Pediatrics---INFANT birth to 1 yr

Birth weight double at 6 mo and triples by 1 yr. Posterior fontanel closes by 8 wks Smile at 2 mo Head turns at 3 mo Moro reflex disappears at 4 mo Head control at 4 mo Peekaboo at 6 mo Can transfer objects from one hand to another at 7 mo Stranger anxiety at 7-9 mo Sits at 8 mo Crawls at 10 mo Pincer grasp at 10-12 mo Erikson- trust vs mistrust

Toddler 1-3 yrs

Birth weight quadroples by 30 mos 50% of adult height by 2 yrs Anterior fontanel closes by 12-18 mo Throws ball overhand at 18 mo Kicks ball at 24 mo Feeds self w spoon at 24 mo Toilet training at 2 yrs Eriksons- autonomy vs shame and doubt Expect bedwetting Provide choices to support autonomy

Preschool-3-5 yrs
Each yrs child gains about 5 lbs Learns to run jump skip and hop 3 yr old can ride a tricycle Scissors at 4 Ties shoe at 5 Thinking is egocentric Masturbation is common Imaginary playmates normal Aggressiveness at 4 is replaced w independence at 5 Erikson- initiative vs guilt Explain that the child did not cause illness Use simple words to answer questions Medical play let child handle equiptment

School age 6-12 yrs

Child gains 4-6 lbs a yr Fine and gross motor skills mature Learns to tell time Can dress self Learns cause and effect Peers become important Molars come in at 6 Adolescent to 19 yrs Girls growth spurt begins at 10 and ends around 15 yrs Boys start at about 14 and finish around 17 Adult like thinking at 15

Diarrhea and dehydration

Signs of dehydration- poor skin turgor Absence of tears Dry mucous membranes Weight loss 5- 15% Depressed fontanel Decreased urinary output increase specific gravity Signs of acidosis- low bicarb Low Na and K Elevated hct Elevated bun Signs of shock- decreased bp Rapid weak pulse Mottled to gray skin Changes in mental status Monitor I&O do not take rectal temp rehydrate check stools give antibiotics isolation precautions Give pedialyte No antidiarrheals No juice, cola or ginger ale If poisoning occurs no syrup of ipecac May need gastric lavage , activated charcoal or narcan Put locks on cabinets Call poison control

Respiratory
1-11 mo HR 100-160, rr 30-60 1-3 yrs 100-150, 25-35 3-5 yrs 80-130, 20-30 6-10 yrs 70-110, 18-22 10-16 yrs 60-90, 16-20 Signs of resp distress increased RR Increased pulse Diaphoresis Flaring nostrils Retractions Grunting Adventitious breath sounds Accessory muscles used Cyanosis pallor Decreased paO2 increased CO2

Asthma
Airways edematous, congested and mucous, constricted Hydrate Monitor blood gases Administer bronchodilators Administer o2 Monitor pulse ox Monitor theophylline levels 10-20 Beta adrenergic agonists albuterol Metered dose inhaler Reduce allergens Monitor peak expiratory flow rate at home

Cystic fibrosis
Autosomal-recessive disease that causes dysfunction of the exocrine glands Lung insufficiency Pancreatic insufficiency Low Na and chloride in sweat Meconium ileus at birth 10-20% Recurrent resp infection Pulmonary congestion Excessive fatty stools foul smelling bulky Delayed growth and poor weight Salty skin taste Cyanosis nail bed clubbing CHF Administer iv antibiotics Pancreatic enzymes Give fat soluble vitamins A,D,E,K Give O2 Nebulizer treatments High calorie high protein diet low carbs

RSV virus
Irritable Paroxysmal cough Poor eating Nasal congestion Nasal flaring Prolonged expiratory phase Wheezing rales Isolate child Monitor resp status Clear airway of secretions using bulb syringe Mist tent, give o2 Maintain hydration Monitor antiviral agent, ribavirin aerosol if prescribed Give synagis to provide passive immunity in high risk children

