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Pediatrics Final Exam Study Guide

Concepts Of Maternal-Child Nursing And Families (Nova Southeastern University)

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. LEWIS PEDS FINAL SG .

For each developmental stage: (Infant, Toddler, Preschool, School age, &
Adolescent)
 The concept of death:
- SCHOOL AGE: By age 10 = view death as inevitable,
universal and permanent

 Anticipatory guidance education for parents

School Age:
- Involved in sports, they are out playing – SAFETY!
Helmets & knee pads
- They are trying to do more, want to do everything,
concerned about success
- They are going to start to go through puberty –
don’t go into detail, just give basic information!

Adolescent:
- Normal for them to be distant, parent will not
understand
- Good time to talk is in the car b/c they can’t go
anywhere (uninterrupted)
- Be non-judgmental (any strategy to increase
communication)
- Be calm before responding
- Allow friends to come to hospital
- Talk about driving with adolescent (texting &
driving, seatbelts)
- Water safety is important!

 Care of Hospitalized Patient:

Hospitalized School Age Child

- Understands the reason for hospitalization & what will happen
- Worried about pain or changes that may occur to his or her
body
- Be open & honest with school-age child

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- May regress to behaviors of a younger child (needing comfort

toys or demanding attention from parents)
- Nurse must provide opportunities for the school-age child to
MAINTAIN INDEPENDENCE, GAIN CONTROL, & increase
self-esteem!
- Bring their homework to them when they are in the hospital
 will develop inferiority if they are not passing their
classes/missing school

Hospitalized Adolescent:
- Adolescent is concerned about how the illness or injury will
affect his or her body image
- They are fearful b/c they understand what is going on
- Fears pain & loss of privacy
- May experience anxiety about being separated from friends &
loss of control
- Nurse: provide opportunities for independence, participation in
decisions, & encourage socialization with friends through
phone, e-mail, & visits when possible

 Erikson’s Developmental Stages:

- Infant (1 month-1 yr.)  “Trust vs. Mistrust”
 Parent has significant impact on infant’s sense of
trust. When infant’s needs are consistently met,
infant develops sense of trust. If parent is
inconsistent in meeting needs in a timely manner,
infant develops mistrust.
- Toddler (2-3 yrs)  “Autonomy vs. Shame &
Doubt”
 Learning to do things for themselves (autonomy)
 Feelings of doubt about independence
 Favorite response = “NO”
 “negativism” = normal part of health
development; result of asserting
independence
- Preschool (4-6 yrs)  “Initiative vs. Guilt”
 Magical thinking – take everything literally (they
may think they caused death)

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 Exploring
- School age (6-12 yrs)  “Industry vs. Inferiority”
 Child is interested in how things are made & work
 Increased activities outside home – clubs, sports
 Needs support & encouragement from important
ppl in child’s life
 Inferiority occurs with repeated failures w/ little
support or trust from those who are important to
the child
 Child is developing their self-worth
 If expectations are set too high  child will
develop a sense of inferiority and
incompetence that can affect all aspects of his or
her life
- Adolescent (12-18 yrs)  “Identity vs. Role
confusion”
 Achieve a sense of identity
 Focuses on bodily changes
 Frequent mood changes
 Defining boundaries w/ parents & authority figures
(time of greatest conflict w/ them)
 Matured sexual identity
 Achieves sense of uniqueness
 Need for acceptance by peer group @ the highest
level
 If they believe they cannot express themselves in
any manner due to social restrictions, they will
develop role confusion

 Post-operative Intervention

Hydrocephalus Shunt post-op:

- FLAT position after SX
- Elevate HOB gradually over a day or two
- Avoid sedation!
- Educate parents concerning shunt infection &
malfunction = irritability after the fever is controlled is
finding of infection
- Measure the head circumference daily

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Tonsillectomy post-op:
- Excessive swallowing = sign of hemorrhage
- Don’t give them anything red! No red popsicles!!
-

Review the common illnesses discussed in each age group

such as:
 Meningitis
 Diabetes
 Glomerulonephritis
 Seizures/epilepsy
 IBD
 Musculoskeletal issues:

