<pulmonary vascular resistance

 >pulmonary blood flow

*starts opening of alveoli

>PO2 = relaxes vascular resistance = >vascular blood flow to lungs

blood flow placenta goes into the (1) umbilical vein =

through the ductus venousus =

to the IVC (bypassing the liver) =

right atrium = F.O. =

left atrium to left ventricle =

some blood goes into the lungs for nutrition only =

larger portion goes through ductus arteriosus = to descending aorta =

to placenta via (2) umbilical arteries

changes to fetal structures

umbilical cord

Foramen ovale

ductus arteriosus

ducuts venosus

umbilical cord: is clamped

Foramen ovale: functional closing within first 1-2hrs, permanent closure may take up to 3mo(remember that this is what is shunting blood from right to the left atrium)

ductus arteriosus: constricts when blood flows the aorta into the pulmonary artery, usually closes within 15hrs, can fibrous within 3wk pd, if the lungs fail to fx this may stay open  

ducuts venosus: when this closes it forces the blood flow to the liver

ages:

neonate

infant toddler

preschooler

school age adolescent

neonate: 1 - 30 days

infant :

toddler:

preschooler:

school age adolescent:

Initiation of Respiration:

what has to be chemical/ product has to be present for respiration to occur?

Initiation of Respiration:

What mechanical factor happens that assists with encouraging respiration?

Initiation of Respiration:

what sensory stimulation happens that stimulates the respiratory center?

1-temperature difference/ cold

15degree temp difference

2-touch

Initiation of Respiration:

what chemical factors happen to stimulate respiration?

1-transitory asfixia: happens during delivery with the cutting of the cord       *this <O2, < pH, >CO2

             * all of these things stimulate the respiratory center in the               medulla obligata causing the infant to take its first breath

2-expansion of the alveoli (requires surfactant)

3- removal of fluid in the lungs by evaporation/drainage/ lymphatic system

Circulatory changes in the neonate:

what structural changes happen to the F.O. and the ductus arteriosus?

Circulatory changes in the neonate:

What happens to the blood volume?

Blood volume is around 300ml and the neonate will get an additional 50-100ml if they don't clamp the cord until it is done pulsing

*which is good if you have a hypovolemic baby

*also increases the baby's iron stores

Circulatory changes in the neonate:

lab values:

What is the common trend?

Hematocrit: 44-72 H < after a few days

Hemoglobin: 14.5-22.5

RBC: 5-7.5

WBC: 30,000 

*all of these numbers are high, this is normal

*WBC count can be 30,000 and still be normal

Thermoregulation in neonate:

heat loss happens in four different ways:

1- evaporation: H2O into water vapor (after/ during bath)

2- conduction: skin to skin (cold hands)

3- convection: warm body to air current (air conditioner)

4- body heat to cooler surface: cold object can transfer heat from baby

Thermoregulation in neonate:

• What assists with regulation of temperature in babys, and is also unique just to babies?
• Where is it found?
• what is it connected/ associated with?
• does it have blood supply?
• when does it develop? would pre-mature babies have this?

-brown fat

-neck, mid scapular area, axillary, trachea, kidneys, adrenal glands

-non shivering thermogenesis

- rich blood supply

-develops closer to term, preme's would not have as much if any

Thermoregulation in neonate:

what is the job of brown fat?

Assessment:

Head: what two things are you looking for that could happen during birth?

-caput: serum in the interstitial spaces, 1-3 days to resolve

-cephalohematoma: collection of blood, DOES NOT CROSS, periosium and the scull, up to 3wks to resolve

Assessment:

- if there is no red reflex what does that tell you?

-how do you check for a red reflex?

-congenital cataracts

-                             

Assessment:

skin: what would you see

vernix: white protects baby's skin for moisture

mongolian spots: on butts

lanugo: across shoulders and backs

erythema toxicome: white papules across/on face, there and gone, like newborn rash, self limiting

acrocyanosis: hands and feet

Assessment of neonate:

vs

97.7-99 axillary

110-160

30-60

65-80/ 30-40

expect < 10% of birth wt

Assessment of neonate:

if you find a lower temp how can you support thermoregulation?

what can low temp lead to ?

1-skin to skin, warm blanket, warmer

2- hypoxia, cardiac issues& respiratory arrest

Assessment of neonate:

genitourinary system:

how long could it be for the first wee?

48hrs

urine is less concentrated

6-44ml is held in bladder

X 5-25 times in 24hrs

Nursing care:

what 5 things are being scored with APGAR

heart rate

muscle tone

respiration's

color

reflexes

- 0-1-2, do at (1) minute and (5)minute

-if the (5) minute APGAR is <7, repeat in (5)minutes, code/ resuscitation

-suction, turn head, position

Nursing care:

what is placed in the eyes after birth?

why is this done?

