NRSG257 – EXAM REVISION
NRSG257 – EXAM REVISION
Children: 0-14 years of age
What are the major issues faced with children in health?
-	Preventable mortality
-	Vaccine preventable disease
-	Adult conditions which originate in childhood
-	Family and social functioning.
Injury – leading cause of mortality and morbidity after the first year of life. Asthma: is the most chronic illness in children and principal cause of hospitalization.
What morbidities are associated with children?
-	Birth defects – neural tube defects (spina bifida), structural defects and visual and hearing impairments.
-	Low birth weight - <2500 grams = 6.4% (very low birth weight <1500 grams =0.5%)
-	Prematurity - <37 weeks gestation
-	Childhood disability – (PKU, CF) early identification screening
Vaccines – prevent diseases
Adult conditions which originate in childhood:
-	Nutrition and physical activity – some children are becoming more overweight an less physically active = implications for future health planning
-	Exposure to sunlight – highest rate of skin cancer in the world
-	Oral health – fluoride has improved oral health
Family and social functioning:
-	Parents and carers – parenting has a profound and lasting impact on health, development and wellbeing
-	Mental health – affects 1 in 5 children and young people
-	Child abuse and neglect – the tip of the iceberg
Services in children’s health care:
-	Early childhood health services
-	Family carer centers
-	Residential family care services
-	Child and family teams
-	Child protection services
-	Hospital services
-	Children’s units in general hospitals
-	Children’s hospitals
-	Outreach programmes.
-	Young people become physically mature and capable of reproduction
-	Girls average is a two year lead on boys
-	BMI is one of the strongest indicators of timing of girls puberty
-	Female puberty usually takes 2-4 years to complete in the following sequence’ budding of breasts, growth spurt, menarche – first
menstruation, appearance of underarm and pubic hair and completion of breast development
-	The first sign of male puberty is the enlargement of the testes and changes in the texture and colour of the scrotum
-	Emergency of pubic hair and enlargement of penis
-	Soon after underarm air appears
-	Spermache usually occurs @ 13 years of age
-	Many boys have an initial period of reduced fertility
-	Facial body hair come later with the process of continuing slowly
-	Deepening of the voice
-	Menarche occurs after the peak of the height spurt that is once girls have nearly reached their mature body size
-	The sequences have clear adaptive value – menstruation is delayed until the girls’ body is large enough for successful childbearing.
Prevention of pregnancy and STI’s:
-	Adolescent decision making about intercourse with ot without protection is complex, factors include;
-	Socioeconomic conditions
-	Psychological factors
-	Peer relationships
-	Family values
-	Accurate knowledge of sex and sexual health can be challenging for adolescents
-	Sex education
-	Mothers are usually more effective communicators than fathers
-	Daughters receive more information than sons
-	Parents who do discuss sexuality openly with their children may reduce their risk of STD’s or unwanted pregnancy
Contraception and STI’s:
-	Low dose contraceptive pill
-	Prevention of STI’s is abstinence
-	Major physiological changes
-	Process of 206 days (38 weeks) from time of fertilization
-	Changes to all the maternal body systems that are controlled by hormones; human chronic gonadatrophin (HCG), human placental lactogen (HPL), oestrogens and progesterone.
-	Obvious changes are in the reproductive system; enlargement of uterus, softening of the cervix, enlargement of the vulva, growth and development of breasts
-	Hematological system
-	CV system
-	Respiratory system
-	GI system
-	Integumentary – gums.
Routine blood screening:
-	Blood group and determination of rhesus factor
-	Full blood count
-	Hep B
-	Rubella antibodies
-	Gestational diabetes
-	Down syndrome and other conditions (1st trimester maternal serum screening in combination with scan or 2nd semester maternal serum screening)
What complications are involved with pregnancy?
-	Spontaneous abortion – abnormal chromosomal complement, uterine or cervical abnormalities, maternal systemic illness, infection
-	Ectopic pregnancy – incidence of ectopic pregnancy increases, adolescents have the higher rate of mortality.
-	History of pelvic inflammatory disease (PID)
-	Use of intrauterine device (IVD)
-	History of pelvic surgery (previous ectopic pregnancy)
Medications in pregnancy:
-	Drug use in pregnancy should be restricted according to necessity
-	First trimester of pregnancy is the critical period for teratogenic effects
-	Folic acid recommended to reduce neural tube defects – 0.5 mg of folic acid/day beginning one month prior to conception until 12 weeks gestation.
-	Iron supplements are often recommended
What drugs are commonly administered in labour?
-	Synthetic oxytocin – induction of labour
-	Prostagalndins – cervical gel – ripening of softening of the cervix
-	Nitrous oxide – laughing gas
-	Pethidine – opiate antagonist naloxone or narcan
-	Epidural analgesia – wide variety of anaesthetic agents and doses
-	Lignocaine hydrochloride – with forceps or for suturing of the perineum
Adolescent prenatal care:
-	Unaware of pregnancy
-	Lack of understanding of the benefits of care
Mothers and unborn infants are therefore at greater risk for complications in pregnancy and birth such as;
-	Premature labour
-	Low birth weight and infants
-	High neonatal morbidity
-	Iron deficiency anaemia
-	Cephalopelvic disproportion (cpd)
-	Prolonged labour.
-	Pregnancies of adolescents <15 years of age have higher complication rates than those >15 years
-	Dietary habits
-	Substance use (particularly cigarettes)
-	Effects of poverty
-	Onset of prenatal care
-	Psychological development of maturing NUTRITION
-	Nutritional needs
-	Marked variation in dietary needs
-	Pregnancy adolescences continue to exhibit food preferences eating behaviours and lifestyle habits as non-pregnant peers; frequent snacking, high intake of fat and sugar, low intake of calcium, iron, zinc, folic acid and vitamins.
-	Pregnant adolescents should be encouraged to have a diet with sufficient nutrients to meet their own growth needs and that of their unborn child.