*Scoliosis: lateral curvature of the spine that exceeds 10

degrees
TX varies based on severity:
- Mild = curve <15-20 degrees  monitor every 3-6
months until musculoskeletal maturity; in mild cases,
bracing is only considered if the patient is symptomatic
(function is affected)
- Moderate = b/w 24-40 degrees (<40)  Milwaukee
brace!
 Worn 23 hours a day to prevent curve
progression
 Compliance issues w/ many adolescents – d/t
discomfort, pain, heat, poor fit, & teens are
concerned with body image
- Severe = curve > 40 degrees  requires SX
correction; involves rod placement and bone grafting
(spinal fusion)

 JRA:

Juvenile Rheumatoid Arthritis (JRA):

- autoantibodies mainly target the joints (some forms
affect the eyes & other organs)
- Joint pain, redness, warmth, stiffness & swelling

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- Stiffness usually occurs after inactivity (in the morning,

after sleep)
- Chronic disease – child may have healthy periods &
flare ups
- Rarely demonstrates positive rheumatoid factor
- TX focused on = inflammation control, pain relief, &
maintenance of mobility
 NSAIDs, corticosteroids, & anti-rheumatic drugs
such as methotrexate & etanercept are prescribed
depending on severity
 NSAIDS = helpful w/ pain relief
 Anti-rheumatics = necessary to prevent disease
progression
 ROM exercises & exercise! (SWIMMING is a
particularly useful exercise to maintain joint
stability without placing pressure on the joints)
- first sign in infant/young child = HX of irritability or
fussiness
- mold-moderate anemia and elevated sedimentation
rate are common
- some may have a positive ANA
- encourage regular eye exams & vision screening to
allow for early TX of visual changes & to prevent
blindness
- JIA results in chronic pain and affects growth &
development as well as school performance

Basic Growth & Development issues (both physical &

psychosocial):

INFANTS: 1 month – 1 year

- Assessment  do painful things last!
 What order to do vital signs? Respirations,
pulse, temperature
 Measure head circumference each visit
 Average full-term newborn = 13-14 in. (33-35
cm)
 Increase in head circumference indicates
brain growth

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- Cephalocaudal growth pattern (they grow head to toe)

- Birth weight should DOUBLE by 6 months!
- Birth weight TRIPLES @1 year
 Ex. If 6-month-old was 3 kg at birth…now should
be 6 kg
- Anterior fontanel closes @ 12-18 months
- Posterior fontanel closes @ 6-8 weeks
 Ex. If an 8-week-old infant’s soft spot isn’t soft
anymore? This is a normal part of G&D.
- Moro reflex should disappear by 4 months
- Palmar grasp reflex – disappears by 4-6 months
- Voluntary grasp present at 5 months
- Babinski reflex disappears around 1 year
- @ 6 months  introduce solids (no cereal until then!)
- after 6-9 months  need IRON supplementation
- “object permanence” concept developed b/w 4-7
months; self-image by 1 year
- WARNING SIGNS possible social/developmental
problem:
 child does not smile @ people at 3 months of
age, refuses to cuddle, does not seem to enjoy
people, shows no interest in peek-a-boo @ 8
months
- 3 months = head control
- 4 month old on target developmentally =
babbles/smiles
- 8 months = pincer grasp (fine motor skill)*
- ~2 months = first “social smile”
- No bottle propping!!
- NO PEANUTS, NO POPCORN!

- HYPOSPADIAS = urethral opening located on the

ventral surface (underside) of the penis
 TX: SX repair delayed after 1 year.
 Post-op: Double diapering = helps keep the
area clean & free from infection (allows separation
b/w bowel & bladder output)

- Cryptorchidism = undescended testicle/s

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 If they do not drop by 1 year  SX

“orchiopexy” indicated to preserve fertility

- DDH: TX = Pavlik harness (under 6 months old) =

ensures hip flexion & abduction. Does NOT allow
hip extension or adduction. Worn for 3-6 months.
 DDH assessment
 Asymmetry of thigh & gluteal folds
 Alli’s sign = unequal knee height
 Ortolani’s maneuver = distinctive
“clunk” or clicking sound heard
 Positive Barlow’s sign = “clunk” =
feeling of femoral head slipping out of the
acetabulum