Nursing Care after birth:

why is vitamin K given?

Nursing Care after birth:

what does the new born hearing screening check for?

Nursing Care after birth:

baby's get hep ___ injection before they go home

Nursing Care after birth:

 the neogen screening includes what test?

Are the parents going to get notified of the results?

- PKU

- no

Nursing Care after birth:

how do you know if baby is getting enough breast milk?

-wet diapers, acting satisfied (not fussy)

Nursing Care after birth:

when does colostrum start developing?

Why is it OK that mom's milk hasn't come in yet? and baby is still the baby is satisfied?

how long for moms milk to come in?

-16 weeks

-it is richer, full of good fat, vitamins, it leaves baby's more satisfied

-24-48hrs

Nursing Care after birth:

what are the two common ways to circumcise?

What are the nursing care considerations?

 what is used for penile block?

Gomco, plastibell(10days to 2weeks)

• sugar water, vaseline gauze, Tylenol
• want to know when the first wet diaper is
• its OK for the first pee to be rust colored
•  zylocain

physiologic jaundice: in ability of the liver(liver is immature when the baby's are born) to adequately bind with the bilirubin for excretion

pathological jaundice: when you have Rh incompatibility, ABO incompatibility

Nursing Care after birth:

what has to happen first before the baby can get a bath?

infancy is considered greater than ___ days to ___.

• >28 days to 12months

Infancy

what can you tell about it?

• during this time they have profound changes in there growth and development
• totally dependent
• susceptible to permanent effects of events
• rapid growth, esp first 6mo
• orderly and sequential fashion (specific pattern everyone follows)

theories on infancy

Erickson

Piaget

Freud

Erickson: trust vs mistrust, failure to learn = delayed gratification

Piaget: sensory motor stage:

primary circular reactions: replaced reflexes with purposeful reactions

secondary circular reactions: cause and effect

Freud: oral stage

according to Piaget

intellectual development is the ___

what acts are the foundation for baby to grow on

• the progression through a series of mental activities in an orderly and sequential fashion for children
• crying, sucking, grasping, rooting

when do reflexes diminish in infants

what takes the place of reflexes during this time

1-4 months

purposeful activity takes its place

*cry = mom picks him up

Piaget's secondary circular reactions:

what is it?

4-8 mo

able to separate from the environment

want to manipulate their surroundings

goal directed behavior

(realize if they shake rattle it makes noise)

engage in mimicry

beginning of object permanence (no more out of sight out of mind)

stranger anxiety happens when

9-12mo:coordination of secondary schemes:

what is it?

build on previous skills/knowledge and apply to new situations

greater motor skills

greater exploration of environment

physical development of infants

weight: doubles by 6mo, triples by time yr old

length: > 50% by yr old

respiratory, circulatory, GI, and renal: abdominal breathing, rate 30breaths/min, HR100, irregular rhythm, iron stores begin to decrease gradually when 5-6mo old, GI fully developed by 3mo, teeth by 5-7mo (1yr=6/ 2yrs=20), renal is immature until 18-24mo (concerned with dehydration)

fontanels:post closes 6-8weeks old, ant closes 12-18 mo

head and chest circumference:by 1yr head and chest measurements should be equal

from prone position: able to move head to side to side/ lift head/ lift chest

roll prone to back 5mo

roll back to prone 6mo

sit with support

sit without support

crawl

cruise

fine motor in infants

grasp reflex = replaced with purposeful

hand fist-ed 4 weeks

hand/eye coordination improves 16 weeks

hold and retrieves/ transfer object one hand to other

pincher grasp 40weeks

language development

cry (first communication)

smiles

can differentiate cry

4mo babbling/cooing (understands more than they are able to verbalize)

dada

1yr old 2-3 words

sleep, play and nutrition

should have ritual

SLEEP *family bed is dangerous

            infant sleeps 15 hrs day

            3-4mo: 9-11 hrs night

PLAY *0-3 mobile/ music boxes

          4-6mo: rattles/mirrors/ teething ring/ squeeze toys

          toys should reinforce object permanence/ cause and effect

NUTRITION *formula/ milk first 1yr

                   introduce to solids 4-5days one at time 

                 *honey = botulism veg/ fruit/ then meat is last

                 *stools change/ pigment change if too much of carrot/sweet potato

                 * by one yr : 3meals with snacks

                 * reflex gone @: rooting gone 3mo/ tongue thrust 4mo/

                 *biting at 6-12 mo                   *need fluoride if water doesn't have it in

                 *start drinking from cup           *iron fortified cereal (iron depletion 6mo)

