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Pediatric Nursing
A lecture
Pediatric Nursing
GENERAL PRINCIPLES
Definition of Terms A. Growth:
increase in size of a structure. Human
growth is orderly and predictable, but not even; it follows a cyclical pattern.
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GENERAL PRINCIPLES
B. Development:
maturation of physiologic and
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Developmental task
A growth responsibility that arises
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GENERAL PRINCIPLES
C. Cephalocaudal:
head-to-toe progression of growth and
development Development proceeds from head down to the toes Infants achieve control of the head before the trunk
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GENERAL PRINCIPLES
D. Proximodistal:
Trunk-to-periphery (fingers and toes)
progression of growth and development Development proceeds from the midline of the body to the extremities
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Growth Pattern
General Principles
Growth and development are continuous
processes from conception until death. Growth and development proceed in an orderly sequence. Different children pass through the predictable stage at different rates. All body systems DO NOT develop at the same rate Development is cephalocaudal
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General Principles
Development proceeds from proximal to
distal body parts. Development proceeds from gross to refined skills. There is an optimum time for initiation of experiences or learning. Neonatal reflexes must be lost before development can proceed. A great deal of skill and behavior is learned by practice.
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Rates of Development
Fetal period and infancy: the head and neurologic tissue grow faster than
other tissues. Infancy and adolescence: fast growth periods T0ddler through school-age: slow growth periods Toddler and preschool periods: the trunk grows more rapidly than other tissue. The limbs grow most during schoolage period. The trunk grows faster than other tissue during adolescence.
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Pre-natal period Neonate- birth to TWENTY-EIGHT days Infancy- One month to 12 months Toddler- 1 year to 3 years Pre-school- 3 years to 6 years School-aged- 6 years to 12 years Adolescence- 12 years to 18 years
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Intelligence
Temperament
Environmental influences
socio-economic level
Parent-child relationship
nutrition
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Psychoanalytical theory Psychosocial theory Cognitive theory Moral development theory Interpersonal Theory
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Psychosexual/Psychoanalytical
Five Stages of Psychosexual Development
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mouth,
area
dormant
Psychosexual/Psychoanalytical
Freud proposes that the underlying motivation to human development is an energy form or life instinct called LIBIDO. Unconscious mind is the mental life of a person of which the person is unaware. Proposed concepts like: ID, EGO, SUPER EGO
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ID
developed during infancy "I know what I want and I want it now! Pleasure principle
EGO
developed during toddler period "I can wait for what I want!" Reality principle balances the id and superego
SUPEREGO developed during preschool period "I should not want that! Conscience- Morality principle
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Psychosexual/Psychoanalytical
Phase Age Focus
Oral
Anal Phallic
0- 1 yr
1 - 3 yrs 3- 5 yrs
Latency
Genital
6- 12 yrs
12 & above
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Psychosexual/Psychoanalytical
Phase Oral Anal Phallic Latency Genital Age 0-1 year 1- 3 years 3- 5 years 6- 12 years 12 - above Focus Major task: Weaning Major task: Toilet training Major task: Oedipal & Electra complex Major task : School/Academics Major task: Sexual intimacy
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3 - 6 years Pleasure through genitals Behaviors: touching of genitals, erotic attachment to parent of opposite sex Develops fear of punishment by parent of same sex, guilt, sexual identity
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6 - 12 years Energy used to gain new skills in social relationships and knowledge Behaviors: sense of industry and mastery Learns control over aggressive, destructive impulses Acquires friends
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5. GENITAL 12 - 20 years Sexual pleasure through genitals Behaviors: becomes independent of parents, responsible for self Develops sexual identity, ability to love and work
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Trust vs Mistrust
Autonomy vs S/D Initiative vs Guilt
Optimism
Self-Control
6- 12 yrs
12- 18
Direction and purpose Industry vs inferiority Competence and method Identity vs Role Devotion and Confusion fidelity
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18 months - 3 years Learn self-control and the degree to which one has control over the environment vs compulsive compliance or defiance
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3 - 5 years Learn to influence environment, evaluate own behavior vs fear of doing wrong, lack of selfconfidence, overrestricting actions
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12 - 20 years Develop sense of self; preparation, planning for adult roles vs doubts relating to sexual identity, occupational career
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18 - 25 years Develop intimate relationship with another; commitment to career vs avoidance of choices in relationships, work, or life-style
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21 - 45 years Productive; use of energies to guide next generation vs lack of interests, concern with own needs
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Piaget
Sensori-motor (birth to 2 )
Pre-operational (2-7)
Preoperational preconceptual (2-4)
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0 - 2 years: sensorimotor reflexes, repetition of acts 2 - 4 years: preoperational/preconceptual -no cause and effect reasoning; egocentrism; use of symbols; magical thinking 4 - 7 years: intuitive/preoperational beginning of causation