-	12-15 years – smaller stature and incomplete growth can lead to prolonged labour due to cephalo-pelvic disproportion (CPD)
-	Higher rates of interventions and caesarian births RESPONSES TO LABOUR AND CHILDBIRTH
-	Very young adolescents (<14 years of age) have fewer coping mechanisms and less experience to draw on than older adolescents
-	Cognitive development is incomplete, may have fewer problem solving capabilities
-	Ego integrity may be more threatened by the experience
-	May be more vulnerable to stress and discomfort
-	May be more child-like and dependent on others.
Adolescents often have unrealistic expectations for the infant in regard to;
-	Feeding breast or artificial feeding
-	Crying – how much is normal?
-	Ongoing demands of parenthood
-	Adolescents may need extra assistance from midwives initially to learn to care for their baby
-	Receive ongoing support when they return home from nurses
-	Many children of adolescents are raised by a grandparent
How do diagnose pregnancy? Serology – urine/blood Physical examination
Pelvic ultrasound or abdominal
4-	day-old neonate assessment:
-	Collect history of parents
-	Genetic factors
-	Home assessment – other children they’ll be living with
-	Physical mental health history
-	Past history or problems with pregnancy
Perinatal mental health:
Psychiatric diagnoses are 4 times greater in the perinatal period possibly due to
-	Adjustment disorder
-	Mood disorder
-	Personality disorder
-	Substance related
Tocophobia: is the fear of pregnancy or childbirth. Predisposing factors include;
-	Sexual abuse
-	Termination of pregnancy
-	Instrumental/operative birth
-	Foetal distress/severe pain
-	Perineal tearing
□	Consequences of having this can result in termination of pregnancy, sterilization.
□	Is to be assessed with hyperemesis gravidorum and depression, PND/AND and PTSD.
How do we predict postnatal depression?
-	Screen in pregnancy
-	30-40% of women with PND display symptoms in pregnancy
-	Routine screening – EPNDS (Edinburgh post natal depression scale)
-	Level of placental CRH (corticotrophin-releasing hormone @ 20 weeks gestation may help predict postnatal depression
-	Assess for non-biological risk factors and explore possible interventions
-	Low self-esteem, antenatal anxiety, low social support, negative cognitive style, major life events, low income, history of abuse etc.
1.	Psychological therapy and support
3.	Social support
4.	Complementary therapy PSYCHOLOGICAL THERAPY AND SUPPORT
-	Information support
-	Home visits PHARMACOLOGY
Need to balance against negative effects of maternal depression
Breast feed immediately before drug intake to minimize infant exposure to medication – when mothers plasma concentration is at its lowest. Give lowest effective dose of medication. Observe child for adverse effects. Consult healthcare provider to discuss whether breastfeeding should be continued.
-	Support groups
-	Indigenous support workers COMPLEMENTARY THERAPY
-	Infant massage, benefits all members of the family, including fathers
-	Exercise (to improve mood)
-	Distraction techniques
What are the effects of maternal depression on a child?
-	Low weight gain
-	Insecure attachment
-	Attention and arousal problems TODDLERS
-	Passive noncompliance
-	Less independence
-	Lower performance
-	Less interaction with others on verbal and memory tests
-	Less creative play CHILDREN
-	Impaired adaptive functioning
-	Depressive disorders
-	Anxiety disorders
-	Attention disorders
-	Lower IQ Adolescents:
-	Depressive disorder
-	Anxiety disorder
-	Substance abuse
-	Conduct disorder
-	Attention disorders
-	Learning difficulties
What mental health disorders are experienced in infancy?
-	Feeding and eating disorders
-	Pervasive developmental disorders
-	Relationship problems or attachment disorders
-	Anxiety disorders or separation anxiety
-	Motor skills disorder
What mental health disorders are experienced in childhood?
-	Parents often report ‘something is not quite right’ Externalizing behaviour:
-	Aggressive and delinquent behaviours
-	Under controlled behaviours
What mental health disorders are in adolescence?
-	First onset psychosis
-	Eating disorders
-	Mood disorders
-	Anxiety disorders
What are the different strategies to assist for mental health in young people, infants, childhood and adolescence?
-	The whole school model – focuses on the way schools enhance protective factors for students; working in partnerships, relationship building, promoting respect and supportive environments
-	Early identification and intervention for young people (12-25 years) at risk of developing MH problems, or those with drug and alcohol problems
-	Early intervention
-	Strengthening Medicare
-	Research and information – policy and planning, measuring progress The healthy for life program aims to improve the health of ATSI mothers, infants and children; and those affected by chronic diseases, through specific
activities in maternal and child health and chronic disease in over 80 sites across Aus. this program aims to develop a whole of life approach to break the cycle of poor health from childhood to adulthood.
How are fractures acquired in childhood?
-	Accidental injury; MVA’s, pedestrian, bicycle, skateboard, falls, playground equipment, sporting
-	Non-accidental injury
Note: childhood obesity increases the risk of fractures by 25% and complications associated with fractures. most fractures affect the upper extremities; the wrist, the forearm and above the elbow.
The characteristics of anatomical and physiological:
-	Young children have more cartilage than bone
-	Assification gradually occurs through to puberty
-	Thicker periosteum occurs through to puberty
-	Bone may bend instead of fracturing
-	Child may even be able to use a fractured arm and walk on fractured leg if the peritoneum is intact.
-	Healing is more rapid in children
-	Bone growth is still occurring
-	Rapid replacement of bone cells
-	High level of bone cells
-	High level of activity stimulates bone growth and remodeling
Fractures in children:
-	Children’s bones are more easily damaged than an adult by twisting, minor falls
-	Less bony so less force is required to cause fracture
-	Active mobility and lack of coordination contribute to frequency of fractures in children
-	Fractures are less likely to be accompanied by self tissue damage
-	They are not so obvious
Treatment for fractures:
-	Alignment depends on age; distance of the fracture from the end of the bone, the amount of angulation, the younger the child and the closer to the epiphyseal plate the greater the chance of deformity
-	Anatomic reduction
-	Maintenance of reduction until complete healing
-	Minimization of complications associated with the injury
-	And its treatment
-	The most important factors determining the outcome of treatment in these injuries as follows; age of the child, type of fracture, degree of displacement of the fracture fragments and length of time since injury
-	Closed manipulation/reduction, plaster immobilization
-	May need operating theatre for light anaesthetic
-	Muscle relaxant – to reduce muscle spasms which is more cause of pain Note: children put things down their casts and fear the plaster cutter on removal. What are the different types of fractures?