Otitis media
Predisposes child to ear infections Risk for hearing loss if untreated Fever, pain, infant may pull ear, enlarged lymphs, ear discharge, URI, vomit, diarrhea Reduce body temp, w/ tepid baths, and acetaminophen Position on affected side Warm compress on ear Smoking and bottle feeding while child is supine are predisposing factors

Tonsilitis
Encourage warm saline gargles, ice chips, antibiotics, manage fever Surgical carepreop teach, give soft foods and fluids avoid red fluids do not use straws Ice collar for pain Signs of bleeding are frequent swallowing, vomiting blood, and clearing throat

Cardiovascular disorders
Acyanotic ventricular septal defect, atrial septal defect, patent ductus arteriousus, coartation of aorta, aortic stenosis
Left to right shunts or increased pulmonary blood flow

Cyanotic- tetralogy of fallot, tuncus arteriosis, transposition of the great vessels

Right to left shunts or decreased pulmonary blood flow Mixed blood flow

acyanotic
Ventricular septal defect-increased pulmonary blood flow Hole between ventricles Oxygenated blood from left ventricle is shunted to right ventricle and recirculated to the lungs Small defects may close spontaneously Large defects cause congestive heart failure and require surgical closures Atrial septal defect increased pulmonary blood flow Hole between atria Oxygenated blood from the left atrium is shunted to the right atruim and lungs Surgical closure recommended before school age

 Patent ductus arteriosus increased pulmonary blood flow Abnormal opening between the aorta and the pulmonary artery Usually closes within 72 hrs If remains open, oxygenated blood from the aorta returns to the pulmonary artery Increased blood flow to the lungs causes pulmonary hypertension Indomethacin may be required or surgical closure

Coarction of the aortaobstruction of blood flow from ventricles There is an obstructive narrowing of the aorta Hypertension in the upper extremities and decreased or absent pulses in lower May require surgery

 Aortic stenosis obstruction of blood flow from ventricles It is obstructive narrowing before at or after the aortic valve Symptoms caused by low cardiac output May require surgery

cyantoic
Three ts Tetralogy of fallot
Ventricular defect Aorta placed over and above the ventricular defect Pulmoary stenosis Right ventricular hypertrophy Tructus arteriosus, one artery (trunctus) rather then two arteries (aorta and pulmonary) arise from both ventricles Transposition of the great arteries, in which the pulmoary artery leaves the left ventricle and the aorta exits from the right

Tetralogy of fallotdecreased pulmonary blood Cyanosis occurs Decreased pulmonary circulation Tet spells- relieved by tripod position Requires surgery

 Truncus arteriosus Pulmonary artery and aorta do not separate One main vessel receives blood from the left to right ventricles together Cyanosis occurs Surgery required

Transposition of the great vesselsmixed blood flow Great vessels are reversed Pulmonary circulation arises from the left ventricle and systemic from the right Incompatible w life medical emergency

CHD
Murmur Cyanosis Clubbing of nails Poor feeding, weight gain, and failure to thrive Frequent regurgitation Frequent resp infections Activity intolerance Assess heart rate rhythm, and heart sounds and pulse Blood pressure Feed small frequent feeds provide high calorie formula Hydrate Neutral thermal environment Frequent rest periods Organize activites Give dig and diuretics as prescribed Antibiotics before dental or invasive procedures

 CHF Tachypnea, SOB, tachycardia, difficult to feed, cyanosis, grunting, wheezing, pulmonary congestion, edema, weight gain, diaphoresis, hepatomegaly Elevate HOB Assess RR Give dig and diuretics Weigh frequently I&O Report weight gain Low Na diet Gavage feed infants

Rheumatic fever Inflammatory disease Usually affects aortic and mitral valves Beta-hemolytic strep infection Chest pain, SOB, tachycardia, joint pain, chorea( involuntary movements) Rash Sub q nodules Fever Elevated ESR and ASO titer Bed rest Assist ambulation Chorea is temp Penicillin or erythromycin, aspirin Prophylactic antibiotics

