NR509 Final Chapter 25 Children.pdf

▪ call 911 i someone shows any o hese signs o oher imporan sympoms ▪ sudden numbness or weakness o he leg, arm, or ace, especially on one side o he body. ▪ Sudden conusion or rouble speaking o...

▪ call 911 i someone shows any o hese signs o oher imporan sympoms ▪ sudden numbness or weakness o he leg, arm, or ace, especially on one side o he body. ▪ Sudden conusion or rouble speaking or undersanding speech. ▪ Sudden rouble seeing in one or boh o he eyes. ▪ Sudden rouble walking, dizziness, loss o balance or coordinaon. ▪ Sudden severe headache wih no known cause. Transien ischemic aack (TIA) o Decreased vascular perusion resuls in sudden ocal bu ransien brain dysuncon, Or in permanen neurological decis and sroke, as deermined by neuro diagnosc imaging. Deecng AT A comma in episode o neurologic dysuncon ha resolves wihin 24 hours, is imporan, in he rs hree monhs aer a Tia, subsequen sroke occurs in approximaely 15% o paens. Chapter 25 Children: Infancy through Adolescence Techniques o examinaon o Inans and young children ▪ perorm non disurbing maneuvers early and poenally disressing maneuvers oward he end. For example, palpae he head and neck and ausculae he hear and lungs early; Examine he ears and mouh and palpae he abdomen near he end. I he child repors pain in he area examine ha par las. ▪ Approached he inan gradually, using a oy or objec or disracon. ▪ Perorm as much o he examinaon as possible wih he inan in he parens lap. ▪ Speak soly o he inan or mimic he inan sounds o arac aenon. ▪ I he inan is cranky, make sure he or she is well ed beore proceeding. ▪ Ask a paren abou he inan srengh o elici useul developmenal and parenng inormaon. ▪ Do no expec o do head o oe examinaon in a specic order. Work wih wha he inan gives you and save he mouh and ear examinaon or las. o Older children and adolescens ▪ use he same sequence as wih aduls, excep examine he mos painul areas las. o Apgar score ▪ Score each newborn according o he able a one and ve minues aer birh according o hree poin scale. ▪ i he ve minue score is eigh or more, proceed o a more complee examinaon. o Gesaonal age and birh weigh ▪ classiy newborns according o heir gesaonal age and birh weigh. o Assessmens several hours aer birh ▪ during he rs day o lie, newborn should have a comprehensive examinaon. Wai unl one or wo hours aer a eeding, when a newborn is more responsive. Ask parens o remain. Observe he babies color, size, body proporons, nurional saus, posure, respiraons, in movemens o he head and exremies. ▪ Mos newborns are bowlegged, reecng heir curled up inrauerine posion. ▪ Inspec he newborns umbilical cord o deec abnormalies. Normally, here are wo hick walled umbilical areries and one larger bu hin walled umbilical vein, which is usually locaed a he 12:00 o'clock posion. ▪ A single umbilical arery may be associaed wih congenial abnormalies. Unbold hernias and inans are rom a deec in he abdominal wall.  ▪ The neurologic screening examinaon o all newborns should include assessmen o menal saus, gross and ne moor uncon, one, cry, deep endon reexes, and primive reexes. ▪ Signs o severe neurologic disease include exreme irriabiliy; Persisen asymmery o posure or exension o exremies; Consan urning over he head o one side; Marke exension o he head, neck, and exremies; Severe accidiy; And limied pain response. Conex o They said he inen o gaher inormaon abou he child ha makes him or her unique compared o oher children o his or her age. Include he dae and place o birh, nickname, in rs and las names o parens. Assess he child developmenal environmen including observing he paren, child, youh ineracon. Priories or he visi o Exper panels noe ha he rs prioriy is o address he concerns o he parens and he child, adolescen and paren. Deermine i hey are he concerns o he child, he parens, a school eacher, or some