Pediatric Assessment and Fetal Development with Selected Pediatric Conditions

Developmental Approach to the Physical Examination

Three rules in the examination of children and adolescents: flexibility ,safety, and
organisation

• Allow the child's age and developmental level to guide your history and physical
examination

• Atmosphere and environment are important

• Incorporate health education and growth and development anticipatory guidance into
the examination

• Move from the easy/simple -> more distressing; use positive reinforcement and
'prizes'

• Use demonstration and play to your advantage (play equipment or 'spares', paper doll
technique, crayons, blocks)

• Expect an age-appropriate level of cooperation; explain what will be involved in the

physical examination and tell the child what she needs to do

Infants
• Keep parent in view
• Before 6 months examination on table; after 6 months examination in parent's lap
• Undress fully in warm room
• Careful with nappyremoval
• Distract with bright objects/rattles. Soft manner; avoid loud noises and abrupt
movements
• Have bottle, dummy or breast handy
• Vary examination sequence with activity level (if asleep/quiet
auscultate heart, lungs, abdomen first)
• Usually able to proceed in cephalocaudal sequence
• Distressing procedures last (ears and temperature)

Toddlers
• Most difficult group to examine
• Approach gradually and minimise initial physical contact
• Leave with parent (sitting or standing if possible)
• Allow to inspect equipment (demonstration usually not helpful)
• Start examination distally through play (toes, fingers)
• Praise, praise, praise
• Parent removes clothes
• Save ears, mouth and anything lying down for last
• Use restraint (with parent)

Pre-schoolers
• Allow close proximity to parent
• Usually cooperative; able to proceed head to toe
• Request self-undressing (bit by bit exposure modesty important)
• Expect cooperation
• Allow for choice when possible
• If uncooperative, start distally with play
• Allow brief inspection of equipment with brief
demonstration and explanation
• Use games/stories for cooperation
• Paper doll technique very effective
• Praise, reward and positive reinforcement

School-agers
• Usually cooperative
• Child should undress self; privacy important; provide drape/gown if possible
• Explain function of equipment; use of 'spares' helpful
• Examination can be important teaching exercise
• Head-toe sequence
• Praise and feedback regarding normalcy is important

Adolescents
• Give the option of parental presence
• Undress in private; provide gown
• Expose one area at a time
• Physical examination can be an important teaching exercise
• Head-toe sequence
• Feedback regarding normalcy is important
• Anticipatory guidance regarding sexual development (use Tanner staging)
• Matter-of-fact approach to examination (and history)
• Encourage appropriate decision-making skills
FETAL DEVELOPMENT WITH SELECTED PEDIATRIC CONDITIONS

DIVISIONS OF UTERINE DECIDUA

 Decidua basalis
 Directly under the embryo
 Portion of trophoblasts establishing communication with maternal blood
vessels

 Decidua Capsularis
 Stretches and encapsulates the trophoblasts

 Decidua vera
 Remaining portion of the uterine lining
EMBRYONIC AND FETAL STRUCTURES

 Chorionic Villi
 Syncytial layer
 Langerhan’s Layer
 Placenta
 Circulation
 Endocrine Function
 Human Chorionic
Gonadotropin
 Estrogen
 Progesteron
 Human Prolactin
 Umbilical Cord
 Amniotic Membranes
 Amniotic Fluid

ORIGIN OF ORGAN SYSTEMS

CARDIOVASCULAR SYSTEM

16 days single heart tube

24 days heart beat
6 – 7 heart chambers
7 wk heart valves
10-12 heart beat on dopplr
20 ECG’
28 SNS development

CONGENITAL HEART DISEASE

 Ventricular Septal Defect

 Atrial Septal Defect
 Patent Ductus Arteriosus
 Tetralogy of Fallot
CLASSIFICATION

