Exam 1 Well Child: Infant Flashcards
Well child visit includes
1) H___, W_____, Head _____ and P____
2) ____ signs
3) Developmental ______
4) ______ Assessment
5) ______ Examination
6) Anticipatory ________
7) I________
1) Height, Weight, Head circumference, Plotting
2) Vital Signs
3) Developmental Screening
4) Nutritional
5) Physical
6) Guidance
7) Immunizations
How do you measure height on an infant?
1) Fully extend the body holding the head in midline, grasping knees together gently and pushing down on the knees
2) Measure from top of head to heels of feet (feet with toes pointing directly to ceiling)
How do you measure weight on an infant?
Average weight for an infant =
Should be weighed naked (diaper off) on an infant scale, in lying position
Balance the scale before each weight with clean sheet of paper
7-8 lb
How do you measure head circumference?
1) Repeat it __ times to get average
2) Should measure until ___ years of age
Measure head at greatest circumference, slightly above eyebrows and pinna of the ears and around the occipital prominence at the back of the skull
1) 3
2) 3
Microcephaly =
Complication)
= Proportionally small head
If skull is not growing, there isn’t enough room for brain to grow
Macrocephaly =
Complication)
= Proportionally large head
Can lead to too much fluid in brain
Plotting =
1) Should stay within __ standard deviations
2) Ex) Child goes from 75th to 25th percentile what should be done?
3) Height, weight, and head circumference should be _____
= Comparing the child to him/herself
1) 2
2) Cardiac, Renal workups, blood work to rule out many conditions
3) proportional
Normal growth Birth - 6 months
1) Weight gain =
2) Height =
3) Head circumference =
1) 5-7 oz/wk, double birth weight by 5-6 months
2) 1 inch/month
3) 1.5cm increase/month
Normal growth 6 months - 1 year
1) Weight gain =
2) Height =
1) 3-5 oz/wk, triple birth weight by 1 year
2) 1/2 inch/month
Infant Vital Signs
Temperature =
How do you take temp?
99-99.7F
Place tip under arm in center of axilla and keep close to skin, hold infant’s arm firmly against side
Infant Vital Signs
Heart Rate =
1) Can go up to ___ bpm with excitement, fever
2) How do you take the apical heart rate?
80-150 bpm
1) 200
2) hold stethoscope at apex of heart (4th intercostal space, midclavicular), count for 1 full minute because of irregularities
Infant Vital Signs
Respiratory Rate =
How do you take respiratory rate?
24-50
Observe abdominal movements, count for 1 full minute due to irregular respirations
What is the most widely used developmental screening test?
1) 4 Areas of Focus =
2) Mostly used to screen for =
3) Examiner should be trained by =
4) Client is expected to =
Denver II
1) Gross Motor, Language, Fine motor, Personal-social
2) developmental delays
3) Master instructor
4) perform every item to the left of the line (of their age) and items that intersect the line are in 75-90th percentile (shaded box)
Note: important to identify delays early on to provide early intervention
Head lift (when supine)
1) at 2 months =
2) at 4-6 months =
If chid is unable, it is a sign of =
1) 45 degrees
2) 90 degrees
Cerebral palsy
Head Lag
1) at 4 months =
2) if seen at 6 months =
1) should not be seen
2) may be linked to cerebral palsy
1) AAP (American Academy of Pediatrics) recommendations=
2) Nurses should =
1) - Breastfeeding is the best source of nutrition for babies at least through first birthday and longer when possible
- Exclusive breastfeeding for the first 6 months is recommended
2) - Inquire about breastfeeding, encourage mother to continue breastfeeding, and offer resources to assist with successful breastfeeding techniques
Nutritional Needs
1) Newborn - 3 months =
2) 4-6 months =
3) 7-11 months =
- Feedings should be ______
- Depends on _____ of baby as well
1) 1-6 oz every 2-4 hours
2) 6-8 oz every 4-6 hours
3) 6-8 oz every 6-8 hours, with max 32 ox per day
- on demand
- weight
Types of Formulas (2)
1) Milk based formulas (Enfamil Lipil, Good Start, Similac)
2) Soy based formulas (Isomil, Nursoy, Prosobee, Soyalac, Good Start supreme Soy)
Different prepartions of formula (3)
- Ready to feed
- Concentrate (2 oz formula, 2 oz water)
- Powder (2 oz water with one scoop of formula)
Formula alerts
1) Can be mixed with =
2) Use only ___ water from tap because =
3) If its an older home, run the tap for __ minutes before using to minimize ____
4) Must _____ formula once mixed to =
5) Formula that baby does not drink must be ____ bc of ____
6) To minimize waste =
1) tap or bottled water
2) cold, lead doesn’t separate from hot water
3) 2 min, minimize led
4) Refrigerate, decrease bacteria
5) discarded, bacteria
6) only prepare as much as infant can consume
Can you give cow’s milk? Why or why not?