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-reality, abstract thought -can deal with the past, present and future
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Interpersonal theory
Personality has three SELF-SYSTEM
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Moral Theory
Pre-Conventional Stage 1 Stage 2 Conventional Stage 3 Stage 4 POST Conventional Stage 5 Stage 6
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PRECONVENTIONAL LEVEL
Stage 1 Age Group: 2-3 years Description of morality: Punishment or obedience (heteronomous morality) A child does the right things because a parent tells him or her to avoid punishment Child is UNABLE to understand others viewpoint
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PRECONVENTIONAL LEVEL
Stage 2
rather than societys. The child does something for another if that person does something for him in return- an eye for an eye
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mutuality- CONFORMITY A child follows rules because of a need to be a good person in own eyes and in the eyes of others Good boy or Good girl
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authority Child FOLLOWS RULES of authority figures as well as parents to keep the system working LAW and ORDER
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perspective child FOLLOWS STANDARDS OF SOCIETY for the good of all people
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consciousness
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Late childhood
Physical skills (ordinary games)
Wholesome attitude Study/play along with age mates Sexual identity Fundamental skills Conscious and personal independence
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Adolescence
Matured roles of both sexes
Masculine/feminine roles Accepting owns body Socially responsible behavior Independence from parents Prepare for economic career, marriage, family
life,ideology
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Early adult
Start occupation
Select a mate Live with marriage partner
Start family
Rearing children Manage home
Civic responsibility
Finding congenial group
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Middle adult
Adult and civic responsibility
Adjustment to changes of middle ages and aging
parents Assist teen-agers to become responsible adults Reaching and maintain a satisfactory career
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Old Age
Adjusting to decreasing physical
strength,retirement,less income and death of spouse Adapting to social roles, physical arrangements and affiliation to members of same age
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Head Control
Newborn
Age 6 months
Sitting Up
Age 2 months
Age 8 months
Sitting up
2months old: needs assistance
6 months old: can sit alone in the
tripod position 8 months old: can sit without support and engage in play
Ambulation
13 month old
Nine to 12-months
Ambulation
9 month old: crawl
1 year: stand independently from a crawl position 13 month old: walk and toddle quickly 15 month old: can run
Objects will be involuntarily grasped and dropped without notice. 6 month old: palmar grasp uses entire hand to pick up an object 9 month old: pincer grasp can grasp small objects using thumb and forefinger
Speech Milestones
1-2 months: coos 2-6 months: laughs and squeals 8-9 months babbles: mama/dada as
sounds 10-12 months: mama/dada specific 18-20 months: 20 to 30 words 50% understood by strangers 22-24 months: two word sentences, >50 words, 75% understood by strangers 30-36 months: almost all speech understood by strangers
Hearing
BAER hearing test done at birth Ability to hear correlates with ability enunciate
words properly Always ask about history of otitis media ear infection, placement of PET tubes in ear Early referral to MD to assess for possible fluid in ears (effusion) Repeat hearing screening test Speech therapist as needed
6-month-old
12-month-old
hand by age 1 year Abnormal pincer grip or grasp by age 15 months Unable to walk alone by 18 months Failure to speak recognizable words by 2 years.
Toddler ( 1-3)
T
O D D L E R
N IS THE FAVORITE WORD: Negativism 1. offer choices 2. limit question o not offer 3 large meals rink well from the cup
et the baby talk
at: do not let play with food isk: Aspiration & poisoning
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TANTRUMS
LACK OF VOCABULARY WORDS
300 WORDS
Toilet training
Signs of readiness:
Pulls/tugs soild diaper Please parent
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Toilet training
Timing of good control
2 3 Day time bladder control 3 4 Night time bladder control
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Separation anxiety
> 18 mos Steps: Protest - cry 2. Despair widrawn 3. Denial repression of feeling
1.
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Play
ParAllel P arallel play; PUSH & PULL A ttention span short R emovable/ replaceable
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Safety:
Car: Lock all doors
Upright forward facing
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Language:
1 y/o = 50 words 2 y/o = 300 words
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and a cross build using small blocks 4 year old: use scissors, color within the borders 5 year old: write some letters and draw a person with body parts
Toddler
Toddler
Toddlers
years Temper tantrums: occur weekly in 50 to 80% of children peak incidence 18 months most disappear by age 3 Sibling rivalry: aggressive behavior towards new infant: peak between 1 to 2 years but may be prolonged indefinitely Thumb sucking Toilet Training
Pre-School
Using scissors
Playing a board game Have child draw picture of himself
Pre-school tasks
washing simple dressing, daytime toileting Lack of socialization Unable to play with other children Able to follow directions during exam Performance evaluation of pre-school teacher for kindergarten readiness
Pool Safety
School-Age
School performance
Ask about favorite subject
How they are doing in school Do they like school By parent report: any learning
animal abuse
School Age
and participate in selfinitiating quiet activities that challenge cognitive skills, such as reading, playing computer and board games.
