UNIT 1- NEWBORN & PEDIATRIC ASSESSMENT Flashcards
0What situations could be considered for emancipation?
- Pregnancy
- However, once the baby is born the underage child is no longer considered emancipated
- Marriage
- High School Graduation
- Independent living
- Military service
What is considered the age of majority?
18
What are some exceptions to parental consent in terms of the informed consent?
Consent by proxy
- examples: school/coach
Life-threatening emergencies
- danger to self or permanent injury— we would stabilize and then worry about consent
Parent refusal
Evaluation of abuse or neglect
Medically emancipated conditions
In what order should we take vital signs of a child to help promote atraumatic care?
1st- respirations
2nd- heart rate
3rd- oxygen saturation
4th- blood pressure and temperature
True or False: It is important to document behavior during vital signs
True– certain behaviors such as crying can impact vitals
Normal pulse and respiration for a newborn?
Pulse: 100-160
Resp: 30-60
Normal pulse and respiration for babies 1-11 months old?
Pulse: 100-150
Resp: 25-35
Normal pulse and respiration for children 1-3 years old (toddlers)
Pulse: 80-130
Resp: 20-30
Normal pulse and respiration for children 3-5 (preschoolers)
Pulse: 80-120
Resp: 20-25
Normal pulse and respirations for children 6-10yrs old? (school aged)
Pulse: 70-110
Resp: 18-22
Normal pulse and respirations for children 10-16 years old (adolescent)
Pulse: 60-90
Resp: 16-20
In children 7 and younger where are we watching to count respirations?
Abdominal area… observing diaphragmatic breathing. We look here because the intercostal muscles are not as well developed.
In children 7 and up where are we watching to count respirations?
Thoracic
How do we count pulses in children 2 years or younger?
Apical pulse for a full min
At what age can we begin to count pulse by the radial pulse?
Children over 2
Why is the pulse higher in children?
They have a higher metabolic rate
Why is selection of the appropriate blood pressure cuff important?
A cuff to big can cause a false low bp and a cuff to small can cause a false high bp.
Which is better a bp cuff too big or too small?
Too big.
What is important to consider when taking a childs temp?
The activity the child was doing prior to temp being taken. Things like active exercise, stress, curing and the environment can affect the result.
What are some pharmacologic interventions for fevers in children?
- Acetaminophen- preferred drug in children and infants
- Ibuprofen- Kids under 6M of age CANNOT take. High risk of renal failure
NO ASPRIN– increased risk of rayes syndrome
What are some education points or things we should know about interventions for fevers?
- It can take up to 1 hour before the medication kicks in… during that time parents can try removing clothes, blankets putting a cool cloth on the child’s head to try and help while we wait for meds to work
- Rest is vital
- Encourage fluids!
What is the very most important thing a new born baby must do in order to survive?
Breath
What stimulates breathing?
Chemical factors: Decreased PH stimulates breathing
Thermal Factors: Cold babies being warmed cry
Tactile: Us messing with them to try and warm them up will stimulate them to cry and breath.
Babies are typically born ____ and it takes about 10mins to get them to normal o2 saturation?
Hypoxic… babies will sometimes be stating in the 60% when they are 1st born
When a baby is born what is happening in their heart?
- Circulatory changes (instead of relying on mom) allow blood flow through lungs
- Pressure changes in the heart, lungs and vessels after umbilical cord has been clamped.– This happens seconds after
What might we hear when listening to a babies heart after just being born?
Murmur- to some extent this is normal as shunts within the heart begin to close off. As the shunts are completely closure the murmur will become more heard as blood flow is meeting resistance. Once shunts are completely closed the murmur will not be audible.
What is a normal newborn temp?
36.5-37.5 Celsius
or
97.7-99.5 F
This is optimal temperature for newborns at these temps the baby is using minimal oxygen conservation
What are principle thermogenic sources?
Heart
Liver
Brain
Brown adipose tissues
True or false: Thermoregulation is not vital to a newborns survival?
