pediatric assessment and fetal development with selected pediatric conditions

8/14/2019 Pediatric Assessment and Fetal Development With Selected Pediatric Conditions

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Pediatric Assessment and Fetal Development with Selected Pediatric Conditions

Developmental Approach to the Physical Examination

Three rules in the examination of children and adolescents: flexibility ,safety, and

organisation

Allow the child's age and developmental level to guide your history and physicalexamination

Atmosphere and environment are important

Incorporate health education and growth and development anticipatory guidance intothe examination

Move from the easy/simple -> more distressing; use positive reinforcement and'prizes'

Use demonstration and play to your advantage (play equipment or 'spares', paper dolltechnique, crayons, blocks)

Expect an age-appropriate level of cooperation; explain what will be involved in the physical examination and tell the child what she needs to do

Infants Keep parent in view Before 6 months examination on table; after 6 months examination in parent's lap Undress fully in warm room Careful with nappyremoval Distract with bright objects/rattles. Soft manner; avoid loud noises and abruptmovements Have bottle, dummy or breast handy Vary examination sequence with activity level (if asleep/quietauscultate heart, lungs, abdomen first) Usually able to proceed in cephalocaudal sequence Distressing procedures last (ears and temperature)

Toddlers Most difficult group to examine Approach gradually and minimise initial physical contact Leave with parent (sitting or standing if possible) Allow to inspect equipment (demonstration usually not helpful) Start examination distally through play (toes, fingers) Praise, praise, praise Parent removes clothes Save ears, mouth and anything lying down for last

Use restraint (with parent)

Pre-schoolers Allow close proximity to parent Usually cooperative; able to proceed head to toe Request self-undressing (bit by bit exposure modesty important) Expect cooperation Allow for choice when possible If uncooperative, start distally with play


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FETAL DEVELOPMENT WITH SELECTED PEDIATRIC CONDITIONS

DIVISIONS OF UTERINE DECIDUA

Decidua basalisDirectly under the embryo

Portion of trophoblasts establishing communication with maternal bloodvessels

Decidua CapsularisStretches and encapsulates the trophoblasts

Decidua veraRemaining portion of the uterine lining


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EMBRYONIC AND FETAL STRUCTURES

Chorionic VilliSyncytial layer Langerhans Layer

PlacentaCirculationEndocrine Function

Human ChorionicGonadotropin

EstrogenProgesteronHuman Prolactin

Umbilical CordAmniotic MembranesAmniotic Fluid

ORIGIN OF ORGAN SYSTEMS


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CARDIOVASCULAR SYSTEM

16 days single heart tube24 days heart beat6 7 heart chambers7 wk heart valves10-12 heart beat on dopplr 20 ECG28 SNS development

CONGENITAL HEART DISEASE

Ventricular Septal DefectAtrial Septal DefectPatent Ductus ArteriosusTetralogy of Fallot


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CLASSIFICATION

Acyanotic Heart Disease blood moves from the ARTERIAL TO THE VENOUS system (L-R shunts)Can develop cyanosis

Cyanotic Heart Disease blood is shunted from the VENOUS TO THE ARTERIAL system (R-L shuntsMay not exhibit cyanosis until seriously ill

Atrial Septal Defect (ASD)

An opening exists between the atriaTwice as common in girlsL-R shuntResults to ventricular hypertrophy and increased pulmonary artery blood flow

Assessment:Murmur, splitting of second heart sound, enlarged right side of the heart

Management:


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Surgery to close the defect between 1-3 yoSilastic patch if hole is large

Ventricular Septal Defect (VSD)

The most common congenital cardiac defectsA hole exists between the ventriclesL-R shuntRight ventricular hypertrophy and increased pressure in the pulmonary artery

Assessment:Easy fatigue at 4-8 weeks, loud, harsh murmur Hypertrophied right ventricle and increased pressure in the pulmonaryartery

Management:

85% of VSDs are so small that they close spontaneouslySurgerySilastic patchAssess for arrhythmias postoperatively

Patent Ductus Arteriosus

Failure of the ductus arteriosus to close after birthMore common in girlsAffects 20%-60% of preterm infants

Assessment :Wide pulse pressureLow diastolic pressure

Management :Indomethacin prostaglandin inhibitor Insertion of stainless steel coils through cardiac catheterization at 6 months to1 year Surgical ductal ligation

Tetralogy of Fallot


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Four Key FeaturesVentricular septal defect (VSD)Pulmonary stenosisRight ventricular hypertrophyOverriding aorta