 Acyanotic Heart Disease

 blood moves from the ARTERIAL TO THE VENOUS system (L-R shunts)
 Can develop cyanosis
 Cyanotic Heart Disease
 blood is shunted from the VENOUS TO THE ARTERIAL system (R-L shunts
 May not exhibit cyanosis until seriously ill

Atrial Septal Defect (ASD)

 An opening exists between the atria

 Twice as common in girls
 L-R shunt
 Results to ventricular hypertrophy and increased pulmonary artery blood flow

 Assessment:
 Murmur, splitting of second heart sound, enlarged right side of the heart
 Management:
  Surgery to close the defect between 1-3 yo
 Silastic patch if hole is large

Ventricular Septal Defect (VSD)

 The most common congenital cardiac defects

 A hole exists between the ventricles
 L-R shunt
 Right ventricular hypertrophy and increased pressure in the pulmonary artery

 Assessment:
 Easy fatigue at 4-8 weeks, loud, harsh murmur
 Hypertrophied right ventricle and increased pressure in the pulmonaryartery

 Management:
 85% of VSDs are so small that they close spontaneously
 Surgery
 Silastic patch
 Assess for arrhythmias postoperatively
Patent Ductus Arteriosus

 Failure of the ductus arteriosus to close after birth

 More common in girls
 Affects 20%-60% of preterm infants

 Assessment:
 Wide pulse pressure
 Low diastolic pressure

 Management:
 Indomethacin – prostaglandin inhibitor
 Insertion of stainless steel coils through cardiac catheterization at 6 months to
1 year
 Surgical ductal ligation

Tetralogy of Fallot
Four Key Features
 Ventricular septal defect (VSD)
 Pulmonary stenosis
 Right ventricular hypertrophy
 Overriding aorta

 Complications:
 Polycythemia
 Thrombophlebitis
 Embolism
 CVA
 Growth restriction
 Impaired cognitive ability

 Assessment:
 Cyanosis after prolonged crying or exertion
 Assumes a squatting or knee-chest position when resting
 Syncope
 Hypoxic episodes (tet spells)

 Management:
 Surgery at 1-2 years old
 Administer oxygen
 Knee-chest position
 Propanolol (Inderal) to dilate the vessels
Surgical Options

 Blalock-Taussig procedure
 Temporary
 Creates a ductus arteriosus
 Uses subclavian artery

 Brock procedure
 Full repair of VSD, pulmonary stenosis, and overriding aorta

RESPIRATORY SYSTEM

3RD Week Respiratory and GI tract single tube

4th Week Septum
6th Week lung buds extends to abdomen
7th Week Diaphragm
24 – 28 wks Slveoli and capillaries
Surfactant is formed
3 mos spontaneous respi practice movements

CROUP

- a group of respiratory diseases that often affects infants and children under age 6

Assessment

 harsh "barking" cough and sneeze

 inspiratory stridor
 nausea/vomiting
 fever
 Hoarseness
 respiratory distress
 On a frontal X-ray of the cervical vertebrae, the steeple sign suggests the diagnosis of
croup.

Management

• exclude other causes of shortness of breath and stridor

• Keep the child in a warm moist environment
• Cool moist air
• Do not trigger the gag reflex
• Croup can be prevented by immunization for influenza and diphtheria; diphtherial
disease, but with vaccination diphtheria is rare
• nebulized adrenaline in addition to steroids (dexamethasone

ASTHMA

- predisposition to chronic inflammation of the lungs in which the airways

(bronchi) are reversibly narrowed.
Assessment:

 nighttime coughing
 shortness of breath with exertion but no dyspnea at rest
 a chronic 'throat-clearing' type cough
 complaints of a tight feeling in the chest
 Wheezing
 Asthma Attack
 shortness of breath (dyspnea), wheezing, and chest tightness
  note inspiratory stridor without expiratory wheeze however, as an upper airway
obstruction may manifest with symptoms similar to an acute exacerbation of asthma,
with stridor instead of wheezing, and will remain unresponsive to bronchodilators.

