Term
| Assessment: Newborns and Infants Younger Than 6 Months |
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Definition
Keep parents in sight
Examine on table or in crib
Distract with rattles and toys
Sequence: Flexible, do what you can when you can |
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Term
| Assessment: Infants Older Than 6 Months |
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Definition
Developing "stranger anxiety"
Keep baby with parent
May perform exam with baby on parent's lap
Sequence: Flexible, do what you can, when you can |
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Term
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Definition
Shy, anxious, cautious, active
Keep parent nearby
Demonstrate on the parent before you do it on them
Make cranial nerve evaluation a game
DON'T ask for permission - they will say NO
Sequence: Start by touching the feet and gradually moving toward the end. Save instruments for the end. |
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Term
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Definition
Usually cooperative if parent is close
Leave underwear on
Involve them in the exam; make it a game
Assess a doll or stuffed animal first, then the child
Give lots of positive feedback
Sequence: Base it on the child's preference |
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Term
| Assessment: School-age children |
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Definition
Usually cooperative
Seat them on exam table
Developing modesty, leave undergarments on
Let child listen to breath sounds, heart sounds, etc. Involve the child in the exam
Sequence: Head to toe, genital exam - last |
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Term
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Definition
Modesty is very important
Cover body parts not being assessed
Allow for privacy without parent in room UNLESS child specifically requests that the parent stay
Need reassurance that they are developing correctly
Sequence: Head to toe |
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Term
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Definition
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Term
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Definition
HR: 80-130
Resp: 25-40 (1-year-old) |
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Term
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Definition
HR: 70-120
Resp: 20-30 (3-year-old) |
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Term
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Definition
HR: 70-110
Resp: 16-22 (6-year-old) |
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Term
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Definition
HR: 60-100
Resp:
10-year-old: 16-20
17-year-old: 12-20 |
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Term
Fontanel closure:
Posterior?
Anterior? |
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Definition
Posterior: 2-3 months
Anterior: 12-18 months (LECTURE: 18 months, text says 12-18 months) |
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Term
| Assessing for Hip Dysplaysia in Newborn |
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Definition
| Check knee height symmetry. Flex the infant's hips and knees so the heels are as close to the buttocks as possible. Place the feet flat on the examining table. Knees should be the same height. ALSO, listen for a "hip click" |
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Term
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Definition
| Baby is supine. Head turns to one side. Extremities on THAT side straighten. Extremities on the other side flex. This reflex lasts for 3 months. |
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Term
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Definition
| Also known as the "startle" reflex. When startled infant straightens arms and hands outward while the knees flex. This reflex lasts for 6 months. |
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Term
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Definition
| Stimulate the baby's palm, and he will grasp firmly. |
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Term
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Definition
| Touch side of newborn's mouth or cheek. Baby will turn toward that side and open the lips to suck. |
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Term
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Definition
| Baby sucks when an object is placed in the mouth or anything that touches the lips. |
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Term
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Definition
| Stroke the bottom of the infant's or child's foot in an upward circular direction toward the great toe. Watch the toes for plantar flexion or a Babinski response: fanning and dorsiflexion of the big toe. Babinski is normal in children under 2. A Babinski response in children over 2 can indicate a neurological disease. |
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Term
| Separation Anxiety in Hospitalized Child: 3 Phases |
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Definition
Protest: screaming, crying, resisting comfort attempts by other adults.
Despair: sadness, quiet, settled in, withdrawal, compliance, crying upon parent's return.
Denial: lack of protest when parent leaves, happy and content appearance, close relationships not established. |
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Term
| Separation Anxiety in Hospitalized Child as a Major Stressor |
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Definition
Most common stressor for the infant is separation from parents.
Children may regress back to a developmental stage they had already conquered. |
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Term
Gross Motor Milestones
6 months |
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Definition
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Term
Gross Motor Milestones
7 months |
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Definition
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Term
Gross Motor Milestones
10 months |
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Definition
creeping/crawling
pulls self to standing position |
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Term
Gross Motor Milestones
15 months |
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Definition
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Term
Gross Motor Milestones
24 months |
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Definition
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Term
Gross Motor Milestones
36 months |
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Definition
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Term
Expected Balance
12 months |
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Definition
| Briefly stands without support |
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Term
Expected Balance
15 months |
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Definition
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Term
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Definition
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Term
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Definition
| Balances momentarily on 1 foot |
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Term
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Definition
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Term
Fine Motor Development
5-6 months |
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Definition
| Transfers objects between hands |
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Term
Fine Motor Development
8 months |
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Definition
| Pincer grasp - thumb/finger |
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Term
Fine Motor Development
18 months |
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Definition
Feeds self
Scribbles with crayon/pencil
Builds 4-block tower |
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Term
Fine Motor Development
15 months |
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Definition
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Term
Language Development
3-4 months |
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Definition
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Term
Language Development
12 months |
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Definition
| 1-2 words: mama, dada, bye-bye |
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Term
Language Development
1-2 years |
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Definition
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Term
Language Development
2-3 years |
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Definition
| 2-3 word sentences to ask for things or talk about things. Speech understood by family members. |
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Term
Language Development
3-4 years |
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Definition
| 4 (or more) word sentences; speech is understood by most people. |
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Term
Language Development
4-5 years |
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Definition
| Says most sounds correctly except a few like l, s, r, v, z, ch, sh, th. Tells stories and uses same grammar as the rest of the family. |
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Term
| Medication Administration: Crushing pills for children |
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Definition
| Pills that are able to be crushed can be added to ONE spoonful of applesauce, pudding or to 1-2 mL of liquid. |
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Term
| Medication Administration: Dilution of Pain Medication |
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Definition
Child under 100 lbs: Dilute with 10 cc.
