Professional Documents
Culture Documents
Three rules in the examination of children and adolescents: flexibility ,safety, and
organisation
• Allow the child's age and developmental level to guide your history and physical
examination
• Incorporate health education and growth and development anticipatory guidance into
the examination
• Move from the easy/simple -> more distressing; use positive reinforcement and
'prizes'
• Use demonstration and play to your advantage (play equipment or 'spares', paper doll
technique, crayons, blocks)
Infants
• Keep parent in view
• Before 6 months examination on table; after 6 months examination in parent's lap
• Undress fully in warm room
• Careful with nappyremoval
• Distract with bright objects/rattles. Soft manner; avoid loud noises and abrupt
movements
• Have bottle, dummy or breast handy
• Vary examination sequence with activity level (if asleep/quiet
auscultate heart, lungs, abdomen first)
• Usually able to proceed in cephalocaudal sequence
• Distressing procedures last (ears and temperature)
Toddlers
• Most difficult group to examine
• Approach gradually and minimise initial physical contact
• Leave with parent (sitting or standing if possible)
• Allow to inspect equipment (demonstration usually not helpful)
• Start examination distally through play (toes, fingers)
• Praise, praise, praise
• Parent removes clothes
• Save ears, mouth and anything lying down for last
• Use restraint (with parent)
Pre-schoolers
• Allow close proximity to parent
• Usually cooperative; able to proceed head to toe
• Request self-undressing (bit by bit exposure modesty important)
• Expect cooperation
• Allow for choice when possible
• If uncooperative, start distally with play
• Allow brief inspection of equipment with brief
demonstration and explanation
• Use games/stories for cooperation
• Paper doll technique very effective
• Praise, reward and positive reinforcement
School-agers
• Usually cooperative
• Child should undress self; privacy important; provide drape/gown if possible
• Explain function of equipment; use of 'spares' helpful
• Examination can be important teaching exercise
• Head-toe sequence
• Praise and feedback regarding normalcy is important
Adolescents
• Give the option of parental presence
• Undress in private; provide gown
• Expose one area at a time
• Physical examination can be an important teaching exercise
• Head-toe sequence
• Feedback regarding normalcy is important
• Anticipatory guidance regarding sexual development (use Tanner staging)
• Matter-of-fact approach to examination (and history)
• Encourage appropriate decision-making skills
FETAL DEVELOPMENT WITH SELECTED PEDIATRIC CONDITIONS
Decidua basalis
Directly under the embryo
Portion of trophoblasts establishing communication with maternal blood
vessels
Decidua Capsularis
Stretches and encapsulates the trophoblasts
Decidua vera
Remaining portion of the uterine lining
EMBRYONIC AND FETAL STRUCTURES
Chorionic Villi
Syncytial layer
Langerhan’s Layer
Placenta
Circulation
Endocrine Function
Human Chorionic
Gonadotropin
Estrogen
Progesteron
Human Prolactin
Umbilical Cord
Amniotic Membranes
Amniotic Fluid
Assessment:
Murmur, splitting of second heart sound, enlarged right side of the heart
Management:
Surgery to close the defect between 1-3 yo
Silastic patch if hole is large
Assessment:
Easy fatigue at 4-8 weeks, loud, harsh murmur
Hypertrophied right ventricle and increased pressure in the pulmonaryartery
Management:
85% of VSDs are so small that they close spontaneously
Surgery
Silastic patch
Assess for arrhythmias postoperatively
Patent Ductus Arteriosus
Assessment:
Wide pulse pressure
Low diastolic pressure
Management:
Indomethacin – prostaglandin inhibitor
Insertion of stainless steel coils through cardiac catheterization at 6 months to
1 year
Surgical ductal ligation
Tetralogy of Fallot
Four Key Features
Ventricular septal defect (VSD)
Pulmonary stenosis
Right ventricular hypertrophy
Overriding aorta
Complications:
Polycythemia
Thrombophlebitis
Embolism
CVA
Growth restriction
Impaired cognitive ability
Assessment:
Cyanosis after prolonged crying or exertion
Assumes a squatting or knee-chest position when resting
Syncope
Hypoxic episodes (tet spells)
Management:
Surgery at 1-2 years old
Administer oxygen
Knee-chest position
Propanolol (Inderal) to dilate the vessels
Surgical Options
Blalock-Taussig procedure
Temporary
Creates a ductus arteriosus
Uses subclavian artery
Brock procedure
Full repair of VSD, pulmonary stenosis, and overriding aorta
RESPIRATORY SYSTEM
CROUP
- a group of respiratory diseases that often affects infants and children under age 6
Assessment
Management
ASTHMA
nighttime coughing
shortness of breath with exertion but no dyspnea at rest
a chronic 'throat-clearing' type cough
complaints of a tight feeling in the chest
Wheezing
Asthma Attack
shortness of breath (dyspnea), wheezing, and chest tightness
note inspiratory stridor without expiratory wheeze however, as an upper airway
obstruction may manifest with symptoms similar to an acute exacerbation of asthma,
with stridor instead of wheezing, and will remain unresponsive to bronchodilators.