Management

 Avoidance of the allergen by environmental control

 Skin testing and hyposensitization to identified allergens
 Relief of symptoms by pharmacologic agents
 Treatment by Classification
a. Inhaled anti-inflammatory corticosteroid (mild but persistent)
b. Moderate persistent: A plus long acting bronchodilator at bedtime
c. Severe persistent: B with higher doses of oral corticosteroids
 Pharmacologic Treaments
a. Albuterol/terbutaline to be given before corticosteroid
b. Metered dose inhalers (should be with spacers in children less than 12 years)

STATUS ASTMATICUS - FAILURE OF ASTHMATIC CHILDREN TO RESPOND TO

BRONCHODILATORS AND THE ATTACK CONTINUES

Assessment

 HR and RR are elevated

 PO2 levels are low
 PCO2 levels are high – ACIDOSIS
 Limited breath sounds
 Concurrent Pulmonary Infection

Management

 BETA 2 Agonists and intravenous corticosteroids

 Oxygen Administration through face mask
 ET intubation with mechanical ventilation
NERVOUS SYSTEM

3 – 4 WKS Neural Plate

8 wks EEG
24 Ears can hear & Sight is present

HYDROCEPHALUS
An excess of cerebrospinal Fluid in the ventricles and subarachnoid spaces of the brain.

Causes: malabsorption of CSF

excessive CSF production
blockage in the pathway of CSF

Conditions that lead to obstruction:

tumors
meningitis
encephalitis

Classifications:
Congenital
Acquired

Diagnostic Tests:
Prenatal: UTZ
CT scan
Transillumination

Signs and Symptoms:

becomes more evident during the first few weeks or months
— Increased ICP
— high-pitched shrill cry
— projectile vomiting (unassociated with feeding)
— change in LOC
— tense, bulging fontanel
— Hyperactive reflexes
— Headache
 — Walking problems

Also:
1. Prominent scalp veins
2. Bossing of forehead
3. Separated suture lines
4. Increased head circumference
5. “Sunset” eyes

Management of Hydrocephalus Aimed at:

 RELIEF OF VENTRICULAR PRESSURE

 TREATMENT OF THE CAUSE OF VENTRICULOMEGALY
 TREATMENTS OF ASSOCIATED COMPLICATIONS
 MANAGEMENT TO PROBLEMS RELATED TO THE EFFECTS OF DISORDER
ON PSYCHOMOTOR DEVELOPMENT

Objective:
to diminish the volume of accumulated CSF; done by means of a shunt

What is a shunt ?
A drainage system which will transport the excess of CSF to other parts of the body
(ABDOMEN and HEART) where it can be reabsorbed.

NURSING DIAGNOSIS:

— Risk for ineffective cerebral tissue perfusion r/t increased intracranial pressure

— Risk for imbalanced nutrition, less than body requirements r/t increased intracranial
pressure

— Risk for impaired skin integrity r/t weight and immobility of head

NURSING INTERVENTIONS

— Lie the infant flat after shunt placement

— Upright position drains the CSF rapidly
 — Assess for the following postoperatively:
— Signs of increasing ICP
— Signs of infection
— Signs of developing meningitis
— Reposition the head every 2 hours
— Manage pain properly
— Crying increases ICP

NURSING ALERT

— Brain stem herniation can occur with increased ICP and is manifested by opisthotonic
positioning (flexion of head and feet backward). This is a grave sign and may be
followed by respiratory arrest. Obtain help, and prepare for ventricular tap. Have
emergency equipment on hand for resuscitation.
Caput Succedaneum: few days ; Cephalhematoma: few weeks

NEURAL TUBE DEFECT

• Causes
– genetic predisposition: mothers who previously gave birth to a baby with spina
bifida
– Nutrition: low folic acid intake
• Types
– Anencephaly
– Microcephaly
– Spina Bifida

