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* Average IQ 90-100
* Gifted child- > 130 IQ
2.
Period of Infancy
a. Neonate- 1st 28 days or 1st 4 weeks of life
b. Formal infancy- 29 day 1 year
3.
Early Childhood
a. Toddler 1-3 yrs
b. Pre school 4-6 years
4.
Middle Childhood
a. School age- 7 12 yrs
5.
Late Childhood
a. Pre adolescent 11 13 yrs
b. Adolescent 12 - 18 21
c. Lymphatic system- lymph nodes, spleen, tonsils---grows rapidly- infancy and childhood
-protection against infection
tonsil adult proportion by 5 years
d. Reproductive system- grows rapidly at puberty
Rates of G&D:
a. Fetal and Infancy period of most rapid G&D -----*prone to develop anemia
b. Adolescent- period of rapid G&D Toddler- slow growth period
c. Toddler and preschool- alternating rapid and slow
d. School age- slower growth
3. Each child is unique
A. Heredity:
4. G&D occurs in a regular direction reflecting a definitive & predictable patterns or trends.
A. Directional Trends- occur in a regular direction reflecting the development of neuromuscular
function. These apply to physical, mental, social and emotional development and includes.
1. Cephalo-caudal--- head to toe
Occurs along bodys long axis in w/c control over head, mouth & eye
movements & precedes control over upper body torso and legs.
2. Proximo- distal---- Centro distal
From center of body to extremities.
3. Symmetrical----side of body develop on same direction at same time at same rate.
4. Mass Specific Differentiation
- Learns simple operations before complex function, from broad general pattern of behavior to a refined pattern.
B. Sequential- involves a predictable sequence of G&D to w/c the child normally passes.
1. Locomotion- creep, crawls, sit then stand.
2. Socio & Language skills- solitary games, parallel games
C. Secular- worldwide trend of maturing earlier & growing larger as compared to succeeding generations.
5.Behavior--most compressive indicator of developmental status.
6. Universal language of child- play
7. Great deal of skill and behavior is learned by practice. Practice makes perfect.
9. Neonatal reflexes must be lost 1st before devt can proceed.
-Plantar reflex shld. disappear before baby can walk
*1st cry--oha
2nd sound-cooing
3rd sound-ahh(bowel)
*1st play-solitary
Age
1 month
1-4 months
4-8 months
8-12 months
12-18
months
(1-1 1/2yrs.)
18-24
months
Behavior
All reflexes
-Activity related to body
-Repetition of behavior (ex. thumb sucking)
-Activity not related to body
-Discover object & persons permanence
-Memory traces present
-Anticipate familiar events.
-Exhibit goal directed behavior
of permanence & separateness (search of
lost toy, knows mom, throw & retrieve)
-Use trial & error to discover places & events
- invention of new means
-capable of space & time perception
(hits fork, spoon on table or drops fork)
-Transitional phase to the pre operational
thought process.
Age
2-4 yrs
2. Initiative
4-7 yrs
Behavior
-Thinking basically complete literal & static
-Egocentric- unable to view others viewpoint
-Concept of dying is only now
-Concept of distance is only as far as they can see.
-Concept of Animism: inanimate object is alive
(-) reversibility concept- in every action theres an opposite reaction or cause & effect
Beginning of Causation
Stage
Level 1
1
Description
-*Punishment/ obedience oriented (heteronymous morality) child does
right cause a parent tells him or her to & to avoid punishment
-Individualism. Instrumental purpose & exchange. Carries out action
to satisfy own needs rather than society.
-Will do something for another if that person does something for the
child.
2. Conventional
7-10
Level
3
10-12
3. Post-conventional
Above 12 yrs
Level III
5
6
V. DEVELOPMENTAL MILESTONES
-Major markers of growth and devt
1. Period of Infancy:
*Universal language of child----- Play
a. Play- Solitary plays (non-interactive)
Priority : Safety (toys: age appropriate)
Main goal: Facilitate motor & sensory devt
Ex. mobile, teeter, music box, rattle
b. Fear- Stranger anxiety begin 7-8 months: peak 8 months diminishes 9 months
c. Milestones:
Neonate:
1 month:
2 months:
3 months:
4 months:
5 months:
6 months:
7 months:
8 months:
9 months:
11 months: >Cruises
>Stands with assistance
>Walking while holding to cribs handle
> One word other than mama & dada
30 months or 2 year:
>Makes simple lines or stroke for crosses with a pencil
>Can jump down from chairs
>Knows full name
>Copy a circle
>Holds up finger to show age
>Temporary teeth complete (deciduous teeth -20)
Draws by age:
2 1/2
3
4
5
c. Milestones
11-12 y/o:
>Pre-adolescents
>Full of energy & constantly active
>Secret language are common
>Share with friends secrets
Boys
I-inc size breast & genitalia (thelarche- 1st sign sexual at.