- RSV = most common cause of bronchiolitis

 Problem = airway partially obstructed allows air to
come in but mucus & swelling of the airway block
expulsion of air (Air can get in, but can’t get back
out)  creates wheezing & crackles!
 The noisier the lungs, the better the air
exchange!
 RSV can live on inanimate objects up to 72 hours
& 30 min on skin
 Once the lower airway is involved = more severe
infection…symptoms = tachypnea (>70
breaths/min); severe distress= nasal flaring

- Otitis media: middle ear infection; related to

Eustachian tube dysfunction
 often preceded by URI.
 Risk factors= day care, second-hand smoke,
using pacifiers for several hours a day, & recurrent
URIs
 Breastfeeding provides some protection
(prevention)

- Neural tube defects: spina bifida, Meningocele,

myelomeningocele

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 Thought to be assoc. w/ folic acid deficiency

prenatally
 DX: prenatal elevation of maternal AFP raises
suspicion

 Spina bifida = mildest form; no herniation of

meninges or SC; no loss of fxn or neuro problems;
tuft of hair & dimpling over the lumbrosacral
area

 Myelomeningocele = most severe form; sac-like

herniation containing meninges, CSF, & spinal
nerves
 Neuro impairment
 Handicap 99% of the time
 Increased risk for infection* (worry
about infection)
 Paralysis of legs, bladder & bowel
incontinence
 Hydrocephalus usually present w/ a
myelomeningocele defect above the sacral
level
 Pre-op: do not let the sac dry out! Apply wet,
sterile, saline dressing
 Post-op: position infant on side or
abdomen (even for feeds)

** Immunizations @ 2 months / 4 months:

- PCV
- HIB
- RV
- IPV
- DTAP

INFANT – CONGENITAL HEART DEFECTS:

- Acyanotic = ASD, VSD, PDA  “Left to Right
shunts”
- Cyanotic = TOF (tetralogy of fallot)
- Obstructive = Coarctation of aorta

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 Acyanotic defects on assessment = JVD & periorbital

swelling (they cause R-sided HF); recurrent respiratory
infections & resp. S/S
 ASD = difficulty breathing when feeding (bottle
feeding=exercise)
 VSD assessment = loud harsh murmur
 PDA  TX= Indomethacin (NSAID) = stimulates closure of
the ductus arteriosus in premature infants; assessment =
mechanistic-sounding murmur

(Acyanotic defects) LR shunt common mgmt.:

 Digoxin – hold if HR < 100 bpm for infants; toddlers < 80
bpm; do NOT re-dose after vomiting.
- Ex. Q: If child vomits the dose of digoxin? A: Administer
the next dose as ordered in 12 hours.
- Rationale: Digoxin should be administered at regular
intervals, every 12 hours, 1 hour before or 2 hours after
feeding. If the child vomits digoxin, the nurse should
not give a 2nd dose and should wait until the next
schedule dose. Not necessary to call the physician.
- Digoxin TX in 5 month old – what is a good response to
med? Increased urine output (sign of increased CO)
- Tell parents: Digoxin slows & strengthens the
infants heart
- Soft nipple w/ bigger opening when feeding
- Normal infant urine output = 1-2 ml/kg/hr

COA = obstructive defect

- High pressure closer to the aorta
- Headaches, nose bleeds
- HIGH BP in ARMS vs. low BP in legs
- Leg cramps & leg pain/weakness d/t poor perfusion
- Bounding radial pulses & diminished femoral &
pedal pulses
- Symptomatic newborns = they give prostaglandin E1
to re-open the ductus arteriosus & promote blood flow
to lower extremities
- Stent placement w/ balloon angioplasty

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TOF = cyanotic; 4 defects:

1. D = defect (VSD)
2. R = right ventricular hypertrophy
3. O = overriding aorta
4. P = pulmonic stenosis
- Clubbing
- TET SPELLS! Put them in knee-chest position or
squatting! (pressure changes gives them an O2 boost)
& calm the child down!
- Lifelong infective endocarditis prophylaxis
required