13 to 18 Year Old
Adolescents
Adolescent
As teenagers gain independence they begin to
challenge values Critical of adult authority Relies on peer relationship Mood swings especially in early adolescents
Suicide
Adolescent Teaching
Relationships
Sexuality STDs / AIDS Substance use and abuse Gang activity Driving Access to weapons
Adolescents
Increases by 50%
Heart rate
20 to 30 breathes/min
Developmental Milestones
1 month
Can see at 18 in (46 cm) distance
2 months
Posterior fontanel closed
2 month
Social smiles Enjoys bright-colored
3 month
Holds head and chest up when prone Beginning eye-hand coordination
4 - 5 months
Birth weight doubles Can turn from abdomen to back Can approximate lips to the rim of a cup
5- 6 months
Teething may begin with eruption of two lower central incisors Chews and bites May hold own bottles; but may not drink from it Recognizes parents; begins to fear strangers Rolls from back to abdomen
7 months
Eruption of upper central incisors Has unidextrous approach and grasp Responds to own name
Teeth
6 to 10 months lower central incisors erupts 8 to 12 months upper central incisors erupts
8 months
10 - 11 months
12 months (1 yr old)
Has total of six to eight deciduous teeth Anterior fontanel almost closed Walks with one hand held
12 months (1 yr old)
Likes toys that fit inside each other; pull toys Vocabulary of two words plus mama and da-da Tend to cry when scolded
Management
1.
Promote infant safety Aspiration prevention Fall prevention Car safety Safety with siblings Bathing and swimming safety Childproofing
2. Promoting Nutritional Health of the Infant Breast milk Best food for first 12 months If with formula fortified iron is necessary High-protein, high-caloric diet necessary
6 month reasons:
1. 2. 3.
Immature kidneys to concrete the solutes Prevent allergies Immature GI deficit in amylase and lipase secretion (3-4 months)
INFANCY (0 to 1 yr)
I ron supplement (4 to 6 months),
Immunization N o choking hazard F ear of stranger peaks at 8 months A llow to use a pacifier if NPO N ote the weight changes T rust V.S. mistrust S olitary play
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Cereal with fortified vitamins and iron First type food introduced because it has less allergen
Vegetables Second type of given Given at noon meal Fruits Offered 1 month after beginning vegetables
Meat and Egg Introduced at 9 months Beef and pork has high iron Chicken has low cholesterol Egg yolks are given 10 months Egg white contains a lot of allergens Hard boiled egg not soft
3.
4.
5.
6.
Teething Thumb sucking Use of pacifiers Head banging Constipation Loose stools
12. Obesity
Teeth 2 years old Canines and molars erupts Language Able to talk two-word
(domestic mimicry)
18 mons (1 yr & )
Anterior fontanel closed Temper tantrums Awareness of ownership (my toy) Develops dependency on transitional objects, such as security blanket Uses pronouns, I, me, you Stage of parallel play
bowel and bladder control Good hand-finger coordination; holds crayon with fingers rather than first Begins to notice gender differences; knows own gender
Promoting Toddler Development in Daily Activities 1. Dressing 2. Sleep 3. Bathing 4. Care of Teeth 5. Promoting Healthy family functioning
Parental Concern associated with the Toddler Period 1. Toilet training 2. Ritualistic Behavior 3. Negativism 4. Discipline 5. Separation anxiety 6. Temper Tantrums
PRE SCHOOLER
Weight
Weight gain is slight
Height
Minimal
Teeth
20 deciduous teeth by 3 years old
PRE SCHOOLER
Language Constantly asked questions of how and why 3 years old Uses primarily telegraphic speech
3 yrs old
Play is parallel and associative play; begins to learn simple games, but often follows own rules; begins to share Very imaginative; cannot differentiate between fantasy and reality
4 yrs old
Aggressive physically and verbally Tells exaggerated stories Play is associative Imagery playmates common Sexual exploration and curiosity demonstrated Dos and donts become important Identifies strongly with parents of opposite sex
Planning and Implementation for Health Promotion of the Preschooler and Family
1. 2. 3.
Promoting Preschooler safety Promoting Nutritional Health Promoting development of daily activities 3.1. Dressing 3.2. Sleep 3.3. Exercise 3.4. Bathing 3.5. Care of Teeth
Fear of dark 2. Fear mutilation 3. Fear of separation or abandonment 4. Telling tall tales 5. Imaginary friends 6. Difficulty sharing 7. Regression 8. Masturbation
1.