W- widening of hips
D-deepening of voice
D- development of muscles
5. Adolescent :
a. Fear :
1. Obesity
2. Acne
3. Homosexuality
4. Death
5. Replacement from friends
b. Significant Person: Peer of Opposite Sex
c. Significant Development
1. experiences conflict bet. his needs for sexual satisfaction & societies expectation
*Core Concern: Change of body image & acceptance of opposite sex
* Hallmark of Adolescence: Nocturnal Emission (wet dreams)
2. Distinctive odor d/t stimulation of apocrine glands
3. Sperm is viable by 17 y/o
4. Testes & scrotum increase until age 17
5. Breast & female genitalia increase until age 18
d. Personality Traits Adolescents:
1. Idealistic
2. Very conscious with body image
3. Rebellious
4. Reformers, adventuresome
e. Problems:
1.
2.
3.
Vehicular accident
Smoking
Alcoholism
10
4.
5.
Drug addiction
Pre-marital sex
11
-Remaining 30%- tricuspid valve- RT ventricle- pulmonary arteries- lungs (for nutrition)--vasoconstriction of lungs
pushes blood to ductus arteriousus to aorta to supply upper extremities.
*3 SHUNTS*
SHUNTS-shortcuts
1. Ductus Venosus- -shunts from liver to IVF (umbilical vein to inferior vena cava)
2. Foramen Ovale- shunts bet 2 atrias
3. Ductus Arteriosus- from pulmonary artery to aorta
Decrease PO2, increase PCO2 acidosis
Increase PO2
1. Closure of Ductus
Arteriosus
2. Closure of Ductus
Venosus & AVA
Failure to Close
Atrial Septal Defect
Patent Ductus
Arteriosus
12
2.
3.
4.
APG
releases:
Prolactin
Posterior P. G.
releases
Oxytocin
w/c acts on
Acinar Cells/Alveoli
To Produced foremilk
13
Let-Down Reflex
14
b. Newborn Condition:
Inborn errors of metabolism
Erythroblastosis Fetalis Rh incompatibility
Hydrops Fetalis, Tay Sachs disease
Phenylketonuria, Galactosemia
Jaundice baby
Under phototherapy
Mucus mixed with stool *Clay colored stool
Chalk clay stool
Black stool
Blood flecked stool -
light stool
bright green
milk allergy
obstruction to bile duct
after barium enema
GIT bleeding (melena)
anal fissure.
15
intussuseption
hirschsprung disease
stool exam
fatty, bulky foul smelling odor stool
malabasorption syndrome
(Celiac disease or Cystic fibrosis)
A- appearance- color slightly cyanotic after 1st cry baby becomes pink.
P- pulse rate apical pulse left lower nipple
G- grimace reflex irritability- (1) tangential foot slap, (2) catheter insertion
A activity degree of flexion or muscle tone
R respiration
Baby cry within 30 secs
Failure to cry after 30 secs asphyxia neonatorum
Resp. depression d/t mom given Demerol. Administer Naloxone
HR (most important)
Respiratory Effort
Muscle Tone
Reflex Irritability
Catheter
Tangential Footslap
No Response
No Response
Color
Blue/pale
Grimace
Grimace
Acrocyanosis
(body- pink
extremities-blue)
2
>100
Good strong cry
Well flexed
Cough, sneeze
Cry
Pinkish
APGAR Result:
0 3 = severely depressed, need CPR, admission NICU
4 6 = moderately depressed, needs addl suctioning & O2 administration
7 - 10 =good/ healthy
CPR cardio pulmonary resuscitation or CPR
New: Cardio pulmonary cerebral resuscitation (CPCR)
5 min no O2 irreversible brain damage
a/w
1. shake, no resp, call for help
2. flat on head, use cardiac board
3. head tilt chin lift maneuver except spinal cord injury over extension may occlude airway
Breathing ( ventilating the lungs)
1. check for breathlessness
if breathless, give 2 breaths- ambu bag
> 1 yr old- mouth to mouth, pinch nose to create a seal
< 1 yr mouth to nose
Force different between baby & child
infant puff
Circulation :
16
CPR breathless/pulseless
Compression for infant: 1 finger breath below nipple line or 2 finger breaths or thumb
CPR :
Infant 1:5
Adults 2:15
B. Respiration Evaluation
1. Assessment tool that determines respiration of baby :
Silvermann Anderson Scale
Criteria
Chest movement
Intercostal retraction
Xiphoid retraction
Nares dilatation
Expiratory grunt
0
synchronized
No retraction
None
None
None
1
Lag on respiration
Just visible
Just visible
Minimal
Heard on stet
only
2
See - saw
Marked
Marked
Marked
Heard on naked ear
Lowest score
best
Interpretation result:
0 -3 normal, no RDS