Complications:PolycythemiaThrombophlebitisEmbolism

CVAGrowth restrictionImpaired cognitive ability

Assessment :Cyanosis after prolonged crying or exertionAssumes a squatting or knee-chest position when restingSyncopeHypoxic episodes (tet spells)

Management :Surgery at 1-2 years oldAdminister oxygenKnee-chest positionPropanolol (Inderal) to dilate the vessels


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Surgical Options

Blalock-Taussig procedureTemporaryCreates a ductus arteriosusUses subclavian artery

Brock procedureFull repair of VSD, pulmonary stenosis, and overriding aorta

RESPIRATORY SYSTEM

3RD Week Respiratory and GI tract single tube

4th Week Septum6th Week lung buds extends to abdomen7th Week Diaphragm24 28 wks Slveoli and capillaries

Surfactant is formed3 mos spontaneous respi practice movements

CROUP

- a group of respiratory diseases that often affects infants and children under age 6

Assessment

harsh "barking" cough and sneezeinspiratory stridor nausea/ vomiting

fever Hoarseness respiratory distressOn a frontal X-ray of the cervical vertebrae, the steeple sign suggests the diagnosis of

croup.

Management

exclude other causes of shortness of breath and stridor Keep the child in a warm moist environment Cool moist air Do not trigger the gag reflex Croup can be prevented by immunization for influenza and diphtheria ; diphtherial

disease, but with vaccination diphtheria is rare nebulized adrenaline in addition to steroids (dexamethasone

ASTHMA

- predisposition to chronic inflammation of the lungs in which the airways( bronchi ) are reversibly narrowed.
http://en.wikipedia.org/wiki/Respiratory_diseasehttp://en.wikipedia.org/wiki/Vomitinghttp://en.wikipedia.org/wiki/Feverhttp://en.wikipedia.org/wiki/Respiratory_distresshttp://en.wikipedia.org/wiki/Frontalhttp://en.wikipedia.org/wiki/X-rayhttp://en.wikipedia.org/wiki/Cervical_vertebraehttp://en.wikipedia.org/wiki/Steeple_signhttp://en.wikipedia.org/wiki/Influenzahttp://en.wikipedia.org/wiki/Diphtheriahttp://en.wikipedia.org/wiki/Nebulizerhttp://en.wikipedia.org/wiki/Adrenalinehttp://en.wikipedia.org/wiki/Predispositionhttp://en.wikipedia.org/wiki/Chronichttp://en.wikipedia.org/wiki/Lunghttp://en.wikipedia.org/wiki/Bronchihttp://en.wikipedia.org/wiki/Respiratory_diseasehttp://en.wikipedia.org/wiki/Vomitinghttp://en.wikipedia.org/wiki/Feverhttp://en.wikipedia.org/wiki/Respiratory_distresshttp://en.wikipedia.org/wiki/Frontalhttp://en.wikipedia.org/wiki/X-rayhttp://en.wikipedia.org/wiki/Cervical_vertebraehttp://en.wikipedia.org/wiki/Steeple_signhttp://en.wikipedia.org/wiki/Influenzahttp://en.wikipedia.org/wiki/Diphtheriahttp://en.wikipedia.org/wiki/Nebulizerhttp://en.wikipedia.org/wiki/Adrenalinehttp://en.wikipedia.org/wiki/Predispositionhttp://en.wikipedia.org/wiki/Chronichttp://en.wikipedia.org/wiki/Lunghttp://en.wikipedia.org/wiki/Bronchi


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Assessment:

nighttime coughingshortness of breath with exertion but no dyspnea at resta chronic 'throat-clearing' type cough

complaints of a tight feeling in the chestWheezingAsthma Attack

shortness of breath ( dyspnea ), wheezing , and chest tightness
http://en.wikipedia.org/wiki/Dyspneahttp://en.wikipedia.org/wiki/Dyspneahttp://en.wikipedia.org/wiki/Wheezehttp://en.wikipedia.org/wiki/Dyspneahttp://en.wikipedia.org/wiki/Dyspneahttp://en.wikipedia.org/wiki/Wheeze


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note inspiratory stridor without expiratory wheeze however, as an upper airwayobstruction may manifest with symptoms similar to an acute exacerbation of asthma,with stridor instead of wheezing, and will remain unresponsive to bronchodilators.