School-age
6 years
Sometimes steals money or attractive items Has difficulty owning up to misdeeds Will cheat to win Has own way of doing things Is a boaster Deciduous teeth are lost and permanent teeth erupt
7 years old
May steal Boys prefer playing with boys; girls prefer playing with girls
8 to 9 years old
Always on the go Hate to lose during games; will change rules at the middle of the games to avoid losing
10 years old Brain growth is complete Fine motor coordination becomes refined Learns rules and fairness during plays
10 to 12 years
Boys slow growth and rapid weight gain Girls changes may begin to appear in the body Chooses friends more selectively; may have best friend Likes father, who is admired and may be idolized
Promoting school-age safety. Promoting Nutritional Health Promoting Daily Activities dressing; sleeping; exercising; hygiene and care of teeth
4.
5.
6.
7.
Anxiety related to beginning of school School phobia Sex education Stealing Violence or Terrorism Bullying Recreational Drug use
Adolescent
11-14 yrs
15 17 yrs
Stature reaches 95% in adult height Has a rich fantasy life Idealistic Major conflicts over independence and control Behavioral standards set by peer group Feeling of being in love
18-20 yrs
Most girls are 1 to 2 inches (2.4 to 5 cm) taller than boys; stops growing with 3 years from menarche
Apocrine sweat glands (glands present in the axillae and genital area) produce strong odor in response to emotional stimulation
Secondary sex characteristics distinguish the sexes from each other
Safety Nutritional Health Daily Activities Dress and hygiene; care of teeth; sleep
sexual activity 2. Concerns about substance abuse 3. Concerns regarding attempted suicide 4. Concerns regarding runaways
Spend time together Encourage expression of ideas and feelings Respect their views Tolerate differences Praise good points Respect their privacy Set a good example
Communicate effectively Give undivided attention Listen, listen, listen Be courteous, calm, and open minded Try not to overreact, if not take a break Avoid judging or criticizing Choose important issues when taking a stand After taking a stand Think through all options Make expectations clear
If a Child lives with shame He learns to be guilty If a Child lives with encouragement He learns to be confident If a Child lives with praise He learns to appreciate If a Child lives with security He learns to have faith
If a Child lives with fairness - He learns to have justice If a Child lives with approval He learns to like himself If a Child lives with acceptance and friendship He learns to find love!!!
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have been drained out. Head lower than the rest of the body (except in increased ICP) Suction secretions properly
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(stimulates vagus nerve) BRADYCARDIA OCCLUDE ONE NOSTRIL AT A TIME Newborns are obligate nasal breathers!
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(confined in an internal body organ) There is heat loss due to immature temperatureregulating mechanisms. COLD STRESS due to large losses of heat (Convection, Conduction, Radiation, Evaporation)
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Effects of Cold Stress: Metabolic acidosis (breakdown of brown fat found in INTRASCAPULAR AREA, THORAX and PERIRENAL REGIONS) Hypoglycemia (due to use of glucose stored as glycogen)
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NEONATAL ASSESSMENT
Initial assessment
Ongoing assessment Physical assessment Sensory assessment Behavioral assessment
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IMMEDIATE ASSESSMENT
APGAR scoring Ballard scoring Gestational Age assessment: BESTS
2.