4 6 moderate RDS
7 10 severe RDS
C. Assessment of Gestational Age
1. Clinical Criteria:
Ballards & Dobowitz
Findings
Less 36 weeks (Preterm)
37 - 38
Sole creases
Anterior transverse crease
Occasional creases 2/3
only
in
Breast nodules
2mm
4mm or 3.5 mm
Scalp hair
Fine & fuzzy
Fine & fuzzy
Ear lobe
Pliable
Some cartilage
Testes and Scrotum testes in lower canal
Some intermediate
Scrotum small few rugae
39 and up
Covered with creases
> 5 or 7mm
Coarse & silky
Thick cartilage
Testes pendulus
Scrotum fully covered w/ rugae
17
Abdomen 31 33 cm or 12 13
c. Bathing
>Oil bath initial : To cleanse baby & spread vernix caseosa
Fx of vernix caseosa :
1. Insulator
2. Bacterio- static
* Babies of HIV + mom immediately give full bath to lessen transmission of HIV
(13 39% possibly of transmission of HIV
*Full bath safely given when cord fall *Dressing the Umbilical Cord: strict asepsis to prevent tetanus
d. Dressing the Umbilical Cord
1. * 3 Cleans in community
1. Clean hand
2. Clean cord
3. Clean surface
Betadine or Povidone Iodine to clean cord
2. Check AVA, then draw 3 vessel cord--- if 2 vessel cordsuspect absence of kidneys
- leave about 1 inch of cord
- if BT or IV infusion leave 8 of cord
*Best site of blood nerve access: umbilical cord
3. Check cord every 15 min for 1st 6 hrs bleeding .> 30 cc of blood----hemorrhage
*Excessive bleeding of cord Omphalagia suspect hemophilia or blood dyscrasias
*Cord turns black on 3rd day & fall 7 10 days
*Failure to fall after 2 weeks- Umbilical granulation (w/o foul smelling odor, pinkish)
Mgt: silver nitrate or cautery
- clean with normal saline solution not alcohol
- dont use bigkis air
- persistent moisture-urine, suspect patent uracus fistula bet
bladder & normal umbilicus
Dx:
7.5 lbs
18
> Small for gestational age (SGA) < 10th % rank or born small
> Large for gestational age > 90th % rank or macrosomia >4000 g
> Appropriate for GA within 2 standard deviation of mean (AGA)
> Physiologic wt loss 5 10% wt loss few days after birth
Small GA < (less) 10
Large GA > (more) 90
V. PHYSICAL EXAM & DEVIATIONS FROM NORMAL
A. Important Considerations:
1. if client is new born, cover areas not being examined to prevent hypothermia
2. if client is infant the 1st yr of life - get VS take RR 1st
- begin from least intrusive to the most intrusive area
3. if client is a toddler and preschool, let them handle an instrument like:
- play syringe or stet, security blanket favorite article.
Let baby hold it, allow bedtime rituals
4. Explain procedure & respect their modesty - school age & adolescent
- by wearing your complete uniform
*Security Blanket--- a transitional object as representation of the parents
B. Components:
1. V/S:
Temp: rectal- newborn to rule out imperforate anus/assess patency of anus
- take it once only, 1 inch insertion
Imperforate anus
1. Atretic no anal opening
more dangerous
2. Agenetic no anal opening
3. Stenos has opening
but narrow opening
4. Membranous has opening
Earliest sign:
1. No mecomium
2. Abdominal destention
3. Foul odor breath
4. Vomitous of fecal matter
5. Can aspirate resp problem may arise d/t aspiration of intestinal
contents----atelectasis
Mgt:
Surgery with temporary colostomy
Cardiac rate: 120 160 bpm newborn
Apical pulse left lower nipple
Radial pulse normally absent. If present PDA (+) radial pulse
Femoral pulse normal present. If absent- COA - coartation of aorta
Cyanotic HD
2 Major Types: AL CR
1. Acyanotic L to R : Left to Right shunting
2. Cyanotic R to L : Right to Left shunting
I. ACYANOTIC HEART DEFECTS L to R ---------( 8 Types)
*With increased pulmonary blood flow
1. Ventricular Septal Defect (VSD ) - opening between 2 ventricles
S&Sx:
19
20
Rt ventricular hypertrophy
High degree of cyanosis
Polycythemia
Severe dyspnea squatting position relief , inhibit venous return, facilitate lung
expansion.
Growth retardation due no O2------ Mental retardation d/t
O2 in brain
Tet spell or blue spells- short episodes of hypoxiablue baby esp. when crying
Syncope
Clubbing of fingernails due to chronic tissue hypoxia
21
9.
Mgt:
1.
2.
3.
4.