                 *finger foods 9-10 mo

s/s: listless/ irritable/ sunken fontanels/ glassy eyes/ tongue dry/ < wet diapers/ turgor is poor and dry

causes: diarrhea, vomiting

*immature kidneys will be a cause and effect for dehydration

*respiration rate is faster = water evaporation

*higher temp = increases metabolic rate/ and fluid balance

interventions: monitor I&O/ may place an IV/ antipyretic (temp)

Hep B

DTap

HTB

IPV

PCV

MMR

Varicella

Influenza

SIDS : back to sleep, around 2-4mo, >risk if smoker, IUGR, low birth wt, male, winter months, HX of heart rhythm abnormalities, no s/s to warn parents,

SUFFICATION: separate beds, bath tubs, baby powder, mattress should be snug against rails , no pillows, strings on pacifiers, nuts, hard candies,

FALLS: unattended, rails not up all the way

POISIONS: medicine, plants, under the counter

BURNS: bath water, stoves, tablecloths,

MVA: car seats, back seat 1yr & 20lbs

three types of vaccines

 Side effects from vaccines

• LIVE ATTENUATED: made from live organisms (MMR)
• made from  dead organism that are purified (pertussis)
• made from toxins in lab (diphtheria)

localized swelling, fever

up to pediatrician if pt has low grade temp/ upper respiratory infection

common medical problems

colic: abdominal pain/ cramping,

*caused with swallowing or improper feeding, changes position frequently, give small more frequent meals, warm towels on abdomen

Seborrheic Dermatitis: cradle cap, 50% of children, self limiting, recurrent inflammatory reaction, occurs b/c sebum production, resolves around 8-12 mo

toddlers:

ages

goal of toddler

trying to ___ ___ over environment

age: 1-3

goal: learn autonomy

-gain control over environment/ develop new skills/ trying to learn how to control others and themselves/ important for intellectual growth and developmental achievement

toddlers:

Psychosocial therory:

Erikson

• autonomy vs shame and doubt
• time of conflict and struggle for independence = frustration
• egocentricity (unable to share/ have delayed gratification)(inability to see others perspective)
• negativity is automatic: give a choice to help with conflicts
• Temper tantrums: is black mail behavior, never give in/ set limits, result of frustration
• ritualism: is security/ bedtime ritual/ meal time ritual = less tantrums feel more in control
• if they have a toy/blanket it is a positive sign(not sign of insecurity) that they are able to transfer emotions to something other than themselves/ never take away in stressful situation

toddlers:

piaget

tertiary circular reactions 13-18mo

mental combinations:(stage 5 & 6 of sensorimotor phase) trial and error stage/ begin reasoning/ memory is improving(will search for objects in several hiding places/ able to relate to previous experiences/ copy gestures and words/

preconceptual phase(2-4yrs): subdivision of preoperational phase spanning 2-7 yrs

toddlers:

strong parental control can lead to

lack of parental control can lead to

inhibitions

disorganization

*both can lead to doubt about his/her own abilities and feelings of shame and doubt about own accomplishments

sexual development of toddlers

Freud

what else is happening?

anal stage

• toilet training bowels before bladder (have to be able to recognize urge, be able communicate need and doing so to please the parent, voluntary control happens 18-24 mo
• domestic mimicry/ exploration of body/
• by 2 they know M/F
• gender ID set at 3 yrs, role is influenced by care giver
• begin to ID sexual differences and pleasures

different than punishment/ goal is to teach self control/ with the use of limit setting

learn choices/ self control

providing controls and limit setting in situations

avoid confrontation by giving choices (give me the vase so it doesn't get broken vs don't do that)

gross motor in toddlers

12mo: stand/ walk

15mo: climbs

18mo: runs

24mo: jumps, climbs stairs

36mo: stands one foot, hops with both feet, up& down stairs, pedal tricycle

*due to completed myelination of nerve tracts

fine motor in toddlers

beginning of good hand eye coordination

able to ID geometric shapes and place into appropriate holes

2yrs: able to scribble and string beads, holds cup and spoon, dresses with supervision

3yrs: draws straight line and cross, copies circle, pours

growth of toddler

wt: growth slows, pot belly appearance

ht: short legs

Head and chest: attention span is short, brain cells continue to grow (75% complete growth)

*5 senses are well developed and coordinated

*mouthing of objects: replaced with exploration of all senses

*ENT: tubes are short and straight, more predisposed to infections

GI: fairly complete, stomach capacity increased, peristalsis decreased, voluntary elimination is possible

arches develop in feet/ and begin to take normal shape: shoes should be flexible

HR 90-120 RESP 20-30 BP 85/90-60 TEMP more stable