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Posterior fontanelle closes at 6-8 weeks Anterior fontanelle closes at 12-18 months Birth weight doubles by 6 months ( eg. Baby is born at 7.5 lbs in 6 months baby weighs 7.2x 2=14.4lbs Average HR 110-118, Average RR 40/min Rolls over by 6 months, Begins to reach for objects by 3 months Sits with support by5 months, Sits alone by 8 months Turns completely over by 6 months, pulls self up by 10 months Teeth eruption begins at 6-7 months begins to crawl 7 months, creeps by 9 months Should be walking by 12-16 months Head lag no longer evident by 6 months Feeding: breast/ formula milk until 6mos, then no homo milk until 1 yr Solid foods introduced at6 months, start with rice, 1 new food every 4 days to a week Erikson stage: Trust vs Mistrust Sleep 8-9 hr/night, naps same amt Object permanence developing Speech 2 months( making vowel sounds) 3 months ( adding consonants n,k,g,b,l) 6 months (imitating sounds) 9-10 months ( obey simple command, understand no) 1 yr ( may say up 3-5 words with meaning and understanding 100 words) Safety: Car seat If less than a 1 yr and less then 22lbs must be rear facing middle, if 20-40 lbs can be front facing Immunizations: DPTP, HiB @ 2, 4, 6 mos, MMR @ 12-15 months Play: solitary play, appropriate toys (
full control at 2 ½ to 3 Sign of readiness waking up dry and staying dry for2 hr Language 18 mos 10 words. and can speak in 2 word sentences Egocentric. compulsive. dark ( leave a light on) pain Erikson Initiative vs guilt Play assitive play Needs discipline. and simple commands. favorite word: No Erikson Autonomy vs self doubt Play: still solitary but also parallel play Milk: 3/ day homo milk until 3yr .TODDLER Triples weight by 1 yr. hand preference. 24 mos 300 words. regression if hospitalized common PRESCHOOLER First year weight doubles Primary teeth present. ritualistic. feeding themselves. then quadruples weight by 2 1/2 HR 70-110 RR 25/min Bladder/bowel control begins18-24 months. speech 2100 words Fear Harm. may be jealous. Serving: 1 table spoon /yr Sleep 12/hr may still nap Car seat 9-18 front faceing Separation anxiety. need prep for new changes . time out rules1 min/yr Imitate adults.
invincible.Grade 7 ◦ ◦ Hepatitis B 2 dose series. fauiler Safety – accidents: bike ADOLESCENT Puberty10-12 boy are longer may take up to 18 yr Secondary sex characteristics: Boys: voice deepened. popularity important Safety – accidents. rebellious. facial hair. acne. double weight over the 6 yr period. may be as early as 10 yrs or as late as 15 yrs Erikson: Identity vs role confusion Prefer friends over family. breast begin to erupted. rapid growth before puberty Begin to lose primary teeth Erikson: Industry Vs inferiority No longer egocentric Friends of same sex important Sleep 12 hr Fears bullys. Menarche: 12 – 13 years.Sleep 12 . sex education Immunizations: 12 yrs . infrequent naps Safety: Booster seat until 8yr or 18-36 kg Immunization – DPT @ 4-6 yrs SCHOOL AGE Slower growth. increased in size Girls: hips widen. 4-6 months apart .
barky cough • Treat: bronchodilators. croupette RSV – Bronchiolitis • Caused by: RSV • Bronchioles obstructed • Classis signs: Deep congestive cough. increased temp Asthma .◦ Given in school. inspiratory stridor. preferably before sexually active RESPIRATORY CONDITIONS Croup – LTB ( braking cough) • May be viral. therefore treatment Antibiotics. Contact isolation Otitis Media • Why occur: Children have shorter. post infection • Symptoms: hoarseness. wider. miserable. funded 14-16 yrs ◦ ◦ HPV Vaccine: o Recommended to all girls ages 9 – 26 yrs o Gardisil o DPT booster Given in Dr. straighter & more horizontal eustachian tubes • • Bacterial. PE tubes Signs: Pulling. crackles.’s office Protects against 4 strains of HPV that are known to cause cervical cancer o Given in Grade 8. poking ear. wheezes • Treat: bronchodilators.