-	Open and closed
-	Vertebral compression What tool classifies fractures? Salter-Hams.
What is the weakest area in fractures?
Growth plates in long bones Weaker than supporting ligaments
Forces that would cause a sprain in an adult may cause a fracture in children Fractures can occur across physes (growth plate) epiphyses and metaphyses growth implications
What are the problems with X-rays finding children fractures?
-	Children’s fractures do not always show on x-rays as they have more cartilage than bone and sometimes an angulation shows.
-	A diagnosis is made on history and clinical sighs for e.g. point tenderness and deformity aswell as an understanding of typical fractures in children
-	The x ray will show as healing occurs and callous forms in 3-4 weeks.
What causes fractures in infancy?
-	Birth trauma (esp. clavicle)
-	Child abuse
-	Rough handling, twisting, pulling
-	Osteogenesis imperfecta
How is abuse indicated?
-	X-ray showing fractures at various stages of healing, periosteal bleeding in long bones, usually caused by rough handling, twisting and pulling of limbs
-	No explanation or hospital visit for injury, yet evidence on xray 3-6 weeks after injury
-	When callous has formed/healing occurred explanation of injury does not fit or is inconsistent with clinical picture
-	Ligaments are stronger than bones – mostly cartilage and balance on these even with fracture
-	Toddlers are not fully balanced- frequently fall even when running, leg may twist resulting in a fracture, non-displaced spiral fracture
-	Fall may not be witnessed- but child does not want to weight bear
-	Often no external signs and full range of motion- splinting or casting required
Fractures in older children:
-	Fractures forearm – from extending hand to break a fall e.g. skateboard, roller skates, running
-	Humerus and clavicle fractures from transmitted pressure/force up arm
-	Falls from heights – trees, roofs, playground equipment, car and bicycle accidents and may result in lower limb fractures
-	Femoral shaft fractures
Compartments are anatomical groups of muscle, nerve and blood vessels confined with inelastic boundaries such as muscle, skin bone and especially fascia.
Intra-compartmental pressure can be raised by;
1.	Increase in compartment content (bleeding, swelling)
2.	Decreasing in size of compartment
bleeding or pressure from another area into the compartment surrounds, including pressure from bandages plaster
pressure results in severely decreased blood flow that potentially threatens damage to and necrosis of surrounding soft tissue or renes
if oedema and further increase in pressure a fasciotomy may be necessary to prevent further damage.
Who is at risk of compartment syndrome?
-	Children who have had open fractures
-	Crush injuries
-	Vascular problems
-	Patients with altered pain perceptions
2.	Passive motion
3.	Paralysis – lack of ability to flex or extend toes or fingers
4.	Paraesthesia – numbness or tingling
5.	Pallor – indicating coldness. Pulselessness is considered a late/unreliable sign – the damage is already done
Signs and symptoms of compartment syndrome:
-	Agitation, anxiety and increasing analgesia
-	Deep throbbing and unrelenting pain
-	Pain seems out of proportion to the degree of injury
-	They never completely settle, even after narcotic pain relief
-	They look anxious
-	Non-verbal body language says “don’t even think about touching my arm, let alone asking me to move my fingers”.
What are the different types of pharmacology of analgesia in children?
1.	Non-opiod analgesic
–	Indication mild to moderate pain
-	Can be used in conjunction with opiod medication for moderate to severe pain to decrease opiod analgesics
-	Has an antipyretic effect
-	Have a ceiling effect
-	Do not product tolerance or dependence
2.	Opioid analgesics
-	Opioids are indicated for moderate to severe pain that is not relieved by non-opioids
-	Have no antipyretic effect
-	Can be titrated up until pain is relieved
-	Common side effects include; urinary retention, constipation, nausea and vomiting pruritus and resp depression.
3.	Adjuvant therapy Includes medications such as;
-	Oral analgesics
These drugs can contribute to pain management by exerting an analgesic effect of their own or reducing/treating the side effects of analgesics or potentiating the effects of analgesics. Or a combination of these actions.
Note: consider levels of drugs used for levels of pain strong medication for “big” pain. WHO analgesic ladder – severe, moderate to severe and mild to moderate Paracetamol:
-	Paracetamol is still considered the safest analgesic drug use for children
-	Dose of 15/kg
-	Hepatoxicity is a constant concern – therapeutic dose and max daily dose must be observed. Minimum of 4 hours between dose is important but usually only 4 doses per day
-	Maximum 90mg/kg/day for 48 hours
-	Adequate hydration nutrition also important
Ibuprofen similar class to aspirin (NSAIDS) they have gastric bleeding potential Note: aspirin not recommended for use in children
Complications with children and medications:
-	Immature hepatic enzyme production and action – reduced capacity to metabolize drugs in early infancy, then enhanced metabolism in late infancy toddlerhood. May need higher doses of pain medications but less frequent doses and may have greater effects of some drugs.
-	Hepatic toxicity – Paracetamol metabolism via a major pathway in liver. Depends on sufficient liver enzymes to bind up the metabolites so they can be excreted in urine. Otherwise minor pathway is used and can result in build up of toxic metabolites.
-	Young children have less hepatic enzymes so dosage is extremely important with Paracetamol, amount given in any 24 hour period is important.
-	IV route for pain is the best practice for hospital situation
-	Infusions are well tolerated
-	Monitoring important and PCA
-	Nurse controlled analgesia
-	Regular pain assessment
-	Use of non-pharmacologic strategies
Routes of administration in children:
-	Oral NGT/PEG
-	Sublingual or buccal
-	Inhalation (MDI)
-	OHC – parenteral
-	Play therapy
-	Music therapy
-	Clown doctors
-	Guided imagery
-	Aromatherapy and essential oils
-	Heat/cold application
-	Therapeutic touch
-	Herbal therapies
-	Cuddling and wrapping to calm infants
Side effects of Opioids:
-	Decreased resp rate then resp depression
-	Sedation, sleepiness
-	Pinpoint pupils
-	Muscle rigidity
-	Urinary retention
-	Nausea and vomiting
-	Delayed gastric emptying
-	Constipation IMPORANT TO CONSIDER:
o	Immature renal system – filtration, re-absorption and secretion. Drugs are excreted slowly and erratically. Toxic levels may be reached if excretion is slow.
o	Immature blood brain barrier in young children- blood braid barrier more permeable, faster uptake into the CNS
o	Plasma protein binding – reduced plasma protein-binding capability and affects distribution of drugs.
