MSN 572 WEEK 2 COMPLILED NOTES FOR TEST (AUTORECOVERED).

MSN 572 WEEK 2 COMPLILED NOTES FOR TEST (AUTORECOVERED). Week 2 Special Populations: Dr. Porter Blocks in book (blue or grey) focus on those important points Child development Tanner staging- go up to stage 5- stages of development that lead up to puberty (i.e. Breast buds) Pubic hair is tanner staging 3 Sexual maturity ratings- breast buds stage 2 (Bright Futures pg 123) Well child visit- start with looking (eyes) – Look listen feel Developmental milestones are important and ages Startle reflex (surprise reaction) develops in utero (birth) and last until 3-6 mths Incurvation- rub baby spine and turn towards way you are rubbing it Red eye reflex- related to retinoblastoma; if not present it is abnormal Failure to thrive- assess weight, height, head circumference, length Gestational diabetes babies are large Moms are high risk if they have gestational diabetes and can develop diabetes after birth – 50% rate Contraindications of vaccines- fever over 105, cry for 3 hrs. after vaccine, seizure after vaccine, allergy to components Flublok- does not have egg components in it Wait 4 weeks between live vaccines; don’t give 2 live vaccines at same time because immune system will be down before going up Mild illness at last vaccine is fine; and okay to vaccinate Immunoglobulins- IgG – Stays the longest; had it and now Gone (needs to ensure it goes up to ensure protection) IgM- immediate; have now 12-year-old PPD skin test- positive if induration, if active TB in the house you will need a chest x-ray and always refer to specialist; and you can still vaccinate What vaccine given every 10 years? Toxoid vaccine Working with adolescent- ask if sexually active; invite parent to leave to ask personal questions; offer privacy BCG vaccine can cause positive reaction with PPD Pregnant women- Baby heart rate is higher than adult- 60 is abnormal; heart rate of 160 is normal in a baby Presumed signs of pregnancy- breast tenderness, increased urination, amenorrhea, If pregnant- cervix exam would be soft and cyanotic Round ligament pain- hormonal change cause this Diastasis recti - when abdominal muscles spread- you don’t treat Normal expected weight gain in pregnancy- 20-25 lbs. healthy is 27 lbs average Mom feels baby move at weeks G- # pregnancies T- # carry to term P- # preterm before 20- 37 weeks L- born alive Vaccines that protect patient and newborn- DTP (diphtheria, pertussis, tetanus) Hypoglossal nerve – cranial nerve 12 – pinch the nose and open mouth Geriatrics- What elevates first in aging population? Diastolic Most common heart valve goes bad as we age? Aortic- due to build up calcium buildup aortic stenosis (right sternal border) Circadian rhythm- lose sleep patterns as we age because we no longer have a schedule Falls- number 1 risk as we age- best thing is to keep them active- walking Number 1 referred pain for hip fracture is knee pain Intimacy questions-highest rate of STI is in retirement communities Vaginal atrophy (occurs most after menopause)- painful intercourse Beers criteria- criteria/guidelines used to improve the safety of prescribing medications to geriatric population Four principles of child development 1. child development proceeds along a predictable pathway 2 the range of normal development is wide 3 various physical, social, and environmental factors, as well as diseases, can affect child development and health 4 the child's developmental level affects how you conduct the history and physical examination Key components of pediatric health promotion 1. age appropriate developmental achievement of the child physical such as maturation growth and puberty Motor such as gross and fine motor skills Cognitive such as developmental milestones, language, school performance Emotional such as self regulation, mood, temperament, self efficiency, self esteem, independence Social such as social competence, self responsibility, integration with family and community, peer interactions 2 . health supervision visits Periodic assessment of clinical and oral health next time more frequent health supervision visits for children with special health care needs 3. integration of physical examination findings with health promotion 4 immunizations 5. Screening procedures 6 anticipatory guidance Health habits Nutrition and healthy eating Safety and prevention of injury Physical activity Sexual development and sexuality Self responsibility, efficiency, and healthy self esteem Family relationships such as interactions strengths and supports Positive parenting strategies Oral health Emotional and mental health Recognition of illness Sleep Screen time Prevention of risky behaviors such as tobacco, alcohol and drug use, unprotected sex School and vocation Peer relationships Community interactions 7. partnership among health care provider, adolescent child and family Tips for examining a newborn examine the newborn in presence of parents Swatow and then undressed the newborn as the examination proceeds Dim the lights and rock the newborn to encourage the eyes to open Observed feeding, if possible, particularly breast feeding A typical sequence for the examination of the newborn; Careful observation before and during the examination Heart Lungs Head, neck, and clavicles Ears and mouth Hips Abdomen and Gu system Lower extremities, back Eyes , whenever they are spontaneously open or at the end of the examination