ANENCEPHALY
• Absence of cerebral hemispheres
• May have difficulty in labor
• Cannot survive due to lack of cerebral function
Microcephaly
• SLOW BRAIN GROWTH
• Cognitively challenged
• Causes:
– Rubella, cytomegalovirus, toxoplasmosis
– Severe malnutrition or anoxia in early infancy

Craniosyntosis

• NORMAL BRAIN GROWTH but there is premature fusion of cranial sutures

• Assessment:
– Abnormally closed fontanelles
– Bossing of the forehead
– Signs of increasing ICP
• Management:
– Surgical remedy

Spina Bifida

S U B T Y P E S:
• Spina Bifida Occulta
– Posterior portion of the vertebra fail to fuse
 – Skin dimpling and tufts of hair
– Benign defect
• Meningocele
– Protrusion of the meninges
• Myelomeningocele
– Protrusion of the meninges and spinal cord
• Encephalocele
Myelomeningocele

Assessment
• UTZ, fetoscopy
• Increased alpha-feto protein (AFP) in amniotic fluid or in maternal serum

– Infants with myelomeningocele void and defecate continually and cannot

move the lower extremities

Management

• Spina bifida occulta

– Surgery is not necessary
• Other types of SB
– Immediate surgery to replace the replaceable contents and prevent infection

Nursing Interventions

• Protect the sac

– Avoid applying pressure
– Prevent from drying
– Prevent infection
• Positioning
– Prone
– Sidelying
• Preserve skin integrity
• Plastic use
– Placed below the sac like an apron to prevent contamination from feces and
urine
Ankyloglossia (Tongue-Tie)

PHYSICALLY CHALLENGED CHILDREN

Cleft Lip

• Failure of fusion between weeks 5-8

• More prevalent in boys
• Causes:
– Teratogens
– Folic acid deficiency
• Risk factors:
– Familial tendency
– Japanese
• Assessment:
– absence of upper teeth and gingiva
– flattened nose
Unilateral Bilateral

Cleft Palate

• Opening in the palate

• Failure of closure of the palate between weeks 9-12
• Most often accompanied with cleft lip
• Can be assessed by depressing the tongue

Cleft Palate
 Cleft Lip and Palate

Management

• Surgical repair after birth

• Revision at 4-6 yo
• Surgical repair at 6-18 months

Nursing Interventions

• Preop Period
– Teach mother to pump milk
– Have infant burp after feeding
– Offer small sips of fluid between feedings to moisten the mucous membranes
and prevent cracking
– If surgery is delayed, teach to feed soft foods
• Preop Period
– Teach mother to pump milk
– Have infant burp after feeding
– Offer small sips of fluid between feedings to moisten the mucous membranes
and prevent cracking
– If surgery is delayed, teach to feed soft foods
TALIPES DEFORMITIES

• Talus: ankle
• Pes: foot
• “clubfoot”
• The earlier the deformity is recognized, the better the correction will be.
• Correction is achieved with the use of casts
– Changed every 1-2 weeks
– Check extremities for compartment syndrome

DEVELOPMENTAL HIP DYSPLASIA

- Improper formation and function of the hip socket

• Assessment:
– (+) Ortolani’s sign
– Asymmetric gluteal folds
– One knee is lower than the other

• Diagnostics:
– X-ray
– MRI

• Management:
– Multiple diapering
– Pavlik harness
– Splint
 Spica Cast

Tracheoesophageal Fistula and Atresia

 Weeks 4-8

 Atresia: obstruction
 Fistula: opening
 5 types

Assessment

 Maternal hydramnios
 Excessive mucus in the mouth (appears to be blowing bubbles)
 Catheter insertion
 X-ray, barium swallow, bronchial endoscopy
 Cough, cyanotic, DOB during initial feeding
Management

 Emergency surgery to prevent

 Pneumonia
 DHN
 Electrolyte imbalance
 Gastrostomy
 Drain food by gravity
 Never push

Nursing Interventions

 Intravenous or Total Parenteral Therapy

 Early introduction of fluids
 Position on right side/upright
 Frequent monitoring

DIGESTIVE SYSTEM

 6TH WEEK Intestines well formed

 10th week abdomen accommodates intestines
 32 wks sucking and swallowing reflex present
 36 wks enzyme secretion for CHO/CHON
DIAPHRAGMATIC HERNIA

Abdominal organs protrude into the chest cavity through a defect in the diaphragm.