dyspnea. Pneumothorax. meds bronco dilatators • GI – will need Pancreatic enzymes for Life NEURO Increased ICP • • • • • Bulging fontanelle. influenza) – * most difficult to treat – bronchiolitis. Productive cough Treatment: Bronchi dilatators. frothy if untreated • Treatment o Lungs – need to mobilize secretions. projectile vomiting Lethargy coma. pneumonia. Pancreatic fibrosis → diabetes and glucose tolerace problems. viruses. hyperinflation. leads to Fluid and electrolyte disorders Stools become bulky.• • • 3 processes: Bronchial spasm . High pitch shrill cry Change in pupils. fever. impaired gas exchange Wheezing. Biliary cirrhosis from blockage of biliary duct . Emphysema. seizures . Bowel disorders – rectal prolapse (poor muscle in rectal area). oxygen Pneumonia • Caused by Bacteria. Inflammation & edema of mucosa . H. headache.Production of thick mucus – increased airway resistance. Respiratory distress • • GI effects – secretions block release of Pancreatic enzymes GI effects Meconium ileus in newborn – blockage of small intestine by thick. staph aureus. sticky meconium stool. Diabetes becoming more common in CF patients High NaCl in sweat. and aspiration • Treat with _Antibiotics • Cough. increased temp Cystic Fibrosis • Disorder of endocrine glands • Secretions become thick viscous • Airways become obstructed with thick sercetions • Can’t cough up secretions d/t decreased action of cilla • Resp Complications_Infections (pseudomonas*.
decrease stimuli Seizures – • What to do if pt seizures: Safe position – turn to side if vomiting – recovery position after. seizures common types: Spastic Most common. Loss of coordination. spasms. projectile vomiting.Constant muscle tension • Treat – maximize potential. • Treat: Antibiotics. or in early infancy • Behaviours – delayedgross motor development.Treat: cause of ↑ ICP. Athetoid : Damage to basal nuclei ganglion (assoc with hyperbilirubenemia). walking). Disabilities caused by brain injury before or during birth. Rigid/Mixed: Combination of spastic and athetoid . corticosteroids • No activities to ↑ ICP. NPO until fully alert. fever…. Resp isolation for 24 hrs minimum Cerebral Palsy • Causes: by dysfunction of motor centre in brain. osmotic diuretic.Abnormal involuntary movements.Unsteady gait – ataxia. delayed milestones (sitting. Check airway and breathing. HOB elevated. Febrile seizure caused by Rapid increased temp Hydrocephalus – increase in CSF • Behaviours – see ICP. delayed head lag after 6months • Treat – VP shunt Meningitis • Caused by virus or bacteria • Diagnosed by lumbar puncture • Symptoms – signs of increased ICP. Ataxic: Lesion in cerebellum. prevent injury Spina Bifida • Neural tube defect . nuchal rigidity.Hypertonicity. Do not try to put something in mouth during seizure. poor head control. damage to cortex of brain (r/t cerebral asphyxia).
improper formula prep. Weight loss. Elevated temp. refuses to eat. tongue & mucous membranes (sticky). May be NPO. ingesting large amounts of sorbitol ( in sugar free items). Emesis will consist of mucous and ingested milk. NG tube. May be expelled with force. IV therapy.Hunger • Treatment : surgery. Provide comfort. CSF and spinal nerves (cord) • Treat – surgery • Protect sac pre op: monitor VS. sunken fontanelle. Small. prone position. Dehydration – sunken eyes. sterile dressing. Colicky pain. cuddling. post op care: Maintain fluid & electrolyte balance. Intake / Output. do not allow sac to dry. frequent feeds as ordered.Projectile vomiting. Weight loss. analgesics. Alleviate parental anxiety Gastroenteritis • Causes: non infectious: usually caused by food intolerance. occurs after eating. May also be from medication or poisoning • Behaviours: Diarrhea – mild to severe. Vomiting Listless. skin care – cleanse skin.Caused by 3-4th week of gestation – folic acid deficiency . protect myelomeningocele sac – moist. burp before & after feeds. Decreased urine output Treatment – IV fluids. dry skin. fleece pad • • • • GI Conditions Pyloric Stenosis • Obstruction of pyloric sphincter by hypertrophy of muscle • Classic signs . neuro status. overfeeding. Maintain nutrition. place in incubator for warmth. oral rehydrating solutions • Celiac Disease • Intolerance to gluten . Salmonella. Infectious causes can be from rotavirus E. yellow – green. Fowler’s position or on rt side pc. Occulta Hidden Meningocele external saclike protrusion containing meninges (membranes) & CSF Myelomeningocele external sac contains meninges. weight. coli. Pacifier.