Child over 100 lbs: Dilute with 5 cc. |
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Term
| Medication Administration: IM injections |
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Definition
| Give in the Vastus Lateralis (which is the anterior thigh) |
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Term
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Definition
Neonatal Infant Pain Scale
Use for babies under one year
Rate: Facial expression, cry, breathing patterns, arm movements, leg movements, state of arousal.
A score of greater than 3 indicates the baby is in pain. |
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Term
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Definition
Face, legs, activity, Cry, Consolability
Use with babies up to one year
0= relaxed 1-3= mild discomfort 4-6 = moderate pain
7-10 = severe discomfort or pain |
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Term
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Definition
3+ years old
6 or 7 cartoon faces with expressions from smiling to tearful |
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Term
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Definition
Toddlers "self-report"
Do not use more than 3 things with them:
None
Some
A lot! |
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Term
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Definition
Weight loss of 3-5%
Alert, restless, thirsty (A,R,T)
Pulse: Normal
HR: Normal or slight tachycardia
Respirations: Normal
BP: Normal
Fontanel/eyes: Normal
Turgor: Immediate retraction
Tears: Present
Mucous Membranes: Moist
Urine Output: Normal
Fluid Deficit: 40-50 mL/kg |
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Term
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Definition
Weight loss: 6-9%
Irritable/lethargic (infants) A,R,T (older children/teens)
Pulse: Rapid and weak
HR: tachycardia
Respirations: Normal to rapid
BP: orthostatic hypotension
Fontanel/eyes: Slightly depressed
Turgor: Slow retraction
Tears: Present or absent
Mucous Membranes: Dry
Urine Output: oliguria (low)
Fluid Deficit: 60-90 mL/kg |
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Term
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Definition
Weight Loss: 10% or greater
Lethargic to comatose (infants, very young)
Conscious but apprehensive (older children/teens)
Pulse: Rapid, feeble, sometimes impalpable
HR: Severe tachycardia
Respirations: Deep, rapid
BP: severe hypotension
Fontanel/eyes: Severely sunken
Turgor: Very slow retraction, >3 seconds
Tears: Absent
Mucous Membranes: Very dry
Urine Output: Oliguria or anuria (no output)
Fluid Deficit: 10% or greater |
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Term
| Holliday-Segar Method for Calculating Daily Fluid Maintenance |
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Definition
Up to the 1st 10 kg X 100 cc
Up to the 2nd 10 kg X 50 cc
Any weight over 20 kg X 20 cc
Total to get the maintenance amount of fluids required per day.
Divide that number by 24 to determine the safe hourly volume. |
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Term
| Calculate Percentage of Dehydration |
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Definition
Amount of Weight Lost DIVIDED by Pre-illness Weight
MULTIPLIED by 100 = Percentage of dehydration |
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Term
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Definition
As a rule:
Minimum output should be 1 cc/kg/hour |
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Term
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Definition
| Serum Sodium Level less that 135 mEq/L |
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Term
| Causes of Hyponatremia (DR BM Fever DINGS) |
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Definition
Diuretics
Renal disease
Burns/wounds
Malnutrition
Fever
DKA
Intoxication (water()
NG suctioning
GI fluid loss (nausea/vomiting/diarrhea)
Sodium intake is low |
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Term
Clinical Manifestations: Hyponatremia
(CD LMN S) |
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Definition
Coma
Disorientation
Lethargy
Muscle cramps
Nausea/vomiting
Seizures |
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Term
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Definition
Treat cause
Neuro assessments
Monitor I&O
Encourage sodium-rich foods
Monitor labs
IF fluid replacement is needed, give hypertonic solution (3%) |
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Term
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Definition
| Serum Sodium Level greater than 5 mEq/L |
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Term
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Definition
Monitor ECG
Administer IV fluids
Discontinue K+ containing fluids/meds
Give calcium gluconate, 100 mg/kg
Give insulin 0.1u/kg + Glucose 0.5 g/kg
Give oral Kayexelate
Restrict salt substitute
Restrict K+ rich foods: meats, milk/milk products, coffee, potatoes, squash, lima beans, tomatoes, plantains, bananas, oranges, avocados. |
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Term
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Definition
Small for Gestational Age
May or may not be preterm
On Assessment scale, numbers will be negative or closer to 0 |
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Term
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Definition
Appropriate for Gestational Age
On Assessment scale, numbers will be closer to3
These babies will "pull into center" to comfort themselves |
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Term
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Definition
Large for Gestational Age
On Assessment scale, numbers will be 4 or 5
May be an IDM baby (infant of diabetic mother) |
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Term
| Preschool Child's Concept of Illness |
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Definition
May feel guilty about being sick
May view illness or hospitalization as punishment
Fears: being alone, dark, loss of self-control
PREOPERATIONAL Thinkin |
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Term
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Definition
Preschoolers:
"Because one nurse gave me a shot, all nurses will hurt me." |
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Term
| Nursing Diagnoses for Parental Anxiety |
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Definition
Deficient knowledge r/t preoperative and postoperative events.