Physical safety: unintentional preventable injury is leading cause of paediatric mortality and a significant cause of morbidity including permanent disability.
Injury is age specific.
Injury prevention programs:
-	Changes to legislation with regard to boating laws
-	Council run playgrounds –review of equipment in playgrounds and soft fall
-	Pool safety
-	Swimming surf lifesaving
-	Slip slop slap – skin cancer
-	Child car restraints
-	Road safety
-	Compulsory bike helmets
-	Council regulated skate parks
-	Stranger danger education
-	SIDS prevention
-	Home injury prevention
-	Changes to clothing labeling with regard to fire resistance
-	Changing of packaging for medication and child safety lids.
Child abuse and neglect:
-	Reported cases of child abuse are the tip of the iceberg.
-	Child abuse can be categorized into 4 categories; physical abuse, neglect, emotional abuse and sexual abuse.
Indicators of Abuse: Child’s behaviour
-	Increase in emotional problems
-	Poor school performance
-	Difficulty in development
-	Regression in development
-	Resumed thumb sucking
-	Bed wetting
-	Abrupt changes in behaviour
-	Was outgoing no withdrawn
-	Changes in eating habits
-	Delay in seeking attention
-	Distance travelled to reach hospital
-	Story not consistent
-	Claim tripped over but has a compound fracture and multiple contusions.
Assessment of child abuse:
-	Suspicious findings
-	History foes not match existing injury
-	Caregiver reluctance to give information
-	Caregiver blames child for injury
-	Delay in seeking treatment for significant injury
-	History inconsistencies
-	Repeated child injuries or hospitalizations
-	Presentation at multiple medical facilities in the same area
-	Response does not match severity of injury
-	Previous foster care or child protection orders
-	Accurate reading – to allow comparison of stories
-	Factual – to minimize misconception
-	Non-judgmental- you may be wrong
-	Verifiable- don’t interview alone- have a third person
-	Written and photographic recording
-	WHO convention – rights of the child
-	National and state legislation
-	AHPRA code of professional conduct
-	AHPRA code of ethics
-	Social obligation and social responsibility
-	Cultural obligation
-	Our own ethical and moral values
Types of Physical injury:
-	Head trauma
-	Ocular injuries
-	Abdominal trauma
-	Munchausen hyproxy
-	Cutaneous lesions – contusion, abrasion, laceration, bite marks, size, shape, location and pattern are indicators of non-intentional vs. intentional injury
Neglect as a form of abuse can take many forms
-	Inadequate hygiene
-	Inappropriate attire
-	Inadequate supervision
-	Inadequate healthcare
-	Exposure to interpersonal violence
-	Exposure to environmental hazards
-	General apathy
There is a psychological component to all forms of abuse
-	Emotional child abuse – “any act by a person having the care of a child that results in the child suffering any kind of significant emotional deprivation or trauma. “Also includes children exposed to family violence
-	Spurning behaviour
-	Terrorizing behaviour
-	Isolating behaviour
-	Exploiting and corrupting behaviour
-	Denying and ignoring social responsiveness
-	Educational neglect WEEK 7
Growth and development:
-	Over a lifetime
-	Growth, maturation, differentiation and development
-	Physiological and biological changes
-	Child development – birth to adolescence.
Which growth chart is used to determine development?
In Australia we use the WHO growth chart as it includes breast-feeding data, recommended for infants 0-24 months. Every child is given a growth chart. Why do we use this chart?
Promotes public health, health checks, immunization status and follow up record. Diversity in family for e.g. mauri big bones compared to Vietnamese child. Data collection, inter-professional communication, parent information, facilitates communication and each state and territory has slightly different versions.
Why we use BMI?
Childhood obesity – indicates overweight and obesity, appropriate weight and if BMI changes.
How to calculate BMI?
Height (metres) BMI = Wt/Ht^2 Dentition:
Another form of growth. The eruption of first teeth.
What are the 5 aspects or avenues for growth and development that nurses measure in paediatrics?
Height, weight, BMI, head circumference and dentition.
What are the stages of development?
-	Early childhood
-	Middle childhood
-	Later childhood/adolescence
Milestones = which development stage.
Fine motor skills:
1-3 MONTHS – reflex grasp
3	MONTHS – brief hold of toy
4	MONTHS – rattle, hand together and reach and miss objects 5 MONTHS – grasp objects, splash and crumple
6	MONTHS – bottle, feet and toes
7	MONTHS – toy transfer, bangs table, in mouth
9 MONTHS – grasp small objects, between thumb and finger 10 MONTHS – points lets go
11	MONTHS – give but not release
12	MONTHS – give and releases, rolls ball and starts with crayon
15 MONTHS – two blocks lower, throws objects, starts to remove clothing,, shoes off first
18 MONTHS – three block tower, starts self spoon feed, turns 2-3 pages and scribbles on paper
2 YEARS – 6-7 block tower, turns door knobs and jar lids wash and dry hands
Spoon and fork
2 ½ years – 8 block tower, pencil between fingers
This is good early identification to show left side and right side of the body works.
Gross motor skills:
0-1 MONTHS – lift head up, strengthen neck 2 MONTHS – chest goes up
4 MONTHS – hold head up when sitting position if you let go they’ll fall back 5 MONTHS – full head control in sitting position themselves
10 MONTHS – to stand sitting crawling position.
Look for differentiation, if by 15 months they are not walking you realize something is wrong.