O2 administration after 1 month oldto wait for the complete closure of the ductus arteriosus
No valsalva maneuver , fiber diet laxative
Morphine hypoxia , Propanolol decrease heart spasms
Palliative repair BLT >Blalock taussig procedure
Brock procedure complete procedure
*Jones Criteria*
Major
1. Polyarthritis multi joint pain
2. Chorea Sydenhamms Chores or St. Vitous Dance
-purposeless involuntary hand and shoulder with grimace
3. Carditis characterized by tachycardia
4. Erythema marginatum - macular rashes
5. SQ nodules
Minor
1. Arthralgia joint pain
2. Low grade fever
3. All Dx Test & Lab results
antibody
C reactive protein
Erythrocyte sedimentation rate
Anti streptolysin O titer (ASO)
*Criteria: Presence of 2 major, or 1 major & 2 minor + history of sore throat will confirm the dx.
Mngt: Supportive only
Nsg Care:
1. CBR , avoid contact sports
2. Throat swab culture & sensitivity for antibiotic therapy
3. *Antibiotic mgt to prevent recurrence
4. Aspirin ( ASA therapy) anti-inflammatory. Low grade fever dont give aspirin.
S/E of aspirin: if given to children continuously w/ bacterial infection:
*Reyes syndrome encephalopathy- fatty infiltration of organs such as liver & brain
2. Respiration
Newborn resp 30-60 cpm, irregular abd or diaphramatic with short period of apnea w/o cyanosis.
If < 15 secs normal apnea newborn , if >15 secs. ---dead already
Resp Check:
Newborn 40 90 bpm
1 yr - 20 40
2-3yr 20 30
5 yrs 20 25
10 yrs 17 22
15 & above 12- 20
BREATH SOUNDS HEARD DURING ASCULTATION:
Sound
1. VESICULAR :
2. BRONCHOVESICULAR:
Characteristics
Soft, low pitched, heard over periphery of lungs, inspiration longer then expiration -Normal
Soft, medium pitched, heard over major bronchi, inspiration equals exp. Normal
3. BRONCHIAL SOUNDS: Loud high pitched, heard over trachea, expiration longer than inspiration. Normal
4. RHONCHI :
5. RALES:
22
6. WHEEZING:
7. STRIDOR:
8. RESONANCE:
9. HYPERRESONANCE:
1. Asthma
Pathognomonic Sign: Expiratory wheezing
Pet fish. Sport swimming
Drugs Aminophylline monitor BP, may lead to hypotension
Allergens: dust
Food allergens: seafood, chocolate,
Climate Changes
2. Respiratory Distress Syndrome (RDS) or Hyaline Membrane
Cause- lack of surfactant for lung expansion ----------------end stage: Atelectasis
Hypotonia, Post surgery, Common to preterm
Fibrine Hyaline : Sx----definite with in 1st 4 hrs. of life ---d/t lack of surfactant
Tachypnea with retraction -------earliest sign
*Inspiratory Grunting Pathognomonic Sx
> 7 10 severe RDS (Silverman Anderson Index), respiratory acidosis
end stage: Cyanosis d/t atelectasis
*Chromolin Sodium---prevents asthmatic attack
before attack administer
> if with asthma attack ----bronchodilator---Aminophyllinemonitor BP
Mgt:
1. Surfactant replacement and rescue
2. Pos- head elevated
3. Proper suctioning
4. O2 with increase humidity- to prevent drying of mucosa
5. Monitor V/S skin color , ABG------R.A.
6.
7.
23
Mongolian Spots: stale gray or bluish discoloration patches commonly seen across the
sacrum or buttocks d/t accumulation of melanocytes.
Disappear by 1 yr old or 5 y/o pre-schooler
Milia plugged or unopened sebaceous gland, white pin point patches on nose, chin or cheek.
Lanugo fine, downy hair common preterm
Desquamation peeling of newborn, extreme dryness that begin sole and palm.
Stork bites (Telangiectasis nevi) pink patches nape of neck
hair will grow as child grows old
Erythema Toxicum (flea bite rash)- 1st self limiting rash appear sporadically &
unpredictably as to time & place.
Harlequin Sign dependent part is pink, independent part is blue
(side lying bottom part is dependent pink)
Cutis Marmorato transitory mottling of neonates skin when exposed to cold.
Hemangiomas vascular tumors of the skin
3 Types of Hemangiomas
a.) Nevus Flammeus port wine stain macular purple or dark red lesions seen on face or thigh.
NEVER disappear. Can be removed surgically
b.) Strawberry hemangiomas nevus vasculosus dilated capillaries in the entire dermal or
subdermal area. Enlarges, disappears at 10 y/o.
c.) Cavernous hemangiomas comm. network of venules in SQ tissue that never disappear with age.
