NRSG257 summary

NRSG257 summary Health in Pregnancy for Adolescents Reasons for high number of teenage pregnancies: • Earlier age of menarche • Increased rate of sexual activity among teenagers • Contraceptives - Lack of knowledge - Access to emergency contraception - Lack of funds to purchase contraceptives • Desire to have a child • Egocentric phenomenon of adolescence – “it won’t happen to me” • Belief that it will free them from intolerable school/home situation • Give them someone to love and someone to love them. • Risk-taking behaviours such as unprotected intercourse, stemming from - Living with emotionally/physically abusive parents - Domestic violence - Substance abuse - Mental illness Developmental tasks of adolescents Four developmental tasks of adolescence as stated by Erikson: • Establish a sense of self-worth or a value system • Emancipation from parents • Adjust to a new body image • Choose a vocation A pregnant adolescent is an emancipated minor, capable of making her own healthcare decisions. Difficulty in establishing a value system/sense of identity: • Abandonment/denial of paternity by baby-daddy • HCP’s treating adolescents as irresponsible • Judgemental attitude and disapproval Prevention of pregnancy and sexually transmitted infections • Factors for adolescent decision-making about intercourse, with or without protection is: - Socioeconomic conditions - Psychological factors - Race - Peer relationships - Family values • Challenges to getting accurate information about sex and sexual health: - Sex education in schools can be limited - 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 sexually transmitted diseases or unwanted pregnancy Adolescent Prenatal Care • Many pregnant adolescents do not access prenatal care: - Unaware of pregnancy - Denial - 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 birthweight infants - High neonatal morbidity - Iron deficiency anaemia - Cephalopelvic disproportion (CPD) - Prolonged labour Complications of adolescent pregnancy and prenatal care Major concerns: • Dietary habits - Poor nutritional stores from years of less than optimal diet -  nutrition = preterm birth and low birthweight (LBW) - Younger the adolescent the  likelihood of LBW infant - Frequent snacking - High intake of fat & sugar - Low intake of calcium, iron, zinc, folic acid & 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. • Substance use (alcohol, cigarettes, illicit) • STIs – unprotected sex • Effects of poverty – homelessness, mental health, nutrition • Onset of prenatal care - Denial of pregnancy - Lack of knowledge of the importance of prenatal care - Dependence on others for transportation - Feeling awkward in an antenatal setting, usually an adult setting - Fear of pelvic examination - Difficult in relating to authority figures (parents, nurses, doctors etc.) • Psychological development or maturity • Pregnancy induced hypertension (preeclampsia) • Anaemia – the adolescent is still growing and must also supply enough iron for foetal growth and her increasing blood volume Week 4 summary Mental Health for Children and Families Perinatal mental health • Could it be - Grief? - Adjustment disorder (an abnormal and excessive reaction to an identifiable life stressor) - Anxiety (anticipation of a future threat. Generalized Anxiety Disorder (GAD), Social Phobia, Panic Disorder, Agoraphobia, PTSD, OCD) - Mood disorder (depressive disorders) - Personality disorder (an enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment) - Psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality) - Substance related? Postnatal Depression Assess for non-biological risk factors & explore possible interventions: • Low self-esteem • antenatal anxiety • low social support • negative cognitive style • major life events • low income • history of abuse etc. Management Strategies • Psychological therapy & support - Psychotherapy - Information support - Debriefing - Home visits • Pharmacology - SSRI’s e.g. Fluoxetine, Paroxetine (Increase the extracellular level of serotonin by inhibiting its reuptake into the pre‐synaptic cell, increasing the level of serotonin in the synaptic cleft available to bind to the postsynaptic receptor) - Tricyclics e.g. Amitryptline, Amoxapine (increase levels of the neurotransmitters norepinephrine and serotonin, and block the action of acetylcholine) - Benzodiazepines e.g. Diazepam, Temazepam (minor tranquilisers used to slow down the CNS) - Antipsychotics e.g. Clozapine, Risperidone, Olanzapine (neuroleptics or major tranquilisers that reduce or eliminate the symptoms of psychosis) - Antidepressants During Lactation • Only small amounts pass into breast milk • Drugs of choice - Sertraline, Paroxetine & Nortriptyline • Adverse effects reported – Fluoxetine & Citalopram • can delay lactation & inhibit the sucking reflex - Low dose does not assure the infant will be unaffected • Immature hepatic & renal function • Infant blood-brain barrier is also immature • No studies of long term effects - Breast Feeding Safety • Breast feed immediately before drug intake to minimise infant exposure to medication (when mother’s plasma concentration is at its lowest) • Give lowest effective dose of medication • Observe child for adverse effects such as GI symptoms, sedation, agitation, poor feeding/weight gain • Consult healthcare provider to discuss whether breastfeeding should be continued • Social support - Family - Friends - Support groups - Indigenous support workers - Others? • Complementary therapy - Infant massage – benefits all members of the family, including fathers - Exercise (to improve mood) • Psychological theories distraction hypothesis, mastery hypothesis, social interaction • Biological mechanisms endorphins, neurotransmitter (monoamines), nor epinephrine, serotonin, dopamine • Thermogenic effect reduces muscle tension, bolsters the immune response, may increase uptake of monoamines (serotonin etc.) Effects of maternal depression on children • Infants – Passivity – Anger – Low weight gain – Insecure attachment – Attention & arousal problems • Toddlers – Passive noncompliance – Less independence – Lower performance – Less interaction with others on verbal & memory tests – Less creative play • School age – Impaired adaptive functioning – Depressive disorders – Anxiety disorders – Attention disorders – Lower IQ • Adolescents – Depressive disorders – Anxiety disorders – Substance abuse – Conduct disorders – Attention disorders – Learning difficulties Specific Mental Health Disorders • Infancy – Feeding & eating disorders (Rumination disorder, Avoidant/restrictive food intake disorder) – Pervasive developmental disorders – Relationship problems or attachment disorders – Anxiety disorders or separation anxiety – Motor skills disorders • Childhood - Internalising behaviour • Mood • Sleep • Thoughts • Parents often report ‘something is not quite right’ - Externalising behaviour • Aggressive and delinquent behaviours • Under controlled behaviours • Adolescence – First onset psychosis – Eating disorders – Mood disorders – Anxiety disorders Anxiety disorders • Generalised Anxiety Disorder (GAD) Excessive worry or apprehension about events and activities. Feelings occur all the time and are not triggered by any one thing. E.g. fear of failure or poor performance, worries about personal/family safety, worries about thunderstorms or wars, worries about what others will think of them, apprehension about new situations. • Phobias highly specific and exclusive fears. Normal functioning until confronted by dreaded object, event or situation, e.g. bugs, flying, heights. • Separation Anxiety Disorder Excessive worry and anxiety about being away from their parents, often fearing for their parents safety and will not return as promised. Often seen in response to stressful events. • OCD Condition involving obsessions (recurrent thoughts, impulses or images that are difficult to control and cause significant distress) and compulsions (behaviours engaged in to make distress feel better, e.g. hand washing, checking, redoing). • Panic Disorder Discrete and intense periods of anxiety that occur unexpectedly, without warning, not always linked to a specific situation. Symptoms include difficulty breathing, feelings of impending doom. • PTSD An intense re-experiencing of a traumatic event by distressing recollections, dreams and/or associations. Therapeutic management - Cognitive behavioural therapy (CBT) - Medication - Family therapy - Parent education and support Feeding and eating disorders • Pica Persistently eating non-food substances (dirt, clay, paint, wool, paper). Danger of accidental poisonings and complications such as constipation, gastrointestinal malabsorption, faecal impaction and intestinal obstruction. Predominantly seen between the ages of 2 – 6 years. • Rumination disorder of infancy Regurgitating and re-swallowing previously ingested food. A rare disorder affecting infants between 3 – 12 months. • Avoidant/restrictive food intake disorder