NO!
Babies cannot digest cow’s milk, it can cause GI bleeding (formula/breast milk is pre-digested)
Goal is brain development with protein, fat, calories - cow’s milk doesn’t have enough to cause highest amount of brain development
Solid Foods
1) Newborn - 3 months =
2) 4-6 months =
3) 7-11 months =
1) No solid foods
2) begin introduction with iron fortified cereal products; then protein/veg/fruits
3) offer finger foods, introduce the cup
Why are fruit juices not recommended?
__g of sugar = __ teaspoons of sugar
Due to high sugar content that contributes nothing to brain development
-40, 10
Solid foods should be introduced with a spoon why?
To stimulate digestive juices, expose to different textures, not for nutirional reasons, but with motor skills, but should not replace what they need for full brain development
Physical Assessment Tips
1) Be =
2) Have parent =
3) Proceed from =
4) Expect tearless cry until at least __ months
5) Posterior fontanel closes by __ months
6) Anterior fontanel closed by ___ months
7) Teeth eruption, usually __-__ teeth by __ year
8) check ____ alignment
1) Happy, Smile! let baby touch equipment
2) hold baby during exam
3) Least intrusive to most intrusive assessment4) 3
5) 2
6) 12
7) 4-8 teeth, by 1 year
8) ear
Pain Scale - FLACC components
Severe pain score =
What vital signs change with pain?
1) Face
2) Legs
3) Activity
4) Cry
5) Consolability
8-10
Heart rate, RR
FLACC Scores (0, 1, 2)
1) Face
2) Legs
3) Activity
4) Cry
5) Consolability
1)
- No expression
- Occasional grimace
- Frequent to constant quivering chin
2)
- Normal position or relaxed
- Uneasy restless and tense
- Kicking or legs drawn up
3)
- Lying quiet
- Squirming or shifting back and forth, tense, moaning
- Arched, rigid, or jerking
4)
- No cry
- Moans or whimpers
- Crying steadily
5)
- Content, relaxed
- Reassurance, hugging
- Difficult to console
PE Vital Signs (2)
- Temp, HR, RR
- O2 sat if any respiratory issues
PE Weight, height, head circumference + percentiles (2)
- Plot height, weight, and head circumference on growth chart every visit
- BMI over 2 years
PE General (2)
- Alert, good eye contact, interactive
- Developmental Screening
PE Skin (3)
-warm, dry, no rash or lesions
PE Head/neck
- ____cephalic
- Posterior fontanel closes by =
- Anterior fontanel appears _____ and ____, closes by =
- Neck with good ____
- Norma
- 2 months
- open, flat, 12 months
- ROM
PE Eyes
- ________
- _____ red reflex bilaterally
- Expect tearless cry until at least ___ months
- PERRL
- positive
- 3
PE Ears
- __mmetrical, appropriately ______, no ____ or ____, _____ grossly intact
- Check ear _____ - can indicate _____ (ex. downs)
- Symmetrical, positioned, sinuses or tags, hearing
- alignment, anomalies
PE Nose/Mouth
- ___ nasal discharge, oral mucosa ___ and ___, palate ____,
- teeth eruption =
- no, pink and moist, intact
- 4-8 teeth by 1 year
PE Respiratory
- Lungs bilaterally ____, respirations ___ without any ______
- obligate _______ until __ months - don’t know how to breath from mouth
- clear, easy without retractions
- nosebreathers 5
PE Cardiovascular
- __ and __ sounds, no ____, lips ___, femoral pulses ___ and ___ bilaterally
- S1 and S2, no murmur, pink, strong and equal
PE Abdomen
- S___, __ distended, bowel sounds x __
- What can be felt ?
