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What info do you collect in a pediatric health history?
Maternal history, biographic data, labor and delivery, present health status, and family history
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What does anxitey indicate?
Teaching need
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What is the approach you should take to the peds assessment?
- developmetnal readiness
- get acquainted time
- determine best exam place
- be systematic, yet flexible
- examine intrusive or painful areas last
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What is a newborn?
- Newborn- birth to 28 days
- Pre- term: <37 weeks
- term: 37-42 weeks
- Post-term- >42 weeks
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What are infants?
- Birth- 6 months: Immoblie, safety, comfort, sensory stimulation
- 6 months-12 months: Separation/stranger anxity, warm up play techniques, examine infant on parents lap if appropriate
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What is a toddler?
age 1-3 years, parent's lap provide security, play, least inrusive assessment first, avoid no responses, offer choices, and let touch equipment
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What is a pre-school age child?
age 3- 5/6, keep parent close, exam table, protect modesty, consider magical thinking, use safe words, let touch equipment
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What is a school age child?
age 6-10/12: Head to toe exam , address questions directly to child, give concrete explanations, answer questions honestly
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What is pre adolescent and adolescent?
- Pre- 10-12 years
- Adolescent: 13-18/21
- Confidentiality
- privacy (exam alone)
- Preventive services
- Issues: body issues, eating disorders, pregnancy, STD, violence
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What do you look for in the lungs and thorax for pediatrics?
- Tachypnea: rapid breathing
- Retractions: intercostal retractions- trouble breathing
- Dyspnea: SOB
- Grunting
- Faring
- Anxiety & air hunger
- Inspriatory stridor
- Second hand smoke
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What is the difference in a child's trachea?
It is higher and shorter so more respiratory problems
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What are signs of airway obstruction?
Restlessness, anxiety or agitation indicate hypoxia, increased HR and RR, stridor/retractions, pallor/xyanosis, avoid sedatives that deress repirations
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What are the differences in RR in children?
- Higher than adults go to 12-20 a min b/w 10-18 years
- Respirations should be counted for a full minute
- Assess when child is calm
- Infants/children under 7 are abdominal breathers
- BV in lungs when younger
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What is croup?
- Acute spasm of larynx resulting in partial airway obstruction
- Peak: 6 months-2 years, grow out of
- Cause: Viral
- Mild fever, inspiratory stridor, barking cough
- Give plenty of fluids
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What is epiglottitis?
- Medical emergency
- Severe inflammation of eiglottis that progresses rapidly
- peak: 3-8 years
- Bacterial
- High fever, trouble swallowing, cherry red color, severe distress, upper airway obstruction, DO NOT examine throat
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What is laryngotracheobronchitis?
- Inflammation of larynx, trachea, and bronchi.
- Predominately in infacts and toddlers
- Viral
- Gradual onset
- Labored inspirations
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What is pneumonia?
- Inflammation of bronchioles and alveoli
- Retractions, tachypnea, labored resps
- percussion: dullness
- vesicular BS change to Bronchial or BV
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What is the difference in HR of children?
- Higher HR than an adult
- In infants under 1 year take aprical pulse because radial pulse is difficult to palpate, count for a full minute
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What are normal BP in children?
- Birth to 1 year: 80/50
- 1 to 5 years: 90/60
- 5 to 10 years: 100-110/60-70
- 10 to 16 years: 110-120/70-80
- Measure annaully at age 3 and up
- use dynamap in infants
- use appropraite pediatric cuff
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What do you assess in a CV/PV assessment?
- -Apical impulse at 4th ICS left of MCL, by age 7 reaches 5th ICS at MCL
- -Heart sounds louder and more high pitched
- -Some children have physiologic murmurs, does not indicate disease
- -Assess peripheral pulse, especially newborns
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What do you look for in CV/PV history?
Growth patterns, clubbing, SOB, fatigue, suck reflex, having trouble keeping up with activity, murmurs, chest pain
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What do you look for in an abdominal assessment in an infant?
- Infant history: breast or bottle fed, spitting up, response to new foods, bowel movements, food allergies.
- Infants have a soft, round abdoment with slight protrusion- bowel sounds in center of abdomen
- -Diastatis recti- when crying, muscle seperation
- -Umbilical cord: 2 arteries, 1 vein
- -Liver palpable .5-2.5 cm below right costal margin for newborns, 1-2 cm below for infants
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What do you look for in an abdominal assessment in children?
- -24 hr diet recall, likes, dislikes, Pica- eating non-nutritional foods like stuffed animals
- -liver palpable 1-2 cm below right costal margin
- -Spleen 1-2 cm below left costal margin
- -Less palpable with age
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What do you look for in an abdominal assessment for an adolescent?
- -Eatting patterns, 24 diet recall, weight loss or gain, level of activity
- -laxative use, vomiting
- -View self as thin or overweight
- -Same assessment as the adult
- -Privacy issues with exam
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What are some eating disorders?
