LC_Exam3 NTK Flashcards
What is the Critical Period in development?
Critical Period: when development is RESPONSIVE to INFLUENCE.
Time during which a developing system is especially vulnerable to injury.
Thought to correspond to periods of rapid growth.
What is the Sensitive Period in development?
Sensitive Period: developing system more amenable to acquisition of certain abilities (e.g. language input during first year of life), more sensitive to certain stimuli (e.g. parent smell), and more readily influenced by certain environmental factors → long term impact on development.
Time when EXPOSURE to things SUFFICES in teaching rather than expending conscious effort to learn.
Describe the core concepts and stages of development in the theories of Freud.
Oral, Anal, Phallic, Latency, Genital = psychosexual development
Describe the core concepts and stages of development in the theories of Piaget.
Piaget: cognitive development through interactions with the environment.
Describe the core concepts and stages of development in the theories of Bowlby.
Bowlby: attachment theory.
Relationship with primary caregiver during infancy forms foundation for later well-being and personality development
Infants programmed to behave in ways that evoke care and ensure survival
Secure base: relationship with a person who provides comfort and safety and enables the infant/young child to explore the environment.
Strange situation: experimental paradigm developed to determine attachment status
Piaget: cognitive development through interactions with the environment.
What is Accommodation?
Accommodation: reorganization of mind based on discordance between new experience and past experiences in order to understand new experience.
Piaget: cognitive development through interactions with the environment.
What is Decalage?
Decalage: unevenness in developmental progress across different cognitive abilities (walking vs. talking).
Piaget: cognitive development through interactions with the environment.
What is Assimilation?
Assimilation: integration of new experience with past experiences and problem-solving based on past experiences.
What are the stages of development according to Piaget?
Stages of development:
Sensorimotor (birth to 18-24 months): dependence on exploration of perceptual stimuli through sensory modalities - development of object permanence
Preoperational (18-24 months to 7 years): language development, symbolic capacities, magical explanations, limited attention span and memory, egocentrism causality based on temporal or spatial nearness
Concrete operations (7 to 12yrs): ability to conserve volume and quantity, reversibility of events, perspective taking, logical dialogue, complex causal sequences
Formal operations (12 yrs - adulthood): manipulation of ideas and concepts, abstract reasoning, etc.
Repression: ?
Repression: hiding away wishes in the unconscious
Displacement: ?
Displacement: symptoms (wishes/impulses) hidden in one area appear in another
Sublimation: ?
Sublimation: using energy from unfulfilled wishes/impulses in a constructive way
Denial: ?
Denial: failure to acknowledge a truth that produces anxiety
Rationalization: ?
Rationalization: actions based on one motive justified by a more acceptable motive
Reaction formation: ?
Reaction formation: displaying a trait that is opposite of a repressed one
Projection: ?
Projection: attribute your own unacceptable impulses to another
Sublimation: ?
Sublimation: channeling instincts/wishes/impulses into socially accepted and valuable activity (e.g. painting)
Regression: ?
Regression: reverting to behaviors seen in earlier stages of development to obtain care/resources that alleviate anxiety
What is the 4 primitive reflexes and when in development do the reflexes go away?
Moro (3 mo)
Rooting (4 mo)
Palmar (6 mo)
Babinski (12 mo)
In terms of Posture, when in dev. do infants develop the following?
- lifts head up prone
- rolls and sits
- crawls
- stands
- walks
- lifts head up prone (1 mo)
- rolls and sits (6 mo)
- crawls (8 mo)
- stands (10 mo)
- walks (12-18 mo)
What what month can an infant pass toys from one hand to another hand?
~6 mo.
When in dev. can an infant do a Pincer Grasp?
10 mo
In terms of Social Dev, when do infants develop the following?
Social smile
Stranger anxiety
Separation anxiety
Social smile (2 mo) Stranger anxiety (6 mo) Separation anxiety (9 mo)
In terms of Verbal/Cognitive dev., when do infants develop the following?
Orients - first to voice, then to name and gestures.
Object permanence
Oratory - says “mama” and “dada” by
Orients - first to voice (4 mo), then to name and gestures (9 mo)
Object permanence (9 mo)
Oratory - says “mama” and “dada” by (10 mo)
Describe the dev. of the Lungs prior to 22-24 weeks gestation?
prior to 22-24 weeks, the capacity for ventilation is limited by lack of air spaces, and the distance of capillaries from rudimentary air spaces.
Describe the 3 phases of the progressive branching of bronchial an pulmonary vascular trees.