SECONDARY ASSESSMENT
Head-to-toe physical assessment Neonatal Reflexes Sensory and Behavioral
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APGAR Score
Virginia Apgar
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BESTS
Criteria B- reast nodule 0 to 36 weeks 2 mm 37-38 weeks 4 mm 39 weeks & above 7 mm
E ar lobe
S calp hair
No cartilage
Fine and fuzzy
Some cartilage
Fine and fuzzy
Thick cartilage
Coarse and silky
T testes/Scrotum
Testes in lower Intermediate; Testes sac; scrotum scrotum with pendulous; with no rugae some rugae scrotum with rugae
Anterior transverse crease only
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S ole creases
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Ballards Scoring
A. Neuromuscular Maturity Posture Square window Arm recoil Popliteal angle Scarf sign Heel to ear B. Physical Skin Lanugo Plantar surface Breast Eye-ear Genitalia
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Head-to-toe Assessment
Physical Examination: Vital signs
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Head-to-toe Assessment
Anthropometric measurements
Length = 47.5 - 53 cm (Ave: 50 cm) HC = 33-35 cm (measure center of forehead and the prominence of occiput) CC = 31-33 cm (measure at the level of nipples) AC = 31-33 cm (measure at the level of umbilicus) Weight = 6.5-7.5 lbs (3.0-3.4 kg)
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Head-to-toe Assessment
Skin
Normally ruddy because of increased RBC concentration and decreased amount of subcutaneous fats Acrocyanosis mottling (normal in 24-48 hrs); HARLEQUIN SIGN generalized mottling (Cutis Marmorata) may sometimes be seen desquamation (drying of skin)
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Head-to-toe Assessment
Common skin marks of the newborn:
Desquamation - peeling of skin; indicates postmaturity Mongolian spots - bluish-black/slate gray pigmentation across the sacrum or buttocks; disappear by SCHOOL AGE. Vernix caseosa - cheese-like material; serves as insulator Lanugo - fine, downy hair at shoulders, back and upper arms; disappear by 2 wks. Milia - plugged or unopened sebaceous gland on the cheek or across the bridge of the nose; disappear by 2-4 weeks
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Head-to-toe Assessment
Common skin marks of the newborn:
Nevi (Stork bites) - pink or red flat areas of capillary dilatation seen on upper lids, nose, upper lip, nape and neck; disappears at 1st and 2nd year. Erythema toxicum - aka fleabite rash; pink papules with vesicles seen at nape, back and buttocks; appears usually 2nd day; no treatment needed. Forceps marks - disappears in 1-2 days
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Head-to-toe Assessment
Head Fontanelles - should be flat; not indented or bulging
Anterior (diamond-shaped) closes 12-18 months Posterior (triangular shaped) closes 2-3 months.
Molding - some overlapping of sutures Craniotabes - localized softening of the cranial bones caused by pressure of fetal skull against the mother's pelvic bone; more common in firstborn infants Caput succedaneum vs. Cephalhematoma
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Head-to-toe Assessment
Criteria Cause Caput succedaneum Cephalhematoma Scalp edema Collection of blood between periosteum and skull bone Does not cross sutures Several weeks
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Extent of Involvement
Absorption
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ducts cornea is round, pupil is dark, iris is gray temporary cross-eyed (STRABISMUS)
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ear should be on a line drawn from the inner canthus to the outer canthus of the eye
Low-set ears Down's syndrome
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Head-to-toe Assessment
Nose
appear large for the face; no septal
deviation
obligate nasal breathers
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Head-to-toe Assessment
Mouth
should open evenly when crying tongue appears large palate intact; lips should have no breaks EPSTEIN PEARLS: small, round glistening cysts on the palate (due to hypercalcemia of the mother) NATAL TEETH: if loose, should be extracted
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stops growth and recedes by 10 years old) head should rotate freely
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hormones
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Head-to-toe Assessment
Abdomen
slightly protuberant; dome-shaped if scaphoid diaphragmatic hernia liver, spleen and kidneys are palpable umbilical cord - 2 arteries and 1 vein (stump falls off 6- 10 days)
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Head-to-toe Assessment
Anogenital region
Pseudomenstruation epispadias, hypospadias, hydrocele Foreskin should be retracted to test for phimosis and paraphimosis testes should be descended (if not, Cryptorchidism)
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Head-to-toe Assessment
Back appears flat when prone mass, hairy nebule or a dimple along axis Spina bifida
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Head-to-toe Assessment
Extremities
Extra digits (polydactyly); fused digits (syndactyly) Simian line: a single palmar crease Downs syndrome Ortolanis sign: congenital hip dislocation
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Systemic Assessment
Meconium
within 24 hours sticky, tarlike, blackish-green, odorless mucus, vernix, lanugo, hormones and carbohydrates that accumulated during intrauterine life.
Transitional stools
- 2nd to 3rd day up to 10th day slimy green and loose resembling diarrhea to the untrained eye
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Systemic Assessment
Criteria Color Consistency Frequency of passage Breastfed Infant Golden yellow Mushy, soft 3-4x/day Bottle-fed Infant Pale yellow Firm 2-3x/day
Smell
Sweet-smelling
Slightly Malodorous
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Systemic Assessment
Urine
about 15 ml of urine per void females: form a strong stream when voiding males: small projected stream when voiding should void within 24 hours.