Neuromuscular disorders
Down syndrome Results from trisomy 21 Associated w maternal age >35 Flat broad nasal bridge, inner epicanthal eye folds, upward outward slant of eyes, protruding tongue, short neck, transverse palmar crease, hyperextensible and lax joints Monitor growth and development Monitor for signs of cardiac and respiratory problems Feed to back and side of mouth Use bulb syringe to suction nares

Cerebal palsy Injury to motor center of the brain causing neuromuscular problems of spasticity or dyskinesia (involuntary movements) Caused by anoxic injury, maternal infections, kernicterus, and low birth weight Persistant neonatal reflexes (moro, tonic neck) Delayed development One hand preference Poor suck and tongue thrust Scissor legs Seizures Position child upright and support lower jaw to prevent aspiration Give anticonvulsant dilantin and valium for muscle spasms

Spina bifida

Malformation of the vertebrae and spinal cord Spina bifida oculta effects vertebrae only Meningocele- has a sac present and has less nero involvement Myelomenigocele is more severe b/c that sac contains spinal fluid meninges and nerves May have latex allergies Folic acid .4mg is taken daily for at least 3 mos prior to pregnancy. And .6mg when pregnant Associated problems are hydrocephalus, neurogenic bladder, poor anal sphincter tone, dislocated hips club feet, skin problems, and scoliosis

Keep sac free of urine and stool Elevate HOB and put child on abdomen Measure head circumference at least every 8 hrs or every shift ck fontanel Assess neuro Empty bladder using credes method Promote parent bonding Administer pro-banthine or urecholine as prescribed to improve continence Develop bowel programhigh fiber, increased fluid, suppositories Assit in ROM

Hydrocephalus- abnormal accumulation of CSF within brain Mostly associated w spina bifida but can be associated w/ meningitis Signs of increased ICP are decrease pulse increase bp In older children classic signschange in LOC, irritable, vomiting, HA on awakening, motor dysfunction, seizure, unequal pupil response, seizures, decline in academics, personality changes In infants, irritable, lethargy, increase head circumference, bulging fontanel, widening suture lines, sunset eyes, high pitched cry Elevate HOB Monitor I&O May put in shunt or tubing that tunnels through skin Child will need shunt revision

Seizures- most common under 2 yrs Tonic-clonic is grand mal and consciousness is lost
Aura, LOC, apnea cyanosis, pupil dilate and nonreactive, incontinent, sleepy after

Tonic phase- stiffness of entire body Clonic phase- spasm followed by relaxation Absence (petit mal) momentary loss of consciousness, posture maintained Usually occurs b/t 4 and 12 5-10 seconds Appear inattentive and day dreaming Poor school performance Myoclonic- sudden brief contractures of muscle Do not restrain and maintain airway turn to side Protect from injury Document seizure Reduce environmental stimuli, pad side rails, have suction and o2, tape oral airway to HOB Give anticonvulsant Monitor therapeutic drug effects

Bacterial meningitis-source of invasion is middle ear or nasopharynx, other sources are wounds skull fractures, shunts and lumbar puntures Lumbar puncture shows increased WBC, decrease glucose, elevated protein, increased ICP, positive culture Older children show signs of increased ICP, fever, chills, neck stiffness, photophobia, positive kernig sign (iniable to extend leg when thigh is flexed) and brudzinski sign (neck flexion causing adduction and flexion movement of lower extremities) Infants show ill, poor feeding, vomit, irritable, bulging fontanel, seizures Give antibiotics Isolate for 24 hrs Keep environment quiet and dark Slightly elevate HOB Measure head circumference Monitor I&O Administer HIB vaccine

Reye syndrome- acute rapid encephalopathy and hepatic dysfunction Antecedent viral infections such as flu or chicken pox Associated w aspirin use School age usually Lethargy, progressing to deep coma, vomit, cerebral edema, elevated SGOT/AST, SGPT/ALT, LDH, ammonia, decreased PT Hypoglycemia Maintain ventilation Monitor cardiac parameters Give mannitol Monitor I&O Care for foley