Skin, as you go along Urological system Apgar score Five components that classify the newborns neurological recovery from stress of birth an immediate adaptation to extrauterine life Score each newborn at one in five minutes after birth Scoring is based on a 3 point scale, (0, 1 , or 2) If the apgar score at 5 minutes is 8 or more proceed to a more complete examination Clarification by gestational age in birth weight Gestational age pre term :less than <34 weeks Late preterm: 34 to 36 weeks Term :37 to 42 weeks Post term: greater than > 42 weeks Birth weight classification: Extremely low birth weight; Less than 1000 grams Very low birth weight; Less than 1500 grams Low birth weight less than 2500 grams Normal birth weight; greater than or equal to 2500 grams Newborn classifications Small for gestational age ; SGA; Less than 10th percentile appropriate for gestational age; AGA; 10th to 90th percentile Large for gestational age; LGA; greater than 90th percentile What a newborn can do Core elements: Do you born she's all five senses, for example they will look at human faces and turn to appearance voice Newborns are unique individuals. Marked differences exist in temperaments, personality, behavior, and learning Newborns interact dynamically with caregivers a two way St Examples of complex newborn behavior Habituation ; Ability to selectively and progressively shut out negative stimuli such as repetitive sound ; It reciprocal, dynamic process of interacting and bonding with the caregiver State regulation; Ability to modulate the level of arousal in response to different degrees of stimulation self consoling Perception; Ability to regard faces turned to voice is quiet in presence of singing, track colorful objects, respond to touch, and recognize familiar scents Tips for examining infants ▪ Approach the infant gradually, using a toy or object for distraction ▪ Perform as much of the examination as possible with the infant in the parents laugh ▪ Speak softly to the infant or mimic the infant sounds to attract attention ▪ If the infant is cranky, make sure he or she is well fed before proceeding ▪ Ask the parent about the infant strengths to elicit useful development and parenting information ▪ Don't expect to do head to toe examination in a specific order. Work with the infant and what they give you an save mouth and ear examination for last Health supervision visits for the infant at the following ages At three to five days By one month 2,4,6,9 and 12 months Components of a health Supervision visit for a 6-month old Discussions with parents ▪ Address parents concerns and questions ▪ Provide advice next client obtained social history ▪ Assessed development, nutrition, sleep, elimination, safety, and health, family relationships, stressors, parenting beliefs, community factors developmental assessment ▪ use a standardized developmental instrument to measure milestones ▪ Assess milestones by history ▪ Assess milestones by examination Physical examination ▪ Perform a careful examination, including growth parameters with percentiles for age Screening test ▪ Vision and hearing by examination, possibly hemocrit an LED it at high risk, screen for social risk factors Immunizations ▪ See schedule Anticipatory guidance Healthy habits and behaviors Injury and illness prevention ▪ Use infant seat, watch for rolling , caution on walkers, poisons, tobacco exposure Nutrition ▪ Breast feeding or bottle, solids, no juice, prevent choking, overfeeding Oral health ▪ No bottle in bed, fluoride, brushing teeth Parent infant interaction ▪ Promoting development like play, reading, music, talking Family relationships ▪ Time for self ; Babysitters Community interaction ▪ childcare, resources Heart rate ranges birth to 1 year ▪ Birth to one month average heart rate is 140 average range is 90 to 190 ▪ One to six months average heart rate 130 average range 80 to 180 ▪ 6 to 12 months average heart rate is 115 average range is 75 to 155 Respiratory rate range between 30 and 60 in the newborn ▪ During active sleep maybe 10 breaths per minute faster ▪ Cutoff for determining tachypnea are greater than 60 breaths per minute from birth to two months greater than 50 breaths per minute from 2 to 12 months Temperature ▪ rectal temperatures are the most accurate for infants ▪ Body temperature in infants and children is less than constant than adults ▪ Usually above 99 degrees Fahrenheit until after three years of age ▪ Body temperature may fluctuate as much as 3 degrees during a single day ▪ In normal child children it can approach 101 degrees Fahrenheit late in the afternoon and after a vigorous activity Newborn skin findings Common nonpathological conditions ▪ ACROCYANOSIS; blush discoloration usually appears in the palms and the soles . Cyanotic congenital heart disease can present with severe acrocyanosis ▪ Jaundice; occurs during two to five days of life and progresses from head to toe as it peaks . Extreme jaundice may signify a hemolytic process or biliary or liver disease Common benign rashes ▪ Miliaria rubra ; Scattered vesicles on an etythematous base, usually on the face and trunk, result from obstruction of sweat gland ducts; this condition disappears spontaneously within weeks ▪ Erythema toxicum; Usually appearing on days two to three of life, this rash consists of erythematous macules with central pinpoint vesicles scattered diffusely over the entire body. They appear