TGA: transposition of the great arteries

- LIFE THREATENING condition; cannot survive w/o SX
- significant cyanosis w/o murmur*
- prostaglandin E1 used to keep a PDA until a palliative
procedure can be done; SX (atrial switch) usually done
before 1 week old

~ TODDLER: 1-3 years old

- Potty training
- Age 2 = voluntary sphincter control
- Favorite word = NO
- Average weight @ 2 years? 26 lbs
- Average height @ 2 years? 34 in.
- Increased ability to maintain body temp.
- Produces antibodies
- Voluntary control
- Anterior fontanel closes = 12-18 months
- Potbelly appearance
- Urine output should = 1 mL/kg/hr
- Routines are important to them!
- Parallel play = playing next to others

~ PRESCHOOL: 3 - 6 years old

- Fantasy play is dramatic & imaginative
- Associative play = playing w/ others
- Interactive play

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- Counting
- “Magical thinking”
- Imaginary friends (abandoned by school age)
- Initiative vs. guilt = provide reassuring feedback to them!
-

~ SCHOOL AGE: 6-12 years old

- Play = cooperative play, team play
- Loses first primary teeth at about 6 years
- All of their senses are mature
- Develop interest for collecting objects
- Develop concrete operational thinking  understanding of the “principle
of conservation” = that matter does not change when its form changes
(for ex. pouring the same amount of water into a wide glass vs. a tall thin
glass, same amount of water)
- Pre-pubescence = development of secondary sex characteristics
- Sexual development in both boys & girls can lead to a negative
perception of physical appearance & lowered self-esteem
o Early development in girls can lead to embarrassment, low self-
esteem; late development in boys can lead to negative self-concept
- By age 10 can view death as inevitable, universal and permanent
- Psychological:
o Morality develops
o Before age 9 = things are right or wrong
o After age 9 = recognizes differing points of view; Sees “gray” areas
o Self-esteem & worth relies on feedback from others (authority
figures, etc)
o They want to be good & please their parents/those around them
- develop interest in religion but still guided by family beliefs & values
- More active, playing outside, sports, rollerblading, etc.  SAFETY =
important! Wear a helmet!
- Important for school-agers to feel accepted by peers
- compare themselves to peers & self-esteem is a central issue
- Cooperative play (team sports) & solitary play (board, video games)
- Rules are important to them! They can understand & obey rules.

~ ADOLESCENT: 12-18 years old

- Puberty, sexual maturation, hormonal changes

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o Girls: menarche around 12 ½ years (irregular first year),

breast changes, increased pelvic growth, pubic/axilla hair
growth
 Girls reach physical maturity before boys!
 Tanner Stages of Breast Development:
 1. Preadolescents: only a small elevated nipple
 2. Breast buds palpable & areolae enlarge ~11
yrs old
 3. Elevation of breast contour; areolae enlarge
~12 yrs
 4. Areolae forms secondary mound on the
breast ~13
 5. Adult breast; only the nipple protrudes;
areola is flush with the breast contour
o Boys: enlargement of testes = first sign of sexual
maturity; scrotum & penis growth, larynx changes,
facial/lip hair, nocturnal emissions
- Interest in opposite sex (heterosexual relationships)
- Nurses should provide anticipatory guidance to adolescent
males regarding involuntary emissions (wet dreams) to assure
them that this is a normal occurrence!
- Guidance to adolescents about the normalcy of sexual feelings
and evolving body changes occurring during puberty
- “risk taking” behaviors
- Parents  set aside appropriate amount of time to discuss
subject matter without interruptions
- When approaching the adolescent:
o Needs privacy
o Use a gown and sheet
o Talk as a professional
o Do not use slang
o Give honest answers to questions
o Emphasize normal
- Habits  Alcohol, smoking, use of substances
- Nutrition  Related to peer pressure, fast foods, empty
calories
o Need Ý calcium for skeletal growth, iron for muscle mass
and blood cell development, zinc for skeletal and muscle
tissue and sexual maturity

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- Safety  Accidents #1 cause of death

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