18 MONTHS – walking well, can pull toy, runs climbs stairs holding on, may walk backward
2	YEARS – kicks ball, up and down stairs, 2 feet per step
2.5 YEARS – jumps with both feet, jumps off step and tiptoes.
3	YRS – Upstairs one foot per step, stands on one foot briefly rides tricycle and runs well
4	YRS – skips on one foot per skip, throws ball overhand, jumps a short distance from standing position
5	YEARS – hops and steps, good balance, can skate or ride a scooter
Speech and Language:
2 MONTHS – coos, different cries 3 MONTHS – laughs
4	MONTHS – talkative
5	MONTHS – simple vowels 6 MONTHS – vowel sounds 9 MONTHS – 1st word
10 MONTHS – 2nd word 12 MONTHS – 4 words
15 MONTHS – 4-6 words
18 MONTHS – 7-20 words
2 YEARS – 50 words, 2 word sentences
2.5 YEARS – knows name, 1 colour 3 YEARS – 900 words, question
4	YEARS – 1500 words, imitates
5	YEARS – 2100 words 6 YEARS – full sentences
Boys are slower at developing speech then girls.
Types of Play:
AGE	PLAY TYPE	EXPLANATION OF THE STAGES OF PLAY DURING
0-2 years	Solitary	Plays alone, limited
2-2.5 years	Spectator	Observes other children
2.5-3 years	Parallel	Play alongside others but
3-4 years	Associate	Starts to interact in play. Fleeting, co-operation in play. Develops friendships and preferences for playing with particular children.
Play usually in mixed sex groups
4-6 + years	Co-operative	Plays with others with shared aims of play. Play may be quite difficult, supportive of other children in play. At primary school age, play is usually in single sex
What are the theories to growth and development?
Freud Erikson Piaget
What are the theories of psychosexual development?
Sigmund Freud – theory of psychosexual development
Personality – structure of three parts i.e the ID, the Ego and the superego. Stages;
-	Oral (infant)
-	Anal all pleasure is derived from anus, toileting (early childhood)
-	Phallic centered sexual energy relationship between parents, friends attraction of sex (end of early childhood),
-	Latency identify same sex parent (middle childhood)
-	Genital sexual maturation away from parenteral onto long-lasting relationships (adolescent)
Erikson’s theory of development:
Infant – 65+
Trust vs. mistrust infant
Shame and doubt toddler (autonomy) Guilt vs. initiative pre-schooler Inferiority vs. industry school ager Role confusion vs. identity adolescent Isolation vs. intimacy young adult Stagnation vs. generativity middle age Despair vs. ego integrity older age Piaget’s theory of development:
4 stages through observations and child’s view on the world. 1st SENSORIMOTOR STAGE
-	Use of reflexes
-	Primary circular reactions
-	Secondary circular reactions
-	Coordination of secondary schemes
-	Tertiary circular reactions
-	Mental combinations 2nd PREOPERATIONAL STAGE
-	Transductive reasoning
-	Magical thinking
3rd CONCRETE OPERATIONAL STAGE
-	Understands concepts and sub-concepts
4th FORMAL OPERATIONAL STAGE
-	Abstract thoughts
-	Thought processes
-	Hypothetical problems
-	Past, present and future
Measuring height and weight:
-	Physical assessment
-	G=Growth monitoring
-	Medication calculations
-	Hydration requirements
-	Body surface area
-	Weight estimation formula (>1 year) (age +4) x2 – if they come in ED and no one knows weight we use this formula.
Always need to measure and document baseline and ongoing assessments
-	Weigh naked
-	Same scales
-	Monitor significant loss or gain
-	Chair scales
-	Stand on scales
-	Routine assessment
-	Body surface area
-	Tape measures (emergency etc) feet bare and pushed up against the wall
-	May indicate abnormalities WHY?
-	To check for hydrocephalis – large amounts of CSF
-	Macrocephaly – enlarged head
***Must document or else it never happened***
Who is impacted from the effects of hospitalization?
-	Parental income
-	Severity of condition important factor WEEK 8
What is the function of the respiratory system?
The primary function of the respiratory system is gas exchange. Inhalation of air containing oxygen and expiration of carbon dioxide.
Respiratory anatomy and physiology:
-	Cellular respiration- at a cellular level, energy in glucose is used to produce adenosine triphosphate (ATP) a multi-functional nucleotide, used by enzymes for cellular processes such as cell division
-	External respiration occurs in the lungs and involves the exchange in gases in the blood and lungs
-	Internal respiration refers to body tissue gas exchange. CO2 in cells is exchanged for 02 in blood
What do the 5 steps of respiration involve?
1.	Pulmonary ventilation – breathing
2.	External gas exchange/respiration. O2 absorption from air to blood and movement of Co2 from blood to air. External and is outside of the body
3.	Gas transport – transport of o2 from lungs to tissues through blood and transport of Co2 from tissues to lungs through blood.
4.	Internal gas exchange/respiration. Transfer of o2 from blood to body cells and transfer of Co2 from cells to blood. Inside body cells.
5.	Cellular respiration – o2 uptake and Co2 production by body cells to generate ATP.
-	Nasophraynx – 4mm airway (child) meaning its really easy to occlude that airway mucus, snot etc resulting in partial obstruction.
-	Lymph nodes/tonsils – extremely large increases bleeding and post op tonsillitis, anything that can get swollen can also get occluded.
-	Everything in child is smaller and needs time to develop usually at 12 years.
Upper airway structural differences:
-	Tonsils and adenoids in children trap foreign bodies and particles and prevent them entering the respiratory tract
-	Tonsils, located either side of oropharynx and adenoids are located either side of nasophraynx
-	They are normally larger in children and will atrophy (wastes away or gradually declines) as the child approaches their 12th year of age
-	Childs trachea smaller and will generally increase in length and diameter in the first five years
-	Bifurcation angle in children is more acute
-	More flexible cartilage supports the child’s trachea
-	Head positioning may compress airway
-	Narrow area increases resistance – hence common affected by infection and inflammation
-	Humans are nose breathers until 4 weeks old unless crying – important of nasal patency
-	Trachea shorter and narrower than adult hence greater risk of obstruction.