Lack of interest, avoidance based on sensory and concern about aversive consequences of eating. Persistent failure to meet appropriate nutritional/energy needs associated with one or more of the following: • Significant weight loss (or failure to achieve expected weight gain) • Significant nutritional deficiency • Dependence on enteral feeding or oral nutritional supplements • Marked interference with psychosocial functioning • Anorexia nervosa Refusal to maintain body weight because of disturbance in perception of the size or appearance of the body. Includes self-induced starvation; a relentless drive for thinness; a fear of fatness, or both; and medical signs and symptoms resulting from starvation. • Binge eating disorder Recurrent episodes of binge eating in a discrete period of time (e.g. 2 hours) and lack of control over eating during the episode. Characterised by distress and three or more of the following: • Eating much more rapidly than normal • Eating until feeling uncomfortably full • Eating large amounts of food when not feeling physically hungry • Eating alone because of embarrassment • Feeling disgusted with oneself Elimination disorders • Encopresis Repeated passage of faeces at least once a month in places where it is not culturally appropriate. PRIMARY – if the child was never fully toilet trained SECONDARY – if the problem began after effective toilet training • Enuresis Repeated voluntary or intentional urination during the day or at night after an age when the child should have attained control over their bladder. Week 5 summary Pathophysiology of Bone Growth & Fractures in Children Types of bones • Long – bones of the extremities including fingers and toes • Short – bones of the ankle and wrist • Flat – skull, ribs, scapula and clavicle • Irregular – vertebrae, pelvis, facial bones Long bones are composed of: • Diaphysis – long central shaft filled with yellow (adipose cell formation) and red (blood component production) marrow. Responsible for formation of platelets ,RBC’s, WBC’s and adipose. • Epiphysis – rounded end portion • Metaphysis – thin area between diaphysis and epiphysis • Epiphyseal (a.k.a. growth) plate – cartilage segment between epiphysis and metaphysis where increase in length occurs. As cartilage cells grow away from the shaft, they are replaced with bone, increasing bone length. Bone formation through remodelling (replacement of old by new bone tissue) and resorption (bone breakdown). In long bones, this is the weakest area. Types of # • Transverse – break a bone shaft across its long axis • Displaced -produce new and abnormal bone arrangements • Nondisplaced – retain the normal alignment of the bones or fragments • Compression – occur in vertebrae subjected to extreme stresses • Spiral – produced by twisting stresses that spread along the length of the bone • Epiphyseal – occurs where the bone matrix is undergoing calcification and chondrocytes (cartilage) are dying. These # can permanently stop growth at this site if not treated carefully • Comminuted – shatter the affected area into a multitude of bony fragments • Greenstick – only one side of the shaft is broken and the other is bent • Colles – break in the distal portion of the radius e.g. reaching out to cushion a fall • Pott’s – (a.k.a. bimalleolar) occurs at the a ankle Compartment syndrome (orthopaedic emergency) Intra compartmental pressure can be raised by: • Increase in compartment content (bleeding, swelling) • Decrease in size of compartment – bleeding or pressure from another area into the compartment surrounds, includes pressure from bandages, plaster Pressure results in severely decreased blood flow that potentially threatens damage to and necrosis of, surrounding soft tissue or nerves. Signs and symptoms of compartment syndrome • Agitation, anxiety and increasing analgesia The 5 P’s of circulation assessment • Pain • Pain on Passive motion • Paralysis - lack of ability to flex or extend toes or fingers • Paraesthesia - numbness and tingling • Pallor - indicating coldness Pulselessness is considered a late/unreliable sign - the damage is already done Pain management - Treat the level of pain with the correct medicine • Step 1 (mild to moderate pain): non-opioids – aspirin, NSAID’s (ibuprofen) or paracetamol • Step 2 (moderate to severe pain): mild opioids (e.g. codeine) with or without non-opioids • Step 3 (severe pain): strong opioids (e.g. morphine) with or without non-opioids The three P’s of pain management • Pharmaceutical pain medicine - Depending on the level of pain • Physical - Apply heat or cold packs • Psychological - Distraction and controlled breathing Pain assessment tools FLACC Face, Legs, Activity, Cry, Consolability Wong-Baker Faces CRIES Week 6 summary Safety and Injury Prevention for Infants, Children & Adolescents Suspected child abuse and neglect Injury is age group specific Inquisitive and exploratory nature of children means that injuries & accidents are common. Children and adolescents do not calculate risks while engaging in their environment and striving to achieve developmental goals • Infancy (0-12months): Highest proportion of intracranial injuries and foreign bodies through natural orifice • 1-4yrs: Main causes - falls, thermal causes, poisoning (pharmaceuticals), transport • 5-9yrs: #’s are most common injury (52%) • 10-14, 15-17yrs, 18-24yrs: Main causes falls and transport. Self harm injuries become more prevalent Child Mortality Major causes by age • 1-14 years – Injury (especially falls) • Prevention strategies Education/Awareness especially parents/caregivers Safety devices as applicable • 15-24 years – Suicide • Prevention strategies Education/Awareness Support services Psychosocial Safety - Ego Competency Skills Based on WHO convention and the ANMC code of practice it is our duty to ensure that every child has a safe environment to grow and develop this includes while in our care with in hospital, and in the community. • Close & trusting relationships • Coping with separation and independence • Negotiating shared decisions and interpersonal conflict • Dealing with frustration and unfavourable events • Celebrating and experiencing pleasure • Delayed gratification • Relaxation and play • Cognitive processing • Adaptable sense of direction and purpose The 4 categories of child abuse: • Physical Abuse • Cutaneous • Burns • #’s • Head Trauma • Ocular injuries • Abdominal trauma • Genital • Poisoning • Munchausen by proxy • Neglect • Malnourishment • Inadequate hygiene • Inappropriate attire • Inadequate supervision • Inadequate healthcare • Exposure to interpersonal violence • Exposure to environmental hazards • General apathy • Emotional abuse • Spurning behaviour • Terrorising behaviour • Isolating behaviour • Exploiting and corrupting behaviour • Denying & ignoring social responsiveness • Educational neglect • Sexual abuse Week 7 summary Growth and development Inclusion of BMI on growth charts To work out BMI: Divide weight in kilograms by height in metres, then divide the answer by height again to get BMI. Fine motor skills • 1-3 months: Reflex grasp • 3 months: Brief hold of toy • 4 months: Rattle, hands together, reach and miss objects • 5 months: Grasp objects, splash, crumple • 6 months: Bottle, feet, toes • 7 months: Toy transfer, bangs table, in mouth, paper • 9 months: Grasp small objects between thumb and forefinger • 10 months: Points, let’s go • 11 months: Give but not release • 12 months: Give and releases, rolls ball, starts with crayon • 15 months: Two block tower, throws objects, starts to remove clothing, shoes off first • 18 months: Three block tower, starts self-spoon feed, turns 2-3 pages, scribbles on paper • 2 years: 6-7 block tower, turns 1 page, turns door knobs & jar lids, wash & dry hands, spoon & fork • 2 ½ years: 8 block tower, pencil between fingers Gross motor development Types of play • 0-2 years (solitary) - Plays alone. Limited interaction • 2-2 ½ years (spectator) - Observes other children playing • 2 ½-3 years (parallel) - Play alongside others but not together. • 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 groups. Freud - Theory of Psychosexual Development Personality • Id - basic, instinctual drives. Pleasure principle; immediate gratification. • Ego - reality; a regulating mechanism that enables the individual to delay gratifying immediate needs and function effectively in the real world. • Super Ego - striving to act in a socially appropriate manner, controls our sense of right, wrong & guilt. Stages • Oral (Infant) - oral stimulation, pleasure. Sucking for enjoyment or relief from tension as well as nourishment. • Anal (Toddler) – focus on anal region through toileting/elimination. Self-discovery and exerting independence through retention & defecation. • Phallic (Pre-schooler) – pleasure zone shifts from anal to genital area. • Latency (School age) – child’s libido appears to be diverted into concrete thinking. • Genital (Adolescent) – main events of this period are establishment of new sexual