frothy stools – food not digested. decrease in protein synthesis TYPE 1 DIABETES IDDM . Buttock atrophystools.Will need to eliminate all gluten in diet for life (no wheat. oats. adult onset diabetes mellitus Involves insulin resistance Associated with sedentary lifestyle. rapid growth. polyphagia • Previously toilet trained child may begin soiling themselves . barley. gastroenteritis. rye) rice and corn ok. Irritability. but most new cases seen at 5-7 yrs & at 11-13 yrs Not inherited but hereditary is a prominent factor being observed more May be linked to stress or exposure to infectious disease which triggers onset Puberty. bulky. Large.Juvenile Onset Diabetes Mellitus Beta cells in pancreas destroyed Autoimmune condition. weight loss common complaints • Abdominal discomfort common complaint • Polydipsia (common complaint!). obesity Symptoms • usually recognized more in children than in adults • Diabetes is a great imitator – may be mistaken for flu. Abdominal distention. weakness. child has genetic predisposition Beta cells may be destroyed by drugs. Diabetes • Chronic disorder of metabolism • Body unable to use insulin properly.• • Symptoms – failure to thrive. Treat . appendicitis • Lethargy. increased emotional stress & insulin antagonism of sex hormones may be contributing factors Type 2 Diabetes NIDDM. impaired glucose transport results • Body not able to store & use fats properly. polyuria. radiation Can occur at any age. chemicals.
and 15% protein • Exchange system and carbohydrate counting used to determine intake & insulin requirements • Carbs should mostly be complex carbs . 30% fats. body image issues Child needs to learn to assume own responsibility for diabetes Test own blood glucose level If in hospital.• • • • • • • • • Recurrent infections. may deny accepting diagnosis of DM A temporary feeling – need to stress importance of proper glucose control American ranges . vaginal yeast infection in adolescent girls Symptoms may go unnoticed until infection or coma results Hyperglycemia.these are absorbed slowly so blood glucose does not fluctuate greatly . peak. child stabilized with insulin. insulin demands/requirements decrease “Honeymoon” phase – feels like remission. condition appears to improve Child feels well. culture. hydration status Children eat irregularly. religion Consider children’s growth spurts.÷17 Treatment Focus of treatment of child with diabetes: Ensure normal growth and development Ensure child able to cope with this chronic illness while having a “normal” childhood Prevent complications Child & parents need education Must consider child’s age. no special foods – well balanced nutrition is key • Will have same nutritional needs as non diabetic children • Need sufficient calories to balance energy expenditure and to satisfy requirements for G&D • Must correlate food with insulin administration (onset. insulin. regular exercise Nutrition • No specific diet. financial & educational status. glucosuria Review /recall lab tests Diagnosis made. will usually bring own testing machines Test urine for ketones if suspect ketonuria Management includes well balanced diet. have irregular activity Puberty will affect insulin requirements Adolescents may rebel against treatment. action…) • Dietician assists with nutritional intake/diet plan • Diet should consist of 55% carbohydrates.