similar to flea bites. These lesions are of unknown etiology but disappear within one week or birth ▪ Pustular melanosis ; Seen more commonly in black infants, the rash presents at birth as a small vascular pustules, over Brown macular base; These can last for several months ▪ Mili; pinhead sized smooth white raised areas without surrounding redness on the nose , chin, and forehead result from retention of sebum in the opening of the sebaceous glands. Although occasionally present at birth they usually appear within the first few weeks and disappear over several weeks Benign birthmarks ▪ Eyelid Patch; The Burke birthmark fades, usually within the first year of life ▪ Salmon Patch ; Also called the “stark bite” or the” Angel kiss”, this blotchy pink mark fades with age ▪ Café-au-lait Spots; These are light Brown pigmented lesions usually have borders in our uniform. They are noted in more than 10% of black infants if more than five exist consider the diagnosis of neurofibromatosis ▪ Slate blue patches; these are more common among dark skinned babies. It is important to note them so that they are not mistaken for bruises Evaluating a newborn or a child with possible abnormal facies Carefully review the history, especially; ▪ Family history ▪ Pregnancy ▪ Perinatal history No abnormalities on other parts of the physical examination, especially; ▪ Growth ▪ Development ▪ Other dysmorphic somatic features Perform measurements and plot percentiles, especially; ▪ Height ▪ Wait ▪ Head circumference Consider the three mechanisms of facial dysmorphogenesis; ▪ Deformities from intra uterine constraint ▪ Disruptions from amniotic bands or fetal tissue ▪ Malformations from intrinsic abnormality in face and head or brain Examine the parents and siblings ▪ Similarly to a parent may be reassuring such as large head but may also be an indication of a familial disorder Try to determine whether the facial features fit recognizable syndrome comparing with; ▪ References including measurements and pictures of syndromes ▪ Tables databases of combination of features Visual milestones of infancy Birth; Blinks, may regard face One month; Fixes on objects 1 1/2 to two months; coordinated eye movements next time three months ; Eyes converge, baby reaches towards a visual stimulus 12 months acuity is around 20 /60-20/80 Signs that an infant can hear Zero to two months ; Startle response and blink to a sudden noise . Calming down with soothing voice or music Two to three months ; Change in facial expression to familiar sounds. Turning eyes and head to sound Three to four months turning to listen to voices and conversation 6 to 7 months ; Appropriate language development Abnormal infant cries if persistent Shrill or high pitched; increased intracranial pressure. Also in newborns born to narcotic addicted mothers Horse; hypocalcemic tetany or congenital hypothyroidism Continuous inspiratory an expert Tori stridor; Upper airway obstruction from various lesions such as polyp or hemoglobinemia , a relatively small lyrics , or delay in development of the cart ledge in the tracheal rings Absence of cry ; Severe illness, vocal cord paralysis, or profound brain damage Observing respirations before you touch the child General appearance; inability to feed or smile , lack of consolability Respiratory rate ; Takip NIA, at Mia Color; Pallor or cyanosis Nasal component of breathing; Nasal flaring enlargement of both nasals opening during inspiration Audible breath sounds; Grunting which is repetitive, short expert Tori sound ; Wheezing which is musical expert Tori sound; Stridor high pitched, inspiratory noise ; Obstruction which is lack of breath sounds Work of breathing; Nasal flaring such as excessive movement of nares , grunting such as X patory noises , retractions or the chest indrawing; ▪ supraclavicular which is the soft tissue above the clavicles ▪ Intercostal which is in drawing of the skin between the ribs ▪ Substernal which is at the xyphoid process ▪ Subcostal which is just below the costal margin Distinguishing upper airway from lower airway sounds in infants Compare sounds from noise versus stethoscope ; Same sounds would be upper airway lower airway is often different sounds Listen to hoarseness of sounds ; Upper airway will show harsh and loud . Lower airway will be variable Note symmetry upper airway will be symmetric . Lower airway often asymmetric Compare sounds at different locations for example higher versus lower; symmetric sounds are louder as stethoscope is moved up chest upper airway . Lower airway often asymmetric often sounds are louder lower in chest towards abdomen Inspiratory versus expert Tori ; Upper airway almost always inspiratory. Lower airway often has expiratory phase Cardiac causes of central cyanosis in infants and children Immediately at birth; Transposition of great arteries , pulmonary valve atresia ▪ Severe pulmonary valve stenosis ▪ Possibly ebstein malformation within a few days after birth; all of the above plus; ▪ Total anomalous pulmonary vein return ▪ Hypoplastic left heart syndrome ▪ Truncus arterious ▪ single ventricle variants Weeks, months, or years of life all of the above plus; ▪ Pulmonary vascular disease with atrial , ventrical , or great vessels shunting would be right to left shunting Non cardiac findings commonly present in infants with cardiac disease Poor feeding; tachypnes, poor overall appearance Failure to thrive; Irritability