 Brain tumors- 2nd most common cancer in children Usually close to vital structures Gilomas are the most common Headace vomiting, LOC, change in behavior, vision problems, tilts head In infants widening sutures, increasing fontal occipital circumference, tense fontanel Get baseline neuro If surgery head will be shaved, explain ICU, dressings, Ivs Monitor IV fluids and output Give steroids and osmotic diuretics

Muscular dystrophy- inherited disease of muscles Duchenne- appears in early childhood and progresses rapidly causing respiratory or cardiac complications, usually death by 25, an X-linked recessive disease Waddling gait, muscle weakness, difficulty rising to standing position, pseudohypertrophy, muscle degeneration, especially the thighs, elevated CPK and SGOT/AST Scoliosis and respiratory difficulty, and cardiac problems Eventually wheelchair dependent Provide exercises, prevent exposure to respiratory infection, encourage diet

Renal disorders
Acute glomerulonephritis- immune response to streptococcal infection of the skin or pharynx. Causing inflammation and decreased glomerular filtration Edema, irritability, lethargy, hypertension, dark urine, proteinuria, elevated ASO titer, and bun and creatinine Monitor vitals, I&O, weights, low Na diet low K, if oliguric. Bed rest during first 4-10 days acute phase. Antihypertensives Monitor for seizures, CHF, renal failure Nephrotic syndrome- basement membrane of glomeruli becomes permeable to plasma proteins Most common in 2 and 3 yrs, may have exacerbations over several yrs Edema severe and generalized, lethargy, anorexia, pallor, frothy appearing urine, massive proteinuria, decreased protein, elevated lipids Monitor temp and signs of infection, provide skin care to edema areas, maintain bedrest during edematous phase Give steroids, monitor I&O, measure abdominal girth, give cytoxan, provide small frequent feedings of a normal protein, low-salt diet. IV albumin followed by diuretic. Instruct to weigh child daily, signs of relapse

 UTI-vauge symptoms in infants, fever, irritable, poor food intake, diarrhea, vomit, jaundice, strong smelling urine. In older children urinary frequency, hematuria, enuresis, dysuria, fever Collect clean voided urine or catheterized specimen Give antibiotics Instruct to finish all prescribed meds Avoid bubble baths, increase acidic oral fluids (apple juice, and cranberry) Instruct to void freq. Clean genital area front to back

Vesicoureteral reflex- backflow of urine into the ureters from the bladder Recurrent UTI Reflux common w neurogenic bladder Reflux noted on voided cystourethrogram Measure output from both catheters Assess dressing and incision for drainage Restrain childs hands as necessary Maintain hydration w IV or oral fluids Manage pain relief

Wilms tumor- renal tumor Tumor is encapsulated It occurs in preschool children With early detection surgery and chemo as well as radiation therapy postop, prognosis is good Mass in the flank area Often discovered by parents when bathing child Fever, pallor, lethargy Elevated BP Hematuria Protect child from injury no abdominal palpatation Prepare from nephrectomy Monitor for increased bp, I&O urine specific gravity. Maintain NG tube ck bowel sounds

Hypospadias- defect of urethral meatus in males. Urethra opens on ventral side of penis behind the glans. Altered voiding stream Presence of chordee Undescended testes and inguinal hernia Prepare for surgery Assess circulation to tip of penis Monitor urinary drainage after using foley suprapubic tube or urethral stent Maintain hydration Restrain childs arms and legs if necessary Teach care of catheters Teach how to empty bag

GI disorders
Cleft lip of palate Palate may not be seen until difficulty with feeding Closure of cleft lip is performed when child weighs 10 lbs and has an Hgb of 10 Closure of palate defect is usually performed at 1 yr to minimize speech impairment Difficulty sucking and swallowing Promote family bonding and grieving during newborn period Assist with feeding upright feed slowly w frequent bubbling, use soft large nipples lambs nipple prosthetic palate, or rubber tipped asepto syringe Support breast feeding Maintain patent airway and proper positioning For cleft lip place client on side or upright in infant seat (not prone) Cleft palate place client on side or abdomen Apply elbow restraints after surgery Minimize crying to prevent strain on lip Maintain logan bow to lip if applied Remove one restraint at a time and perform ROM Cleanse suture site after feeding

