Debbie King

1
Debbie King

• BSN, RN, MSN
• CFNP, CPNP, CS

2
New Born Visits (3 days old)

• Introduction
• Congratulations
• Other children
• Pre-natal
• Due date

3
Newborn visit

• Type of delivery
• Birth weight
• Discharge weight and age
• Hearing test
• GBS stats

4
Newborn visit

• PKU
• Hepatitis B 1
• Billirubin ordered stat as needed
• Circumcision-research contends reduced risk of
  HIV in circumcised males
• Diet
• Breast/bottle

5
New Parent Education

• Provide verbal and written information
• Feeding
• Schedule
• BF support
• Positioning of the newborn

6
New parent education

• Exposure-limit visitors and outings
• BMs- vary with babies
• Hick-ups- are frequent
• Sneezing-normal and frequent
• Congestion-of and on and is normal

7
New parent education

• Dressing/layers- do not overdress
• Siblings
• Car seat
• Finger nails- file only for 6 weeks

8
New parent education

• Cord care- there is none
• Smoking-avoid exposure
• Sun-not directly, can use sun-block
• Oral Needs- Gums and Pacifier-new research
  contends pacifier use for all sleep periods is
  necessary to prevent SIDS

9
New parent education

• Illness
• Office procedures with calls
• When to call
• Recheck schedule- varies

10
General info

• Average weight 7 lb
• Average length 20-21 inches
• Normal average weight loss is 10 in first 3-4
  days
• Normal is to regain back to birth weight by 14
  days

11
General info

• Weight doubles by 4 months
• Weight triples by one year
• Weight quadruples by two years
• Normal weight gain is 6-8 oz per week for 6
  months
• Normal weight gain is 3-4 oz per week from 6-12
  months
• Normal weight gain 1-2 years old is 8-9 oz per
  month

12
FYI

• Theories are important in practice to help you
  know normals
• They will be on boards (only a few peds
  questions)
• Should self study- ex
• Erikson
• Mahler
• Skinner
• Maslow
• Kohlberg
• Piaget

13
Exam Of Newborn - Importance of Clinical
Experience

• General
• Skin- Color- Birth marks
• Head- Shape- Size
• Eyes- red reflex- alignment
• ENT- ear placement

14
Newborn

• Mouth- palate
• Chest/heart- 140- murmur, check for tachypnea,
  poor feeding, cool lower ext-?COA
• Lungs/resp- 30-60
• Abdomen- cord
• GU- Open, rectum

15
Newborn

• Musculoskelatal- hips
• Neuro- (reflexes) startle, tone, grasp,
• rooting, sucking, gag, crying
• symmetry of movement

16
2 Week Visit

• Birth weight
• Weight today-should be back to BW
• Age of discharge-if this is first visit
• Diet
• Color
• Advise parents not use any medications

17
2 Week Visit

• Circumcision
• PKU
• Address concerns of parents
• Exam- 2 week is Repeat of New Born exam

18
1 Month Visit

• Temperature
• Height
• Weight
• HC
• Percentiles- Know how to plot yourself

19
1 Month Visit

• Diet- Vitamins A,C,D for babies BF only
• Startles
• Lifts head
• Focus
• Head support

20
1 Month Visit

• Hands fisted
• Eyes- sees short distance, may cross of and on,
  follows to mid line, may seem to look just by or
  over you
• Sleep-still pretty irregular
• Personality- fussy vs. happy

21
1 Month Visit

• Spitting- amounts
• Sneezing/ congested
• Grunting
• Only sleeps, eats, and poos
• Colic

22
1 Month Visit

• Medication not to be used this early
• Safety
• 1 month exam
• Same as New Born
• -Summarize
• -Warn- immunizations at 2 months

23
2 Month Visit

• Temperature
• Height
• Weight
• HC
• Percentiles- no pattern yet

24
2 Month Visit

• Smiles
• Coos
• Focus follow
• Tone- increased head control
• Diet- vitamins if breast fed, no solids

25
2 Month Visit

• Cuddle, eye contact, play
• Increase tummy time
• Position
• 2 month exam- Same as New Born
• Still no medications