• Assessment:
– Respiratory difficulty at the time of birth
– Cyanosis and intercostal retractions
– Sunken abdomen
– Absence of breath sounds on affected lung

• Management:
– High mortality rate – 25% to 50%
– Emergency surgical repair
– Position: upright
– Kept on NPO
– Oxygenation and suctioning prn
– NGT insertion for decompression

PYLORIC STENOSIS

 Pylorus:
• lower portion of the stomach that connects to the small intestine

 Pyloric stenosis:
• Pyloric muscles enlarge, narrowing the opening of the pylorus and eventually
preventing food from moving from the stomach to the intestine

 Assessment:
 • Forceful, projectile vomiting
• Hungry and eats/nurses eagerly
• Milk vomited is curdled in appearance
• weight loss
• lack of energy
• fewer bowel movements
• constipation
• frequent, mucous stools

 Management:
• surgical repair

HIRSCHSPRUNG’S DISEASE

 occurs when some of the nerve cells that are normally present in the intestine do not
form properly while a baby is developing during pregnancy
 the intestine can become partially or completely obstructed (blocked), and begins to
expand to a larger than normal size
 the problems a child will experience with Hirschsprung's disease depend on how
much of the intestine has normal nerve cells present

 Assessment: apparent at 6-12 months

 Cannot pass stool by 24 hours of age
 Chronic constipation
 Ribbonlike stools
 Distended abdomen
 Thin and malnourished
 Diagnostic Tests:
 Rectal exam
 Barium enema
 Biopsy
 Management:
 Dissection, removal and anastomosis
 Permanent colostomy for absence of nerve endings in anus
INTUSSUSCEPTION

 Assessment:
 Intermittent abdominal pain and discomfort
 Vomiting with bile
 Blood in stool, “currant jelly” appearance
 Abdominal distention

 Diagnostic test:
 Confirmed by UTZ
 Management:
 Non-surgical
 Instillation of water-soluble solution, barium enema, or air
 Surgery to straighten the invagination

CELIAC DISEASE

 Malabsorption Syndrome
 Sensitivity to GLUTEN (barley, rye, oats, wheat)

DEFINITION:

 Inability to absorb fat

 Deficiency of ADEK vitamins
 Rickets may occur
 Anemia, hypoprothrombinemia, hypoalbuminemia
 Northern European background
 Inherited illness
 Increased incidence in children with Down Syndrome
Assessment:
 Irritable and anorectic
 Skinny with wasted buttocks
 Distended abdomen
 Signs of malnutrition
 Bulky, foul-smelling fatty stools (STEATORRHEA)
Diagnostic Tests:
 Biopsy of intestinal mucosa
 Oral glucose tolerance test
 Stool exam
 Response to gluten-free diet
 Interventions:
• Lifetime intake of gluten-free diet
• Record stool characteristics
• Teach parents and children to recognize foods with gluten (BROW)
  Wheat flour, gravy, soups, sauces, pasta, cookies, cakes and pastries,
hotdogs, frozen and packaged foods

CYSTIC FIBROSIS

 Dysfunction of the exocrine glands

 Thickened and tenacious mucus secretions particularly in the lungs and pancreas
 More salty sweat
 an inherited disease of the mucus and sweat glands; autosomal recessive gene
 affects mostly the lungs, pancreas, liver, intestines, sinuses, and sex organs
 symptoms and severity of CF vary from person to person
 Respiratory failure is the most common cause of death in people with CF