Management
Assessment
Management
HYDROCEPHALUS
An excess of cerebrospinal Fluid in the ventricles and subarachnoid spaces of the brain.
Classifications:
Congenital
Acquired
Diagnostic Tests:
Prenatal: UTZ
CT scan
Transillumination
Also:
1. Prominent scalp veins
2. Bossing of forehead
3. Separated suture lines
4. Increased head circumference
5. “Sunset” eyes
Objective:
to diminish the volume of accumulated CSF; done by means of a shunt
What is a shunt ?
A drainage system which will transport the excess of CSF to other parts of the body
(ABDOMEN and HEART) where it can be reabsorbed.
NURSING DIAGNOSIS:
Risk for ineffective cerebral tissue perfusion r/t increased intracranial pressure
Risk for imbalanced nutrition, less than body requirements r/t increased intracranial
pressure
Risk for impaired skin integrity r/t weight and immobility of head
NURSING INTERVENTIONS
NURSING ALERT
Brain stem herniation can occur with increased ICP and is manifested by opisthotonic
positioning (flexion of head and feet backward). This is a grave sign and may be
followed by respiratory arrest. Obtain help, and prepare for ventricular tap. Have
emergency equipment on hand for resuscitation.
Caput Succedaneum: few days ; Cephalhematoma: few weeks
• Causes
– genetic predisposition: mothers who previously gave birth to a baby with spina
bifida
– Nutrition: low folic acid intake
• Types
– Anencephaly
– Microcephaly
– Spina Bifida
ANENCEPHALY
• Absence of cerebral hemispheres
• May have difficulty in labor
• Cannot survive due to lack of cerebral function
Microcephaly
• SLOW BRAIN GROWTH
• Cognitively challenged
• Causes:
– Rubella, cytomegalovirus, toxoplasmosis
– Severe malnutrition or anoxia in early infancy
Craniosyntosis
Spina Bifida
S U B T Y P E S:
• Spina Bifida Occulta
– Posterior portion of the vertebra fail to fuse
– Skin dimpling and tufts of hair
– Benign defect
• Meningocele
– Protrusion of the meninges
• Myelomeningocele
– Protrusion of the meninges and spinal cord
• Encephalocele
Myelomeningocele
Assessment
• UTZ, fetoscopy
• Increased alpha-feto protein (AFP) in amniotic fluid or in maternal serum
Management
Nursing Interventions
Cleft Lip
Cleft Palate
Cleft Palate
Cleft Lip and Palate
Management
Nursing Interventions
• Preop Period
– Teach mother to pump milk
– Have infant burp after feeding
– Offer small sips of fluid between feedings to moisten the mucous membranes
and prevent cracking
– If surgery is delayed, teach to feed soft foods
• Preop Period
– Teach mother to pump milk
– Have infant burp after feeding
– Offer small sips of fluid between feedings to moisten the mucous membranes
and prevent cracking
– If surgery is delayed, teach to feed soft foods
TALIPES DEFORMITIES
• Talus: ankle
• Pes: foot
• “clubfoot”
• The earlier the deformity is recognized, the better the correction will be.