26
4 Month Visit

• Temperature
• Height
• Weight
• HC
• Percentiles- 3 is a pattern

27
4 Month Visit

• Diet- cereal, BF, formula
• Laughs
• Reaches
• Rolls- front to back
• Sleep- longer at night
• Still no medicines are recommeneded

28
4 Month Visit

• Self Soothes
• Increase tummy time
• Review safety- car seats, toys
• Activities- ex. Johnny Jump Up
• 4 month exam- same as New Born
• -extra focus on tone and strength
• - encourage team work of parents

29
6 Month Visit

• Temperature
• Height
• Weight
• HC
• Percentiles

30
6 Month Visit

• Diet- more solids, less liquids
• - finger foods, new research contends
  that meat be included in the food package for
  breast-fed infants at 6 months
• Reaches, grasps
• Sits alone
• Rolls both ways
• Set schedule- eating, sleep

31
6 Month Visit

• Knows name
• Encourage crawling
• Vocalizes
• Safety! Child proof
• Teeth
• May use tylenol for pain or fever. Motrin is now
  approved down to six months. Benadryl may also
  be used if really necessary.

32
6 Month Visit

• 6 month Exam
• -Same as all past with focus on
• -Strength -Standing
• -Socializing with provider
• -Add Fluoride-if on well water
• -Summarize -Encourage
• -No immunizations at next visit (9 month check
  up)

33
9 Month Visit

• Temperature
• Height
• Weight
• HC
• Percentiles

34
9 Month Visit

• Diet- table food, cup, self feed
• Schedule- toddler like
• Safety- add poison control
• Encourage mobility- crawling
• Pulling up

35
9 Month Visit

• Cruising
• Stands alone
• Transfer
• Responds to name
• Understands no, bye

36
9 Month Visit

• Babbles- mama, dada
• Same PE
• Order/evaluate- HGB
• Summarize
• Next exam 12 months
• Advise may see increase illness with increase in
  mobility

37
12 Month Visit

• Height
• Weight
• HC
• Temperature
• Percentiles (Triple BW)

38
12 Month Visit

• Diet- all table food
• -except shell fish and honey
• -start whole milk, cup, self feed
• Sleep- schedule
• Continue to encourage
• -verbalizing, mobility, walking

39
12 Month Visit

• Says mama and dada well
• Waves
• Good pincer grasp
• Temper tantrums
• Plays games

40
12 Month Visit

• Loves books and outside
• Safety is more important
• Car seat-12 months and 20 lbs to face forward
• Teeth-just water and tooth brush

41
12 Month Visit

• Follow one step command
• Stoops and recovers
• Imitates
• T.B./ lead questionnaires for exposure

42
12 Month Visit

• 12 month exam
• -head to toe
• -More difficult
• -Be creative, playful
• -May notice hand preference soon, yet could be
  as late as 5 years for set handedness
• -testicles- should be down

43
12 Month Visit

• -hydrocele- gone
• -summarize
• -Choose care givers carefully (babysitters)
• -Next visit 15 month and all basic vaccines
  will be completed

44
15 Month Visit

• Height
• Weight
• HC
• Temperature
• Percentile

45
15 Month Visit

• Diet- same as 15 month
• - avoid juice trap, no juice is needed
• Schedule
• Climbs
• Knows some body parts
• Stacks 2 blocks

46
15 Month Visit

• Behavior- big issue
• Books/ music
• 1 hr TV only or none or baby videos
• Follow directions
• Few words only

47
15 Month Visit

• 15 month exam
• - head to toe
• - very difficult
• - heart first
• - mouth last
• - observe walking forward and backward

48
15 Month Visit

• - FYI intoeing is normal until age 7
• Summarize
• Encourage parents
• Next visit at 18 month with focus on development

49
18 month visit

• Same growth evaluation
• Diet- no battles!
• Sleep- constant schedule
• Safety- ex. Lead exposure
• Development- important issue now
• -can see signs of autism

50
18 month visit

• Expected milestones
• - 2 word combos starting
• -kicks ball
• -runs
• -climbs
• -sustains eye contact