- Anorexia
- Bulimia
- OBessesd with food, weight, distorted body image
- Control issue
- Tooth decay, anemia, dry skin, hypotension, etc
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What do you look for in musculoskeletal in infants?
- Cranial bones soft at birth (soft sport)
- Sutures ossify around age 6
- assess for congenital birth defects
- Bones arent fused at birth
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What do you look for in musculoskeletal in children and adolescents?
- Children: Height, weight each visit, look at percentiles
- Assess gait, knees for alignment
- Toddlers have a wide stance which ends after 2.5 years
- Adolescents:
- Screen for scoliosis
- Injuries due to sports or trauma
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What do you look for in an infants lymphatic assessment?
- System develops at 20 weeks, very susceptible to infection due to inability to produce immunoglobulins
- Receive IgG from Mother through passive immunity
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What do you look for in a child lymphatic assessment?
increase b/w ages 6-9, larger than adults, shotty nodes 3mm to 1 cm in cervical and inguinal areas, small nontender nodes
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What to look for in a infant & pediatric HEENT
- Head: Symmetry of skull and face
- Neck: Structure, movment, trachea, thyroid, vessels, lymph nodes
- Eyes: vision, placement
- Ears: hearing, external ear, ear canal, and otoscopic exam of tympanic membrane
- Nose: nose and sinuses
- Mouth: Structures of mouth, teeth and phaynx
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Assessment of head: Infant
Head circumference: asses each visit for first 2 years of life Measure just above eyebrows, rapid increase in HC during first 3 months of life 34-35 cm at birth
Fontanels: Anterior 2.5-4 cm, close by 24 months. Sunken- dehydration, bulging: increased hemorrhage
Molding: cone head, overlapping of sutures due to pressure from birth. Resolves in a week
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What is caput succedaneum?
- Accumulation of fluid beneath scalp
- crosses the suture line
- Normal findings: resolves in 3-4 days after birth
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What is cephalhematoma?
- -Collection of blood and fluid beneath scalp, localized over one cranial bone, does not cross suture line
- Normal finding: take 3-4 weeks to resolve
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Assessment of the Face
- Assess for symmetry, twitching-should be none, tics, edema
- Assess expression
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Assessmentof the eyes
- Symmetry: outer canthus should align with pinna of ear
- Wide set or close eyes can indicate chromosomal problems
- Assess conjunctive for drainage
- 2-4 weeks: can focus on objects
- 3-4 months: coodination of EOM and follow objects
- 5-6 months: Follows peoples movements, plays with hands
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Visual acuity in children
- Gets to 20/20 at age 6
- Use E on snellen chart to assess vision until age 6
- Color vision age 4-8
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Assessment of the Neck
- Turns head side to side by 2 weeks of age
- Steady head control at 3-5 months
- Assess for short neck (Down Syndrome) or webbing (turners Syndrome)
- Head lag (poor neck control) after 6 months may indicate CP
- Assess shape and size of thyroid
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Oral Pharynx assessment
- Assess color, drainage, uvula size
- Tonsils
- Bed breath can indicate chronic sinusitis, infected tonsils
- Tonsils grow to maximum size between 2-6 years, can obstruct airway
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Nose Assessment
- Assess nasal patency
- Infants are nose breathers
- Nasal flaring is respiratory distress
- watery discharge with allergies
- Yellor or green discharge: infection
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Sinuses Assessment
- Maxillary and Ethmoid sinuses present at birth
- Frontal sinuse develops around age 7
- palpate and transilluminate
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Mouth Assessment
- Inspect mucosa, gingivae, tongue
- Assess for cleft palate
- Tongue movement
- Lips for color
- Salivary glands developed by 3 months
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Ears/Hearing Assessment
- 4-6 months- infant turns head to sound
- 6-10 months- responds to name and follows sounds
- Assess for hearing loss if decreased vocabulary
- Assess ears for abnormalities of auricle
- Low set ears- mental retardation
- Tragus and auricle pain: otitis externa
- To examine pull pinna down and back to straighten out until age 3
- hearing screenings at birth
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Neurologic Assessment
- Primary concerns: Reflex, posture, tone
- closely tied with developmental tasks
- voluntary control will take over as brain develops
- Functions develop in orderly process
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What are the soft signs in school-age children
- Signs are vague and conroversial
- Clumsiness, language distrubances
- delay in child to perform age specific activites
- continued presnce is a developmental delay or lag
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What are infant reflexes?