False. It is critical
For ever degree in temp a newborn drops the mortality rate increases by….
10%
What is does our initial newborn management consist of?
- Providing warmth
- while assessing
- Stimulation
- Newborn identification
- Medication
What is the purpose of the Apgar score and what do we need to know about it?
- Used to assess adjustment to extrauterine life
- Completed at 1 and 5 mins
- Reflects the general condition of the infant
- Not used to determine the need for resuscitation
What are some factors that might effect the Apgar score?
- Physiologic immaturity “preterm babies”
- Infection
- Maternal sedation
- Congenital disorders
What signs do the Apgar look at and how is it scoredd?
Heart Rate
0- Absent
1- Less than 100 BPM
2- More than 100 BPM
Resp. Effort
0-Absent
1-irregular, slow, weak cry
2- Good; strong cry
Muscle Tone
0- Limp
1- Some flexion
2- Well flexed
Response
0- No response
1- Grimace
2- Cry, sneeze
Color
0- Blue, pale
1- body pink, extremities blue
2- Completely pink
Total
0-3- severe stress
4-6- moderately diff
7-10 Stable
What is acrocyanosis?
Cyanosis (blue tint present )of the hands and feet
What is the normal posture of a newborn?
flexed
What is the general behavior of a newborn?
- Easily awakened by a loud noise
- Easily comforted
- Satisfied after feeding
- Level of responsiveness to noxious stimuli
- Transition of sleep states is evident
What is the normal skin texture of a newborn?
- Smooth
- Puffy Areas
- seen around eyes and genital area due to moms hormones
- Vernix present- white cheesy looking stuff (skin protectant)
- Lanugo- hair- Skin protectant
What is the normal color newborns?
Acrocyanotic or pink with no jaundice on the first day of life
What is not a normal skin color in newborns within the 1st 24 hours of life?
Jaundice– typical onset of jaundice 1-3 days after birth
Grey/blue/dusky color is never normal
In which direction does jaundice move?
Starts in eyes and moves down the body towards feet. When jaundice clears it clears from the feet to head.
What is a Mongolian spot?
bluish/purple like spot on the babies bottom often times mistaken for a bruise if not documented correctly.
What should we know about a neonates eyes and the assessment?
- Slate grey/blue or brown color at birth, color of eye establishes around 6-12 months.
- note any bruising caused by the vaginal canal
- Make sure there is no jaundice or edema (abnormal)
- Visual field 8-12 in away
- Strabismus (eye crossing) normal at birth.
- No tear production until about 2 months old
- Pupils are reactive to light
- No drainage
At what age does tear production occur?
2 months
What should we know about a neonates ears and the assessment?
- Note the position of the Penna of the ear it should be even with the outer canthus of the eye
- if it isn’t this could indicate downs.
- May have some drainage since they’ve been in amniotic fluid
- flexible Penna with some cartilage
What should we know about neonates nose and the assessment?
- Check the patency- should be clear, with clear drainage, may sneeze a lot as they try and clear the airway
- May have bruising caused by delivery
- Bloody discharge, nasal flaring this is a cause for concern
What should we know about neonates mouth and throat and the assessment?
- Assess for cleft lip/cleft pallet, natal teeth
- Make sure if they have cleft pallets there are no holes
- Natal teeth: bad root system will need to be pulled as they can be aspirated
- Assess that throat/neck is midline. Webbing can indicate downs
What should we know about neonates neck and chest and the assessment
- Lift up chin… look for skin breakdown and clean gunk that collects under the neck
- Note chest alignment, nipple alignment, supranormal nipple
- may have nipple discharge due to hormones (witches milk)
When is the best time to auscultate the lungs?
When the infant is quiet
What is a normal resp rate for a newborn?
30-60 breaths per min
What type of respiratory pattern does a newborn have?
Irregular– Periodic breathing which are characterized by periods of apnea lasting less than 15 seconds with no other VS changes or color changes.
What should we expect to hear when listening to a newborns lungs?