51
18 month visit

• -enjoys being bounced/swung
• -interested in other children
• -play hide and seek
• -pretends
• -points with index finger
• -plays appropriately with toys

52
18 month visit

• -stacks 3-4 blocks
• -7-15 word vocab
• -listens to stories
• -names objects
• -scribbles
• -shows affection- kisses

53
18 month exam

• Head to toe
• May still be difficult
• Not all bruises are abuse
• Encourage parents
• Foster independence

54
18 month exam

• Wash own hands
• Pick up toys
• Remind some decrease in eating is nl
• Advise parents to call as needed
• Next check up is at 2 years

55
General info

• Growth slows from 2-6 years
• Normal growth is about 3 inches per year
• Normal weight gain is about 4.5 lbs per year
• An average 6 year old is about 46 lbs and 46
  inches

56
2 year visit

• Repeat of 18 month exam
• If new pt review milestones
• Now should
• -jump
• -3-5 word combo
• Still on infant scale for height and weight and
  infant growth chart

57
2 year visit

• Last HC done
• Usually more cooperative
• Advice on
• -toileting

58
FYI

• FYI
• immunization- know schedule
• head circumference
• Macrocephaly- too large
• Microcephaly- too small
• Plagiocephaly- abnormal shape
• Know what to do- for each DX

59
FYI

• Day care
• Assess plans at every visit
• DWP illness-expectation
• biting

60
Teething (formation begins 3rd fetal month, ends
in adolescence)

• Central incisors upper 6-8 months, lower 5-7
  months
• Lateral incisors upper 8-11 mo, lower 7-10 mo.
• Cuspids upper and lower 16-20 mo.
• First molars upper and lower 10-16 mo.
• Second molars upper and lower 20-30 months

61
FYI

• Refer to Harriet Lane for all normals on
• Respirations - based on age
• Blood pressures - based on age and size
• Heart rates - based on age
• may be helpful to keep charts in exam rooms

62
3 year visit

• Add vision screen
• Stands for height and weight
• No HC
• Add BP
• Chart on proper growth chart!

63
3 year visit

• Assess BMI
• TB questionnaire
• Pre-school?
• Verbal skills- 75 understood by strangers
• Knows colors

64
3 year visit

• Count 1-10
• Pedals tricycle
• Knows gender
• friends

65
3 year visit

• 3 year exam
• Head to toe- may still have round tummy
• Advise parents
• Stool holding is common
• Stuttering is common
• Time outs should be for 3 minutes
• Encourage more playtime and reading

66
4 and 5 Well-care

• Height
• Weight
• Temperature
• Percentiles
• UA- 5 and up
• Hearing, vision

67
4 and 5 Well-care

• 4 year milestones
• Stacks 10 blocks
• Throws overhand
• Sings, draws
• Knows real vs. fiction
• Talks about day/life
• Knows gender
• 100 understandable

68
4 and 5 Well-care

• 5 year milestones
• Skips
• Rides bike
• Counts on fingers
• Draws shapes
• Prints some letters

69
4 and 5 Well-care

• Draws about 4 body parts
• Knows ABC and colors
• Knows about strangers
• Knows about secrets

70
4 and 5 Well-care

• Exam 4 and 5 year
• -head to toe exam
• -add cranial nerve exam know how!
• -add walk on toes and heels
• -jumps
• -check spine

71
4 and 5 Well-care

• Remember! At All check ups review
• -seatbelt -teeth
• -school -safety
• -sun block -diet
• -elimination -strangers
• -sleep -sports
• -behavior -TV time!!- increase in education
  of limited time spent here
• -friends -chores

72
School age 6-10

• Height
• Weight
• Temperature
• Percentile
• BP
• BMI

73
School age 6-10

• Development 6-10
• Varies
• Read pg 16 U/G
• Age 9-10
• Begin tanner assessment
• Assess preparation for puberty

74
FYI Obesity

• Screen thyroid
• Screen lipid
• Screen metabolic panel
• With increased lipids-refer to cardiology
• screen fasting insulin
• With or without increased insulin-refer to endo
• Refer all to nutritionist