MOST DANGERIOUS intestinal hemorrhage
10. Vernix Caseosa white cheese like for lubrication, insulator
Skin Color & its significance: Blue cyanosis or hypoxia
Ringworm Infestation:
White edema
Tinea Pedia : foot (atheltes foot)
Grey infection
Tinea Capites: head
Yellow jaundice , carotinemia
Tinea Cruris: singit
Pale anemia
Tinea Corporalis body
Representative Problems of the Skin:
1. Burn Trauma injury to body tissue caused by excessive heat.
INFANT
5-9 y/o
ANTERIOR POSTERIOR
Ant
Post
Head
9.5
9.5
6.5
6.5
Neck
1
1
1
1
Upper arm
2
2
2
2
Lower arm
1.5
1.5
1.5
1.5
Hand
13
1.25
1.25
1.25
Trunk
13
13
Back
13
13
24
Genital
@ buttocks
Thigh
Leg
foot
DEPTH:
1st degree
2nd degree
3rd degree
1
2.5@
2.75
2.5
1.75
2.75
2.5
1.75
1
2.5 @
4
3
1.75
4
3
1.75
2.) A/W
a.) Suction PRN, o2 with increased humidity
b.) Endotracheal intubation
c.) Tracheostomy
3.) Prevention of shock & F&E imbalance : Burns: HyperkalemiaMD will give insulin
for K to go back to cells
a. colloids to expand blood volume
b. isotonic saline to replace electrolytes
c. dextrose & H2o to provide calories
4.) Tetanus Toxoid Booster
5.) Relief of pain IV analgesic MORPHINE SO4 needed for 2nd degree very painful
6.) 1st defense of body intact skin
Prevention of Wound infection
i. Cleaning & debriding of wound
ii. Open or close method of wound care
iii. Whirlpool therapy drum with solution
7.) Skin grafting 3rd degree thigh or buttocks (autograft), pigs/ animals xenograft
frozen cadaver hallow graft
8.) Diet increase CHON, increase calories.
2. ATOPIC DERMATITIS - Infantile eczema (hika ng balat) (asthma of the skin)
Papillovesicular erythematus lesions with weeping & crusting
Usual Cause : Food allergies: milk, citrus juice, eggs, tomatoes, wheat
Sx:
> Extreme pruritus---linear excoriation----weeping crusting----- scaly shiny & white to ------------Lichenification
Goal of Care:
25
26
b.) Epistaxis
c.) Blood in urine & emesis
Signs of Anemia :
a.) Pallor , body malaise , constipation
2. From invasion of body organ:
a. Hepatosplenomegaly
b. Abdominal pain
c. CNS affectation & increase ICP
Dx Tests:
1.
2.
3.
4.
5.
6.
Therapeutic Mgt:
TRIAD FOR CANCER:
1.
2.
3.
Surgery
Irradiation
Chemotherapy
S/E of Chemotherapy
1. N/V adm anti-emetic drugs 30 mins before chemo until 1 day after chemo
2. Ulcerations / stomatitis / abscess of oral mucosa: Nsng. Dx: Altered oral mucus membrane
> Oral care alcohol free mouthwash , betadine mouthwash
> Dont brush use cotton pledgets
> Topical xylocaine before meals
> Diet- soft, bland diet according to childs preference
Temporary S/E of Chemo:
Alopecia altered body image
Hirsutism abnormal growth of hair to other body parts
-give emotional support to parents, always repeat instructions
Irradiation Management:
27
3 principles:
1. Time
2. Distance
3. Shielding
> with visitors but not more than 10
New Management: Chemotherapy or Bone Marrow Transplant
8. Hemolytic Disorders:
a.
Rh Incompatibility
> Rhesus means foreign body
> mother (-), fetus & father (+)
> 4th baby severely affected
> if (-) or no antigen : CHON factor
> (+) has antigen : CHON factor
O2 carrying capacity
Globin
brokendown
28
Iron
(removed in the body)
(not involved in jaundice)
Protoporphyrin
broken down
Indirect Bilirubin (fat-soluble converted by kidney)
Converted by Glucoronyl Transferase (liver enzyme)
4. Head
largest part of baby , of its length
Normal head : 33-35 cm or 13-14 inches
Size:
Anterior Fontanel 1 x 1
Posterior Fontanel 3 x 4
A. Cephalo-caudal Assessment:
Noticeable Structures of the Head:
1.