Management

Avoidance of the allergen by environmental controlSkin testing and hyposensitization to identified allergensRelief of symptoms by pharmacologic agentsTreatment by Classification

a. Inhaled anti-inflammatory corticosteroid (mild but persistent) b. Moderate persistent: A plus long acting bronchodilator at bedtimec. Severe persistent: B with higher doses of oral corticosteroids

Pharmacologic Treaments

a. Albuterol/terbutaline to be given before corticosteroid b. Metered dose inhalers (should be with spacers in children less than 12 years)

STATUS ASTMATICUS - FAILURE OF ASTHMATIC CHILDREN TO RESPOND TOBRONCHODILATORS AND THE ATTACK CONTINUES

Assessment

HR and RR are elevatedPO2 levels are lowPCO2 levels are high ACIDOSISLimited breath soundsConcurrent Pulmonary Infection

Management

BETA 2 Agonists and intravenous corticosteroidsOxygen Administration through face mask ET intubation with mechanical ventilation
http://en.wikipedia.org/wiki/Stridorhttp://en.wikipedia.org/wiki/Wheezehttp://en.wikipedia.org/wiki/Stridorhttp://en.wikipedia.org/wiki/Wheeze


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NERVOUS SYSTEM

3 4 WKS Neural Plate

8 wks EEG24 Ears can hear & Sight is present

HYDROCEPHALUSAn excess of cerebrospinal Fluid in the ventricles and subarachnoid spaces of the brain.

Causes: malabsorption of CSFexcessive CSF productionblockage in the pathway of CSF

Conditions that lead to obstruction:tumorsmeningitisencephalitis

Classifications:CongenitalAcquired

Diagnostic Tests:Prenatal: UTZCT scanTransillumination

Signs and Symptoms:becomes more evident during the first few weeks or monthsIncreased ICP

high-pitched shrill cry projectile vomiting (unassociated with feeding)change in LOCtense, bulging fontanel

Hyperactive reflexesHeadache


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Walking problems

Also:1. Prominent scalp veins2. Bossing of forehead

3. Separated suture lines4. Increased head circumference5. Sunset eyes

Management of Hydrocephalus Aimed at:

RELIEF OF VENTRICULAR PRESSURETREATMENT OF THE CAUSE OF VENTRICULOMEGALYTREATMENTS OF ASSOCIATED COMPLICATIONSMANAGEMENT TO PROBLEMS RELATED TO THE EFFECTS OF DISORDER

ON PSYCHOMOTOR DEVELOPMENTObjective:

to diminish the volume of accumulated CSF; done by means of a shunt

What is a shunt ?A drainage system which will transport the excess of CSF to other parts of the body(ABDOMEN and HEART) where it can be reabsorbed.

NURSING DIAGNOSIS:

Risk for ineffective cerebral tissue perfusion r/t increased intracranial pressure

Risk for imbalanced nutrition, less than body requirements r/t increased intracranial pressure

Risk for impaired skin integrity r/t weight and immobility of head

NURSING INTERVENTIONS

Lie the infant flat after shunt placementUpright position drains the CSF rapidly


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Assess for the following postoperatively:Signs of increasing ICPSigns of infectionSigns of developing meningitis

Reposition the head every 2 hoursManage pain properly

Crying increases ICP

NURSING ALERT

Brain stem herniation can occur with increased ICP and is manifested by opisthotonic positioning (flexion of head and feet backward). This is a grave sign and may befollowed by respiratory arrest. Obtain help, and prepare for ventricular tap. Haveemergency equipment on hand for resuscitation.

Caput Succedaneum: few days ; Cephalhematoma: few weeks

NEURAL TUBE DEFECT

Causes genetic predisposition: mothers who previously gave birth to a baby with spina

bifida Nutrition: low folic acid intake

Types Anencephaly Microcephaly

Spina Bifida

ANENCEPHALY Absence of cerebral hemispheres May have difficulty in labor Cannot survive due to lack of cerebral function


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Microcephaly SLOW BRAIN GROWTH Cognitively challenged Causes:

Rubella, cytomegalovirus, toxoplasmosis Severe malnutrition or anoxia in early infancy

Craniosyntosis

NORMAL BRAIN GROWTH but there is premature fusion of cranial sutures Assessment :

Abnormally closed fontanelles Bossing of the forehead Signs of increasing ICP

Management : Surgical remedy

Spina Bifida

S U B T Y P E S: Spina Bifida Occulta

Posterior portion of the vertebra fail to fuse


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Skin dimpling and tufts of hair Benign defect