75
FYI Obesity

• 6. Encourage sport participation
• 7. Re-check height, weight 3 month

76
General info

• Average school age child gains about 5 lbs and
  2.5 inches per year
• Average 10 year old is 70 lbs and 54 inches

77
Well Care 11-13 years

• Height
• Weight
• Temperature
• Percentiles
• BP
• BMI

78
Well Care 11-13 years

• Medications
• Parental concerns
• Sports concerns
• HEADSS
• Adolescent questionnaires review together

79
Well Care 11-13 years

• Confidentiality!
• P.E.
• Head to toe
• Be considerate

80
Adolescence

• The period of life beginning with puberty and
  extending for an average of 8-10 years.
• Puberty focuses on physical changes resulting in
  the ability to reproduce.
• Mean age for the initiation of puberty is 11.2
  years but may range from 9.0 to 13.4.
• Females typically reach adolescence 2 years
  earlier than males.

81
Adolescence

• During adolescence, a teenagers weight doubles,
  and height increases 15-20.
• During puberty, major organs double in size,
  lymphoid tissue decreases in mass.
• Musculature increases in size and strength.
• Boys attain greater strength and mass continues
  into late puberty.
• Motor coordination lags behind in growth and
  stature and musculature but improves.

82
Growth and Development of Puberty

• Physical changes of puberty include
• Growth spurts
• Development of secondary sexual characteristics
• Maturation of genital organs
• Onset of menstruation for girls

83
Male Growth Spurts

• Height spurt beings at age 11. Reach peak height
  velocity 13 ½ to 14yrs.
• Boys increase the quantity of body fat before
  beginning their height spurt.
• They lose fat until the growth spurt has finished
  and gradually again increase fat.
• 1st sign of puberty begins around 10 and 12
  marked by scrotal and testicular growth.
• Pubic hair can occur any time between ages 10 and
  15.

84
Boys

• Penis grows significantly a year or so after the
  onset of testicular and pubic hair(10-13).
• 1st ejaculation is a notable event, occurring 1
  year after initiation of testicular growth.
• 90 of boys have this event between 11-15.
• Gynecomastia occurs in a majority of boys.
  Usually disappears within 2 years.
• Pubertal development may not be completed until
  age 18.

85
Boys

• Height velocity is higher in males(8-11cm) than
  in females(6 ½ -9 ½cm) per year.
• Axillary hair, deepening of the voice, and the
  development of chest hair occurs in mid puberty,
  about 2 years after onset of growth of pubic
  hair.
• Facial and body hair begin to increase at ages
  16-17.

86
Female Adolescents

• Onset of growth spurt is between 8-17.
• Mean age for peak height velocity growth is 12
  years.
• Average duration of growth spurt is 3 years.
• Females grow 2½-5 inches in height per year and
  gain 8-20 lbs.
• Increase in height may lead to poor posture.
• Pelvis grows and becomes shapely.
• Increase of adipose tissue from 15-27.

87
Secondary Sex Characteristics

• Thelarche (breast development)
• Stimulated by estrogen
• Breast size varies and asymmetry is common
• Development of a breast bud from glandular tissue
• Areola widens and eventually elevates from the
  chest wall
• Mature breast is characterized by the protrusion
  of the nipple

88
Secondary Sex Characteristics

• Adrenarche (pubic hair growth)
• Concurrent with breast development
• Initial growth is slightly pigmented and straight
• Starts off with fine growth on the labia majora
• Quantity of hair increases and distribution
  spreads from the labia to the mons veris
• Texture becomes coarser, curlier, and darker
• Final stage established in about 2 yrs with
  typical female triangular distribution with a
  horizontal upper border

89
Tanner Staging

• Breast Development or Thelarche
• Pubic Hair Development or Adenarche or Pubarche
• Male Genital Development

90
External and Internal Genitalia

• Labia major, mons veris and symphysis pubis
  develop as fat is deposited.
• As a result of increase in fat, the labia majora
  fall inward and obscure the labia minora.
• Clitoris becomes larger and more erectile and the
  entire entroitus appears largers.
• Estrogen causes vaginal lining to transform into
  think stratified squamous epihelial cells
  containing glycogen.