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NEONATAL SENSES
HEARING:
able to hear in the utero
within hrs after birth, hearing in NB becomes acute
VISION:
focus on black and white objects distance of 9-12 inches pupillary reflex present at birth
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NEONATAL SENSES
TASTE:
developed before birth
TOUCH:
MOST developed sense at birth react to painful stimuli
SMELL:
present as soon as the nose is cleared of mucus ability to respond to odors can be used to document
alertness
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Neonatal Reflexes
Reflexes Rooting reflex Sucking Reflex Extrusion Reflex Palmar grasp Stepping (Walk-in-place/Dancing) Reflex Tonic neck (Fencing/Boxer) Reflex 6 weeks 6 months 4 months 6 weeks-3 months 3 months Disappearance
2-3 months
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Neonatal Reflexes
Reflexes Moro reflex Disappearance 4-5/6 months
Babinski Reflex
Landau Reflex (Parachute Reaction) Bauer's (Crawling) Reflex Blink Reflex (see objects 9-12" at midline) Swallowing Reflex
3 months
3 months 6 weeks Do not disappear Do not disappear
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BEHAVIORAL ASSESSMENT
First Period of Reactivity 30 minutes after birth Awake and active VS are increased Mother infant bonding breastfeeding Resting Period 2 to 4 hours VS returning to baseline 1 sleep and difficult to be aroused Second Period of Reactivity 4 to 6 hours
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Implementation
Routine Care of the Newborn: Give initial oil bath to cleanse the baby of blood, mucus and vernix. Dress umbilical cord (70% alcohol or PNSS) Crede's prophylaxis - against Ophthalmia neonatorum
2 gtts 1 % AgN03 on lower conjunctival sac; flush with
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Implementation
middle third
1.0 mg full term infants 0.5 mg preterm infants
Identification
Bands; footprints
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Implementation
Routine Care of the Newborn:
Feeding
NSVD = within 30 mins C/S = within 3-4 hours Initial feeding - with sterile water only; glucose is irritating to the lungs if aspirated (1 oz) Subsequent feeding - per demand
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Implementation
Composition Calories CHO Human Milk 20 cal/oz High (Lactose) Low (Lactalbumin/ Whey) Same (Linoleic Acid) Cow'sMilk 20 cal/oz Low
CHON
COOH
High (Casein)
Same
Minerals
Iron
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Implementation
Bathing
done anytime but not within 30 minutes
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Implementation
Constipation
add more fluids or carbohydrates/sugar
Mgt:
Feed by self-demand Burp the baby twice during a feeding feed in upright position change milk formula if needed reduce sugar content
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Implementation
Spitting up - due to poorly developed sphincter Mgt: feed in upright position position on right side after feeding burp more frequently
Skin irritation - may be due to poor hygiene, or irritation from urine, feces or laundry products Mgt: expose to air careful washing and rinsing of skin starch bath (for Miliaria or prickly-heat rash)
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Implementation
Seborrheic dermatitis/cradle cap - involves sebaceous glands; due to poor hygiene Mgt:
apply mineral oil or Vaseline on the scalp at night giving shampoo bath in the morning
Clothing
If mother feels warm, keep the baby cool. If the mother feels cold, keep the baby warm.
Sleep patterns
need 16-20 hours of sleep a day
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Implementation
Jaundice
Use natural light and blanch skin on the chest or tip or the nose Inability to conjugate bilirubin (decreased GLUCORONYL TRANSFERASE) Physiologic jaundice: 2nd to 7th day Breastfed babies have longer physiologic jaundice because human milk has PREGNANEDIOL depresses glucoronyl transferase
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Implementation
Pathologic jaundice - within 24 hours
Phototherapy (photoisomerization of indirect bilirubin) cover eyes and scrotum with an opaque mask monitor temperature and adequate hydration turn q 2H to expose all body areas measure I & O Exchange transfusion
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Pre term
Post term
P rofuse scalp hair On long finger nails S kin is dry & leather like T he absence of vernix caseosa
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Infancy
FIRST "period of rapid growth and
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Head Circumference a reflection of rapid brain growth at the end of 1 st year, brain has already reached 2/3 of adult size
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fetal RBC's life span is through and new replacement is not adequate yet serum iron levels decrease
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2 3
Holds head up when prone Holds head & chest up when prone
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5 6
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11
12
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6 7
Bathtub toys, rubber rings for teething Objects that are good size for transferring
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Socialization / Language
Peaked fear of stranger
Play
Rattle toys of different textures
9
10
11 12
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Language:
0 2 = cooing
3 -6 = mono syllabic babbling 6 9 = linking syllable
9 12 = simple words
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Infant
Nutrition
6 - 12 months
Introduction of solid foods starts with cereal (usually rice cereal), which is continued until 18 months. Sequence: R ice cereals I ntroduce Yellow Fruits & vegetables C unod green F & V unod Meat (9 mos) / Cheese E gg yolk till 1 year old ( >1 ok egg white)
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Infant
6 - 12 months
D. Nutrition
4 7 days at a time AVOID: D o not feed with seed O popcorn Hotdog piece N uTs No honey Pls raisin S Grape S
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Infant
6 - 12 months
D. Nutrition
Special consideration:
C up use 12 13 mos U will not mix meds w/ food P ruit juice is limited d/t high sugar; try fresh
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skills 2
4
8 9
5
10
12
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Fine skill
1 6 123 7 4 9 12
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Infant
Play (Solitary)
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Infant
Play (Solitary)
a. Provide variety of brightly colored objects, different sizes and textures. b. Hang mobiles within 8-10 inches of infants face.
