have fewer/smaller alveoli ○ Large, floppy epiglottis ○ Faster metabolic rate results → higher O2 consumption → worsens when sick/febrile  Swetha ★ Croup (laryngotracheobronchitis) ○ Acute viral illness → causes swelling to the glottic & subglottic region = obstruction ○ Causes: Parainfluenza Rhinovirus Influenza A RSV ○ Most common in kids 6 months – 3 yrs ○ Onset Gradual ○ Sx: Low grade fever Barking cough Steeple sign on neck film ★ Epiglottis ○ Acute bacteria illness → Complete airway obstruction ○ Causes: Hemophilus influenza B Strep pneumoniae Staphylococcus Rarely seen now cuz of vax ○ Onset Sudden ○ S/Sx: Thumb sign on lateral neck films Difficulty swallowing Muffled voice Tripod position Anxious / restless Blood cultures → + w/ causative organism ★ Foreign Body Aspiration ○ Usually goes to R side ○ Typically food items, toys, coins, small disks ○ Common in kids < 4 y/0 ○ s/sx: Drooling Stridor Grunting Unequal breath sounds Wheezing Pain ○ Dx: CXR ○ Item may be logged in trachea, esophagus or passed to stomach ○ ABC’s & prep for OR  Swetha ★ Pertussis (aka whooping cough) ○ Vax occurs at 1 y/o ○ 3 stages: Catarrhal : 1-2 wks Low grade fever Runny nose Cough → becomes progressively worse Paroxysmal : 1-6 wks Severe coughing episodes ○ results in cyanosis & prolonged inspiration w/ high pitched sound (whoop) ○ post -tussive emesis often occurs Convalescent : 2-3 wks Sx gradually improve ○ Caused by: Bordetella pertussis ○ Tx: Erythromycin ○ Can cause: Leukemoid rxn Severe cough → cyanosis Week 2 ★ Respiratory distress ○ Compensated state in which oxygenation and ventilation are maintained Oxygenation: process of delivering oxygen to the body’s tissues & organs Ventilation: process of moving air in and out of lungs ○ Characterized by any increased work of breathing Flaring Grunting (noise they make, this happens when alveoli is obstructing) Retractions ★ Respiratory failure → most common cause for cardiac arrest in kids ○ Inability of resp system to provide adequate gas exchange ○ Compensatory mechanisms are no longer effective ○ Not enough O2 or ventilation → acidosis (↓pH, ↑Co2) Abnml blood gas w/ hypercapnia(↑Co2) / hypoxia (↓O2) ○ Med emergency– must protect airway ○ Strongly consider intubation ○ MAJOR EVENTS LEADING TO IT: Hypoventilation → ↓LOC, unable to generate breathing-paralysis Diffusion impairment alveolar collapse Fluid in lungs → pneumonia, drowning, fluid overload Intrapulmonary shunting & V/Q mismatch ARDS, pneumonia, pulm edema Lungs are perfused but not ventilated or they are ventilated and not perfused 🚩 Asthma ★ Red Flags of resp distress/failure  Swetha ○ Pronounced retractions and work of breathing ○ Seems tired and ↓ LOC ○ Anxiety-air hunger ○ ↓ sats, ↑ O2 requirement & cyanosis Cyanosis → not clinically apparent until 88% ○ stridor/snoring respirations ○ Head bobbing ○ Prolonged expiration ○ abdominal breathing ○ Beware of ↓ resp rate ★ Viral upper resp infections (UPI) ○ Viral infections NOT tx with ABX Self-limited Multiple infections each yr ○ Complications Progress into an opportunistic bacterial infection ○ Causes: Fever Congestion Rhinorrhea Fatigue 🙁 Poor appetite **Think of our sx when we have a bad cold ★ Nasopharyngitis → common cold ○ MANY viral causes: RSV Rhinovirus Adenovirus Influenza Parainfluenza ○ MORE severe in infants and young children ○ Tx/what to do? Treat fever HYDRATE or die dydrate LOL Monitor urine output Contact precautions (ewwww germies) ★ Acute streptococcal pharyngitis → strep throat ○ Group A beta-hemolytic streptococcus ○ Ranges from brief illness to serious complications Scarlet fever ○ Sx: Sore throat Painful swallowing HA Abd pain Fever Cervical lymphadenopathy  Swetha ○ Complications: Peritonsillar abscess Retropharyngeal abscess Post-streptococcal glomerulonephritis Occurs 1-2 weeks s/p strep s/sx: ○ Facial edema ○ HTN ○ Proteinuria ○ Hematuria ○ ↑ BUN/Cr, ESR, CRP ○ Mildly low blood protein Acute rheumatic fever 1-5 wks post under/untreated infection S/sx: ○ Fever ○ Joint pain ○ Fatigue ○ Chest pain ○ Erythema marginatum Non-painful rash w/ wavy appearance ○ Chorea ○ New heart murmur ○ Cardiomegaly ○ Pericardial effusion ★ Tonsillitis ○ Lymphoid tissue ○ Filters pathogens & forms antibodies ○ Frequent viral URI → inflammation & swelling ○ Can obstruct airway & swallowing ○ Palatine tonsils ○ Causes: Adenovirus, EBV (epstein-barr virus) Streptococcus