With CF, the body cannot utilize the following enzymes

 Lipase – fat
 Trypsin – protein
 Amylase - carbohydrates

 Highest priority: respiration

 Diet:
 increased CHON, CHO
 Moderate fat
 Increased sodium
 Pancrease: taken 30 minutes before ingesting a heavy meal, lifetime
 ADEK: once a day, lifetime
 Dx: sweat test, NaCl test
 nutrients (protein, carbohydrate, salts) leave the body unused, and one can become
malnourished
 stools become bulky and greasy
 may not get enough vitamins A, D, E, and K
 may have intestinal gas, a swollen belly, and pain or discomfort

KWASHIORKOR

1. A disease caused by PROTEIN DEFICENCY.

2. Occurs most frequently from 1-3 yo
3. Developing countries
4. (Africa, Asia, Latin America)
Assessment:
a. Growth failure
b. Severe muscle wasting
c. DEPENDENT Edema
d. Ascites
e. Irritable
f. Zebra sign
g. Diarrhea
h. IDA
i. Hepatomegaly

Management - HIGH PROTEIN DIET

MARASMUS

• Disease caused by deficiency of all food groups.

• STARVATION
• Developing countries
• Neglected children
• Younger than 1 yo
• Invariably hungry and will suck any object offered

Treatment

Supply a diet rich in all nutrients

DOWN’S SYNDROME

• most common chromosomal abnormality

• presence of three copies of chromosome 21 rather than the normal two copies
• Affected individuals most often exhibit mild to moderate mental retardation and have
characteristic facial and physical abnormalities, as well as possible congenital defects
in the cardiac, visual, gastrointestinal, and endocrine systems
• Incidence is 1/800 to 1/1000 births, affecting all races, genders, and socioeconomic
classes
• Incidence increases with increased maternal age, however 80% of affected babies are
born to women under 35 years
• There is no cure for Down syndrome
CEREBRAL PALSY

 Nonprogressive disorders of upper motor neuron impairment that result in MOTOR

DYSFUNCTION.
 Muscle is poorly controlled due to BRENDA
Types:
 Spastic – excessive tone in voluntary muscles
 Athetoid or dyskinetic – abnormal involuntary movement
 Ataxic – awkward wide-based gait

Signs and symptoms:

 May/may not move head
 Poor sucking and swallowing
 Delayed developmental task
 Preschool (signs of mental retardation)

Early Signs:
 At birth a baby with cerebral palsy is often limp and floppy, or may even seem
normal.

 Baby may or may not breathe right away at birth, and may turn blue and floppy.
Delayed breathing is a common cause of brain damage.
 Slow development. The child is slow to hold up his head, to sit, or to move around.
 He may not use his hands. Or he only uses one hand and does not begin to use both.

 Feeding problems difficulties with sucking, swallowing and chewing

 Difficulties in taking care of the baby or young child
 Communication difficulties

 Dx:
• History
• Signs and symptoms

 Diagnoses:
• Ineffective breathing pattern r/t uncontrolled accessory muscle
• Self-care deficit
• Fatigue due to non-purposeful movements
 Management
• Correction or alleviation of specific neuromotor deficits or associated
disabilities.
• Administration of antispasticity medications, such as dantrolene (Dantrium) or
diazepam (Valium).
• Administration of antireflux medications, such as metoclopramide (Reglan) or
bethanechol (Duvoid).
• Orthopedic management of scoliosis, contractures, dislocations.
• Selective dorsal rhizotomy in an attempt to decrease spasticity.
• Developmental enrichment experiences.
• Development of prevocational, vocational, and socialization skills.
• Emotional, behavioral, and social adjustments.
• Family's ability to carry out supportive and participant roles in
rehabilitation—key determinant of the success of any comprehensive
management program.
• Complications
• Contractures.

Diseases with it Complication

 AGE – DHN
 Pernicious Anemia – Peripheral neuritis
 Sickle cell – CVA
 CF – Sterility
 Lead poisoning – mental retardation
 Meningitis – hearing impairment