• Correction is achieved with the use of casts
– Changed every 1-2 weeks
– Check extremities for compartment syndrome
• Assessment:
– (+) Ortolani’s sign
– Asymmetric gluteal folds
– One knee is lower than the other
• Diagnostics:
– X-ray
– MRI
• Management:
– Multiple diapering
– Pavlik harness
– Splint
Spica Cast
Weeks 4-8
Atresia: obstruction
Fistula: opening
5 types
Assessment
Maternal hydramnios
Excessive mucus in the mouth (appears to be blowing bubbles)
Catheter insertion
X-ray, barium swallow, bronchial endoscopy
Cough, cyanotic, DOB during initial feeding
Management
Nursing Interventions
DIGESTIVE SYSTEM
Abdominal organs protrude into the chest cavity through a defect in the diaphragm.
• Assessment:
– Respiratory difficulty at the time of birth
– Cyanosis and intercostal retractions
– Sunken abdomen
– Absence of breath sounds on affected lung
• Management:
– High mortality rate – 25% to 50%
– Emergency surgical repair
– Position: upright
– Kept on NPO
– Oxygenation and suctioning prn
– NGT insertion for decompression
PYLORIC STENOSIS
Pylorus:
• lower portion of the stomach that connects to the small intestine
Pyloric stenosis:
• Pyloric muscles enlarge, narrowing the opening of the pylorus and eventually
preventing food from moving from the stomach to the intestine
Assessment:
• Forceful, projectile vomiting
• Hungry and eats/nurses eagerly
• Milk vomited is curdled in appearance
• weight loss
• lack of energy
• fewer bowel movements
• constipation
• frequent, mucous stools
Management:
• surgical repair
HIRSCHSPRUNG’S DISEASE
occurs when some of the nerve cells that are normally present in the intestine do not
form properly while a baby is developing during pregnancy
the intestine can become partially or completely obstructed (blocked), and begins to
expand to a larger than normal size
the problems a child will experience with Hirschsprung's disease depend on how
much of the intestine has normal nerve cells present
Assessment:
Intermittent abdominal pain and discomfort
Vomiting with bile
Blood in stool, “currant jelly” appearance
Abdominal distention
Diagnostic test:
Confirmed by UTZ
Management:
Non-surgical
Instillation of water-soluble solution, barium enema, or air
Surgery to straighten the invagination
CELIAC DISEASE
Malabsorption Syndrome
Sensitivity to GLUTEN (barley, rye, oats, wheat)
DEFINITION:
CYSTIC FIBROSIS
Lipase – fat
Trypsin – protein
Amylase - carbohydrates
KWASHIORKOR
MARASMUS
Treatment
DOWN’S SYNDROME
Early Signs:
At birth a baby with cerebral palsy is often limp and floppy, or may even seem
normal.
Baby may or may not breathe right away at birth, and may turn blue and floppy.
Delayed breathing is a common cause of brain damage.
Slow development. The child is slow to hold up his head, to sit, or to move around.
He may not use his hands. Or he only uses one hand and does not begin to use both.
Dx:
• History
• Signs and symptoms
Diagnoses:
• Ineffective breathing pattern r/t uncontrolled accessory muscle
• Self-care deficit
• Fatigue due to non-purposeful movements
Management
• Correction or alleviation of specific neuromotor deficits or associated
disabilities.
• Administration of antispasticity medications, such as dantrolene (Dantrium) or
diazepam (Valium).
• Administration of antireflux medications, such as metoclopramide (Reglan) or
bethanechol (Duvoid).
• Orthopedic management of scoliosis, contractures, dislocations.
• Selective dorsal rhizotomy in an attempt to decrease spasticity.
• Developmental enrichment experiences.
• Development of prevocational, vocational, and socialization skills.
• Emotional, behavioral, and social adjustments.
• Family's ability to carry out supportive and participant roles in
rehabilitation—key determinant of the success of any comprehensive
management program.
• Complications
• Contractures.
AGE – DHN
Pernicious Anemia – Peripheral neuritis
Sickle cell – CVA
CF – Sterility
Lead poisoning – mental retardation
Meningitis – hearing impairment