Meningocele Protrusion of the meninges

Myelomeningocele Protrusion of the meninges and spinal cord

Encephalocele


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Myelomeningocele

Assessment UTZ, fetoscopy Increased alpha-feto protein (AFP) in amniotic fluid or in maternal serum

Infants with myelomeningocele void and defecate continually and cannotmove the lower extremities

Management

Spina bifida occulta Surgery is not necessary

Other types of SB Immediate surgery to replace the replaceable contents and prevent infection

Nursing Interventions

Protect the sac Avoid applying pressure Prevent from drying

Prevent infection Positioning

Prone Sidelying

Preserve skin integrity Plastic use

Placed below the sac like an apron to prevent contamination from feces andurine


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Ankyloglossia (Tongue-Tie)

PHYSICALLY CHALLENGED CHILDREN

Cleft Lip

Failure of fusion between weeks 5-8 More prevalent in boys Causes:

Teratogens Folic acid deficiency

Risk factors: Familial tendency Japanese

Assessment: absence of upper teeth and gingiva flattened nose

Unilateral Bilateral

Cleft Palate

Opening in the palate Failure of closure of the palate between weeks 9-12 Most often accompanied with cleft lip Can be assessed by depressing the tongue

Cleft Palate


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Cleft Lip and Palate

Management

Surgical repair after birth Revision at 4-6 yo Surgical repair at 6-18 months


Preop Period Teach mother to pump milk Have infant burp after feeding Offer small sips of fluid between feedings to moisten the mucous membranes

and prevent cracking

If surgery is delayed, teach to feed soft foods Preop Period

Teach mother to pump milk Have infant burp after feeding Offer small sips of fluid between feedings to moisten the mucous membranes

and prevent cracking If surgery is delayed, teach to feed soft foods


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TALIPES DEFORMITIES

Talus: ankle Pes: foot clubfoot The earlier the deformity is recognized, the better the correction will be. Correction is achieved with the use of casts

Changed every 1-2 weeks Check extremities for compartment syndrome

DEVELOPMENTAL HIP DYSPLASIA

- Improper formation and function of the hip socket

Assessment : (+) Ortolanis sign Asymmetric gluteal folds One knee is lower than the other

Diagnostics : X-ray MRI

Management : Multiple diapering Pavlik harness


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Spica Cast

Tracheoesophageal Fistula and Atresia

Weeks 4-8

Atresia: obstructionFistula: opening5 types

Assessment

Maternal hydramniosExcessive mucus in the mouth (appears to be blowing bubbles)Catheter insertion

X-ray, barium swallow, bronchial endoscopyCough, cyanotic, DOB during initial feeding


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Management

Emergency surgery to preventPneumoniaDHNElectrolyte imbalance

GastrostomyDrain food by gravity

Never push


Intravenous or Total Parenteral TherapyEarly introduction of fluidsPosition on right side/uprightFrequent monitoring

DIGESTIVE SYSTEM

6TH WEEK Intestines well formed10th week abdomen accommodates intestines

32 wks sucking and swallowing reflex present36 wks enzyme secretion for CHO/CHON


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DIAPHRAGMATIC HERNIA

Abdominal organs protrude into the chest cavity through a defect in the diaphragm.

Assessment : Respiratory difficulty at the time of birth Cyanosis and intercostal retractions Sunken abdomen Absence of breath sounds on affected lung

Management : High mortality rate 25% to 50% Emergency surgical repair Position: upright Kept on NPO Oxygenation and suctioning prn NGT insertion for decompression

PYLORIC STENOSIS

Pylorus : lower portion of the stomach that connects to the small intestine

Pyloric stenosis : Pyloric muscles enlarge, narrowing the opening of the pylorus and eventually

preventing food from moving from the stomach to the intestine

Assessment :


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Forceful, projectile vomiting Hungry and eats/nurses eagerly Milk vomited is curdled in appearance weight loss lack of energy fewer bowel movements constipation frequent, mucous stools

Management : surgical repair

HIRSCHSPRUNGS DISEASE

occurs when some of the nerve cells that are normally present in the intestine do not

form properly while a baby is developing during pregnancythe intestine can become partially or completely obstructed (blocked), and begins toexpand to a larger than normal sizethe problems a child will experience with Hirschsprung's disease depend on howmuch of the intestine has normal nerve cells present

Assessment : apparent at 6-12 monthsCannot pass stool by 24 hours of ageChronic constipationRibbonlike stoolsDistended abdomenThin and malnourished