Canalicular Phase: 17-27 weeks’ gestation, type II cells begin to differentiate, capillary network begins to form.
Saccular Phase: 26-36 weeks’ gestation, thinning of interstitial space, closer association of capillaries to air spaces and type I cells.
Alveolar Phase: 36 weeks’ gestation to 3 or more years, presence of true alveoli
22-24 weeks is therefore the physiologic limit of viability as the anatomic requirements for pulmonary gas exchange are not present prior to this point in gestation.
What is Surfactant deficiency?
Surfactant deficiency: leads to diffuse microatelectasis, macromolecular pulmonary edema (proteinaceous hyaline membranes), and very poor compliance (sticky, poorly expanded airspaces): also known as Hyaline Membrane Disease (HMD)
In the fetus, the pulmonary epithelium secretes fluid by __________ (in lambs, 5 ml/kg/hr at term – that’s a lot!)
This forms the basis for testing amniotic fluid for lung maturity
The fluid produced maintains lung volume and lung growth in utero PPROM (Premature prolonged rupture of membranes) with severe oligohydramnios leads to pulmonary hypoplasia
active Cl secretion
APGAR scores: rapid description of newborn condition at birth and response to resuscitation.
HR: absent, < 100, > 100
Respiration: absent, irregular/gasping, regular/crying
Tone: limp/flaccid, some flexion, active motion
Response to suction: non, grimace, cough/sneeze/cry
Color: pale/blue, acrocyanosis, completely pink
In first year of life, infants can distinguish between the two sexes.
- By 7 months, infants can discriminate between male and female faces and voices, using hair length and voice pitch.
- By 9 months, infants show some basic gender knowledge.
- By 12 months, babies will look to female faces when they hear a female voice and male faces when they hear a male voice.
Gender identity: ?
Gender identity: ability to label oneself as girl or boy and others as a girl, boy, woman, or man - a person’s self-representation as male or female
Gender stability: ?
Gender stability: recognition that gender remains constant over time
Gender consistency: ?
Gender consistency: gender is invariant despite changes in appearance, dress, or activity
Gender constancy: ?
Gender constancy: the belief that one’s own gender is fixed and irreversible
Medical Emergencies from physical child abuse include what? (5)
Any infant w/ bruises (head/facial/abd), burns or fractures
Any <2 yrs with suspected “shaken baby” or head trauma
Any child with suspected abdominal trauma
Any child with burns in stocking or glove distribution, unusual pattern, burns to genitalia, unexplained burns
Any child with disclosure or sign of sexual assault within 48-72 hrs after alleged event if possibility of acute injury is present or if forensic evidence exists
What form of child abuse is the most commonly reported?
Neglect is the most commonly reported and substantiated form of mistreatment annually.
What are common historical features in child abuse?
Common historical features in child abuse:
- discrepant or absent history
- delay in seeking care
- hx of abuse in caregiver’s childhood
- stress/crisis
- social or physical isolation
- increasing severity or number of injuries if no intervention.
Be sure to get a detailed psychosocial history, including who is at home (and who’s missing), domestic violence, substance abuse, prior physical/sexual abuse.
What is Munchausen Syndrome by Proxy?
Caregiver (usu mother) either simulates or creates the symptoms or signs of illness in a child –> now termed “factitious disorder by proxy”.
Bizarre, recurrent complaints.
Most common presentations are recurrent apnea, dehydration from induced vomiting/diarrhea, sepsis, change in mental status, fever, GI bleeding, seizures.
Persistent doctor-shopping and enforced invalidation
Define Aging:
Aging is the natural progressive decline in body function that leads to death
Is universal and follows a fairly predictable course (though there is considerable variation among individuals)
The effect are cumulative (and essentially irreversible) and accelerates with increasing age
Summerize adolescent mordidity stats:
72.3% are preventable deaths!
Causes of death:
- Accidents (45.5%)
- Homicide (15.3%)
- Suicide (11.3%)
With respect to the elderly population:
\_\_\_% of 85+ require assisted living \_\_\_ yrs (“old” old) is fastest growing group
40% of 85+ require assisted living
> 85 yrs (“old” old) is fastest growing group
Life expectancy: ???
Life expectancy = average age at death.
o currently about 77 yrs for men and 82 yrs for women (women outlive men by 7-10 yrs)
o If all major disease were eradicated (cancer etc.) would only probably live to about 90 yrs.
Life Span: ???
Life span = greatest possible life expectancy.
about 110 yrs (longest of all mammals)
o For many species, life span correlates with metabolic rate (faster the rate, shorter the lifespan)
What happens to hair, skin, and eyes as we age?