Expect clear, equal lung sounds bilaterally
some crackles are normal after birth due to amniotic fluid. Should resolve around 6-8 hours after birth. Stridor is not normal
What is a normal apical heart rate in a newborn?
100-160 beats per min
What location might we hear a murmur?
Left sternal border
The more term the baby the ____ the heart rate
Lower
The more premature the baby the ____ the heart rate
Higher
If you cant hear heart sounds on the left side but you can hear them on the right side what is this called?
Dextrocardia
Where can we find the babies apical pulse?
3-4 intercostal space
A newborns abdomen is what shape?
Rounded
When might you hear a newborns bowel sounds?
Takes about 20mins to 1 hour before bowel sounds to become active
What should we assess on the umbilical cord?
- Locate to see if the umbilical cord has 2 arteries and 1 vein. This is WNL
- If a baby only has 1 artery and 1 vein this could indicate future problems with heart and kidneys. Not always though
- 10-14 days after the cord is clamed it should fall off. It will become black, clean around base with warm water or alcohol swabs. do NOT submerge. When it falls off put inside a biohazard bag
- smell/drainage could indicate infection
What are we assessing for when looking at the back and anus?
Spine
1. Sacral dimple
2. Sacral tuft
3. Pilonidal sinus or cyst
4. Spina bifida (occulta)– all of the above if found on assessment could indicate spina bifida but not always
Anus
1. Imperforate anus– missing the opening of the anus
What should we know about meconium?
It is the babies first poop
Color: Dark green, black
Consistency: Thick, sticky, shiny, tar-like, mixture of bile, cells, mucus and amniotic fluid, usually doesn’t smell
Occurrence: 1st 24 hours
Sometimes used for drug testing
What should we know about breastfeeding poop?
Color: Yellow or yellow green
Consistency: Seedy, soft and squishy; similar to mustard, cottage cheese or scrambled eggs usually has a sweet smell
Occurrence: w/in 3-5 days. The stool indicates baby is getting mature breast milk.
What should we know about formula poop?
Color: Yellow-brown, green-tan brown
Consistency: Thick and firm; similar to peanut butter or toothpaste stinky compared to breastmilk
Occurrence: Within 1st and 2nd week
What should we know about solid food poop?
Color: Dark brown, brown yellow
Consistency: Think and firm but also soft and mushy, changes colors, stinks.
Occurrence: 4-6 months when babies start solids
What are we assessing the female genitalia of a newborn baby for
- Labia majora and minora, hymenal tag
- vaginal discharge, pseudomenstration
- blood streak normal due to mothers hormones
What are we assessing the male genitalia of a newborn baby for?
- Penis
- Foreskin and urethral opening
- do not retract foreskin
- make sure urethral opening on correct side
- Scrotom, testes
- hydrocele, hernias
When we are assessing the extremities what are we looking for?
- Symmetry (shape, size and movement)
- ROM
- gentle passive ROM
- Digits (polydactly, syndactly)
- Palmar Crease/ Webbing
- Muscle tone
- Morro reflex (startle)
- If one side doesn’t startle this is a concern
- good tool to use when looking at symmetry
When assessing a newborns neurologic system what are we looking for?
- Reflexes (grasp and babinski)
- Posture, tone, head control, and body movement
- Behavior response to care
- consolable
- cry (frequency and pitch)– high pitch/inconsolable
- Bad tone– due to
- drug abuse, sedation from mother, neuro issues
What are the sensory areas that we assess in a newborn?
- Vision
- Hearing
- Smell
- Taste
- Touch
newborns are able to perceive and react to smell taste and touch.
What is the priority goal in the nursery?
Maintaining a patent airway
What are ways we can maintain a patent airway?
- Supine positioning for sleep
- Suction the oral and nasal secretions with a bulb syringe
- More forceful mechanical suctioning should be done gently, with sufficient time for the infant to recuperate
- At birth they have a lot of secretions in their mouth. We need to suction mouth then nose… sucking nose first might cause baby to inhale mucus from mouth.