2. Microcephaly small, slow growing brain d/t alcohol & HIV mom
>5th percentile
3. Anencephaly absence of cerebral hemisphere
4. Craniotabes localized softening of cranial bone. Common 1st born child (normal)
-d/t early lightening (2 weeks prior to EDD)
Rickets d/t Vit. B deficiency soft cranial bone in older children
5. Caput Succedaneum edema of scalp d/t prolonged pressure at birth
Characteristics:
1. Present at birth
2. Crosses suture lines
3. Disappear after 2-3 days
6. Cephalhematoma- collection of blood due to rapture of periosteal capillaries
Characteristics :
1. Present after 24 hours
2. Never cross suture line
3. Disappear after 4-6 weeks
4. Monitor for developing jaundice
29
Sx:
a. Abnormally large head, bulging fontanel Earliest Sx of
ICP
b. Cushings Triad----- Hyper, bradypnea,bradycardia
c. High pitched cry
d. For older children & >6 months
Diplopia eye deviation, projectile vomiting---earliest sx
e. Fontanel bossing prominent forehead
f. Prominent skull vein
g. Sunset eyes
Mgt:
a. Position to lessen ICP low semi-fowlers 20-30 degree angle
b. Administer- osmotic diuretic Mannitol/ Osmitrol , Diamex- Azetam
c. Decrease CSF production ----drug: acetazolamide or Diamox
d. Shunting AV shunt or Vp shunt (ventriculoperitoneal shunt)
Shave hair in OR to prevent growth of micro org.
e. Hyperventilate child
Nsg Care:
1.) Post VP shunt position: immediately after---supine then after anesthesia
--- side lying on non operated site
- to prevent increase ICP
Monitor for good drainage in catheter: good sign is a sunken fontanel
if bulging fontanel blocked shunt
Catheter change as child is growing
5. Senses
A. Assessment of Eyes:
30
COMMON TESTS
Age
Common Tests
1. Newborn
General Appearance:
Can only see 10-12 inches
Visual Acuity 20 /200 to 20/ 800
3. Preschool
1. RETINOBLASTOMA
Outstanding Sign:
Mgt.
a. Surgery: Enucliation the removal of the eyeball & replacement of artificial aye
B. Assessment of the NOSE
1.
2.
3.
4.
(Sense Of Smell)
31
If ears not properly aligned with the outer cantus of eyes or low set ears: Suspect
A. KIDNEY MALFORMATION:
1.
Kidney Transplant
32
Epicanthal Fold
= extra fold of eyelids
Brushfields Spot = black & white specks in the iris
Pectum Excavatum = sunken sternum
Puppys neck
Hypotonic =
muscle tone prone to URTI
Simian crease = a single transverse line on palm.
Alert:
Always check PR for tachycardia d/t hypotonia
Check for respiration
Check for mental retardation----educable
b. TRISOMY 18 or ENDVARD SYNDROME
Sx:
Short height
Lack of developing ovaries
Sterile
e. KLINEFELTERS SYNDROME
- 47XXY or XXY syndrome is a condition caused by a
chromosome nondisjunction in males; affected individuals have a
pair of X sex chromosomes instead of just one
- Has male genitalia
- No deepening of voice
- Small testes, penis -sterile
*Klinefelter Calvin Kline male
33
3. TRANSLOCATION ABNORMALITIES
- Abnormalities in chromosome structure follow a chromosome break
& during the repair process, the reunion of the wrong segments of the
chromosome.
- Involves two nonhomologous chromosomes (e.g., chromosome 2 and
chromosome 6). Following a break in each of the chromosomes &
subsequent reunion, a segment of chromosome 2 becomes attached to
chromosome 6 and vice versa.
a. BALANCED TRANSLOCATION CARRIER
- When there is no loss or gain of chromosomal material & the individual
is mentally & physically normal. However, there is an increased risk of having
chromosomally abnormal offspring because individuals who carry balanced
chromosome rearrangements may produce chromosomally unbalanced gametes.
b. UNBALANCED TRANSLOCATION SYNDROME
- Happens if following repair, there is a loss or gain of chromosomal
material . There are significant clinical consequences for this type.
4. Others
a. MOSAICISM
a situation where the nondisjunction of chromosomes occurs during the
mitotic cell division after fertilization results to diff. cells contains
different # of chromosomes.
- Where an individual has two or more cell populations that differ in
genetic makeup. This situation can affect any type of cell, including blood
cells, gametes (egg and sperm cells) & skin.
b. ISOCHROMOSOMES
a situation w/in the chromosomes instead of dividing vertically it
divides horizontally
NOTE FOR:
*OTITIS MEDIA
= Inflammation of middle ear
Common to children d/t wider & shorter Eustachian tube
Causes :
1. Bottle propping w/c may also lead to dental carries
2. Cleft lip/ cleft palate
Sx:
34
Nsg Care:
2.