oher person. healh supervision o Include inormaon ha is relevan and specic o he child age. Deermine how each amily member responds o he child sympoms, while he or she is concerned, in he impac o he child unconing. These may include gahering inormaon relaed o pas medical hisory, pernen amily hisory and on occasion relevan social hisory. I age appropriae may include; ▪ prenaal hisory, labor, and delivery ▪ prenaal-maernal healh; Medicaons: obacco, drug, and alcohol use; Weigh gain, duraon o pregnancy ▪ Naal-naure o Labor and delivery, birh weigh, apgar scores a one and ve minues ▪ Neonaal-resusciaon eors, cyanosis, jaundice, inecons, bonding ▪ eeding hisory ▪ breas eeding-requency and duraon o eeds, dicules, ming and mehod o weaning ▪ boleeeding-ype: amoun: requency: voming: colic: diarrhea ▪ viamins, and iron or uoride supplemens; Inroducon o solid oods ▪ eang habis-ypes and amouns o ood eaen, perinaal audes and responses o eeding problems ▪ allergies ▪ pay parcular aenon o hisory o eczema, ucaria, Perennial Allergic rhinis, ashma, ood and olerance, inspece hypersensiviy, and recurren wheezing. o hisory ▪ General quesons ▪ pas medical hisory ▪ amily hisory ▪ social hisory o surveillance o developmen ▪ Physical growh ▪ weigh and heigh a all ages; Head circumerence a birh and younger han wo years; periods o slow or rapid growh; BMI aer age 2  ▪ developmenal milesones, speech developmen, perormance in preschool and school ▪ social developmen ▪ day and nigh sleeping paerns; Toile raining; Habiual behaviors; Discipline problems, social behavior wih amily and riends, social risks such as povery, ood insecuriy and adverse childhood experiences o review o sysems o observaon o paren, child, youh ineracon o physical examinaon-his is a crical componen o he pediaric evaluaon. This also provides opporuniy or discussion o he physical changes associaed wih he child developmen. ▪ assessmen o growh ▪ less han wo years; Weigh, lengh, head circumerence, and wai or lengh. ▪ Over wo years; Weigh, heigh, and BMI ▪ lisng o parcular componens o he examinaon ha are imporan or he child a each age visi o screening ▪ universal screening ▪ Applied o each child a ha visi. ▪ selecve screening ▪ These vary according o he child's medical, developmenal, and social condions. Include newborn screening resuls, anemia screening, blood blood levels, sickle cell disease, vision, hearing, developmenal screening, and ohers. ▪ risk assessmen o immunizaons ▪ Include daes given and any reacons. Discussion regarding parenal anxiey and misinormaon regarding immunizaons mus be addressed. ancipaory guidance o inormaon or he healh care proessional o healh promoon quesons or he priories or he visi o ancipaory guidance or he paren and child Growh chars o Inan physical examinaon (including reexes) o General survey ▪ ailure o hrive is a condion reecng signicanly low weigh gain, below second percenle, or jus saonal age, correced age and sex. Causes can be environmenal or psychosocial or various gasroinesnal, neurological, cardiac, Endocrine, renal, or oher diseases. ▪ measures above he 97h or below he hird percenle, or recen rises or alls rom prior levels, require invesgaon. o Heigh and weigh ▪ reduced growh in heigh may indicae endocrine disease, oher causes o shor saure, or, i weigh is also low oher chronic diseases. o Head circumerence  ▪ premaure closure o he suures or microcephaly may cause small head size. Hydrocephalus, subdural hemaoma, or rarely brain umor or inheried syndromes may cause an abnormal large head size. o Vial signs ▪ blood pressure ▪ measure blood pressure a leas once during inancy. Alhough he handheld mehod is shown he mos easily used measure o sysolic blood pressure and inans in young child is o obain wih Doppler mehod. ▪ Pulse ▪ he hear rae is quie variable and will increase markedly wih exciemen, crying, or anxiey. Thereore