Pediatric Assessment and Fetal Development with Selected Pediatric Conditions Developmental Approach Approach to the Physical Physical Examination Examination Three rules in the examination of children and adolescents: adolescents: flexibility flexibility ,safety, ,safety, and organisation •
Allow the child's age and developmental level to guide your history and physical examination
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Atmosphere and environment are important
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Incorporate health education and growth and development anticipatory guidance into the examination
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Move from the easy/simple -> more distressing; use positive reinforcement and 'prizes'
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Use demonstration and play to your advantage (play equipment or 'spares', paper doll technique, crayons, blocks)
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Expect an age-appropriate level of cooperation; explain what will be involved in the physical examination and tell the child what she needs to do
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. objects/rattles. Soft manner; avoid loud loud noises and abrupt 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 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
DIVISIONS OF UTERINE DECIDUA
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 ORIGIN OF ORGAN SYSTEMS
CARDIOVASCULAR SYSTEM 16 days single heart tube 24 days heart beat 6 – 7 heart art ch chambers 7 wk heart valves 10-1 10-12 2 heart heart bea beatt on dop doppl plr r 20 ECG’ 28 SNS development
CONGENITAL HEART DISEASE
Ventricular Septal Defect Atrial Septal Defect Patent Ductus Arteriosus Tetralogy of Fallot
CLASSIFICATION
Acyanotic Heart Disease blood moves from the ARTERIAL ARTERIAL TO THE VENOUS VENOUS system (L-R shunts) Can develop cyanosis Cyanotic Heart Disease blood is shunted from the VENOUS VENOUS TO THE ARTERIAL ARTERIAL system (R-L shunts May not exhibit cyanosis until seriously ill
Atrial Septal Defect (ASD)
An opening exists between the atria Twice as common in girls L-R shunt Results to ventricular hypertrophy and increased pulmonary artery blood flow
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
Ventricular Septal Defect (VSD)
The most common congenital cardiac defects A hole exists between the ventricles L-R shunt Right ventricular hypertrophy and increased pressure in the pulmonary artery 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
Failure of the ductus arteriosus to close after birth More common in girls Affects 20%-60% of preterm infants
Assess Ass essmen mentt: Wide pulse pressure Low diastolic pressure
Managem Man agement ent : 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
Assess Ass essmen mentt: Cyanosis after prolonged crying or exertion Assumes a squatting or knee-chest position when resting Syncope Hypoxic episodes (tet spells)
Managem Man agement ent : 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
3RD Week 4th Week 6th Week 7th Week 24 – 28 28 wks wks 3 mos
Respiratory and GI tract single tube Septum lung buds extends to abdomen Diaphragm Slve Slveol olii and and capi capill llar arie iess Surfactant is formed spontaneous respi practice movements
CROUP
- a group of respiratory of respiratory diseases that often affects infants and children under age 6 Assessment
harsh "barking" cough and sneeze inspiratory stridor nausea/vomiting nausea/vomiting fever Hoarseness respiratory distress On a frontal X-ray of the cervical vertebrae, the steeple sign suggests the diagnosis of croup.
Management • • • • •
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exclude other causes of shortness of breath and stridor Keep the child in a warm moist environment Cool moist air Do not trigger the gag reflex Croup can be prevented by immunization for influenza for influenza and diphtheria; diphtheria; diphtherial disease, but with vaccination diphtheria is rare nebulized adrenaline in addition to steroids (dexamethasone
ASTHMA
- predisposition to chronic inflammation of the lungs in which the airways ( bronchi) bronchi) are reversibly narrowed.
Assessment:
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 (dyspnea), ), wheezing, wheezing, and chest tightness shortness of breath (dyspnea
note inspiratory stridor without 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
Avoidance of the allergen by environmental control Skin testing and hyposensitization to identified allergens Relief of symptoms by pharmacologic agents Treatment by Classification a. Inhaled Inhaled anti-in anti-inflammat flammatory ory corticosteroid corticosteroid (mild but persistent) persistent) b. Moderate persistent: A plus long acting bronchodilator at bedtime c. Severe persistent: persistent: B with higher higher doses of oral corticostero corticosteroids ids Pharmacologic Treaments a. Albuterol/t Albuterol/terbutal erbutaline ine to be given before corticosteroi corticosteroid d b. Metered dose inhalers (should be with spacers in children less than 12 years)
STATUS ASTMATICUS - FAILURE OF ASTHMATIC CHILDREN TO RESPOND TO BRONCHODILATORS AND THE ATTACK CONTINUES
Assessment
HR and RR are elevated PO2 levels are low PCO2 levels are high – ACIDOSIS Limited breath sounds Concurrent Pulmonary Infection
Management
BETA 2 Agonists and intravenous corticosteroids Oxygen Administration through face mask ET intubation with mechanical ventilation
NERVOUS SYSTEM 3 – 4 WKS 8 wks 24
Neural Pl Plate EEG Ears can hear & Sight is present
HYDROCEPHALUS An excess of cerebrospinal Fluid in the ventricles and subarachnoid spaces of the brain.