91
External and Internal Genitalia

• Thickness of vaginal lining varies with cyclic
  circulating levels of hormones.
• Vaginal secretions result from decrease hormone
  stimulation.
• Leukoreah(white muciod discharge) often precedes
  menarche by approx. 1 year.
• Uterus changes from tubular formation into a
  hollow muscular organ.
• Endometrial lining proliferates in preparation
  for menarche.

92
External and Internal Genitalia

• Fallopian tubes grow.
• Ovaries increase in size and develop an adequate
  vascular system to trigger the release of
  lutenizing hormone and to initiate ovulation.
• Anovulatory menstrual cycle is due to slower
  development of ovarian function compared to
  endometrial function.

93
Menarche

• Grand finale of puberty in women, average 12.5
  years.
• Occurs approximately 1-3 years after thelarche
  and during Tanner Stage 3 or 4.
• Initial menstrual cycle may be irregular in
  quantity and duration.
• Frequently anovulatory, secondary to immature
  ovarian function.
• Rhythmic menstrual pattern set in about 3-4 years
  after menarche begins.

94
Early Adolescence 11-13 years

• Interests focus on same gender peer group
  identification. Peer acceptance importance.
• Define normalcy in relation to their peers.
• Thinking is concrete. Lacks the ability for
  abstract thinking. Easily overwhelmed and
  overruled.
• Expresses sexuality through dress, body language,
  and curiosity about sexual acts.
• Reasearch contends the last area of the brain to
  mature is the part capable of deciding, Ill
  finish my homework, take out the garage, and then
  Ill IM my friends

95
Middle Adolescence 14-16 yrs

• Most turbulent stage. Psychologically egocentric
  and preoccupied with self.
• Self esteem is established through recognition of
  the peer group.
• Behavior is characterized by profound mood swing
  and rebellion.
• Struggles for independence. Uses abstract
  reasoning and introspection for a better
  understanding of self and other.
• Sexual behavior is explorative and exploitative.

96
Risk factors for suicide attempt in adolescent

• Lack of social connections
• Alcohol and substance use
• Non-intact family of origin
• Firearms in the household
• Poor communication with parents
• Prior suicide attempt
• History of abuse/violence victimization
• Sexual identity issues

97
Suicide risks

• Family history of
• Depression
• Sucicide attempts
• Mood disorders in mothers
• Alcoholism or legal troubles in father
• Stressful life events, to include
• Break-up with a partner (in males)
• Separation of parents
• Disciplinary crisis
• Problems at school or work, or not being
  affiliated with either.

98
14-16 Well-care

• Height
• Weight
• Temperature
• Percentiles
• BP
• BMI

99
14-16 Well-care

• Vision, hearing
• Medication
• Sports form
• HEADSS
• Adolescent questionnaire review together

100
14-16 Well-care

• Discuss driving and risky behavior
• P.E.- head to toe
• -girls are usually tanner iv

101
FYI- Eye exams

• Age 5 or 6 begin
• Optic nerve
• Optic disk/cup
• Darken room
• Practice makes perfect
• Dr. Berland

102
17-21 Well-Care

• Treat as adult
• P.E.
• STD screen
• Paps- start age 20 or 3 yrs after 1st intercourse
• FYI-get up to date on street drugs, or at least
  have a cheat sheet to refer to.
• For example do you know that the effects of
  inhalants include hearing loss, neuropathies,
  limb spasms, CNS damage, bone marrow damage,
  liver and kidney damage, O2 depletion..

103
Late Adolescence 17-21 yrs

• Develops a sense of self and purpose to life.
• Sexual behavior is more expressive and less
  exploitative.
• Intimate and monogamous relationships are
  developed.
• Abstract reasoning skills are fully developed.
• Individual is able to interact with the adult
  world and consider long term implications.

104
(No Transcript)
105
(No Transcript)
106
(No Transcript)
107
Review immunization

• -Hep B -Pneumoccal
• -DTAP -Influenza/ Flumist
• -Hib -Varicella
• -IPV -MMR RotaTeq
• Hep A -Menactra
• Boostrix and ADACEL
• Two new- for HPV- Gardasil and Cervarix