measure he pulse when he inan or child is quie. ▪ Tachycardia is greaer han 180 o 200 beas per minue, usually indicaes proxamol super venricular achycardia. Bradycardia may righ From serious underlying disease. ▪ ▪ ▪ Respiraory rae ▪ he respiraory rae has a very wide range and is more responsive o illness, exercise, and emoon han aduls. ▪ Respiraory disease such as bronchiolis or pneumonia may cause rapid respiraons up o 80 o 90 breahs per minue, and increase work o breahing period peaceul achypnea, wihou increased work o breahing, may be a sign o cardiac ailure. ▪ Temperaure ▪ body emperaure and inans and children is less consisen han aduls. Recal emperaures are he mos accurae or inerence. The average recal emperaure is higher in inancy and early childhood, usually above 99 degrees Fahrenhei unl aer age hree. ▪ Skin ▪ Texure and appearance, vasomoor changes, pigmenaon, hair, common skin condions, color, urgor. ▪ Head ▪ examine suures and onanels careully. The inerior onanel a birh measures 4 o 6 cenmeers in diameer and will close by 18 o 22  monhs o age. The poserior onanelle measures 1 o 2 cenmeers a birh and usually close This is by wo monhs. ▪ Palpae he inan skull wih care period he cranial bones generally appear so or palpable. They will normally become rmer wih increasing gesaonal age. ▪ Swelling rom subperioseal hemorrhage does no cross suure lines; Swelling rom bleeding associaed wih racure does. ▪ Check he ace rs symmery. Examine or an overall impression o he acies. comparing wih he aces o he parens is helpul. ▪ Abnormal acis occur in a child wih a consellaon o acial eaures ha appear abnormal. A variey o syndromes can cause a normal asces. Examples include Down syndrome and eal alcohol syndrome. ▪ Eyes ▪ newborns and young inans may look a your ace and ollow a brigh ligh i you cach hem while aler. For ha ophhalmoscope examinaon wih he newborn awake and eyes open, examine he red renal reex by seng up Dallas cope a 0 diopers and viewing he people rom abou 10 inches. ▪ Nysagmus, srabismus ▪ Leukocoria-is a whie papillary reex, insead o he normal red papillary reex. I can be a sign o a rare umor called renoblasoma. ▪ Papilledema-is rare In inans because he onanelles and open suures accommodae any increased inracranial pressure, sparing he opc discs. ▪ Ears ▪ small, deormed, or low se arcles may indicae associaed congenial deecs, especially renal disease. ▪ Nose ▪ wih chonal aresia, he baby canno breahe i one nosril is occluded. ▪ Mouh and pharynx ▪ supernumerary eeh, Epsein pearls ▪ hrush ▪ vesicles in he mouh can be caused by environmenal inecons and herpes simplex virus inecons. ▪ Neck ▪ lymph adenopahy is usually rom viral or bacerial inecons. ▪ Oher neck masses include malignancy, brachial cle or hyroglossal duc cys, and periarcular cys and sinuses. ▪ Thorax and lungs ▪ Apnea ▪ upper respiraory inecons may cause nasal aring ▪ duraso abdominal paradox, or paradoxal breahing, is inward movemen o he ches and ouward movemen o he abdomen during inspiraon. This is normal nding in newborns bu no in older inans. ▪ Hear and peripheral vascular sysem  ▪ Birh-ransposion o he grea areries, pulmonary valve aresia or senosis. ▪ Wihin a ew days o birh-Love, also, oal anomalous pulmonary venous reurn, hypoplasc le hear. ▪ Absen or diminished emoral pulses sugges corcaon o he order. Week or hready, dicul o eel pulses may reec mild cardial dysuncon in hear ailure. ▪ Inans and children commonly have a normal sinus dysrhyhmias, wih he hear rae increasing on inspiraon and decreasing on expiraon, somemes quie abruply. The mos common dysrhyhmias in children is proximal super venricular achycardia. ▪ A louder han normal pulmonic componen suggess pulmonary hyperension. Persisen spling o S2 may indicae arial sepal deec. ▪ Mos inans wih cardiac pahology have signs beyond hear murmurs such as a poor eeding, ailure