Causes: malabsorption of CSF excessive CSF production blockage in the pathway of CSF Conditions that lead to obstruction: tumors meningitis encephalitis Classifications: Congenital Acquired
Diagnostic Tests: Prenatal: UTZ CT scan Transillumination
Signs and Symptoms: becomes more evident during the first few weeks or months Increased ICP high-pitched shrill cry projectile vomiting (unassociated with feeding) change in LOC tense, bulging fontanel Hyperactive reflexes Headache
Walking problems
Also: 1. 2. 3. 4. 5.
Prom Promin inen entt scalp scalp vein veinss Boss Bossin ing g of of fore forehe head ad Sepa Separat rated ed sutu suture re line liness Incr Increa eased sed head head circu circumf mfere erenc ncee “Su “Sunset nset”” eyes eyes
Management of Hydrocephalus Aimed at:
RELIEF OF VENTRICULAR PRESSURE TREATMENT OF THE CAUSE OF VENTRICULOMEGALY TREATMENTS OF ASSOCIATED COMPLICATIONS MANAGEMENT TO PROBLEMS RELATED TO THE EFFECTS OF DISORDER ON PSYCHOMOTOR DEVELOPMENT
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 INTERVENTIONS
Lie the infant flat after shunt placement Upright position drains the CSF rapidly
Assess for the following postoperatively: Signs of increasing ICP Signs of infection Signs of developing meningitis Reposition the head every 2 hours Manage pain properly Crying increases ICP
NURSING ALERT
Brain stem herniation can occur with increased ICP and is manifested by opisthotonic positioning (flexion of head and feet backward). This 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
NEURAL TUBE DEFECT DEFECT •
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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 • •
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NORMAL BRAIN GROWTH GROWTH but there is premature fusion of cranial sutures Assess Ass essmen mentt: – Abnormally closed fontanelles – Bossing of the forehead – Signs of increasing ICP Managem Man agement ent : – Surgical remedy
Spina Bifida S U B T Y P E S: Spina Bifida Occulta • – Posterior portion of the vertebra fail to fuse
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– 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 • –
Infants with myelomeningocele void and defecate continually and cannot cannot move the lower extremities
Management •
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Spina bifida occulta – Surgery is not necessary Other types of SB – Immediate surgery to replace the replaceable contents and prevent infection
Nursing Interventions •
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Protect the sac – Avoid applying pressure – Prevent from drying – Prevent infection Positioning – Prone – Sidelying Preserve skin integrity Plastic use – Placed below the sac like an apron to prevent contamination from feces and urine
Ankyloglossia (Tongue-Tie)
PHYSICALLY CHALLENGED CHILDREN
Cleft Lip Failure of fusion between weeks 5-8 More prevalent in boys • Causes: • – Teratogens – Folic acid deficiency Risk factors: • – Familial tendency – Japanese Assessment: • – absence of upper teeth and gingiva – flattened nose Unilateral Bilateral •
Cleft Palate • • • •
Opening in the palate Failure of closure of the palate between weeks 9-12 Most often accompanied with cleft lip Can be assessed by depressing the tongue
Cleft Palate
Cleft Lip and Palate
Management • • •
Surgical repair after birth Revision at 4-6 yo Surgical repair at 6-18 months
Nursing Interventions •
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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
DEVELOPMENTAL HIP DYSPLASIA -
Improp Improper er form formati ation on and functio function n of of the the hip socket socket
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Assess Ass essmen mentt: – (+) Ortolani’s sign – Asymmetric gluteal folds – One knee is lower than the other
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Diagnos Dia gnostic ticss: – X-ray – MRI
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Managem Man agement ent : – Multiple diapering – Pavlik harness
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Splint
Spica Cast
Tracheoesophageal Tracheoesophageal Fistula and Atresia
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
Emergency surgery to prevent Pneumonia DHN Electrolyte imbalance Gastrostomy Drain food by gravity Never push
Nursing Interventions
Intravenous or Total Parenteral Therapy Early introduction of fluids Position on right side/upright Frequent monitoring
DIGESTIVE SYSTEM
6TH 6TH WEEK WEEK 10th 0th week week 32 wks 36 wks
Inte Intest stin ines es wel welll form formed ed abdo abdome men n acco accom mmoda modate tess inte intest stin ines es sucking and swallowing enzyme secretion for
reflex present CHO/CHON
DIAPHRAGMATIC DIAPHRAGMATIC HERNIA
Abdominal organs protrude into the chest cavity through a defect in the diaphragm.