- soft, non-distended, x4
- lower edge of liver
PE Genitalia
- female and male, testes are ____
- Blood tinged vaginal mucosa is ___ in newborn
- Foreskin is ___ _____ until age 1-2 years
- down
- OK
- non-retractable
PE Musculoskeletal
- Moves all extremities well with good ____, _____ ortalani’s, ____ gluteal folds
- Check for ____ hips by =
- Feet may turn __ or __, this is okay if they can be turned back to normal position
- If you cannot reposition =
- ROM, negative, equal
- dislocated by looking for uneven gluteal folds or ortalani’s clinck/clunk
- in or out
- may indicate club feet, needs to be cast
PE Neuro
- good ____, interactive, h____, reflexes (3)
- good cry, happy, (moro, grasp, babinski)
Anticipatory Guidance (6)
1) Sleep
2) Oral health
3) Mental health
4) Play
5) Disease prevention
6) Injury prevention
Hours of Sleep Per day
1) birth - 3 months =
2) 3-6 months =
3) 6-12 months =
1) 10-16 hrs/day
2) 14 hrs/day
3) 12-14 hrs/day
Sleep Interventions
1) Place baby in a =
2) Provide a consistent =
3) Establisth a consistent _____ and ___ (ex) rocking, cuddling
4) Put baby in crib while still _____
5) Remain in room for =
6) Always place baby on ____ (SIDS prevention!)
7) If child wakes up in the middle of the night, what should you do?
1) quiet, dark room
2) transitional object (blanket)
3) routine, time
4) awake
5) few minutes
6) BACK!
7) verbally reassure it’s still time to sleep (do the same thing every time)
Oral Health
- Wipe infants gums ____ times/day, even if:
- Do not nurse or bottle while _____, why?
- When teething, offer =
- 1-2, no gums!
- bed, linked to carries
- safe, cool teething toys for comfort
Mental Health
1) What is a good measure of secure infants in nurturing environments?
2) Child and parent interactions include (3)
3) Difficulty in self comforting may indicate =
1) good growth and development
2) eye contact, secure holding and cuddling, comforting
3) mental health issues or other environmental factors
Play
1) play with infant ____
2) ____ frequently with infant - ____ inches from face
3) ____ to infant daily
4) Promote stimulation with (3)
5) Nurture infants by c___, r____, m_____, s____
6) ____ time, ____ time
7) ____ large toys, ____ rattles
1) daily
2) vocalize, 12-15
3) Read
4) Mirrors, musical mobiles, bright colors
5) cuddling, rocking, massaging, singing
6) Floor, Tummy
7) Grasp, shake
Immunizations
Passsive Immunity =
Explore patients =
Do RN’s need orders?
= passed from mother if she has immunity either through disease process or vaccination
Concerns regarding immunizatins and provide evidence based information
No, don’t need to wait for provider to write an order
Advisory Committee on Immunization Practices (ACIP)
Centers of Disease Control (CDC)
15 experts in vaccinology, immunology, pediatrics, nursing, internal medicine, family medicine, virology, public health, infectious disease and preventative medicine expert
Evaluate scientific information about the vaccines, review the evidence regarding safety and effectiveness of the vaccines, the severity of the diseases prevented by the vaccines, the number of children who get the disease if there is no vaccine, how well the vaccines work for children of diff ages
ACIP 2016 Vaccine Schedule Pay attention to: 1) \_\_\_\_\_\_\_ \_\_\_\_\_ between vaccines (max is irrelevant, body doesn't respond if given early) 2) \_\_\_\_\_\_ age to get vaccine 3) Any required \_\_\_\_\_ and \_\_\_\_ 4) Details below the schedule = 5) \_\_\_\_ \_\_ schedule
1) Minimum interval
2) Youngest
3) boosters and when (at what age)
4) Footnotes
5) Catch-up
VIS Vaccine Information Statements
1) Explains:
2) Federal law =
3) Available in ___ languages
4) Offer parent enough ____ to read info
5) Ask parent if he/she has any ____ after reading
6) Obtain ____
7) _____ vaccine
1) risks and benefits of vaccine
2) MUST give to parent BEFORE vaccine administration
3) 40
4) time
5) questions
6) consent
7) administer
Needle Lengths
IM =
- Newborns:
SC =
- only two live vaccines (2)IM = 1 inch
: may consider using 5/8 inch for IM if less than 4 weeks old
SC = 5/8 inch
- MMR, Varicella (come in powder form)
Where to administer
1) IM =
2) SC =
What is the preferred IM sight for < 3 years old
1) anterior lateral thigh
2) arm or thigh
vastus lateralis (anterior lateral thigh)
if giving multiple , separate injection sites by at least =
Why?