aims and the finding of new love objects. Erikson Stages • Infant – developmental task is form a sense of trust Vs. mistrust. Child learns to love and be loved. • Toddler – developmental task is form a sense of autonomy Vs. shame. Child learns to be independent and make decisions for self. • Pre-schooler – developmental task is form a sense of initiative Vs. guilt. Child learns how to do things (basic problem solving) and that doing things is desirable. • School age – developmental task is form a sense of industry Vs. inferiority. Child learns how to do things well. • Adolescent – developmental task is form a sense of identity Vs. role confusion. Adolescents learn who they are and what kind of person they will be by adjusting to a new body image, seeking emancipation from parents, choosing a vocation, and determining a value system. Piaget’s Theory of Cognitive Development The infant • Relates to world through senses, only using reflex behaviour • People are entities separate from objects • Objects are permanent in the environment and continue to exist even though out of sight (peek-a- boo games) • When object permanence is learned, trust falls in to place • Goal-directed behaviour e.g. hitting a mobile makes it move The toddler • Egocentrism and symbolic thought • Symbols to represent objects • Draw conclusions from obvious facts they see: daddy is shaving therefore he must be going to work because he went to work after shaving yesterday. • This can also led to wrong conclusions The pre-schooler • Intuitive thought • Centring – looking at an object and seeing only one characteristic e.g. a banana is yellow, but not seeing that it is also long • Lack of conservation – the ability to discern truth, even though physical properties change • Lack of reversibility – the ability to retrace steps • Role fantasy – how children would like something to turn out • Accommodation – change their ideas to fit reality, rather than the reverse The school-aged child • Concrete operational thought – discovery of concrete solutions to everyday problems • Recognise cause-and-effect relationships • Conservation of numbers (7 years) • Conservation of quantity (7 – 8 years) • Conservation of weight (9 years) • Conservation of volume (11 years) • Understands concepts and sub-concepts • Classifications • Seriation • Reversibility The adolescent • Formal operational thought – cognition achieves final form • Abstract thoughts – what could be • Thought processes, scientific/deductive reasoning • Reasoning proceeds from general to specific • Hypothetical problems • Causality • Past, present future Week 8 revision Respiratory function in children Respiratory Anatomy and Physiology • The primary function of the respiratory system is gas exchange. Inhalation O2 and expiration CO2 • 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 O2 in blood • Cellular respiration – energy in glucose is used to produce ATP a multi-functional nucleotide, used by enzymes for cellular processes such as cell division. 5 steps of respiration • Pulmonary Ventilation Breathing • External Gas Exchange/Respiration O2 absorption from air to blood and movement of Co2 from blood to air • Gas Transport Transport of O2 from lungs to tissues through blood and transport of Co2 from tissues to lungs through blood • Internal Gas exchange/respiration Transfer of O2 from blood to body cells and transfer of Co2 from cells to blood • Cellular Respiration O2 uptake and Co2 production by body cells to generate ATP 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 underdeveloped 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 Normal Ranges for Physiological Variables SOURCE: Common Paediatric Respiratory Conditions • Respiratory Syncytial Virus (RSV) - a highly contagious, common virus that infects your airways and lungs. Spreads easily can cause breathing problems and lung infections in children including bronchiolitis and pneumonia. • Asthma - Also known as reactive airway disease. Where symptoms are a consequence of an external trigger. • Croup - An upper airway condition caused by parainfluenza, RSV, adenovirus and characterised 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 characterised by increased work of breathing, decrease in oral intake, lethargy, mottling and wheeze. Diagnosed in infancy and has similar symptoms as asthma Respiratory Acidosis (build-up of CO2 in blood) • Acid-Base balance of the body is disrupted and body fluids become acidic • Chronic - Kidneys will produce bicarbonates