pyogenes ★ Otitis Media ○ Eustachian tube is more parallel in children, filled w/ mucus, fluids, pathogens ○ Sx: Fever Signs of URI Pain Hard to hear  Swetha Fussiness ↓ appetite Poor breast or bottle feeding ○ Fluid & inflammation of middle ear Behind tympanic membrane ○ Serous otitis media: Inflammation, but no specific etiology indicated ○ Acute otitis media: Inflammation w/ evidence of acute infection (viral or bacterial) ○ Otitis media w/ effusion: Presence of middle ear fluid w/o evidence of infection ○ Most common bacterial pathogens Streptococcus pneumoniae Haemophilus influenzae Moraxella catarrhalis Tx: Amoxicillin ○ If this doesn’t work → then augmentin due to it having beta lactamase inhibitor ○ Most common viral pathogens RSV Influenza Parainfluenza Rhinovirus Adenovirus Watchful waiting Tx: Decongestants Antihistamine (seasonal allergies) ○ Causes: Mastoiditis → infection of mastoid bone Fatal if untx IV abx needed May need surgery Sx: ○ Fever, pain, HA, erythema over mastoid, protruding ear, hearing loss ★ Otitis Externa (outside tympanic membrane) ○ “Swimmers ear” ○ Ear canal is protected by cerumen ○ Causes: Swimming Changes in environment Trauma Finger or q tip ○ Ear canal becomes macerated & skin can breakdown ○ Susceptible to infection ○ Most common pathogens: Staphylococcus aureus  Swetha Pseudomonas Candida Aspergillus ○ Sx: Pain (esp w/ mvmt) Discharge Erythematous ear canal or ear itself. **ear complications → perforated tympanic membrane; infection (pressure build up due to pus/fluid) and trauma (q tips, pencils, foreign bodies) ★ Foreign body aspiration ○ Typically food items, coins, toys, teeny tiny batteries ○ Most common in kids < 4 yrs ○ Signs: Drooling Stridor Grunting Unequal breath sounds Wheezing Pain ○ Dx by CXR 😣 ○ Lodged in trachea, esophagus or passed to the stomach ○ PROBLEM → when it goes into the windpipe. ○ Tx: ABCs Prep to OR ★ Asthma – common illness of childhood & leading cause of morbidity ○ Hyper reactive airway = bronchial smooth musc constriction & inflammation ○ Non-hispanic black kids have a death rate 7.6x HIGHER from asthma compared to white kids. ○ Risk factors for death: Hx of severe asthma w/ ICU admits Previous intubations Hospitalizations & ED visits within last yr ○ Tx: Albuterol (beta-2 agonist) Relaxes bronchial smooth musc Single nebulization dose ○ 2.5mg in 3mL NS q 20 min Meter dosed inhaler ○ 4-8 puffs Cont nebulization Ipratropium (anticholinergic bronchodilator) [longer duration of action] Aka atrovent Blocks ach → causes smooth musc relaxation Neb dose ○ 0.5 mg in 2.5mL Can give w/ albuterol nebulizer Methylprednisolone (brand name: solumedrol)  Swetha Corticosteroid Anti-inflammatory → reduces the inflam component of airway obstruction Dose ○ 1-2mg/kg IV/IM, max. 125mg Mg sulfate Bronchodilator Used for fever asthma flare Not for sole therapy Dose ○ 25-75 mg/kg/dose Monitor for HYPOtension Epinephrine!!! Adrenergic agonist For most severe cases Dose: [during class, said NEED to know this] ○ 1:1000 concentration, give 0.1mg/kg IM Max: 0.5 mg single dose Cont drip: 0.1 mcg/kg/min Supplied in ampule Tx of choice for anaphylaxis ○ 1:10,000 Supplied in syringe 0.01mg/kg (0.1ml/kg) IV/IM Repeat q 3-5 min Tx of choice of cardiac arrest ★ Bronchiolitis ○ Occurs in infants less than 1 yr of age ○ Caused by RSV ○ It causes: Airway swelling ↑ mucus production ○ Sx: Runny nose Cough Expiratory wheeze Prolonged expiratory phase Tachypnea ↑ work of breathing Poor intake by mouth Low grade fever Apnea spells ○ Tx Supportive care w/ supplemental O2 **bronchodilators & steroids have NOT been shown to be beneficial** ★ Pneumonia ○ Acute inflammation of lung tissue → followed by accum of fluid ○ Caused by diff types of organisms  Swetha ○ S/Sx: URI sx Fever Chills Vomiting Abd pain Poor po intake Increased WOB ★ OSA – sleep disordered breathing ○ Upper airway obstruction during sleep ○ Disrupts BOTH breathing & sleeping ○ Caused by: Adenotonsillar hypertrophy Craniofacial defects Airway defects Allergies GE reflux Obesity ○ Dx: Sleepy study ○ Can cause: Cor pulmonale (R sided HF) Pulm HTN Neg airway pressure > alveoli & small airways collapse Hypoxia ○ Causes vasoconstriction in lungs RV has to work harder against higher resistance in pulm vasculature ★ Pediatric resuscitation *** slides 36 & 37 ○ ?????????????????????? add info? But idk what ?? ★ Epidemiology ○ Cardiac arrest in kids Primary card arrest = rare in kids Often by resp failure/shock and rarely sudden ○ Terminal rhythm in kids is usually bradycardia that progresses to pulseless electrical activity and asystole ○ SEPTIC SHOCK → most common in peds 80% of children in it will require intubation & mechanical ventilation w/n 24 hrs of admission ★ SYSTEMIC priorities (ABCs) ○ Airway Open airway head/chin tilt Jaw thrust Sniffing position Shoulder roll Suction for excess secr ○ Bulb ○ Yankaur  Swetha ○ Deep Oral airway Measure from teeth to mandible angle Use tongue depressor to insert Do NOT use on pts with intact cough / gag reflexes Nasal airway → aka nasal trumpet Semi-conscious patients Measure from nare to tragus ○ Breathing 🚩 Do NOT wait for apnea Red flags Tachypnea Bradypnea Irreg breathing pattern Restlessness Mouth breathing Nasal flaring / retractions Tripod position ↓ LOC Watch for ↓ O2 sats & ↑ O2 requirement Lung sounds Due to kids having thin chest walls that makes it easier to hear their lung sounds, if you can NOT hear it = PROBLEM Listen for adventitious sounds, but also for aeration ○ aeration = measure of airflow to all areas of lungs Vol of lung sounds should be the same bilat NO SOUND? Child not moving air!!!!!! D: 100% O2 via non rebreather mask Wean o2 as pt stabilizes using face mask or NC Provide bag valve mask vent for children not breathing effectively Unable to maintain O2 sats on oxygen Cyanosis Unable to protect the airway? Bag with enough force to make chest RISE 1 breath q 3 sec CE had position Do NOT occlude airway with fingers Rapid sequence intubation (RSI) ○ For emergency/unplanned intubations ○ Pts who were not NPO Pts need to be NPO before surgery because if eat or drink, stomach contents can go into lungs ○ Rapid admin of meds to take control of pts breathing and place endotracheal tubes (ETT) Sedative Neuromuscular blockers  Swetha 🚩 ○ Circulation Red flags Tachy Brady (threatening sign) Delayed cap refill: 3 or more sec Cool extremities Mottled skin Cyanosis ○ Check lips/nailbeds ↓ urine output ○ Neonate: 2mL/kg/hr ○ Child: 1mL/kg/hr Assess rhythm Place on monitor Child will often be tachy first and then progress to brady & asystole IV/IO access 2 large bore IVs If IV can not be placed ASAP → place IO Drugs, fluid and blood may be given via IO Fluid bolus: ○ 20mg/kg IV push using stopcock Reassess circ status b/w bolus’, repeat if needed May require multiple bolus’ Consider blood or ionotropic support after 3-4 bolus Dopamine drip can be considered Chest compressions ○ Initiated for HR < 60 ○ Dextrose/disability AVPU scale Alert: AOx3  Swetha Verbal: requires verbal stim to wake / respond Pain: require painful stimuli to wake / respond Unresponsive: does not respond to ANY stimuli Dextrose AMS = sign of hypoglycemia ○ Tx with D10 Check POC glucose & recheck q 15-30 min ○ Exposure/envmt Naked = cold (brrrrr) Check temp Warm IV fluids (if applicable) Room temp fluids are about 20° colder than nml Warm blankets Portawarmer mattress / warming blanket Place under blanket to avoid burns to skin Hypothermia exacerbates acidosis!!! ○ Friends/family Someone needs to be assigned role of caring Often social work / chaplain, may be nurse Fam presence during resuscitation ○ Get everything else foley , NG, imaging, runners Who’s watching rest of unit & pts? Answering phones Whatever else is needed Make yourself useful Week 3 ★ Congenital Heart Defects (CHD) ○ Structural defects present at birth ○ ~ 1% of infants born with it ○ Severity can range from mild to severe ○ Often requires surg repair ○ Survival rate: non - critical : 95% critical : 69%  Swetha ○ ○ Shunting Blood flow going elsewhere, not following proper direction L side = systemic R side = pulmonic The pressure is greater on the L side in a nml heart bc it pumps blood to the whole body & needs more force whereas the R side pumps blood to the lungs & doesn’t need much force ○ Fetal circulation MATTERS In utero, fetus supported by mothers ★ Fetal circulation ○ Blood flows b/w mother (placenta) & fetus through umbilical cord ○ 2 arteries & 1 vein ○ Fetus lives in hypoxic state ~ 80% saturated ○ Fetal metabolism mostly anaerobic ○ During last few weeks of gestation Metabolism starts to transition to aerobic More blood is shunted to lungs in prep for extrauterine life ★ Acyanotic – ↑ pulm flow ○ PDA Opening b/w 2 blood vessels leaving the