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PEDS Exam 1 Study

Developmental Milestones, Safety, Nutrtion, and Immunizations
by

Michelle Merlet

on 9 December 2014

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Transcript of PEDS Exam 1 Study

Developmental, Nutrition/Health Promotion, Immunization, and Safety.
Pediatric Exam 1
Developmental Milestones
Developmental Milestones
(Continued)
Nutrition and Health Promotion
Antigen: foreign body Antibody: immunity to antigen

Active: Exposure Passive: Transfer (IVIG, IMIG, WBC
transfusion, or mother/infant.)

Primary reaction in 4-7 days, with a peak response in 7-10 days, memory in 1-3 days, with a peak response in 3-5 days.
Immunizations
Newborn/Neonate - birth to 30 months

Gross: Lift head side to side with some head lag
Fine: Clenched fist, grasps
Safety
Infant
Toddler
School Aged
Adolescent
Pre Schooler
Gross: lifts head off bed
Fine: hands in open postion

Cooing noises
Gross: lift head and shoulders when prone, improve head control
Fine: holds open hands in from to of face
Gross: roll prone to supine, good head control
Fine: bats at objects

Gurgling sounds
Gross: rolls supine to prone, sit supported
Fine: hands to mid-line, grasp rattle, grasps by raking

Vowel sounds, laughs, and responds to name and 'no'
Gross: tripod sits
Fine: releases object in hand to take another, holds bottle

Squealing
Gross: sits with hands for support, bears full weight on feet
Fine: transfer objects hand to hand
Gross: sits alone
Fine: gross pincer grab

Imitates sounds
Gross: crawling
Fine:bangs things together
Gross: pulls to stand, begins to cruise (10-11)
Fine: fine pincer, puts objects in/takes them out of cup
Gross: begins to stand alone, continues cruising
Fine: releases object to another person
Gross: sits from standing, walks alone
Fine: points, feeds self, 'colors' - 18 mos throws ball, keeps balance, turns hard page

Will point from lack of words but has 3-5 words with meaning
Gross: Kicks ball, stands on tiptoes, walks one step at a time up or down stairs
Fine: build towers with 6-7 blocks, puts round pegs into holes
Gross: Runs well, climb stairs alternating feet, pedals tricycle
Fine: draws circle, undresses self
Trust vs Mistrust - 1 month to 1 year

Growth:
5-7 oz/week (double in 6, triple by 1 year)
2.5 cm/month (double by 1 year)
1.5 cm/month head circumference (0.5 cm during second 6 months)

8 mos - Separation from self, fear of strangers, and object permanence.

Solitary play

Vocalizations become words with 3-5 words by 1 year.
Language red flags: hearing concerns, no interaction, no communication by 4 mos, or hearing concerns or loss of previous language.
Infant
Formula is based on cow's milk.

Could be
Lactose intolerant - gas, bloating or diarrhea, switch to soy based formula.
Protein intolerant - (can occur with cow or soy based) v/d with blood, abdominal pain, rash, switch to hydrolyzed formula.

Supplementation
Vit D - 400 IU starting a few days after birth, until drink 32+ oz vit d fortified formula or milk.
Iron - cereals at 4-6 mos, liquid for breastfed.
Flouride at 6 months if not present in water supply.

Burp midway through bottle (or q 30 minutes) and at the end of feeding.

No cow's milk until 1 year - unable to digest, causing GI bleeding, also displaces iron.

One new food every 4-7 days.
4-8 teeth by end of first year.
Autonomy vs Shame and Doubt - good/bad orientation -1 to 3 years

Try to stop all non-nutritive sucking around 1.5-2 years.
Allow a security item.
End night time feedings and allow them to self-soothe.
Keep a routine!
Does not fully understand concept of time.
Infant and Toddler
Car Safety
Highest rate of injuries in 15-17 month olds (due to ambulation).

'Back to sleep' campaign - SIDS.

Drowning - lock doors to pool, have screens, children can't really learn to swim until 4, even with safety classes don't leave alone.

Aspiration - no objects to fit into toilet paper roll (1.25")

Falls - gate off stairs and other dangerous or rooms not child-proofed.

Poisoning - lock cabinets, keep contents in original container, and if necessary put out of reach.