to restabilise the body’s acid-base balance, hence stabilising • Acute - dangerous due to rapid acidity and kidneys unable to produce the stabilising chemicals. Complications can include shock. • Causes - Asthma, COPD, narcotics, scoliosis. • Sx • Dx • Tx • Fatigue/Lethargy • Shortness of breath • Confusion • Chest x-ray • ABG’s (arterial blood gas) • Lung Function test • Bronchodilators - short acting beta2-agonists such as albuterol, long-acting beta2- agonists (such as salmeterol, formoterol), anticholinergic agents (e.g. ipratropium) and theophylline. • CPAP - continuous positive airway pressure ventilator, which applies mild air pressure on a continuous basis to keep the airways continuously open. • BiPAP - Bi-level positive airway pressure ventilator delivers different levels of pressure during inspiration (IPAP) and expiration (EPAP). • O2 Respiratory Alkalosis (decreased levels of CO2 in blood) • Caused by anxiety, fear, hyperventilation • Rarely life threatening unless pH7.5. • Complications vary, seizures may occur • Sx • Dx • Tx • Dizziness • peripheral numbness • chest x-ray • Pulmonary function tests • ABG’s. • Conservative - breathe into a paper bag • Aim of Tx: treat the underlying problem. Asthma triggers • Viral infections • Food additives • Allergens e.g. dust mite, pollens, and mould • Weather/cold air • Cigarette Smoke • Physical activity • Recent research has dispelled the dairy food myth Manifestations of Asthma • Increased work of breathing • Accessory muscle use - rib retraction - intercostal and substernal recession - tracheal tug - nasal flaring • Colour changes • Skin temperature changes - peripherally • Mental status changes • Tachypnoea • Tachycardia • 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 - Pt may have such severe airway obstruction or be so fatigued that they are unable to generate enough airflow to wheeze. This is an ominous sign of impending respiratory failure. Reliever Medications • Bronchodilators - salbutamol (brands: Ventolin, Respolin, Asmol) • Work on relaxing the bronchiole muscle and preventing bronchospasm. • PRN and acts within 5 minutes. Has a 3-4 hr half-life. • Side effects include hyperactivity and tachycardia. Some report rigors, headaches and palpitations • Anticholinergic - Ipratropium bromide (brand: Atrovent) blocks the neurotransmitter acetylcholine and inhibits parasympathetic nerve impulses. Steroidal Anti-inflammatory’s • Allows the bronchioles to respond better to Ventolin by reducing inflammation and oedema. • Brands: Prednisolone, Redipred, Predmix • Daily dose of 2mg/kg first dose then 1mg/kg for 2 more days in an exacerbation. • Side effects include hunger, weight gain, some swelling and mood swings. Non-steroidal Anti-inflammatory’s Intal, Intal forte, Tilade, are inhaled non-steroidal preventers that help prevent exacerbations of asthma induced by physical activity Preventer medications • 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 chance of these side effects. Acute Exacerbation of Asthma • 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 they do not require the reliever medication more frequently than hourly • Oxygen may also be given if respiratory status requires. • Initial Tx consists on administration of Prednisolone (2mg/kg) and Ventolin therapy x3 in an hour and then reassess. • Children under 6 are given 6 puffs of Salbutamol per dose and children over 6 are given 12 puffs of Ventolin per dose. Severe Exacerbation - Emergency Resus • Sx • Confusion • Exhaustion • Inability to speak • Spo2 below 90% • Marked accessory muscle use and tachycardia. Week 9 revision Applying General Nursing Techniques in Caring for Infants, Children and Adolescents General Principles • Hands off approach to assessment • Establish rapport with child and family – Use distraction therapy to assist in establishing trust with children, for example bubbles – Use a doll/teddy to demonstrate procedures – Place parents at easy by appearing confident and in control • Process observations with information received to draw conclusions • Allow the child to have some control where possible – autonomy • 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 – directly address school age children and adolescents Approximate Normal Vital signs Age Heart rate/min Respiratory rate/min Average BP mmHg Temperature °C Birth – 6 months 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 Apgar Scoring (at birth) - 0 - 10 Sign 0 1 2 Heart Rate Absent Slow100 Over 100 Respiratory