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Assess Ass essmen mentt: Respiratory difficulty at the time of birth Cyanosis and intercostal retractions Sunken abdomen Absence of breath sounds on affected lung – – – –
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Managem Man agement ent : High mortality rate – 25% to 50% Emergency surgical repair Position: upright Kept on NPO Oxygenation and suctioning prn NGT insertion for decompression – – – – – –
PYLORIC STENOSIS
Pylo Py loru russ: lower portion of the stomach that connects to the small intestine •
Pyloric stenosis stenos is: Pyloric muscles enlarge, narrowing the opening of the pylorus and eventually • preventing food from moving from the stomach to the intestine
Assess Ass essmen mentt:
• • • • • • • •
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
Managem Man agement ent : 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 Asses sment : apparent apparen t at 6-12 months mont hs Cannot pass stool by 24 hours of age Chronic constipation Ribbonlike stools Distended abdomen Thin and malnourished Diagnostic Tests: Rectal exam Barium enema Biopsy Managem Man agement ent : Dissection, removal and anastomosis Permanent colostomy for absence of nerve endings in anus
INTUSSUSCEPTION
Assess Ass essmen mentt: Intermittent abdominal pain and discomfort Vomiting with bile Blood in stool, “currant jelly” appearance Abdominal distention
Diagnost Diag nostic ic test te st: Confirmed by UTZ Manage Man agemen mentt: 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:
Inability to absorb fat Deficiency of ADEK vitamins Rickets may occur Anemia, hypoprothrombinemia, hypoalbuminemia Northern European background Inherited illness Increased incidence in children with Down Syndrome Assessment: Irritable and anorectic Skinny with wasted buttocks Distended abdomen Signs of malnutrition Bulky, foul-smelling fatty stools (STEATORRHEA) ( STEATORRHEA) Diagnostic Tests: Biopsy of intestinal mucosa Oral glucose tolerance test Stool exam Response to gluten-free diet Interv Int erventi entions ons : Lifetime intake of gluten-free diet • Record stool characteristics • Teach parents and children to recognize foods with gluten (BROW) •
Wheat flour, gravy, soups, sauces, pasta, cookies, cakes and pastries, hotdogs, frozen and packaged foods
CYSTIC FIBROSIS
Dysfunction of the exocrine glands Thickened and tenacious mucus secretions particularly in the lungs and pancreas More salty sweat an inherited disease of the mucus and sweat glands; autosomal recessive gene affects mostly the lungs, pancreas, liver, intestines, sinuses, and sex organs symptoms and severity of CF vary from person to person Respiratory failure is the most common cause of death in people with CF
With CF, the body cannot utilize the following enzymes
Lipase – fat Trypsin – protein Amylase - carbohydrates
Highest priority: respiration Diet: increased CHON, CHO Moderate fat Increased sodium Pancrease: taken 30 minutes before ingesting a heavy meal, lifetime ADEK: once a day, lifetime Dx: sweat test, NaCl test nutrients (protein, carbohydrate, salts) leave the body unused, and one can become malnourished stools become bulky and greasy may not get enough vitamins A, D, E, and K may have intestinal gas, a swollen belly, and pain or discomfort
KWASHIORKOR
1. A disease disease caus caused ed by PRO PROTEI TEIN N DEFICE DEFICENCY NCY..
2. Occurs Occurs most most frequen frequently tly from from 1-3 1-3 yo 3. Deve Develo lopi ping ng coun countr tries ies 4. (Afri (Africa ca,, Asia, Asia, Lati Latin n Ameri America ca))
Assessment: a. b. c. d. e. f. g. h. i.
Grow Growth th fail failur uree Severe muscle wasting DEPE DEPEND NDE ENT Ed Edema ema Ascites Irritable Zebra sign Diarrhea IDA Hepatomegaly
Management - HIGH PROTEIN DIET MARASMUS • • • • • •
Disease caused by deficiency of all food groups. STARVATION Developing countries Neglected children Younger than 1 yo Invariably hungry and will suck any object offered
Treatment
Supply a diet rich in all nutrients DOWN’S SYNDROME • • •
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•
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most common chromosomal abnormality presence of three copies of chromosome 21 rather than the normal two copies Affected individuals most often exhibit mild to moderate mental retardation and have characteristic facial and physical abnormalities, as well as possible congenital defects in the cardiac, visual, gastrointestinal, and endocrine systems Incidence is 1/800 to 1/1000 births, affecting all races, genders, and socioeconomic classes Incidence increases with increased maternal age, however 80% of affected babies are born to women under 35 years There is no cure for Down syndrome
CEREBRAL PALSY
Nonprogressive disorders of upper motor neuron impairment that result in MOTOR DYSFUNCTION. Muscle is poorly controlled due to BRENDA
Types:
Spastic – excessive tone in voluntary muscles Athetoid or dyskinetic – abnormal involuntary movement Ataxic – awkward wide-based gait
Signs and symptoms: May/may not move head Poor sucking and swallowing Delayed developmental task Preschool (signs of mental retardation) 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. 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.
Feeding problems difficulties with sucking, swallowing and chewing Difficulties in taking care of the baby or young child
Communication difficulties
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. • Diseases with it Complication
AGE – DHN Pernicious Anemia – Peripheral neuritis Sickle cell – CVA CF – Sterility Lead poisoning – mental retardation Meningitis – hearing impairment