What are our newborn interventions?
- Safety (identification/airway)
- ID must match halo and must stay on baby/mom/dad until discharge, staff have special badge
- Vitamin K admin
- Prevents hemorrhagic disease… babies born don’t have vitamin. Shot given in vastus lateralis at birth
- Hep B. vaccine admin
- need consents
- Newborn screening
- Helps screen for disorders/infection/inherited metabolic disorders. Want to do this within the 1st 24 hours after birth and must have protein in belly
- Avoid center of foot due to possibility of damaging gait
- Universal hearing screen
- Has to be done before discharge. Sometimes babies fail.. can repeat and if they fail again then they follow up after.
What are our newborn interventions concerning the eye?
Prophylaxis (ophthalmia neonatorum)
1. Drugs (Opthalmic ointment or drops)
- erythromycin (0.5%)
- tetracycline (1%)
- Silver Nitrate (1%)
Needs to be done within the 1st hour of life
Helps prevent blindness from STI infections even if they are c sectioned
Assess eyes before administration
What teaching/discharge edu and parental support can we center around bathing
- Bathing
- opportunity for hygiene, assessment and anticipatory guidance for parents.
What discharge teaching can we provide regarding the umbilical cord care?
Don’t submerge until cord falls off. Clean base with warm water or alcohol pad
What discharge teaching can we provide regarding circumcision care?
No submerging
What discharge teaching can we provide about skin care and skin concerns?
Use mild soap and lotions
Circumcision is whose choice?
Parents
What are the risks of circumcisions?
Bleeding- anymore than a quarter size is a concern for bleeding
What are the benefits of circumcisions?
decrease risk in penile cancer and STI’s
What do we need to know about a circumcision procedure?
- Done under local numbing agent. Tylenol may be ordered but not always given
- Never a guarantee that a child will not need another circumcision later on if not enough foreskin was removed
- Don’t submerge
- Baby will eat after procedure.
Our assessment of attachment behavior includes….
Assessing
Emotional bonding between the parents and newborn
En Face position
Falling in love with the newborn.
Report any behaviors that indicate post partum depression even as the newborns nurse
What should we know about multiple births?
- critical for mother to bond to each newborn
- Nurses are instrumental in promotion of bonding
- Rooming-in and breastfeeding are encouraged
- Early visitation of an ill infant
- Identify unique characteristics of each
- No COBED
What might be our cumulative and subjective impression of a pediatric patient assessment include?
- Physical Appearance
- Hygiene & clothing appearance
- Nutrition
- Question both parent and child
- Behavior
- Ask Parents about red flags
- Personality
- Some are friendly and others are slow to warm up
- Interactions
- Between parents, siblings, and caregivers
- Posture
- Development
- Are they on track or close?
- Speech
- Can they talk and how is there speech
Our skin assessment on a pediatric patient should include?
- Color
- Texture
- Not any dry spots, oily or clammy spots
- Temperature
- Moisture
- Turgor
- Lesions
- Acne
- Common problem in adolescents
- Rashes
- Hair and distribution
- looking for any abnormal bald spots, fleas, ticks, lice.
On our head assessment of a pediatric patient what are we looking at?
- General shape/symmetry of the head
- Head control/ROM
- The older the child the better head control they will have
- Sutures
- Will fuse together as they get older
- Fontanels
- Posterior: 2-4 months
- Anterior: 12-18 months
When assesing eyes on a pediatric patient, what are we looking at?
- Size, shape and spacing
- PERRLA
- Color
- By 3-4 months they have binocularity
- They can fixate on one visual field with both eye simultaneously
- Strabismus (“Cross-eye”)
What are some treatments for strabismus
- Glasses
- Patching
- Eye drops
- Surgical intervention
What happens if strabismus is not detected and corrected by age 4-6?
- Develop Amblyopia (lazy eye)… Can also lead to blindness
What visual test are there for children?