• If travelling. quieter activity best _________meals when blood glucose is lower • Carry money for snacks. insulin requirements • Wear medical bracelet. cell phone Home Management • Proper hygiene. alert teachers. emotional upsets will affect appetite. using sterile technique. especially foot care • Assess injection sites for lipodystrophy • Maintain immunizations up to date • Stress. bring proper equipment.• • • • Insulin o Short o Rapid Insulin Pumps Administers continuous subcutaneous insulin through battery powered pump Delivers fixed amounts of regular or lispro insulin continuously so it imitates the function of the pancreas Tubing changed q48 hrs. device worn on belt or shoulder holster If needs to be removed – not for more than 1-2 hrs. exercise lowers blood sugar • If planning vigorous activity. extra supplies – put in carry on luggage • Time changes may affect child • Will need very close monitoring when ill Carb Counting • Carbs considered equivalent but portions are looked at • Insulin given in relationship to amount of carbs eaten • Used to determine insulin to scale • Match insulin doses to amount eaten ie 1 unit insulin for each 15gms carbs eaten • Insulin usually given after child eats Example Fats from animal sources limited Need to look at glycemic index of foods – foods with low glycemic index will take longer to increase blood glucose levels Need to allow excesses occasionally to prevent rebellion. occlusion Exercise • Body uses glucose. ie birthdays Need to respect cultural patterns & personal preferences . coaches. water proof models available Watch for malfunctioning – low battery. should carry extra sugar or blood sugar will drop • Diabetic child can participate in all activities but must plan properly • Increased activity better after meals because blood glucose is _________. etc….
Childhood cancers grow faster because body tissues are normally in a state of rapid growth and high metabolic rate. immature WBCs o Immature WBC’s referred to as “blasts” or stem cells o Leukemia is most common form of childhood cancer o Immature WBC’s are overproduced which leads to disruption in bone marrow function Types of Leukemia Classified by which cells are affected Acute lymphocytic leukemia (ALL) – most common (1/3rd of all childhood cancers) – produces blast cells which destroy normal marrow Acute nonlymphocytic leukemia (ANLL) Acute myelogenous leukemia (AML) – affects granulocytes Main Consequences of Leukemia • These WBC’s cannot do their proper function – ie to fight infection. kidneys. lungs. spleen. therefore increased susceptibility to ___________________ • WBC’s infiltrate where RBC’s should be forming – therefore ↓RBC’s & RBC destruction – results in ______________ • If WBC’s infiltrate where platelets should be forming . Treatment for cancers includes surgery (for solid tumors). GI tract) • Invasion of CNS . ovaries.0. such as leukemia. He checks his blood sugar and notes that it is 11. He plans on eating 90 gm of carbs for his lunch. chemotherapy and radiation.↓ platelets & destruction – results in __________________________________ • Overgrowth in bone marrow pain • Bone marrow invasion leads to weakened bones – results in fractures • Infiltration of lymph system enlarged liver and spleen • Leukemic cells can invade liver. vision disturbances . Other types include brain tumors. Leukemia o Bone marrow disorder in which there is proliferation of abnormal.headaches. His “insulin/carb ratio” is 1:15 • How much insulin should he bolus? 15/ 90= 6 so jonh will get 6 units of insulin Cancer Most common cancers in children are bone marrow cancers. convulsions. lymphomas. John wears an insulin pump. lymph nodes – leads to poor functioning of these organs • Cancer cells may also invade CNS and other organs (testes.
g. weight loss Dyspnea Bacterial invasion (WBC’s not functioning) Ulcers and bleeding to mucous membranes around mouth and anus Anemia even with transfusions Diagnosis: by bone marrow aspiration – will look at type & # of cells present • WBC’s & RBC’s formed in bone marrow • Insertion of needle into iliac crest to withdraw sample • Child is positioned prone on hard surface • Local anesthetic. vomiting.Signs and symptoms Initial – may develop slowly or suddenly Low grade fever. Pale skin Bruise easily Leg & joint pain Fatigue Abdominal pain Enlarged lymph nodes As disease progresses Liver & spleen enlargement Skin – lemon yellow colour Petechiae. purpura Anorexia. EMLA. e. is used • May also obtain sample from sternum Nursing Care • Explanation of procedure – pain from local anesthetic use (if with needle) and feeling of pressure as needle is inserted • Pressure after procedure to prevent bleeding – monitor closely q 15 min x 1hr • Keep child quiet for 1 hr post procedure • Monitor temp for 24 hours • May also do xrays to determine if bones affected • May do lumbar puncture to see if CNS involved • Blood tests include liver & kidney function Treatment Stages Induction of remission **** • Achieve remission .