What about fat dist.?
o Hair: loss and graying
o Skin: wrinkles, age spots on sun-exposed surfaces
o Eyes: farsightedness (presbyopia), cataracts, macular degeneration.
Everything declines except fat! Especially central fat
What special consideration of the kidneys do we have to take when working with elderly pt.s
Kidneys: loss of nephrons; weighs less, less smooth (more granular=benign arteriolnephrosclerosis);
decrease ADH response –> less renal excretion of drugs and ability to compensate for volume depletion/overload –> serum creatinine does not provide adequate information about renal function.
(use Cockcroft-Gault)!!!
What happens to the heart as we age?
Heart: some atrophy of myocytes; accumulation of lipofuscin (“wear-and-tear” pigment that is a product of peroxidation of unsaturated fatty acids);
increased LV stiffness (from HTN); decrease in HR and CO, decreased beta-adrenergic receptor responsiveness (also increase postural hypotension)
What happens to the Lungs as we age?
Lung: loss of elastic tissue, accumulation of anthracotic pigment (black dust).
increase atelectasis;
brain responds less to low PAO2
decrease in VO2 max
What is Sarcopenia?
Sarcopenia: loss of muscle mass (decrease in strength and decrease basal metabolic rate)
What is the best strategies to combat aging!?
Physical exercise, fatty!
What is Homeostenosis?
“Homeostenosis”—idea that elderly have more limited margin of homeostasis (decreased ability to adapt to perturbations)
What are the typical diseases that are ~w/ aging?
o Cancer: because it takes time for mutations to accumulate and cells to become malignant peak mortality rate is at age 70
o Generalized atherosclerosis, with special involvement of coronary arteries (leading to MI, CHF)
o Cerebrovascular accidents (strokes) seen in the
setting of HTN (increases with age)
o Type 2 Diabetes
o Alzheimer’s and Parkinson’s disease: about 20% of 80+ yr olds have Alzheimer’s; incidence of Parkinson’s is highest around age 75
o Thromboembolism
What is the clock theory of aging?
Idea that aging is controlled by genes that program cell to die when “time is up”.
Somatic cells have been shown to be “programmed” to die after a certain time. (d/t shortening of telomeric ends of chromosomes over time (in contrast to malignant cells))
What are 3 (rare) genetic diseases that causes premature aging?
o Progeria: accelerated aging and death from laminin A/C mutation (part of nuclear lamina needed for transcription, chromatin replication, etc)
o Werner’s syndrome: affected patients develop cataracts, skin aging, hair loss while in 20s and early onset of DM, osteoporosis, cancer, heart disease. Mutation in DNA helicase (chr. 8) leading to rapid telomere shortening
o Down Syndrome: premature death
What rust theory of aging?
Idea that aging is due to accumulation of somatic mutations and oxidative damage.
Aged individual have elevated levels of lipofuscin (cross-linked collagen and oxidized DNA and protein) –> can be due to decreased antioxidants (glutathione) and less ability to degrade oxidized protein
How is the care of the elderly different in the hospital setting?
Avoid iatrogenic immobility!!!
keep them moving! (discontinue bladder catheters, IV lines, order PT early)
o For every day in bed, it takes 3-5 days to regain the lost muscle function (1-2 days for younger patients).
o Evidence based medicine is tricky because the trials are not done with the frail elderly for which the results are extrapolated.
What may be absent in an elderly pt. with a serious infection?
A fever!
Fever may be absent in 20-30% in elderly with serious infection. Must adjust fever definition to single temp >100 or repeated temp >99 or >2 rise over baseline.
What is the most common cause of wt. loss in the elderly?
Depression.
if cancer/malignancy is ruled out
All women > 65 yrs require what screening?
DEXA scan.
Other screens
o Mammogram (USPSTF every 2 yrs; do if expect 5+ yrs of life expectancy)
o Colonoscopy (every 5 yrs)
o Stop paps at 70 yrs
What is PHQ9?
9 question screen for depression
What drug can be safely used in the elderly for the Tx of acute depression?
methylphenidate (Ritalin) acutely for depression/apathy in elderly
Mild cognitive impairment is perhaps precursor to ______________.
Mild cognitive impairment is perhaps precursor to Alzheimer’s (~10%/yr with this progress to Alzheimer’s)
What are the stages of Ulceration? (4)
Stages of Ulceration:
o Stage 1: non-blanchable erythema
o Stage 2: break in epidermis/dermis
o Stage 3: involves subcutaneous tissue, maybe fascia but not completely through fascia.
o Stage 4: through tissue to bone
How often do you have to turn pt. in their beds to avoid pressure ulcers?
every two hours
In Peds, renal clearance is predictable and higher in kids compared to adults. Therefore, what changes do you have to make to their medications?