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Infant
Play (Solitary)
a. Provide brightly colored toys to hold and squeeze. b. Allow infant to splash in bath. c. Provide crib mirror.
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Infant
Play (Solitary)
a.
Provide toys with movable parts and noisemakers; stack toys, blocks; pots, pans, drums to bang on; walker and push-pull toys.
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Infant
Fears 1. Separation from parents a. Searches for parents with eyes. b. Shows preference for parents. c. Develops stranger anxiety around 6 months, peak at 8 months 2. Pain a. hold and comfort infant b. reduce painful procedures if possible
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Infant
PROMOTING SENSORY STIMULATION
VISION
Teach parents to make eye-to-eye contact with the
infant to stimulate vision and to promote socialization. Infants enjoy mobiles and crib mirror Photos of family members may be posted near the baby's crib.
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Infant
HEARING
Infant's toys should have soft, musical
or cooing sounds. An audiotape of family voices might be soothing reminder of their presence when they are not around.
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Infant
TOUCH
Clothes should feel
comfortable and diaper should always be dry. Teach parents to handle the infant with assurance and with gentleness. Kangaroo hold" promotes close physical contact.
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Implementation
INFANTS DAILY ACTIVITIES
communicate with the baby. d. to give the baby the opportunity to learn different textures and sensations.
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Implementation
SLEEP Infants need 10-12 hours of sleep a night and one or several naps during the day. Caution parents not to place pillows to avoid possibility of suffocation.
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Implementation
PARENTAL CONCERNS AND PROBLEMS RELATED TO INFANCY
2. Thumb sucking reassure parents, provide sucking pleasures 3. Use of Pacifiers ensure cleanliness 4. Head Banging pad rails and reassure parents
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Implementation
PARENTAL CONCERNS AND PROBLEMS RELATED TO INFANCY 5. Sleep Problems provide soft toys and music
6. Constipation increase fluid intake and fiber 7. Loose Stools assess and intervene 8. Colic assess, burp, make feeding stimulating
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Implementation
PARENTAL CONCERNS AND PROBLEMS RELATED TO INFANCY
9. Spitting up upright position feeding, burp
baby, bib during feeding 10. Diaper Dermatitis frequent change, air dry 11. Miliaria bathing with baking soda 12. Baby bottle syndrome avoid bottle during sleep
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Implementation
IMMUNIZATION BCG
Infants
Intradermal
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Implementation
BREAST FEEDING
ADVANTAGES: Readily available Economical Promotes facial muscles, jaw and teeth Mother infant bonding Reduced incidence of allergies Reduced incidence of maternal breast cancer Transfer of maternal antibodies
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Implementation
BREAST FEEDING ADEQUATE feeding? Wets 6 to 8 diapers a day Gaining weight Sleeps well
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Implementation
BOTTLE FEEDING DISADVANTAGES: Cost Greater preparation and effort Hands should be clean Requires refrigeration and storage No transfer of maternal antibodies Doesnt benefit mother physiologically
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Implementation
Safety
A Ve sure age appropriate toys ut of reach mobile O strangulation nfant protection I o not hold hot while holding D the infant
void offering small piece way from curtain
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1 month to 1 year Double weight at 6, triple weight at 12 months First tooth at 6 months GROSS: lift chest at 2, sits at 6-8, creeps at 9, cruise at 10, walks after 12 FINE: transfers object at 7, pincer grasp at 9-10 LANGUAGE: Cries at 2, Mama-Dada at 9 VISION: Past midline at 3, focus object at 6 PLAY: Solitary, toy: mobile, rattles, mirror Theory: Oral, Id, Trust vs Mistrust, Sensori-motor
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INFANCY (0 to 1 yr)
I ron supplement (4 to 6 months),
Immunization N o choking hazard F ear of stranger peaks at 8 months A llow to use a pacifier if NPO N ote the weight changes T rust V.S. mistrust S olitary play
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INFANCY (0 to 1 yr)
COMMON ACCIDENTS P revent further absorption O ff, shower or wash off I - dentify S - upport O ngoing safety education N otify local poison control center
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muscles Noticeable lordosis baby fat begins to disappear CJT3 Pediatric Nursing Wide-based gait
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24
30
Walks up stairs alone still using both feet on same step at same time Makes simple lines Can jump down from or strokes for crosses chairs with a pencil
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18
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spends time playing house imitating parents actions Play is rough- housing or active
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Toddler ( 1-3) T
O D D L E R s
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T
N
Negativism O IS THE FAVORITE WORD: 1. offer choices 2. limit question D o not offer 3 large meals (SFF) rink well from the cup D et the baby talk L E at: do not let play with food R isk: Aspiration & poisoning
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TANTRUMS
D/T LACK OF VOCABULARY WORDS
300 WORDS
Toilet training
> 18 mos complete myelination of spinal colums Signs of readiness:
Pulls/tugs soild diaper Please parent
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Toilet training
> 18 mos complete myelination of spinal colums Timing of good control
2 3 Day time bladder control 3 4 Night time bladder control
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Separation anxiety
> 18 mos Steps: Protest - cry 2. Despair widrawn 3. Denial repression of feeling
1.