Burns - keep out of sun/wear clothes/sunscreen, and water heater under 120 degrees.
Rear facing car seat until over 2 years or over manufacturer's limit.

Forward facing car seat until size limit met.

A school-age child may use booster seat until the seat belt fits properly (around 4'9").


Lap and shoulder belts should be worn at all times.

Children in the backseat until over the age of 13.
Weight gain slows - 4-6 lb/year
About 3 in/yr
Anterior fontanel closes by 18 months
Think terrible twos. Egocentric.
Does not like to share - play is parallel. Animism.
Ignore tantrums.
Time-out - specific safe area with 1 minute per age, if they come out restart the time.
Separation anxiety still an issue.
Language development
Stop the pointing
More comprehension than expression
Starts with telegraphic speech, echolalia, and stuttering.
Increasing vocab - 50+ words
Uses descriptive words - 2-3 word 'sentences'

Red flags (in months):
12 - no 'mama' or 'dada,' loss of milestone
15 - no single words, poor understanding of language
24 - < 50 words, no 2 word phrases, < 50% spoken language is understandable to strangers
36 - > 75% of speech is not understandable
Toddler
Offer small, balanced, variety foods.
Habits made by 3 years will stick.

24-32 oz milk/day, skim after 24 months

Sleep 12 hours with one or no nap

Regular dental exams by 12-18 months (unless there are complications earlier) and brushing with flouride.
All primary teeth in by 30 months.
Toilet training:

Need sphincter control, dry for 2 hours, and undresses self.
Usually achieved by 3-4 years.
Nighttime wetting takes longer (increased risk if one or both parents wet bed). May use medication or alarms.
5 lb/year
2.5-3 in/year

Vocab and complexity of language increases dramatically between 2 and 5 years.

Only 1-2 hours of screen time (includes phone, TV, computer, video games, etc.).
Play is predominantly associative - no rules, preparing them to enter school.
Very imaginative, imitative, and dramatic.

Wants to please but often challenges values - 'why?'
Give them things to do.
Shift from egocentric to consider other viewpoints.
Concept of time still incompletely understood (link to events).

Body image issues are usually learned from home (desirable/undesirable) - are aware of races, differences in appearances, and biases. Speak with them about differences. Great fear of bodily harm.

Attached to opposite sex parent while identifying with same sex parent. Questions sexual topics and may begin to masturbate.

True separation anxiety is much less.
Do not leave children unattended in any vehicle.
Continuation of improving coordination and movement (walks, runs, climbs, dresses self, ties shoes by 5 years)
Initiative vs Guilt - 3 to 6 years
Preschooler
Always be on the lookout for child abuse.

Sleep disturbances:
Night terror - not awake and cannot remember
Nightmare - awake and scared

Activities that emphasize fun and safety.

Lock up guns. Keep all parts in separate places where children cannot access them. Explain to them gun safety.

Use bike helmets, knee, and wrist protection.

Parents - set a good example.
Humpty Dumpty Falls Prevention - score 7-23 ( 12+ indicates a risk for falls): based on age, gender, diagnosis, cognitive impairment, environmental factors, response to surgery/sedation/anesthesia, and medication usage.

Caregivers should always know CPR.
Early 11-14 Years
Late 17-20 Years
Puberty:
Males - (11-13)
Females - (9-11)

Menstruation (average = 12.8 years) occurs 2 years after secondary characteristics begin (thelarche, adrenarche).

Peer acceptance while still desiring family support, same sex friends, with sexual identity uncertainties.

Idealistic, challenges the way things are.
Limited abstract thinking.
6-7 lb/year
2.5 in/year

Now assessed annually versus at every immunization appointment as an infant and toddler
Sebaceous - acne, exocrine - all over, and apocrine - sweat/odor.
Tanners: 3-5

PHV:
Female - 2-8
Male - 4-12 inches

Complicated play and sports - coordination difficulties with sports.
Neonate Vitals:

R - 30-60
HR - 110-180
BP - 60-90/20-60
T - > 97, < 110.4
Vitals:

R - 30-60 BP - 87-105/53-66
HR - 100-160 T - > 97, < 110.4
Vitals:

R - 24-40 BP - 95-105/53-66
HR - 80-110 T - > 97, < 110.4
Vitals:

R - 22-34 BP - 95-111/57-69
HR - 70-110 T - > 97, < 110.4
Vitals:

R - 18-30 BP - 97-112/57-71
HR - 65-110 T - > 97, < 110.4
Vitals:

R - 12-20 BP - 104-135/60-83
HR - 70-110 T - > 97, < 110.4
Fluid Calculations
Maintenance fluid (24 hours):
First 10 kgs - 100 mL/kg
Next 10 kgs
(between 11-20kg)
- 50 mL/kg
Remaining kgs - 20 mL/kg

Minimum expected output - 1-2 mL/kg/hour.

1 gram in diaper weight = 1 mL of urine
Pain
QUESTT:
Question the child, using rating tools, evaluate behavior and physiological changes, secure parents involvement, take cause of pain into account, and take action/evaluate results.

Manage/prevent rather than resolve. Medicate and use of non-pharmacological methods (relaxation, distraction, imagery, biofeedback, heat/cold, massage/pressure).

Assess q 4 hours, prior to giving pain medication, and after (PO - 1 hr, SC/IM - 30 minutes, and IV - < 5 minutes).

Scales (based on age, development, LOC):
CRIES - newborn to 2 months
FLACC - 2 months to 4 years (sedated or developmentally delayed - used for sleeping/comatose patients)
FACES - as young as 3-4 years
Numbers - for school age and adolescents mostly
Growth and
Blood Pressure
BMI:
Children - (use chart) underweight (< 3%),
normal (3-84%)
, overweight (85-94%), obese (> 95%)

Adults - (no chart) underweight (< 19),
normal (20-25)
, overweight (25-32), obese (> 32)

Calculation - (lb)/height/height x 703 (also need gender and age)

3 years +. Make sure bladder width is 40% of upper arm and length is 80-100%. Be calm and relaxed 3-5 minutes before taking.

Height:
within 3-97%

Identification of hypertension (prevent end organ damage). Need stature %, age, and gender.
< 90% normal
> 90% <95% pre-hypertension
> 95% on 3 or more occasions hypertension
95-98% stage 1
> 99% stage 2


CRIES
0 1 2
Crying No High Pitched Inconsolable
Requires O2 for sat > 95 No/Baseline < 30% above baseline >30% above
Increased vital signs HR and BP < base < 20% above base > 20% above base
Expression None Grimace Grimace/Grunt
Sleeplessness No Wakes at frequent intervals Continually awake
FLACC
Categories 0 1 2

Face No particular expression Occasional grimace or Frequent to constant
or smile frown, withdrawn, quivering chin,
disinterested clenched jaw
Legs Normal position or relaxed Uneasy, restless, tense Kicking, or legs
up

Activity Lying quietly, normal Squirming, shifting back Arched, rigid or
position moves easily and forth, tense jerking

Cry No cry, (awake or asleep) Moans or whimpers; Crying steadily,
occasional complaint screams or sobs
frequent complaints
Consolability Content, relaxed Reassured by occasional Difficult to console or
touching hugging or comfort
being talked to, distractable
School Age
70 kcal/kg or about 1,400-2,100 calories/day (versus 108 calories/kg for infants).

1,800-2,200 mL/water.

28 g or four 7 oz servings of protein.
800 mg of calcium.
Around 30% of fat.

60+ minutes of exercise daily.

Have child participate in food and meal choices, eat out at places with healthy options (balance meals).

Brush 2-3 times and floss daily. Assist until about 10 year old. Bruxism, malocclusion/braces, fluoride supplementation, and sealants.
Industry vs Inferiority - 6 to 11 years
Involved in multiple activities (don't over schedule in order for them to achieve self-worth and a sense of competence).
Egocentrism is gone and they see other points of view.
Able to rethink actions.
Likes joke books.
Classification and collection.
Follows rules and wants to be the good child.
20/20 vision by 7 years.
May speak multiple languages.
Family influence is still strongest but they prefer peer company.
Lying, cheating, and stealing is not typical. Help them to correct action.
Tanners: 1-2

Increasing coordination. May be more awkward due to body changes and growth.
School Age
Increase in preventable accidents due to increased independence and motor skills.