Esophageal atresia w tracheoesophageal fistula

Esophageal atresia w tracheoesophageal fistula- esophagus does not fully develop Most common upper esophagus ends in a blind pouch and the lower part of the esophagus is connected to the trach Surgical emergency Three Cs of TEF Choking, coughing, cyanosis Excess salivation Resp distress Aspiration pneumonia Remove excess secretions Elevate infant into antireflux position of 30 degrees Provide o2 Maintain NPO Give iv fluids Monitor I&) Pyloric stenosis- narrowing of the pyloric canal the spincter hypertrophies to twice the norm size Vomiting usually begins after 14 days of life and becomes projectile Hungry fretful infant Weight loss, failure to gain weight Dehydration w decreased Na and K Metabolic alkalosis Olive shaped mass in upper right quadrant of the abdomen Visible peristaltic waves Give fluids and electrolytes Weight and I&Os Provide small frequent feedings w electrolyte solutions or glucose Position on right side in semi fowlers post op Burp frequently

 Intussusception- telescoping of one part of the intestine into another part Partial to complete bowel obstruction Blood vessels become trapped in the telescoping bowel, causing necrosis Screaming with legs drawn to abdomen Vomiting Currant jelly stools Sausage shaped mass in upper right quadrant while lower right is empty Give fluids, monitor I&O Prepare for barium enema if does not work surgery necessary

Hirschsprung disease- absence of parasympathetic gaglion cells in a distal protion of the colon and rectum Lack of peristalsis in area of colon Temp colostomy Reanastomosis and closure of the colostomy Suspected in newborn who fails to pass meconium within 24 hrs Distended abdomen, chronic constipation alternating w diarrhea Ribbon like stools in the older child Begin bowel cleansing program Observe for symptoms of bowel perforation- distention, vomiting, tenderness, irritability, dyspnea, cyanosis Ck vitals, auxillary temp Iv fluids, I&O, care for NG tube with connection to intermittent suction Ck abd. Perineal dressings Assess bowel sounds

 Anorectal malformationsoften associated with fistula, or urinary tract anomalties Unusual appearing dimple Newborn who does not pass meconium stool within 24 hrs Determine first temp, typically with rectal thermometer, to assess for imperforate anus Iv fluids before surgery, I&O Keep perineal site clean Position infant in side-lying prone position w hips elevated

Hematologic Disorders

Iron deficient anemiaMay be caused by inadequate stores during fetal development, deficient dietary, chronic blood loss, poor utilization of iron by the body Pallor, paleness of mucous membrane, tired, usually seen in infants 6-24 mos old, toddlers and female adolescents most affected Overweight milk baby Milk intake of greater then 32oz, pica habit, decreased hemaglobin, low iron, elevated total iron binding capacity Hemaglobin norms newborn 14-24, infant 1015, child 11-16 Provide rest periods Give iron ferrous sulfate, give on empty stomach, with citrus juices, use dropper or straw to avoid discolor teeth, stools will become tarry do not give with dairy Meat, green leafys, fish, liver, grains, legumes

Hemophilia- inherited bleeding disorder recessive 0-25% activity in blood norm is 50-100% Either missing factor 8 or 9 Male child prolonged bleeding following circumcision Hemarthrosis most common site of bleeding Loss of motion in joints pain PTT prolonged Administer first frozen plasma Give pain med no aspirin Risk for hepatitis Recognize signs of bleeding in joints Pressure splinting ice Teach administration of factor replacement Use soft toothbrush Protective care padded bed rails, soft toys