Risk for altered parenting r/t lack of knowledge of infant care.
Risk for impaired parenting r/t deficient knowledge of infant care and prolonged separation of infant and parents secondary to illness |
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Term
| What tells us an infant is in pain? |
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Definition
Bulged brow
Eyes squeezed shut
Taut tongue
Facial grimacing and quivering
VS go up
Crying |
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Term
| What tells us a baby 6-12 months is in pain? |
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Definition
Reflex withdrawal to stimulus
Facial grimacing
Disturbed sleep
Irritability
Restlessness
Crying |
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Term
| What tells us a toddler is in pain? |
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Definition
Localized withdrawal
Resistance of entire body
Aggressive behavior
Disturbed sleep
Crying, screaming
Describing hurt "boo boo" |
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Term
| What tells us a preschooler is in pain? |
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Definition
Active physical resistance
Directed aggressive behavior
Strikes out verbally and physically
Low frustration level
Verbally expresses pain
Can identify location and intensity of pain |
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Term
| What tells us a school-age child from 7-9 is in pain? |
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Definition
Passive resistance
Clenches fists
Holds body rigidly still
Suffers emotional withdrawal
Plea bargaining
Can specify location and intensity of pain |
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Term
| What tells us a school-age child from 10-12 is in pain? |
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Definition
May pretend comfort to project bravery
May regress with stress/anxiety
Able to describe intensity/location of pain
May also describe psychological pain |
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Term
| What tells us an adolescent is in pain? |
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Definition
Want to behave in a socially acceptable manner so may show a controlled response.
May not complain about pain, esp, if he thinks that nurses and other healthcare providers believe it should be tolerated.
More sophisticated descriptors
Might think nurses are in tune with his thoughts so he doesn't need to tell about his pain. |
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Term
| Vital Sign Response to Pain (TTPPHHI) |
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Definition
Tachycardia
Tachypnea
Pupil dilation
Pallor
Hypertension
Hormonal release: catecholamines, adrenocorticoid
Increased perspiration |
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Term
| Respiratory Depression in a child |
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Definition
Unresponsiveness and a rate of less than 12 breaths per minute may progress to respiratory arrest.
Major complication of opioid administration
Watch for: sleepiness, pupil constriction, shallow breathing
Most likely to occur when child is sleeping |
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Term
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Definition
Majority of boys have unilateral or bilateral breast enlargement during adolescence.
Most noticeable around age 14
Commonly disappears by time of full sexual maturity |
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Term
| Pain Management: Staying Ahead! |
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Definition
Delays in analgesia increase the chances of breakthrough pain.
More medication is often needed to restore pain control than would have been required if there had been continuous infusion analgesia. |
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Term
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Definition
Eutectic Mixture of Local Anesthetics
Cream
Apply 1-2 hours prior to a needle stick
Can be used as young as 3 months
Usually takes an hour to kick in. |
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Term
| Sucrose Solution for Infant Pain Relief |
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Definition
Sucrose in contact with oral mucosa promotes natural pain relief
Give the solution 2 minutes before the procedure
Analgesic effect lasts approx. 3-5 minutes |
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Term
| FVE (Fluid Volume Excess) |
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Definition
Urine Specific Gravity readings - LOW
Weight gain
Edema
Full, bounding pulse
Increased BP
Increased central venous pressure
JVD
Moist crackles, rales
Dyspnea
Shortness of breath
Confusion |
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Term
| Phototherapy (Bilirubin Lights) |
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Definition
Need adequate fluid intake
Must take temp. regularly to make sure there is no overheating
Eyes should be covered
Keep under lights except for during feeding and changing diapers
Check under eye patches once a shift for corneal irritation or drainage |
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Term
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Definition
Infant of Diabetic Mother
Large
Sugar is passing to baby through placenta
Signs and symptoms of hypoglycemia: tremors, cyanosis, apnea, temp. instability, poor feeding, hypotonia, seizures in severe cases.
CHECK the baby's blood sugar is he has the jitters |
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