Lower respiratory structural differences between adult and child:
-	Lower respiratory tract in the child continues to grow after birth
-	Full term newborns have 25 million alveoli compared to 300 million in adults but still have sufficient gas exchange capabilities
-	Adult bronchi and bronchioles have smooth muscle to trap particles in air, unlike the newborn buy by 5 months there is sufficient smooth muscle to react (coughing, bronchospasm)
-	Alveoli infected means gas exchange impaired which is the ability to breathe gets reduced
-	Left lobe thinner and longer than the right
-	Left lung superior to fit in the heart. Is superior and inferior lobe concavity and than cardiac notch.
-	Almost fills the thoracic cavity
-	Two lungs – asymmetrical due to other thoracic structures i.e heart occupying space on left side of thorax, liver occupying space of the right
-	Right lung contains superior middle and inferior lobes
Lower respiratory tract:
-	The bronchi are passages that filter air to and from the lungs.
Anatomically they have cartilage and mucous glands in their walls as well as ciliated epithelium
-	Are air passage to and from alveoli
-	Anatomically they have no cartilage or mucous glands but are smooth muscle
-	Lined with ciliated epithelium like the bronchi
-	Continuously branch into respiratory bronchioles then alveolar ducts then alveoli
-	Then bronchus and bronchioles is the conducting portion of the lung
Respiratory function in children:
-	Higher oxygen consumption in children – this increases in times of respiratory distress
-	Rapid muscle fatigue can occur due to lack of muscle glycogen reserves when child is in respiratory distress
Differ from adults
-	Respiratory anatomy underdevelopment until 12 years of age
-	Respiratory system can easily become compromised
-	Intercostal muscles and diaphragm perform the work of breathing
-	Children have a higher metabolic rate
-	Children with higher resp rate have increased glycogen reserve
Airway assessment findings:
-	The rapid release of gas at the end of expiration is called grunting
-	Common in neonates with decreased lung function
-	Immature intercostal muscles promote diaphragmatic breathing in children under six. More effectively used after 6 years
-	Flexible ribs (cartilage)
-	Retractions in respiratory distress – diaphragm movement causes negative pressure and thoracic wall is drawn inward.
What are the common paediatric respiratory conditions?
-	Asthma – also known as reactive airway distress. Where symptoms are a consequence of an external trigger
-	Croup – an upper airway condition caused by parainfluenza RSV, adenovirus and characterized by a stridor and barking cough
-	Hyaline- Membrane syndrome – also known as respiratory distress syndrome. Normally seen in premature babies with underdeveloped lungs
-	Bronchiolitis – a lower respiratory infection caused by RSV and characterized by increased work of breathing, decrease in oral intake lethargy, mottling and wheeze. Diagnosed in infancy and has similar symptoms as asthma
Auscultation of breath sounds:
-	Normal vesicular breath sounds
-	Bronchial breath sounds
-	Bronchovesicular sounds
-	Early inspiratory crackles
-	Atmospheric oxygen is 21%
-	Atmospheric co2 is 0.02%
-	Atmospheric nitrogen is 79%
-	Other trace gases include argon, neon and helium
-	The atmospheric gases aid in human respiration as they influence oxygen uptake. Respiration is influenced by atmospheric pressures
-	Diving, mountain climbers, flying etc will effect pressures hence ventilation and gas exchange.
Complications of respiratory system:
-	Respiratory acidosis
-	Respiratory alkalosis
–	A build up of carbon dioxide makes body very acidic. Acid-base balance of the body is disrupted.
–	Chronic – kidneys will produce bicarbonates to restabilize the body’s acid base balance hence stabilizing.
–		Acute – dangerous due to rapid acidity and kidneys unable to produce the stabilizing chemicals.
–	Causes – asthma, COPD, narcotics, scoliosis.
–	Symptoms; fatigue, lethargy,. Shortness of breath, confusion, shock
–	Diagnosis through chest x-ray, ABG’s (arterial blood gas) and lung function test.
–	Treatment – bronchodilators, CPAP, BIPAP (bilateral), o2.
-	Excessive breathing causes decreased levels of co2 in blood
-	Caused by anxiety, fear and hyperventilation
-	Symptoms include dizziness and peripheral numbness
-	Diagnosis – chest x-ray, pulmonary function tests and ABG’s
-	Complications vary, seizures may occur
-	Treatment – treat the underlying problem, rarely life threatening unless pH 7.5. Conservative treatment is to get person to breath into a paper bag
-	Less common in children then acidosis.
Is a respiratory condition characterized by coughing, wheezing and breathlessness caused by the inflammation and narrowing of the bronchioles. Hypersensitivity response of the bronchioles to an external trigger.Triggers are something we come in contact with.
-	Most common cause of hospital admissions for children
-	Many triggers
-	Research indicating genetic links
-	Sometimes difficult to diagnose depending on age of patient.
□	Hypersensitivity to the trigger causes oedema sometimes mucus production and as a result bronchoconstriction – limits the amount of air able to pass through for gas exchange into alveoli.
□	Bronchoconstriction will limit the amount of air hat is able to pass through for gas exchange into the alveoli, which is where gas exchange occurs, if there is bronchoconstriction gas exchange will be limited. Homeostatic response in our body and that is where the body starts to say hang on, gas exchange impaired lets
set off intercostal muscle to maximize oxygen uptake that’s where we see laboured breathing- not getting enough oxygen and homeostasis takes over.
□	Asthma, hayfever, eczema and allergies go hand in hand is a immunological response to external trigger.
What triggers are involved with asthma?
-	Cold air
-	Viral infections’
-	Food additives
-	Allergens e.g. dust mite, pollens and mould
-	Cigarette smoke
-	Physical activity
What are the manifestations of asthma?
-	Increased work of breathing
-	Accessory muscle use – rib retraction, intercostal and substernal recession, tracheal tug, nasal flaring
-	Colour changes
-	Skin temperature- peripherally - need blood to pump to warm essential organs
-	Mental status changes – lethargic, confused, agitated from not getting adequate supplies of oxygen to the brain
-	Non-productive cough that can become productive
-	Decreased oxygen saturations
-	Abdominal pain (excessive use of these accessory muscles)
-	On auscultation a wheeze is present but can also be audible without a stethoscope
-	Silent chest – auscultate and don’t hear a single sound means not getting any breath complete indicating complete obstruction
How is one diagnosed with asthma?