Diagnostic Tests:Rectal examBarium enemaBiopsy

Management :Dissection, removal and anastomosisPermanent colostomy for absence of nerve endings in anus


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INTUSSUSCEPTION

Assessment :Intermittent abdominal pain and discomfortVomiting with bileBlood in stool, currant jelly appearanceAbdominal distention

Diagnostic test :Confirmed by UTZ

Management : Non-surgical

Instillation of water-soluble solution, barium enema, or air Surgery to straighten the invagination

CELIAC DISEASE

Malabsorption SyndromeSensitivity to GLUTEN (barley, rye, oats, wheat)

DEFINITION:

Inability to absorb fatDeficiency of ADEK vitaminsRickets may occur

Anemia, hypoprothrombinemia, hypoalbuminemia Northern European backgroundInherited illnessIncreased incidence in children with Down Syndrome

Assessment:Irritable and anorecticSkinny with wasted buttocksDistended abdomenSigns of malnutritionBulky, foul-smelling fatty stools (STEATORRHEA)

Diagnostic Tests:Biopsy of intestinal mucosaOral glucose tolerance testStool examResponse to gluten-free dietInterventions :

Lifetime intake of gluten-free diet Record stool characteristics Teach parents and children to recognize foods with gluten (BROW)


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Wheat flour, gravy, soups, sauces, pasta, cookies, cakes and pastries,hotdogs, frozen and packaged foods

CYSTIC FIBROSIS

Dysfunction of the exocrine glandsThickened and tenacious mucus secretions particularly in the lungs and pancreasMore salty sweatan inherited disease of the mucus and sweat glands; autosomal recessive geneaffects mostly the lungs, pancreas, liver, intestines, sinuses, and sex organssymptoms and severity of CF vary from person to personRespiratory failure is the most common cause of death in people with CF

With CF, the body cannot utilize the following enzymes

Lipase fatTrypsin proteinAmylase - carbohydrates

Highest priority: respirationDiet:

increased CHON, CHOModerate fatIncreased sodium

Pancrease: taken 30 minutes before ingesting a heavy meal, lifetimeADEK: once a day, lifetimeDx: sweat test, NaCl testnutrients (protein, carbohydrate, salts) leave the body unused, and one can becomemalnourishedstools become bulky and greasymay not get enough vitamins A, D, E, and K may have intestinal gas, a swollen belly, and pain or discomfort

KWASHIORKOR

1. A disease caused by PROTEIN DEFICENCY.


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2. Occurs most frequently from 1-3 yo3. Developing countries4. (Africa, Asia, Latin America)


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Assessment:a. Growth failure

b. Severe muscle wastingc. DEPENDENT Edemad. Ascites

e. Irritablef. Zebra signg. Diarrheah. IDAi. Hepatomegaly

Management - HIGH PROTEIN DIET

MARASMUS

Disease caused by deficiency of all food groups. STARVATION Developing countries Neglected children Younger than 1 yo Invariably hungry and will suck any object offered

Treatment

Supply a diet rich in all nutrients

DOWNS SYNDROME

most common chromosomal abnormality presence of three copies of chromosome 21 rather than the normal two copies Affected individuals most often exhibit mild to moderate mental retardation and have

characteristic facial and physical abnormalities, as well as possible congenital defectsin the cardiac, visual, gastrointestinal, and endocrine systems

Incidence is 1/800 to 1/1000 births, affecting all races, genders, and socioeconomicclasses

Incidence increases with increased maternal age, however 80% of affected babies are born to women under 35 years

There is no cure for Down syndrome


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CEREBRAL PALSY

Nonprogressive disorders of upper motor neuron impairment that result in MOTOR DYSFUNCTION.Muscle is poorly controlled due to BRENDA

Types:Spastic excessive tone in voluntary musclesAthetoid or dyskinetic abnormal involuntary movementAtaxic awkward wide-based gait

Signs and symptoms:May/may not move headPoor sucking and swallowingDelayed developmental task Preschool (signs of mental retardation)

Early Signs:At birth a baby with cerebral palsy is often limp and floppy, or may even seemnormal.

Baby may or may not breathe right away at birth, and may turn blue and floppy.Delayed breathing is a common cause of brain damage.Slow development. The child is slow to hold up his head, to sit, or to move around.He may not use his hands. Or he only uses one hand and does not begin to use both.

Feeding problems difficulties with sucking, swallowing and chewingDifficulties in taking care of the baby or young child


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pediatric assessment and fetal development with selected pediatric conditions

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