Mgt:
Inability to open the eye & close the other eye at the same time---monitor for dryness
Refer to PT
Outstanding Sx: 4 Cs
Mgt:
Coughing
Choking
Continuous drooling
Cyanosis
Emergency surgery
c. EPSTEIN PEARL :
- White glistering cyst at palate & gums r/t hypercalcemia ( 1-2 small shiny mass)
d. NATAL TOOTH
- Tooth at birth d/t Hypervitaminosis of mother during pregnancy
- If movable remove with a clean gauze
35
f. NEONATAL TOOTH
- Appearance of temporary teeth w/n the 28 days of life instead of 6 months
* ANODONTIA No eruption of temporary teeth even at 5 y/o
g. ORAL MONILIASIS or ORAL THRUSH Oral Candidiasis
- White cheese-like substances & curd like patches that coats tongue
CA: Candida Albicans
Nsg Care:
Do not remove, wash mouth with cold boiled water
Administer meds: Nystatin / Mycostatin: Antifungal
g. *KAWASAKI DISEASE or Mucocutaneous Lymphnode Syndrome
- A Strawberry tongue, originated in Korea
- Dr. Kawasaki discovered it
- Common in Japan
Criteria For Diagnosis Of Kawasaki Disease
1. Fever lasting more than 5 days
2. Bilateral Conjunctivitis
3. Changes of lips & oral cavity
- Dry, red fissure of lips
- Strawberry tongue
- Diffuse erythema of hands & feet
4. Changes of Peripheral Extremities
- Erythema of the hands & soles
- Indurative edema of the hands & feet
- Membranous desquamation from fingertips
5. Polymorphous rash
6. Acute nonpurulent swelling of cervical lymph node to > 1.5 cm in diameter
Complication: Myocardial Infarction in Children ( only MI in children)
Mgt:
36
Mgt:
1. Surgery : Depends on the Rule of 10
10 wks. Old
10 grams HgB
10 lbs. weight
a. Cleft Lip Repair = Cheiloplasty
- Done 1-3 months to save sucking reflex (lost in 6 months )
b. Cleft Palate Repair = Uranoplasty
- Done 4-6 months to save speech
Pre- Operative Care:
1. Provide emotional support especially to mom
2. Provide Proper nutrition to prevent colic
Feeding : Upright seating position
Burp frequently :
2x at middle & after feeding in a prone position& in a lower to upper tap
3. Orient parents to type of feeding
Rubber tipped syringe = Post-cheiloplasty
Paper cup/ soup spoon/ plastic cup = Post-uranoplasty
4. Apply restraints; Elbow restraints pre-opt so baby can adjust post op & decrease movement
5. 7-8 years after: Velopharyngeal Flap Operation: To fix nostril & pharynx
ALL Operation for mouth (adenoidectomy, tonsillectomy):
MOST IMPORTANT DIAGNOSTIC TEST TO CHECK: CLOTTING TIME
37
b. CONGENITAL CRETINISM
- Absence or non functioning thyroid glands or Hypothyroidism
Reasons for Delayed Dx:
1.
2.
3.
1. Mental Retardation
Prognosis: Mental retardation preventable when Dx is early
New Born Screening: it is included in the 6 diseases to be tested
Dx:
1.
2.
3.
Mgt:
Synthroid (Sodium Levothyrosin) = Synthetic thyroid given lifetime
Check PR before giving synthroid
Tachycardia = Sx of Hyperthyroidism
7. Assessment of the Chest
1. Check for Symmetry
NOTE FOR:
a. WITCH MILK
- Transparent fluid coming out from newborn r/t hormonal changes
b. Respiratory Distress Syndrome (RDS)
- Retroactive chest
c. PECTUS EXCAVATUM
- Sunken Sternum
d. BRONCHCOLITIS
- Distention of the alveoli
- Viral in origin
Sx:
- Respiratory Distress
- Increase RR > 60/minute
- Wheezing: high-pitch on expiration
38
a.
b.
c.
d.
Inspection
Auscultation
Percussion
Palpation
I
A
P
P =Last to perform because it will change bowel sounds
Sunken abdomen
Signs of RDS
R to L shunting
Mgt:
1. Emergency surgery within 24h
Diaphragmatic Repair w/ the use of Teflon Patch while place on
(ECMO) Extra Corporal Membrane Oxygenation
2. Continuous CPAP & CPPB
b. OMPHALOCELE
Protrusion of stomach contents in bet. junction of abdominal wall & umbilicus.
Mgt:
Very small surgery return the stomach contents
If large: Suspension surgery - Let the baby grow more to accommodate the
stomach content
Nsg Mgt:
1. Protect the sac with sterile wet dressing
2. Apply silver sulfadiazine ointment to prevent infection
c. GASTROCHISIS
- Absence of the abdominal wall exposing all the stomach contents
Nsg Mgt:
1. Provide sterile wet dressing
2. FUNCTION OF THE GIT
a.
b.
c.