Combination vaccines are given to =
1-2 inch
To determine which injection caused it, if a local reaction occurred
Decrease # of injections
Rights of medication administration
- Right Patient
- Right vaccine or diluent
- Right time
- Right dosage
- Right route, needle length, technique
- Right site
- Right documentation
Also correct age, appropriate interval, before vaccine or diluent expires
Comfort measures during Vaccinations
1) What is given for fever/pain, but not as preventative measure?
2) _____ techniques
3) _______ immediately after injections
4) Order of injections =
5) Tactile stimulation =
6) Administration technique =
7) ____ analgesics are applied ____ (ex lidocaine)
8) Dual administration =
1) Antipyretics (tylenol)
2) Distraction
3) Breastfeeding
4) least to most painful
5) rubbing skin near injection can decrease pain (for age >4), but can cause more pain for child < 4
6) rapidly, without aspiration
7) Topical, prior
8) 2 nurses administer injection at same time in 2 sites
Citywide Immunization Registry =
It is mandated in NYC that providers put every vaccine they administer into the registry
Medical Management for Adverse Reactions (2)
Reporting adverse reactions =
Epi-pen and Benadryl must be available
Must report anything that happens to the child within 21 days of vaccination
Home Management after vaccinations
1) Mild pain/fever =
2) Local redness and swelling (2)
3) Fever for more than __ days, high fever of ____, ___ pitched cry
4) Emergency =
1) analgesics (tylenol)
2) ice, benadryl
3) 3, 105, high
4) seizures - need immediate medical management
Infant car seat should be
Rear facing until 1 year old , but recommended to keep rear facing until 2 years
Crib safety =
rails up, avoid toys in crib
Violence in the home
Never do what?
Shake baby!
- come up with a plan when parent becomes frustrated with baby, take deep breaths, count to ten, have someone else over
Other methods of injury prevention
1) On stairs and windows =
2) For electrical outlets =
3) Avoid (3)
4) Medicine safety =
1) install gates and guards
2) safety plugs
3) string toys, necklaces, cords
4) install locks, keep medicine out of reach, poison control center = 1800 222 1222 (NY)
Interventions to prevent separation anxiety in the hospitalized child (4)
1) Have parents stay with child
2) Assess daily routines (try to mimic schedule at home, establish similar daily patterns)
3) Assign consistent staff members
4) Assist parents in communicating their absences
Interventions to minimize pain in the hospitalized child
1) ____ infant gently and securely by ____
2) Distractions such as (4)
3) After procedure ask parent to =
4) Don’t have parent do what during procedure?
5) Treatments/procedures should take place where?
1) Immobilize, swaddling in blanket
2) touch, voice, pacifier, bottle
3) hold, rock, sing
4) hold down during procedure, parent shouldn’t be associated with pain/distress
5) NOT in patient’s room
Reactions to pain in a hospitalized child include (5)
Irritability, restlessness
Poor feeding
Disturbed sleep pattern, Tachycardia, increased respiratory rate
Lethargy
Pain scales (2)
Neonatal infant pain scale
FLACC
Common themes among parents of hospitalized infant include
1) Feelings of _____
2) ______ skills of staff
3) Accepting _____ of hospitalization
4) Need to have information explained in =
5) Dealing with ____
6) Coping with _____
1) helpless
2) Question
3) Reality
4) Simple language
5) Fear
6) Uncertainty
How the nurse can help comfort parents with hospitalized infant
1) ______ parents in child’s care
2) Explain every ______
3) ______ parents in simple, plain language
4) Inform parents of plan of care using:
1) Involve
2) Procedure
3) Educate
4) Family centered rounds
Sibling reactions to hospitalized infant
Encourage ____ visitations
- loneliness, fear, worry,
- anger, resentment, jealousy, guilt
- perceive their parents to be treating them differently compared with before sibling’s hospitalization
- receive little info about siblings
- perception of stress they experience is equal to that of hospitalized infant
Sibling
Safety, Safety, Safety!
1) ______ surroundings
2) ____ parents, they know their child!
3) Respond if child does not?
4) If vitals are off, what do you do?
5) Know your team (7)
6) Good ____ skills
1) Environmental
2) Trust
3) Doesn’t look “right”, something is going on
4) Recheck and respond
5) Charge nurse, nurse manager, attending, resident, nurse educator, respiratory therapist, response team
6) Communication