Need higher maintenance dose!
In Peds.
Dosing calculations for drugs that need accurate dosing/narrow therapeutic windows should be made using what?
body surface area calculation is better for drugs that need very accurate dosing/narrow therapeutic window
What drugs are contraindicated before puberty because risk of Reyes Syndrome?
Salicylates
List common/major drugs that are Toxic to peds.
- Iron
- Antidepressants (TCADs) and Antipsychotics (1st gen)
- Antimalarials
- Antiarrhythmics
- Ca-channel blockers
- Sulfonylurea hypoglycemics
- Opioid analgesics
- Acetaminophen
- Diphenhydramine
Patients over 65 yrs account for __a__% of prescription drug use; 40% of 60+ yrs take at least __b__ medications.
a. 30-40%
b. 5 meds
In evaluating a medication, what epidemiological stat is most important?
Number needed to treat is most important factor!!
NNT=100/(incidence in controls-incidence in treated)
What changes in the Absorption of drugs in the elderly?
Absorption: decreased gastric acid, gastric emptying/GI motility, decreased splanchnic blood flow –> theoretic decrease in peak Cp but not significant.
What changes in the DISTRIBUTION of drugs in the elderly?
Distribution: decrease in TBW and lean body mass, increase in fat –> decreased Vd for water soluble drugs and prolonged elimination and accumulation for lipid soluble drugs.
Does first pass metabolism increase or decrease with age? Explain why.
Increase age = decreased 1st pass metabolism!
due to decrease hepatic mass and decrease blood flow rate of 1%/yr after age 40.
(Phase II reactions appear to be minimally affected by aging, but Phase I decreases with age in 30-35% of elderly)
If you had to pick between drugs that was metabolized via phase 1 or phase 2, which would you pick for an elderly pt.?
choose Phase II metabolized drugs over Phase I since it is less affected.
What is most affected pharmacokinetic factor in elderly?
Elimination
Renal function declines predictably (Cockroft-Gault equation –> about 10 ml/decade).
renal dosing adjustments should be used regularly
What is Beer’s List?
“Beers List” defines explicit criteria for determining potentially inappropriate mediation use in elderly –> drugs are categorized as medications to avoid or to use within dose and duration ranges in the elderly OR medications to avoid in elderly patients with specific concomitant diseases.
What two common drugs are usually the correct answer to questions about which drugs to avoid/discontinue in the elderly?
Avoid all “muscle relaxers” and TCADs (“discontinue amitriptyline” is always the right answer!)
Also: all BDZs,`diphenhydramine, 1st gen antihistamines, Class I antiarrhythmics; Digoxin >.125 mg/day
Which regards to Tx and Drugs for elderly pt. what is STOPP and START?
STOPP (Screening Tool of Older Person’s potentially inappropriate Prescriptions)
START (Screening Tool to Alert doctors to Right Treatment)
The most important aspects of dying for people at end of life include: (5)
- Dedicated decision maker
- Financial affairs in order
- Knowing what to expect (prognosis and physical condition)
- Dignity
- Pain control
Palliative care fills in the GAPS. What does GAPS stand for?
- Goals of care
- Advance directive
- Psycho-social spiritual support
- Symptom control
What does palliative care and hospice do for the qaulity of life?
- Palliative care increase QOL in seriously ill.
- Hospice increases QOL at end of life
What is palliative care vs. hospice?
Palliative care: specialized medical care for people with serious illnesses (NOT necessarily terminal or EOL).
o Provided by team of specialists with the goal of improving QOL for patient and family.
NOT dependent on prognosis.
NOT the same as hospice (which IS end of life, subset of palliative care—EOL defined as 6 months or less by Medicare).
Hospice: ask yourself “Would I be surprised if this person died in the next year”. good place to start with prognostics.
Hospice can increase QOL and increase survival for some illnesses.
How longs does the active dying process take?
hours to days
What are some steps in the active dying process?
o Social isolation (less interested)
o Decreased need for food (don’t force feed! Body is not using the energy and force feeding can risk aspiration)
o Increased need for sleep
o Delirium: disorientation/clouded thinking and restlessness/agitation think pain management if patient is grimacing usually give opioids which do NOT hasten death)
oDecreased senses (though assume that patient can still hear/feel you)
o Loss of bowel/bladder control