- Snellen Chart-Letters
- HOTV/Tumbling E/Pictures
HOW TO
- HOTV/Tumbling E/Pictures
- 10’ from chart
- Cover 1 eye
- Keep both eyes open
- Glasses remain on if worn
When assessing ears on a pediatric patient, what are we looking at/for?
- Ear canal
- Eustachian Tube
- Remember a child’s Eustachian tube is more horizontal than an adults making them more prone to ear infections
- Foreign bodies
What are signs of hearing impairment in infants?
- Lack the startle or blink reflexes to loud sounds
- Absence of babble or voice by 7 months old
- Absence of well-formed syllables by 11 months
What are signs of hearing impairment in children?
- Use gestures, rather than words, to express desires
- Failure to develop intelligible speech by 24 months
- Asking to have statements repeated
- Avoidance of social interaction
When assessing the nose of a pediatric patient, what are we looking at/for?
- Midline and patency
- Internal structures
- Make not of pinkness, swelling, discharge but do take in consideration allergies. Note color and consistency of drainage.
When assessing the nose of a pediatric patient, what are we looking at/for?
- Lips
- Mucous Membranes
- Gums
- Teeth
- Tongue
What is the cause of early childhood caries?
Result of teeth bathed in carbohydrate rich solution
How do we prevent early childhood caries?
- Teach parents not to prop the bottle
- Teach parents to put child to bed with a bottle
- Clean gums/single teeth with soft cloth and water… as they get more teeth then introduce a toothbrush.
What is a general rule of thumb for the amount of teeth a child should have?
Age in months - 6 = the amount of teeth they should have
When is the normal time frame a child should start getting teeth?
Around 6-9 months but also depends on genetics
What is the teething order that children usually get their teeth?
- Lower central incisors
- Upper Central Incisors
- Upper Lateral Incisors
- Lower Lateral Incisors
How can you tell if the discomfort a child is having is from teething or something else?
Gently press on gum where tooth should erupt. If this relieves discomfort it is likely teething
What are signs of teething?
- Difficulty sleeping
- Increase in nonnutritive sucking/biting on hard objects
- Ear rubbing/pulling
- Excessive drooling
- Anorexia
What are some interventions we can teach parents to do for a teething child
Cold teething toys, acetaminophen, frozen breast milk in paci
benzocaine… done over do it… it can affect the heart.
When should kids have there complete set of baby teeth?
24 months
When should we encourage the stopping of thumb sucking and pacifier use?
By age 4-5
Malocclusion may occur if thumb sucking persists beyound 5 years of age
When do kids start loosing teeth?
Starts around age 6
How many teeth do kids lose?
Lose 20 primary teeth
How many teeth (permanent) do kids gain
32- 16 top and 16 bottom
When assessing the chest of a pediatric patient, what are we looking for/at?
- Shape with growth
- Movement
- birth to 7 Y– they are abdominal diaphragmatic breathers
- Older than 7Y thoracic breathers
When assessing the heart of a pediatric patient, what are we looking for/at?
- Apical pulse & Ausculatation
- Children younger than 7– fourth intercostal space for apical
- Children older than 7– fifth intercostal space for apical pulse
When assessing the lungs of a pediatric patient, what are we looking for/at?
- Auscultation
- Evaluate findings
- Look for signs of respiratory distress/failure
- Nasal flaring, grunting, crackles, wheezing, stridor, retractions
When assessing the abdomen of a pediatric patient, what are we looking for/at?
- Inspection
- Auscultation
- Palpation
When assessing the genitalia of a pediatric patient, what should we do
- Wear gloves
- Should be performed in the presence of the parent, guardian, or another health care professional
- This is a great time to elicit questions or concerns about body function
- An opportune time to discuss appropriate vs. inappropriate touch
When assessing back and extremities of a pediatric patient, what should we look for/at?
- Curvature of spine
- Scoliosis: Lateral curvature of the spine
- Muscle Strength
-Arm, hand and Leg strength