hydrocortisone Maintenance • Begun after successful induction to preserve remission • Continues for 2-3 years • Combination of drugs • Regular testing to detect relapse Reinduction following relapse • Leukemic cells seen in bone marrow. L-asparaginase. diarrhea. doxorubicin ** side effects include: nausea. alopecia. vincristine. • Private room – avoid contact with possible infections. skin breakdown. CNS… • Using similar regimen as initial induction • Consider bone marrow transplant Bone marrow transplant • Not done initially as chemotherapy usually produces excellent results • Autologous (own) or allogeneic (compatible donor) • High-dose radiation or chemotherapy to destroy bone marrow • IV infusion of new bone marrow – migrates to bone marrow by 3 weeks • Anti-rejections drugs given • Reverse/Protective isolation Nursing Care of the Child with Cancer Risk for infection r/t nonfunctioning WBC & chemotherapy effects • Monitor for signs of infection – Temp. urine. weight loss. piercings. anemia** CNS prophylaxis (sanctuary) • Prevent leukemic cells from invading CNS • Because chemotherapy drugs do not cross blood-brain barrier well • Intrathecal (into spinal column by lumbar puncture) methotrexate.• Chemotherapy for 4-6 weeks • Effective for about 95% children with ALL • Uses prednisone. vomiting. reverse isolation • Good hygiene practices • Nutritionally complete diet • Avoid administration of vaccines – body cannot manufacture antigens Risk for injury (hemorrhage) r/t decreased platelet formation .
soft toys • Pressure & ice following injections. No toothbrush – use soft sponge brush. counseling. disease pathology. gentle oral care. e. Ronald McDonald house. avoid rough handling. • Supplements can be given (Pediasure). treatments. • . nausea and vomiting from chemotherapy • Administer anti-emetics prior to chemotherapy • Frequent small feedings of favorite foods. palliative care. minimize injurious treatments (injections) • Assess for bleeding • Avoid aspirin products • Provide quiet activities. pastoral care. etc. sitz baths • Prevent constipation Activity intolerance r/t cancer & chemotherapy effects • Plan care to provide adequate rest • Quiet diversionary activites • School tutoring Altered family processes r/t diagnosis of cancer & effects of long-term illness • Arrange support services – home care. • Bland diet • Local oral anesthetic if ordered. Oragel to gums • Hygiene to genital and rectal areas. • Help parents to identify and mobilize their own support systems • Be accepting of parent's anger and anxiety • Recognize parents' stage of acceptance of diagnosis • Complete and careful explanations of procedures. pressure-reducing mattresses & sheepskins.Safe environment – pad bedrails. venipuncture • May need blood transfusion (platelets or RBC’s) – see pg 622 – watch for transfusion reaction Pain r/t cancer effects and treatments • Analgesics on regular schedule • Use alternative pain management techniques • Gentle handling • Monitor pain levels and effectiveness of medication Altered nutrition: less than body requirements r/t anorexia. high calorie diet • Create a pleasant environment for eating • I&O Impaired mucous membranes (oral & rectal) r/t chemotherapy effects • Frequent. etc. TPN • High protein.g. • Lip balm to lips • Avoid acid-containing drinks.
rock child. brain • . etc. tibia. • Offer non-verbal support • Arrange palliative care services. jaw or phalanges . -fear of pain and process of dying Anticipatory grieving r/t child's impending death • Demonstrate respect for child's and family's wishes • Spend time with family to listen. but tend to feel it won't happen to them. provide answers and information • Encourage expression of feelings of loss (Note: this is a Western culture expectation – may increase distress for some other cultures) • Be aware of family's religious. cultural beliefs and practices related to dying. recognition of their needs and fears • Develop a coordinated system – "everyone on the same page" – family/health care team conferences Care of the Dying Child Infant & toddler – no comprehension of death Preschooler – think death is reversible – terms like "sleep" are understood literally (may become afraid to go to bed) -feel their thoughts are powerful – may feel they have caused the death -repeated questions about death School age – begin to understand permanence of death -curious about physical details -accept parents' religious beliefs re: life after death -need tangible ways to show grief o Adolescent – understand death.15 years of age but even up to 19 yrs Peaks during periods of rapid growth Most occur in femur (>50%). grief counseling • At death.occurs in the metaphyses of long bones May cause pathological fractures If had radiation for other cancers – may have increased incidence of osteosarcoma May metastasize to lungs. Arrange for appropriate spiritual care. average 10 . pelvis. but can involve humerus. BONE CANCER Malignant tumour of long bone –more common in males.Involve siblings in family care – explanations of what is going on. allow family time with child as desired – hold.