- Moro or startle
- Tonic: Head to one side, other side arm and leg up disappears 4- 6 months
- Palmer grasp: Disappers 3-4 months
- Step in place
- Babinski- Disappears at 18 months
- Rooting: disappears at 3 months
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Infant Skin
- Newborn red in color-decreased fat, vasomotor instability
- Covered with white wazy coating (Vernix Caseosa)
- Immediately after birth lips, nail beds, and feet may be cyanotic
- Temp regulation not develop
- Sub-Q fa layer is poorly developed
- Apocrine glands not active until adolescense-mid perspiration odor
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What are some infant skin conditions?
- Storkbites, Angelkiss- Vascular birthmarks
- Strawberry Mark- Immature hemangioma, slightly raised sharp demarcation 2-3 cm in diameter, disappear by age 5
- Cavernous Hemangiomas- reddish round mass blood vessels, may continue to grow until 10-15 months, regularly reassess
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Infant hair and nails
- Lanuago- soft fine hair on ears, shoulds, and back-sheds 10-14 days after birth
- Postmature infants will have long nails
- Tufts of hair on back of spine- spina bifida
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Children skin, hair and nails
- Bruising-inconsistent brusing with development= suspicion
- Common lesions associated with communicable diseases
- Varicella-Chickenpox
- Rubella, Rubeola, Roseola
- Tinea corporis
- Impetigo
- Pediculosis
- Scabies
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What is diaper Rash?
- Result of prolonged contact with urine and feces
- Can be fungal with lesions
- Treatment: If dry, wet it. If wet, dry it!
- Caldesene medicated powder or desitin cream
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What is Impetigo?
- Most common cause is Staphyloccus aureus, can be strptococcal.
- Predisposing factors; poor hygiene, antecednet lesions
- Occurs around the mouth and nose as oozing that becomes honey-crusted lesions
- Scratching will spread the infection
- Treatment: antiseptic soap/water, ATB
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What is Tinea corporis?
- Ringworm: superficial fungal infection that is most prevalent in hot, humid climates and children
- Transmitted by direct or indirect contact and is communicable as long as lesion is present
- Treatment: fungal cream or griseofulvin for systemic treatment
- Keep skin dry, avoid tight clothing
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What is scabies?
- Caued by mites that burrow under the skin to lay eggs
- Pruitus is caused by feces and ova
- Highly communicable and spread skin to skin
- Most common sites are the finger webs, wrists, and anticubial fossa
- Lesions are linear, threadlike, grayish burrows
- Treatment: Elimite cream applied and left on skin 8-14 hours head to toe
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Adolescent Skin
- Apocrine glands enlarge and become active
- Incresed sebaceous gland activity
- Have oiler skin
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Adolescent hair and Nails:
- Increased andrgoen levels
- Axillae adn pubic areas will develop coarse terminal hair
- Nails: same as adults
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Adolescents
- Tanner Stages- developmental assessment
- Asymmtrically-normal may resolve
- Gynexomastia- normal, resolves
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Should children warm up before sports?
Yes, if not many injuries can occur
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What is the most common disorder in babies?
Aorta problems
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What is the test used to assess development of a newborn/infant/child?
The Denver developmental Screening Test- tests approproiate milestones for a child's gross motor, language, fine motor, and personal social development
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What are the developmental stages of infants/newborns?
- Cognitive and Language development (Piaget)- Sensorimotor stage
- Moral Development (Kolberg)- Love and affection of the parents, follows them
- Psychosocial Development (erikson)- Trust v. Mistrust
- Psychosexual Development (Freud)- Oral Stage
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What is the APGAR scoring in Newborns.
- Check at 1 and 5 minutes after birth
- Score less than 8 may indicate poor transiton from intrauterine to extrauterine life
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Female Breast Development Rating
- Stage 1-5 based on Tanner
- 1: none
- 5: highest
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Male Genitalia and Public Hair Rating
- Stage 1-5, based on Tanner
- Stage 1: No hair
- Stage 5: Adult configuration, adult pattern hair
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Female Pubic Hair Rating
- Stage 1-5, based on Tanner
- Stage 1: No hair
- Stage 5: Inverse Triangle
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Developmental Stage based on Piaget from Toddler to Adolescents
- Toddler- Sensorimotor to Preoperational Stage
- Preschoolers- Preoperational
- School-age children: Operational
- Adolescents: Formal Operations Stage
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Moral Development by Kolberg from Toddler to Adolescent
Toddler- precoventional stage, punishment and obedience
Preschooler- preconventional stage, 10 years, external control
School-age child- role conformity-please others
Adolscent- postconventional, individual conscience and defined set of moral values
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Psychosocial Development by Erikson from Toddler to Adolescent
- Toddler- Autonomy versus shame and doubt
- Preschooler- initiative v. guilt
- School-age child- industry v. inferiority
- Adolescent- identity v. role diffusion
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Psychosexual Development by Freud from Toddler to Adolescent
- Toddler: Anal stage
- Preschooler: Phallic Stage
- School-age chld: Latency period
- Adolescent: Genital Stage
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