Males are injured more than females.

No child under 16 on ATVs.

Always wear seat belts in cars, have booster if necessary, or be in the back seat until 13 years old.

Practice pedestrian safety.

Bike and skating safety as well as maintenance (appropriate sized helmet).

Fire: smoke detectors on all floors (sleeping areas), fire retardant bed clothing, check monthly, change annually (or bi-annually), have escape plan, supervise children cooking or around campfires.

Water: water heater under 120, close supervision, swim instructions, life jacket available, dive in sufficient depths.
Have mutual respect and communication.
Less than 2 hours of screen time each day.
Assess for weight issues (parents may fail to recognize).
Birth to 2 months
2 months to 4 years
sedated or developmentally delayed
Bullying
Bully:
Physical or verbal/cyber.
Show appropriate methods on handling anger.
Show child how it feels.
Bullied:
It is not their fault.
Increase self esteem.
Give strategies to handle bullying.
Form strong relationships.

Intervene by screening violence in home and educate parents.

Consequences include later weapon carrying, frequent fighting, and depression or suicidal ideation.
May have somatic complaints, later disease morbidity or domestic violence.
Adolescent
Hospitalization
Infant: make as comfortable as possible (security items), stay close with infant (holding), pair nursing students with them!,

Toddler: separation anxiety, loss of control, temper tantrums, recalling traumatic events. Bring familiar objects, keep them busy, be gentle, play therapist.

Preschooler: concrete/egocentric/magical thinking limits ability to understand, think they caused their illness, fear mutilation, needs security from family, true separation anxiety is less than that of younger children, may be uncooperative, cry, or refuse to eat/take medication.

School Age: concerned about death/disability, fear injury/pain, desire explanation, uncomfortable with sexual examinations, loss of control, may regress. Allow visits from friends, keep active in school, assist in own care, provide activities with a final product.

Adolescent: (explanation 7-10 days prior - give teen area/recreation room) Do not appear rushed, talk face to face, speak matter of fact, reassure normalcy, praise them for making a tough decision, be non-judgemental, and gender neutral. They fear body image, separation from friends, decreased support system, and loss of control.
Types of Vaccines
Killed:
IPV, IIV, Rabies
Live attenuated:
MMR, VAR, LAIV, Rotavirus
Recombinant:
Hep B, HPV
Toxoid:
DTaP/DT/Tdap/Td, PCV, PPSC
Precautions and
Contraindications
Precautions (depends on level of disease in community):
Seizure, fever, crying, moderate/severe illness (high fever with crying non-stop for 3+ hours), and recent recipient of IG.

Contraindications:
HIV, chemotherapy, antiviral therapy, and pregnancy.
Steroid use: greater than 2 mg/kg/day for over 14 days or 20 mg for over 14 days

PERMANENT - encephalopathy or anyphylaxis
Screen where/when vaccines were received, sickness, allergies, chronic illness, pregnancy, recent virus vaccines, herd immunity, prematurity...
Infants
Toddler to School Age
Adolescent to Adult
Overview
Immunizations/Illnesses
Screening Tools
Denver Developmental:
Testing date - Birth date = Testing age (format: YY/MM/DD)
Subtract when child is born more than 2 weeks premature and is less than 2 years old.
Line passes through:
25 - Advance for age, only 25% can do this skill
50 - Average for age, 50% can do this skill
75-90 - 75-90% can do this skill (area of concern if unable to achieve task)

CHAT for autism done at 18 months.
Adolescent
Non-Pharmacologic Comfort Measures
Infant: positioning, 5 Ss, sucrose drops, massage, auditory/olfactory stimulation, ...

Toddler:

Preschooler:

School Age:

Adolescent:
For all ages: distraction, decrease stimulation, ...
Testicular cancer happens as early as 15 years so self-examination teaching should occur before this time.
Nutritional needs: protein, calcium, iron, and zinc.
Decrease soda consumption.
30% or less fat.

Identity vs Role Confusion
Middle 14-16 Years
Peer acceptance at its highest, adjusting to changes in body image, conflict with parents.

Feelings of invincibility (risk taking).
Rejects prior held values, religious, and cultural beliefs.
More secure with body image, role within peer group/sexual identity, career goals, and independence from parents.