acute resp. part of body’s defense mechanism o Most commonly age 4-12 yr. adenoiditis. sleep apnea • Contraindicated for children with bleeding disorders. ct scan. bone scan – “sunburst” appearance with needle-like projections alkaline phosphatase Management Resection of bone or amputation (3” above tumour) or limb salvage procedure (resection and prosthetic replacement of bone) Anti-neoplastic drugs – before &/or after surgery 50% five years survival Nursing Care • • • • • • • pain (phantom limb pain) r/t amputation assess for pain. difficulty breathing. not recommended in children < 3 yrs When should tonsillectomy be removed Indications: recurrent tonsillitis. cleft palate . seen through mouth) o Child may have 1 or both procedures o Tonsils made up of lymph tissue. infection. baseball cap encourage visits from friends Tonsillectomy – 5 questions o Palantine tonsils removed for tonsillectomy (sides of pharynx.Assessment Taller than average child – accelerated growth of osseous tissue Pain. signs of infection speak with others who had amputation stump care prosthesis fitted in 6-8 weeks discuss hair loss wear wig. swelling at tumour site Diagnosed by biopsy. difficulty eating recurrent otitis media airway obstruction..
Preop screening (Hg. No surgery if has current infection Signs & symptoms • Enlarged. partly on abdomen with upper leg flexed to promote drainage Rest. sore throat. fever. gargling or vigorous brushing of teeth • Needs rest. swallowing. settled DISCHARGE TEACHING • Pain management . freq. keep quiet. throat clearing. dysphagia • Increased temp • Mouth breathers • If abscessed – grey discharge on tonsils Post-Op • Cool. PTT) is done – assess child pre-op for signs of URI – runny nose. Note loose teeth( loose teeth could fall out and cause aspiration if hit during surgey) . apple juice. reddened tonsils • Sore throat.analgesics (acetaminophen). non-acidic fluids. no Aspirin • Gravol for vomiting • May have dark brown blood in vomit Call Doctor if: • Large amounts of fresh bleeding • Fever > 38 • Pain not relieved by analgesic • . vapourizer • Allow to chew gum – increases saliva production which is antibacterial & ↓ odour • No nose blowing. trickle of bright blood at back of throat • Child often vomits old blood – watch for bright emesis • Gentle suctioning if necessary when recoving Position on side. no strenuous exercise • Can usually resume school in a week or so • Watch for bleeding days 7 – 14 post op prone to re hem • Tylenol for pain. clear fluids – popsicles. restlessness. ice chips • No red or red brown fluids • Frequent small amount –unrealistic to expect child to drink 4-8 oz at one time • Encourage parents to give drinks frequently while at bedside • Milk & milk products coat throat so child will want to clear throat – BAD! NO STRAWS!!!! Monitor for complications • Watch for HR. ice collar. PT. .
paralytic ileus o Lumen of appendix becomes obstructed with feces. no heat assess…… . release causes severe pain) o Ultrasound thickened appendix. • Are enemas and laxatives required pre op???? NO. soft tissue mass Nursing diagnosis Pre Op: • Risk for infection • PC Peritonitis • Deficient Fluid Volume • Pain Post Op: • Risk for Infection • Acute Pain Treatment • Prepare for surgery • Bed rest pre-op – to ensure that minimul pressure is being placed on the appendix. which will be increase the chance of a rupture.Appendectomy – 3 questions o Most common reason for emergency surgery o Frequently seen in children. IV. dressing. rebound tenderness (press RLQ. parasites Sign & Symoptams o o o o o o o o PAIN – initially periumbilical Pain then moves to RLQ . • IV antibiotics if ruptured appendix • Usual post op care – NPO. because it will force pressure through the bowels and then end at the appendix.as peritoneum becomes inflamed Pain at McBurney’s point – midway between umbilicus & anterior superior iliac crest Elevated WBC Vomiting May have diarrhea or constipation Fever – but may have other causes Guarding. average age is 10 yrs o Appendix can rupture or perforate within 36 hours of onset of pain o Rupture leads to peritonitis. lymph tissue.
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