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Play
ParAllel P arallel play; PUSH & PULL A ttention span short R emovable/ replaceable
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Safety:
Car: Lock all doors
Upright forward facing
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Language:
1 y/o = 50 words 2 y/o = 300 words
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Skills toddlers
12
12
3
2
3
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Skills toddlers
Fine: undressing building blocks
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Gross Motor Runs Alternates feet on stairs Rides tricycle Stands on one foot Constantly in motion, jumps, skips Throws overhand
4 5
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4
5
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PRESCHOOL
Freuds: phallic
Ericksons: initiative vs. guilt Dentition: 3 y/o = complete primary teeth
6 y/o = erupt of the first permanent teeth Note: food fads & strong taste preference P primary teeth is completed R regular dental care E eating social aspect; manners; willingness to feed S sleep 12 hours CJT3 Pediatric Nursing 293
S
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S
Mngt:
V oid before sleeping O n limit fluids before sleep I nvolve child in care of sheets D o reward
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PRESCHOOL ( Safety)
P
R
E
S
C
H
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PRESCHOOL ( Safety)
P ractice safety: follow simple instruction
R Estrained booster seat
Emotional Development
Developmental Tasks Initiative Imitation Fantasy Oedipus and Electra Complexes
Gender Roles Socialization Impt. Person: Basic family
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A bondonment
R oom dark
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Behavior Variations
Telling tall tales Imaginary friends Difficulty sharing Regression Sibling rivalry
W/o rules All girls only Beware of girls Dress up Papers & scissors Puzzle
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On expression
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SCHOOL-AGE
Freud: latency
Sleep: 10 12 hours
Dentition: 6 y/o = 1st permanent teeth Proper dental care Soft nylon toothbrush & length of 6 inches
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SCHOOL-AGE
Play: competitive
O N rules in games MUlti tech task: Articipate in team sports, peer P & scout
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SCHOOL-AGE
SAFETY
Eat belts ( shoulder belt fit across chest & shoulder) Lap belts (across the thigh) Ause of injuries: Bicycle, skateboard & team sports
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Adolescent
puberty
Freuds: Puberty / genital
Growth
Reproductive organ begin to function Secondary sex characteristics Body mass index
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Adolescent
Safety:
A D O L
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Dolescents are risk taker Natural urge to experiment Angers of vices Ther choices is present if danger arises
Sex education
Stealing Violence or terrorism
Bullying
Recreational drug use
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Keys to Success!
Confidence
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relaxation of rectal sphincter Respiratory distress due to mechanical plugging Tx: suction, intubation, CPT, O2
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Apnea
Pause in Respiration >20 mins with bradycardia
Causes: preterm, infection, hypoglycemia,
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Nursing Interventions
Feed slowly Keep infant warm Maintain clear airway Rub back or soles of feet to stimulate
infants breathing. Transport infant to special care facility as soon as possible. Avoid handling infant more than necessary for feeding and changing of diapers.
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Establish and maintain adequate respiration. Ensure ability to take in adequate nourishment. Foster the development of an infant-parent bond. Nurses should be familiar with the most frequently encountered physical anomalies so that they can make truthful statements
Nursing Interventions
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Nursing Diagnosis
Anticipated grief related to the loss of perfect child. Self-esteem disturbance related to interference with establishing parent-infant bond Altered nutrition, less than body requirements, related to malabsorption of necessary nutrients
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Nursing Intervention:
Provide opportunities for parents to
participate in the childs care. Promote open parent visiting. Support sibling and grandparent visitations. Ample analgesia, including techniques of distraction or imagery; traditional comforts such as a change of clothing or positions; and reading to the child.
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Nursing Intervention:
To assure children that their bed is an area that is safe, all painful procedures should be done in the treatment room away from the bed.
Offer children a sense of control. Explain to the children the procedures and give choices whenever possible to limit their fear of hospitalization.
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