o hrive, irriabiliy, poor overall appearance, weakness, akip NIA, clubbing, hepaomegaly and ague. ▪ Breas ▪ he breas o males and emales may be enlarged or monhs aer birh as a resul o maernal esrogen. ▪ Abdomen ▪ you will nd i easy o palpae in inans abdomen, because inans like being ouched. ▪ Abnormal abdominal masses can be associaed wih kidney, bladder, or bowel umors. In Pi lorick senosis, deep palpaon in he righ upper quadran or midline can reveal in olive, or a 2 cenmeer rm pyloric mass. ▪ Male genialia ▪ inspec wha he inan supine. The oreskin o a newborn is non reracable a birh or jus enough o visualize ha urehral mieus. In 3% o inans, one or boh eses canno be el in he scroum or inguinal canal. Tried o milk he eses ino he scroum. ▪ Common scroal masses are hydrocele and inguinal hernias. ▪ Inabiliy o palpae eses even wih he maneuvers, indicaes undescended escles. ▪ Female genialia ▪ in emales, genialia maybe prominen or several monhs aer birh rom he eecs o maernal esrogen. This decreases during he rs year. ▪ Ambiguous genialia involves masculinizaon o he emale exernal genialia. ▪ Recum and anus ▪ In general in digial recal exam is no perormed on inans or children unless here is a queson o paency o he anus or abdominal mass. ▪ Muscular skeleal sysem ▪ skin ags, remnans o digis, polydacyly, or syndacyly or congenial deecs. Fracure o he clavicle can occur during a dicul delivery.  ▪ congenial hip dysplasia may have a posive Orolani or Barlow es, parcular during he rs hree monhs o age. Wih hip dysplasia, you eel a “clunk”. ▪ Pahologic bial orsion occurs only in associaon wih deormies o he ee or hips. ▪ Nervous sysem ▪ evaluae he developing cenral nervous sysem by assessing inanle primive reexes. ▪ Suspec a neurologic or developmenal abnormaliy i primive reexes are absen and appropriae age, presen longer han normal, asymmeric, or associaed wih posuring or wiching. ▪ Hypoonia can be a sign o a variey o neurologic abnormalies. ▪ Primive reexes ▪ Palmer grasp reex-birh o hree o our monhs ▪ place your ngers ino he inans hands and press agains he Palmer surace is. The inan will ex o ngers o grasp your ngers. ▪ Planer grasp reex-birh o six o eigh monhs ▪ ouch he soul a he base o he oes he oes will curl. ▪ Roong reex-birh o hree o our monhs ▪ sroke he perioral skin a he corners o he mouh. The mouh will open in he inan will urn he head oward he simulaed side and suck. ▪ Moro reex (sarle reex)-birh o our monhs ▪ hold he inan supine, supporng he head, back, and legs. Abruply lower he enre body abou 1 oo. The arms will abduc and exend, hands will open and legs will ex. The inan may cry. ▪ Asymmeric onic neck reex-birh o wo o hree monhs ▪ wha he inan supine, urn head o one side, holding jaw over shoulder. The arms and legs on side o which head is urned will exend while he opposie arm, leg will ex. Repea on he oher side. ▪ runk incurvaon (galan reex)-birh o hree o our monhs ▪ suppor he inan prone wih one hand and sroke once I he back 1 cenmeers rom midline, rom shoulder o buocks. The spine will curve oward he simulaed side. ▪ Landau Reex-birh o six monhs ▪ suspend he inan prone wih one hand. The head will li up, in he spine will sraighen. ▪ Parachue reex-8 monhs and does no disappear. ▪ Suspend he inan prone and slowly lowered he head oward a surace. The arms and legs will exend In a proecve ashion. ▪ posive suppor reex-birh or wo monhs unl six monhs ▪ hold he inan around he runk and lower unl he ee ouch a a surace. The hips, knees, and ankles will exend, he inan will sand up, parally bearing weigh, sagging aer 20 o 30 seconds.  ▪ Placing and sepping reexes-birh(bes aer our days; variable age o disappear) ▪ hold he inan up righ as in a posive suppor reex. Have one soul ouched he ableop. The hip and knee o ha ooball ex and he oher oo will sep orward. Alernae sepping will occur. Scroal/escular examinaon or newborns o Two common scroal masses in newborns are hydroceles and inguinal hernia; requenly boh coexis, and boh are more common on he righ side. o When you canno eel a escle in he scroum o a newborn, when he ess is up in he inguinal canal, genly milk i downward ino he scroum. Need o dierenae beween undescended eses (in he inguinal canals) and highly reracle eses. Common pediaric skin diseases (including eczema) o Acrocyanosis ▪ bluish discoloraon on palms and soles o Aopic Dermas (Eczema) ▪ Eryhema, scaling, dry skin, and inense iching o Jaundice ▪ physiologic jaundice occurs during days 2-5 o lie and progresses rom head o oe as i peaks o Miliaria rubra ▪ Scaered vesicles on an eryhemaous base, usually on he ace and runk, resul rom obsrucon o he swea gland ducs, disappears sponaneously wihin weeks. o Eryhema oxicum ▪ rash consiss o eryhemaous macules wih cenral pinpoin pusules on an eryhemaous base, scaered diusely over he enre body o Transien neonaal pusular melanosis ▪ Seen in black inans, pusules, scale, and hyperpigmened macules o Milia ▪ pinhead-sized whie pearly papules wihou surrounding eryhema on he nose, chin, and orehead resul rom reenon o sebum in he openings o sebaceous glands o Salmon pach ▪ sork bie o Caé-au-lai Spos ▪ ligh-brown pigmened lesions have borders are uniorm o Congenial dermal melanocyoc ▪ common among dark-skinned babies and look like bruises Surveillance o developmen o Age-appropriae developmenal achievemen o he child ▪ Physical ▪ Moor ▪ Cognive ▪ Emoonal social o Healh supervision visis  ▪ Periodic assessmens o physical developmenal, socio-emoonal, and oral healh ▪ More requen visis or children wih special healh care needs Inegraon o physical examinaon ndings wih healh promoon o Immunizaons o Screening procedures Oral healh o Ancipaory guidance o Parnership among healh care provider, child/adolescen, and amily Developmenal milesones (oddlers and school-age children Tanner saging o boys’ genials ▪ Sage 1 ▪ no pubic hair, preadolescen size, eses are he same size ▪ Sage 2 ▪ sparse growh o long slighly pigmened, downy hair, sraigh or only slighly curled, chiey a he base o penises, eses and scroum larger, somewha reddened and alered in exure ▪ Sage 3 ▪ darker, coarser, curlier hair spreading over symphysis, penis elongaed  ▪ Sage 4 ▪ coarse and curly hair as an adul, penis enlarged in lengh, breadh, and glans developed. Scroal skin darkened ▪ Sage 5 ▪ hair adul in quany and spreads, adul in size and shape o Tanner Sages Girls Pubic Hair ▪ Sage 1 ▪ preadolescen—no pubic hair ▪ Sage 2 ▪ sparse growh o long, slighly pigmened downy hair ▪ Sage 3 ▪ dark, coarse, curly spreading o pubic symphysis ▪ Sage 4 ▪ coarse and curly hair in aduls, has no spread o hings ▪ Sage 5 ▪ hair adul in quany and qualiy, spreads on he medial suraces o high o Tanner Sages Breass ▪ Sage 1 ▪ elevaon o nipple only ▪ Sage 2 ▪ breas bud sage; elevaon o breas and nipple as a small mound, enlargemen o areolar diameer ▪ Sage 3 ▪ urher enlargemen o elevaon o breas and areola, no separaon o conours ▪ Sage 4 ▪ projecon o areola and nipple o orm a secondary mound ▪ Sage 5 ▪ mauraon sage: projecon o nipple only Genec disorders (including Turner syndrome) o Chapter 26 Pregnant Woman Techniques o examinaon o Assess general healh, emoonal sae, nurional saus, and neuromuscular coordinaon Measure heigh and weigh. Calculae BMI ▪ Weigh loss due o nausea and voming ha exceeds 5% o pre-pregnancy weigh is considered excessive, represenng hyperemesis gravidarum, and can lead o adverse pregnancy oucomes o Measure BP a every visi ▪ Gesaonal hyperension ▪ SBP >140 or DBP >90 rs documened aer 20 weeks wihou proeinuria or oher evidence o preeclampsia ha resolves by 12 weeks posparum. ▪ Dyspnea accompanied by increased RR, cough, crackles, or respiraory disress poins o possible inecon, ashma, PE, or periparum cardiomyopahy