Effort Absent Weak Cry, Hypoventilation Good Strong Cry Reflex Response • (1) Catheter in nostril after oropharynx is clear No response No Response Grimace Grimace Cough or Sneeze Cry and withdrawal of foot • (2) Tangential Foot Slap Colour Blue/Pale Body Pink Extremities Blue Completely Pink. Newborn Screening Test 48-72hrs regardless of gestational age or feeding status tests for: • Phenylketonuria (PKU) • Cystic Fibrosis (CF) • Congenital Hypothyroidism (CH) • Other detectable genetic conditions Scenario 1 summary Aisha Connolly – teenage pregnancy Signs and Symptoms of Pregnancy • Amenorrhea • Implantation Spotting • Darkening of areola’s • Polyuria • Tender Swollen Breasts • Taste change –metallic taste • Morning sickness • A positive pregnancy test –Urine HCG present • HCG present in blood test • ultrasound can date and confirm pregnancy Legal Issues • Issues of consent • age of partner • mandatory reporting. Growth and development factors to consider • Adolescents are: • still transitioning into adulthood; • Still finding their own identities • Still dependent on Parents/Carer’s • Nurses may wish to consider: • Counselling • Some professional support may be required • Education Depending on decision of the adolescent surrounding the baby • Options e.g. Adoption, Abortion (if consult during pregnancy), Keeping the baby, Foster care • Referrals Assessment of a four day old neonate • A head to toe • Weight –can lose up to 7% of body weight within the first week but should gain weight thereafter • Length –Baby should be growing • Head Circumference • Peripheral circulation • Feeding • Baby’s colour (Jaundice) • Reflexes: sucking, rooting, grasp, startle, plantar, Babinski (what the big toe does when the sole of the foot is stimulated), step • Eyes • Hydration • Check the umbilicus for any signs of inflammation/infection Appropriate feeding and sleeping patterns for a newborn • Feed on demand • Stomach is the size of the newborns clenched fist hence will feed regularly • Crying is a method of communication • Breast is best but if unable/chooses not to, educate about choosing formula and how to clean and sterilise bottles • Baby’s will wake regularly for feeds and to be expected • Neonates should be sleeping between 16 to 19 hours a day, approx. • Baby’s should not sleep in bed with their parents • Consider SIDS education and prevention Role in providing health promotion education and advice to an adolescent young woman with a neonate • Education, reassurance and support • Bathing safety/appropriate water temperature. • Breastfeeding support/bottle feeding education • Sleeping arrangements/education on SIDS prevention. • Nutrition and post-natal self-care • Nurse may organise financial support for the adolescent. • Education on contraception. • Confidence/reassurance parents are capable of caring for their baby. • Building a routine • Support/Help Lines Immunisation • Women planning on becoming pregnant should be up to date with immunisation • Status checked and immunised at least 28 days before trying to fall pregnant • Education/benefits of immunisation and health of Australian children with preventing childhood diseases • Mother need to be informed about the Australian Immunisation schedule. • Discuss concerns/myths reported and possible increased risks with regards to immunisations Developmental markers in a well 6 week old neonate • Baby begins to recognise mum and dad • Baby is a awake and alert in between naps • Baby is able to coo and smile. • Baby can support head when placed on belly • A routine is usually established by week 6. • Baby exposed to SSRI during pregnancy may exhibit withdrawals • Breast feeding infant is far less exposed to Zoloft concentrations through breast milk than the placenta • Zoloft has a predictable peak and trough time; guide breast feeding mothers to fed baby prior to taking dose, wait until medication concentration is at its lowest and feed again Support during pregnancy and labour Good support has the following benefits: • Lower caesarean rates • Lower epidural requests • Shorter labour • Less use of analgesia • Increased maternal satisfaction • Less forceps use • Family support important when baby arrives as adolescent mother continues to growth and develop • Pregnancy is usually not planned • Social stigma surrounding the event may be negative • The mother is pressured to change negative habits (smoking) • Financial and social dependence • Factors such as education and future prospects must be considered