-	Can be difficult to diagnose in children
-	A wheeze is a symptom of asthma but can be a symptom of other conditions such as bronchiolitis
-	Usually not diagnosed as asthma under 6 years old
-	Despite a positive response to salbutamol, paediatric specialists are moving away from asthma diagnosis on first presentation
-	Assessment includes a history of nighttime respiratory symptoms and spirometry. – Temperature drops at night meaning cold air.
-	The impact on a child’s daily living depends on asthma severity
-	Management is essential is maintaining quality of life as asthma can impact on where the sufferer can work, their living environment or their ability to participate physical activity.
-	Medication is an important part of asthma management
-	Asthma medication consists of a combination of reliever, preventer and anti-inflammatory medications in the steroidal and non-steroidal families. Each child is individually assessed and prescribed medications that meet their requirements depending on the severity of their condition.
-	Bronchodilator - PRN and acts within 5 minutes, has a 3-4 hour half-life. Side effects include; hyperactivity and tachycardia. Some report rigors, headache and palpitations, tachycardia. You can’t overdose on this.
-	If asthma is diagnosed this medication should be distributed to all care givers and one kept with the child with their volumatic spacer
-	The common brands of salbutamol include; Ventolin, respolin, asmol.
Works on relaxing the bronchiole muscle and preventing bronchospasm.
-	Other reliever medication take longer to act but can last upto 12 hours.
-	Anticholinergic – atrovent.
-	Methelpred- aminofolone
-	Prednisolone, redipred, predmix
-	Daily dose of 2mg/kg first doe then 1mg/kg for 2 more days in an exacerbation
-	Allows the bronchioles to respond better to Ventolin by reducing inflammation and oedema
-	Side effects include; hunger, weight gain, some swelling and mood swings
-	Intal, intalforte and Tilade are inhaled non-steroidal preventers that help prevent exacerbations of asthma induced by physical activity.
-	Liquid form
-	Singulair comes in a chewable tablet and is also non-steroidal
-	Becotide, becloforte, respocort, pulmicort, flixotide, qvarare corticosteroids and can cause oral thrush and a sore throat. Advised to mouth wash after use
-	Use of a volumatic spacer can also reduce a chance of these side effects
-	Preventers should be taken daily regardless of symptoms and is discussed with the health professional as part of asthma management plan.
Acute exacerbation of asthma:
-	asthma is treated depending on the severity
-	a respiratory assessment and vital signs are essential first line management
-	the objective of acute exacerbation of asthma treatment is to slowly reduce the frequency of reliever administration. Children are generally kept in the ED until they are stable and they do not require the reliever medication more frequently than hourly
-	Oxygen may also be given if respiratory status requires
-	Initial treatment consists on administration of prednisolone (2mg/kg) and Ventolin therapy x3 in an hour and then re assess. Children under 6 are given 6 puffs of salbutamol per dose and children over 6 are given 12 puffs of Ventolin per dose.
Emergency – Resus:
-	Severe exacerbation
-	Symptoms include; confusion, exhaustion, inability to speak, Spo2 below 90% and marked accessory muscle use and tachycardia.
-	If o2 92% means not good.
-	Children must be stable
-	Respiratory assessment continues and delivery of inhaled medication is weaned
-	When the child is comfortable at intervals of four hours between reliever doses they can be discharged home with education and an asthma management plan
-	Prednisolone should be continued upto three days and as prescribed
-	Adolescents can silently and rapidly deteriorate, therefore must be monitored closely- they sometimes take longer to recover especially if they have a long history of hospital admissions for asthma. Also more obvious signs of extended steroid use can be noted.
ANMC code of conduct in paediatrics:
-	Speak to them alone
-	Ask open ended questions
-	Show concern for their point of view
-	Use non-threatening appropriate language
-	Start with less sensitive issues then proceed to more sensitive issues Nurses are the “face” of health and health professionals because they are in the front line, and so hear and see more. Nurses are privy to extensive patient and family information such as;
-	Financial information
-	Relationship problems
-	Parenting issues
-	Child behavioural problems
-	Family dynamic and structure
-	Hands off approach to assessment
-	Establish rapport with child and family
-	Use distraction therapy to assist in establishing trust with children, for e.g. bubbles
-	Use a doll/teddy to demonstrate procedures
-	Place parents at ease by appearing confident and in control
-	Process observations with information received to draw conclusions
-	Allow the child to have some control where possible
-	Communication is very important
-	Active listening to parents/carers concerns helps them feel they can trust you
-	Always address the child and the family, even if the child is an infant and directly address school age children and adolescents
-	Explain to parents prior to treatment for parents to be at ease and then the child will be
-	Give control to the child
Stages of development:
o	Prenatal – in utero
o	Neonatal – 0-28 days
o	Infancy – 1-12 months
o	Early childhood – 1-4 years
-	Toddlers – 1-13 years
-	Preschool 4 years
o	Middle childhood – 5-12 years
o	Adolescence – 13-18/20
The hospitalized child:
-	Disruption for child and family from day to day activites increases stress and pressure on family unit – financial, emotional, social and physical
-	Effects on development
-	Separation anxiety;
Phase 1 – protest – crying, anger, kicking, hitting out Phase 2 – despair – regresses less developed state
Phase 3 – detachment – detaches themselves from parents may not want to go back to parents
-	Loss of control – in child’s life
-	Finance – who is going to pay the bills?
-	Distance – can the rest of the family come too?
-	Parenteral relationships – finding time for each other
-	Siblings – a range of reactions
-	All families grieve for loss of normality
-	Stages of grief – Kubler ross;
Denial anger, bargaining, depression and acceptance
-	Different for everyone
-	Back and forward
-	Regression if condition worsens
-	Severity/length depend on condition and persons ability to adapt
AGE	HEART RATE/MIN	RESP RATE/MIN	AVERAGE BP
6months	100-150	45	90/60	37.5
6 months – 3 years	80-120	30	90/60	37.5-37.2
4-7 years	90-110	25	95/70	36.8-37.0
8-10 years	60-95	20	100/70	36.7-36.8
11-12 years	60-85	20	105/75	36.5
-	Hands off
-	Observe first
Activity level, interaction, position, colour, use of accessory muscles and respiratory rate
-	Touch second
Auscultation, percussion, Sao2 with fingers toes or ears.