Sickle cell anemia- autosomal recessive Red blood cells sickle when o2 is released into tissues Dehydration promotes sickling Tissue ischemia causes pathological changes in spleen liver kidney bones and CNS Frequent infections, nonfunctional spleen, fatigue, chronic anemia, delayed physical growth, vasooclusive crisis- 1 fever, 2 abdominal pain, hand-foot syndrome in infants edematous hands and feet, arthralgia Leg ulcers Cerebral vascular accident Prevent crisis, keep from exercising strenuous, keep away from high altitudes, avoid infection, use prophylactic penicillin, hydrate w/ vasoocclusive crisis give iv fluids 1- 2 times maintenance levels I&O, blood products, pain meds, warm compresses Pneumococcal, meningicoccal vaccine, hep b vaccine Folic acid

Acute lymphocytic leukemia- presence of immature lymphocytes 75% have null cell- good prognosis Pallor, fatigue, petechiae, bleeding, thrombocytopenia, infection, fever due to neutropenia, bone and joint pain, enlarged lymph nodes, hepatosplenomegaly, HA, vomiting, anorexia Private room, isolation Look for infection give blood products Give chemo Monitor for side effects, vincristine , lasparaginase, methotrexate Epinephrine and o2 available to treat anaphylaxis when giving l-asparaginase Give antiemetics increase calories and proteins Prednisone is commonly used

Metabolic and endocrine disorders

Hypothyroidism- inadequate thyroid tissue developed in utero, mental retardation and growth delay if untreated Low t4, high TSH Long gestation more then 42 weeks Large hypoactive infant Delayed meconium passage, poor feeding, poor such, prolonged jaundice, hypothermia, large protruding tongue, coarse hair, lethary, flat expression, constipation Replacement thyroid hormone, lifelong need, dose in morning, ck pulse before giving Signs of overdose rapid pulse fever weight loss diarrhea Signs of underdose lethargy, constipation, poor feeding Phenylketonuria PKU- autosomal recessive disorder body cannot metabolize amino acid Phenylalanine Leads to CNS damage, decreased melanin causes light hair Frequent vomit, failure to gain weight, hyper, musty odor of urine Early detection can prevent mental retardation PKU restriction Special formula Avoid high protein, meat, dairy, eggs

 Type 1 diabetes- insulin cells non functioning Insulin, dietary, exercise to treat Three ps- polydypsia, polyuria, polyphagia Weight loss, abdominal complaints Fasting blood sugar greater then 120 Ketoacidosis monitor vitals, neuro give iv NSS and iv insulin, I&O 2 injections daily, rapid and intermediate acting Carb counting, meals and snacks growth and exercise Snacks before or during exercise

Skeletal disorders
Fractures- injury to bone\ complete and incomplete, comminuted fractures fragments break free Spiral fractures Pain, swelling, contusions, guarding 5 ps- pain, pallor, pulselessness, parastesia, paralysis Ck pulses distal to injury, color, movement, temp, swelling elevate extremity, pain monitor for pain that is not relieved by analgesic compartment syndrome Maintain traction weights pulleys, pins, ace wraps, splints, casts Monitor pin site for infection Cast care, dont get wet, dont put anything in cast, modify toileting to avoid soiled cast Appropriate toys Congenital dislocated hipTreat with splinting, surgery necessary if splinting not sucessful Positive ortolani sign- clicking with abduction, unequal folds on butt and thigh, limited abduction of hip, unequal leg lengths, limp in older child, trendelenburg sign Pavalik harness Position legs in flexed abducted Keep splint on 24 hrs Provide care for infant in bryant traction if splinting uneffective, maintain hips in elevated position, elevate butt of bed, monitor circulation to feet Ck cast for drainage and bleeding after surgery, neuro assesment, resp, narcotics demerol or morphine

Scoliosis- curve of spine can cause resp. compromise if severe May require surgery Elevated shoulder or hip Rib hump apparent when bending forward Screen all adolescent children Use brace, wear 23 hrs a day, wear shirt under, ck skin for irritation. Log rolling, exercise regimen Pca after surgery Baseline neuro Iv fluids and analgesics Bowel sounds Ambulate