Abstract thinking established.
Realistic goals and career plans.
Adolescent Questions
H: Home
Lives with, family structure, siblings...
E: Education/Employment
Grade/grades, educational and life goals, days missed...
E: Exercise/Eating -
Eating disorders, ideal weight, what do you think about how you look...
A: Activities -
Hobbies, free time spent, sports, screen time per day and week...
D: Drugs -
Usage (including alcohol), regret anything while high, how do you afford...
S: Suicidality/Depression -
Usual mood, coping skills, stress relievers, ever in counseling/hospital...
S: Sexuality -
Sexual/Reproductive, menstrual hx, sexual hx, partners, pregnancy...
S: Safety -
Abuse (sexual or otherwise), safety (car, bike, etc.)...
(S): Spirituality (optional) -
Religion, activities, connection in day to day life, influences on sex/contraception...
Wear seat belt.
No driving impaired/with impaired persons.
No cell phone use while driving (establish driving rules with parent).
Screen for suicide risk.

Infection control for tattoo/piercings.
General
Site:
IM - ventrogluteal, vastus lateralis (side), rectus femoris (top), and deltoid
PO -
SubQ - (change needle ideally after rubber stopper) 26-30 gauge, 0.5 mL, 45 vs 90 degree angle, center third lateral upper arm/abdomen/center third anterior thigh
Intranasal -

Fluid volume limits: infant 0.5 to adolescent 2.5 mL
Needle length: 5/8 to 1.5 in

Local - redness, swelling, pain (at site)
Systemic - rash, fever, malaise/fatigue, and lack of appetite: 1-3 days following or 7-21 days with live vaccines (including anaphylaxis and encephalopathy)
Report to Vaccine Adverse Event Reporting System (VAERS)
Document: name (child), date, lot number, expiration, site/route, VIS date, facility site, and name (administering health care professional)
Influenza -
LAIV (intranasal) for persons age 2-49 years (this over IIV for 2-8 years)
IIV (IM) all children age 6 months to elderly, with special emphasis on vaccinating children age 5 and younger
Killed
HiB - (meningitis, pneumonia, epiglottitis)
Under 5 (over 5 in those with immune disorders)
Pneumo -
PCV-13 all infants
PPS-23 2 all elderly over 65
Meningococcal - (sepsis)
XXXX vaccinate at risk children under 2 months and 11-12 or college freshmen (chronic illness, immunocompromised, cochlear implants)
Diptheria, Tetanus, Pertussis -
DTaP/DT for under 7 years
Tdap/Td for over 7 years
Illnesses
Illnesses (continued)
Diptheria - causes membrane formation at the site of the infection that may cause respiratory obstruction.

Varicella - first appears as a rash (then fever) that progresses from macules to papules to vesicles before crusting (usually starting on the head and then progresses to the trunk, where majority of lesions are). Secondary complication includes encephalitis.

Pertussis - disease is often called whooping cough. Starts as a cold which becomes for severe and lasting from 1-10 weeks. Loss of strength from coughing.

Rotavirus - most common cause of severe gastroenteritis in infants and young children. Starts with v/d for 3-8 days along with fever and abdominal pain. Has a seasonal pattern and most are infected by 2 years.
Tetanus - commonly called 'lockjaw.' Has a descending pattern. Symptoms include elevated temperature, sweating, elevated blood pressure, and episodic rapid heart rate.

Measles - (leading cause of preventable death) upper respiratory symptoms before rash starts at hairline and moves down face to body. Sometimes will find blue-white spots inside cheeks (Koplick spots).

Pneumococcal - source of many different types of infections (pneumonia, bacteremia, meningitis, and otitis media). Pneumo - fever, SOB, cough, and chest pain. Menin - all listed and stiff neck, photophobia, and altered LOC. Bacter - blood infection, may have joint pain as a symptom. Otitis - painful ear, swollen eardrum, and irritibility.

Rubella - (German measles) rash, swollen lymph nodes, and fever (2-3 days).

Polio - infects nervous system, highly contagious and may cause paralysis. Moat have no symptoms, some have non-specific symptoms, but 1% may result in complete motor paralysis of lower limbs.
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