-	Mental state of patient – confused, lethargic,
-	Pale, use of accessory muscles increased sound, rhythm, rate and depth
-	Colour – if dark skin then assess mucous membranes
-	Level of activity – e.g. sleeping more than developmentally appropriate
-	Pulses – not just radial
-	Capillary refill – should be instantaneous
-	Blood pressure – remember to assess if required
-	Children under 5 yrs are rate dependant
-	Apical location changes as child grows
-	<7 yrs located at 4th intercostal space, just left of the midclavicular line on the left side
-	>7 yrs located 5th intercostal space at midclavicular line on the left side
-	Intensity/amplitude – 0. Absent pulse 1. Weak and easily obliterated 2.
Normal easily palpable 3. Full pulse 4. Bounding and easily visible
-	Upper arm or lower leg
-	Little difference for young children
-	BP cuff should cover 2/3 of the part of the limb
-	Upper arm 2/3 distance from elbow to shoulder- arrow over cubital fossa
-	Lower leg 2/3 of distance from knee to ankle, with the arrow over outer ankle
Neurological – Glasgow Coma Scale:
-	Specific for children language they can understand
-	Seek guidance from parents for a correct response
-	Appropriate for developmental age
-	FLACC pain assessment tool <2 years - behavioural; faces, legs, activity, cry consolability
-	Numerical (careful with phrasing); 0-10
-	Various pictorial descriptor scales
-	Children can have cows milk after 1 years of age
-	Should have full cream milk until atleast 2 years of age
-	Toddlers are grazers
-	Acknowledge cultural eating patterns
-	Healthy food at this age promotes lifelong habits
-	Societal concerns – due to obesity statistic increases, changes have been made to canteen and long day care food
-	Dental care should begin early and first dentist visit around age 3
-	Children should not go to bed with milk or cordial bottles – this promotes early dental decay
-	Dental caries are one of the most common chronic diseases in children 5- 17 years
-	Drug calculations are based on the weight of the child
-	Each medication has a particular threshold for optimum usage
-	Consideration of medications include the development of child and maturity of their organs
-	Pre-term- before 36/37 weeks gestation
-	Term – 37 to 42 weeks gestation
-	Post term after 42 weeks gestation
-	Assessed at birth – Apgar score
-	Injections at birth – vitamin k, hepatitis b
-	Newborn screening test (NBST) within days of birth
-	Genetic anomalies – cystic fibrosis to treat early
-	Heel prick – pick and dab blood on cupboard
Apgar Scoring 0-10:
Sign	0	1	2
Heart Rate	Absent	Slow <100	Over 100
Respiratory effort	Absent	Weak, cry, hypoventilation	Good strong cry
-	Catheter in nostril after oropharynx is clear
-	Tangenital – foot step	No response	Grimace	Cough or sneeze
withdrawal of foot
Colour	Blue/pale	Body pink extremities blue	Complete pink
Newborn Screening Test:
-	48-72 hours regardless of gestational age or feeding status
-	Tests for; phenylketonuria (PKU), cystic fibrosis (CH) and other detectable genetic conditions
-	SIDS (sudden onset death infant syndrome)
-	Cystic fibrosis – genetic condition damages lung and digestive system
The average newborn:
-	Weight – 2500 to 4000 grams (2.5-4 kg)
-	Length – 45-52.5 cm
-	Chest circumference – 30.5-33cm
-	Head circumference 33-35.5cm
-	Reflexes – grasp, rooting, sucking, step, moro, tonic neck
-	Infants identify with the primary care giver – so include them in nursing care and interaction
-	Skin prick assessment, CRT, jaundice
-	Mottled = cold skin
-	Jaundice= yellow due to low vitamin D
-	Crying = normal reflex
-	Stepping reflex = to investigate their developing
-	Distended testes
-	Have they passed urine and faces
-	Meconium – usually before day 4, it is poo blood, parts of gut and bile
-	Look at spine
-	Umbilical cord
-	Nursing considerations for toddlers – make it fun for them, make it a game and they will cooperate find a way to give them control
-	Nursing considerations school children – want to be responsible and so give them the opportunity. They are trying to be grown up, may hide pain or feelings, becoming more self critical and self reflective logical thinking emerging, beginning transitioning to adults
-	Feeding – 8-12 times a day good for antibodies and immunity of baby.
Baby stimulates milk
-	Free benefits versatile
-	Cholesterol has antibodies
-	Encourage breastfeeding atleast for 48 hours or formula feeding
-	Metabolize really quickly therefore always hungry
-	Sterility of bottles and equipment
-	Position of baby when sleeping
-	Women bleeds for 6-8 weeks after birth – big clots most fertile stage
-	Higher birth rate in indigenous population
-	Australian national health priorities – are chosen by the level of financial and social burden on their nation, the government then implements to plan strategies that can address and combat the constraints. The national health priorities in this unit are; asthma, mental health, injury prevention and control and nutrition obesity ‘
-	The importance of PAP tests
-	Holistic care and approach
-	Tackling diabetes
-	MDT approach to care
-	Importance of education on sexual and reproductive health
-	Role of the nurse in a remote rural setting
-	Questions asking for the wrong answer (except)
-	Questions asking in the negative (which is NOT)
CPAP – continuous positive airway pressure helps a person with sleep apnoea or obstructive breathing during sleep
Croup grows out at 6 years of age
Suffactin – traps body particles foreign bodies
Examples of questions;
Explain why a young child may be prone to a burn injury from a stove in their home kitchen.
Young children are curious as they learn about the world. The child may reach up to the saucepan handle and pull the saucepan down to see what is inside, spilling hot liquid or food on themselves causing a burn. MAKE sure you discuss the nurses role in relation to preventing burn injuries in a home kitchen.
Education and employment Eating
Drugs and alcohol Sexuality
Suicide, depression and self-harm Safety from injury and violence