Newborn:
39
40
Laryngotracheobronchitis (LTB)
b. RESPIRATORY ALKALOSIS = Carbonic acid deficit
Causes:
Hyperventilation
Fever
Encephalopathy
c. METABOLIC ACIDOSIS = Base HCO3 deficit
Causes:
Diarrhea
Severe dehydration
Malnutrition
Celiac crisis
d. METABOLIC ALKALOSIS = Base HCO3 excess
Alkalosis Up
Causes:
Uncontrolled vomiting
NGT aspiration
Gastric lavage
7. CONDITIONS THAT PRODUCES F & E IMBALANCE
Acidosis Down
1.
2.
3.
4.
Nausea
Dizziness
Facial flushing
Abdominal cramping
Assessment:
Mgt:
41
Early Signs
5% wt loss
10% wt loss
15 % wt loss
Signs of Dehydration
Hypotension
Tachycardia ---- 1st sign in newborn
Tachypnea
+ Fever
Weight loss -----Best criteria to determine dehydration
Sunken fontanel & eyeballs
Scanty & dark urine
Absence of tears
Poor skin turgor
Severe dehydration:
Marked Oliguria & Prolonged capillary refill time > 3 sec.
Mgt:
1. Acute Diarrhea = NPO (to rest the bowel )
With fluid replacement IV
Oresol : 1 glass & 1 tsp. of sugar, 1 pinch of salt
Prone to Hypokalemia : Give K chloride
Before administering of K chloride : Check if baby can void
If cannot void = Hyperkalemia
Drug: Na HCO3 : Administer slowly to prevent cardiac
overload
8. GASTRIC MOTILITY DISORDER: (Lower GIT Obstruction)
a. HIRSCHPRUNGS DISEASE
- Congenital aganglionic megacolon
- Aganglionic: Absence of ganglion cells needed for peristalsis
Earliest Sign in Neonate:
1. Failure/Delayed passage of mecomium after 24h
2. Abdominal distension
3. Vomitus of fecal material ---lead to aspiration----Atelectasis
4. Foul-smelling breath
Signs in Early Childhood:
1. Ribbon like stool
2. Foul smelling stool
3. Constipations
4. Diarrhea
Dx:
1.
2.
3.
4.
42
Chronic vomiting
Failure to Thrive Syndrome
2 Types:
a. Organic - d/t abnormality in the body/affected organ
b. Non-organic d/t abuse
Esophageal bleeding manifested by Melena or Hematemesis
3.
Complication:
1. Aspiration pneumonia
2. Esophagitis
3. Inflammation
4. Esophageal cancer (Organic type)
Dx Procedure:
1. Barium Esophogram reveals reflux
2. Esophageal Manometry reveals lower esophageal sphincter
pressure
3. Intraesophageal pH content reveals pH of distal esophagus.
Medication For GERD
1. Anti-cholinergic
Nissen Funduplication
- Creation of a valve mechanism by wrapping the greater curvature of the stomach
Nsg Care:
9. OBSTRUCTIVE DISORDERS
a. PYLORIC STENOSIS
Hypertrophy of the muscles of pylorus causing narrowing & obstruction
- Progressive thickening of the muscular layer of the pylorus
43
Assessment:
1.) Outstanding Sx: Projectile vomiting d/t pressure from narrowed pylorus
Nursing Alerts:
a. Vomiting is an Initial Sign of Upper GI obstruction
b. Vomitus of upper GI can be blood tinged not bile streaked. (with blood)
c. Vomitus of lower GI is bilous ( with pupu)
d. Projectile vomiting increase ICP or GI obstruction
e. Abdominal distension Major Sign of Lower GIT Obstruction
2.) Metabolic Alkalosis
3.) Failure to gain weight
4.) Olive shaped mass On palpation (almond-shaped mass)
5.) Peristaltic wave visible from L to R across epigastrum
6.) Always hungry, irritable
Dx:
1. Ultrasound
2. X-ray of upper abdomen with barium swallow reveals a STRING SIGN
Mgt:
1.
2.
Nsg Care:
1. Serum electrolyte: Increase Na & K, Decrease chloride
2. If on enteral feeding, provide pacifier
Pre-Opt:
Post-Opt:
b. INSTUSSUSCEPTION
- Invagination or telescoping of position of bowel to another
- Common Site: Ilio-Cecal junction (Junction bet. the small intestine)
Cecum is bigger than the ileum
- Not congenital
Prone People:
Complication:
Invagination
O2 supply
Necrosis
Swelling-----burst -------Peritonitis: An emergency
Sx:
1.)
2.)
3.)
4.)
Dx:
1.) X-ray with Barium Enema reveals Staircase Sign (coiled spring)
Mgt:
1.) Hydrostatic Reduction with barium enema
2.) Anastomosis & pull thru procedure
10. INBORN ERRORS OF METABOLISM
Created by Nia E. Tubio
44
45
1.
2.
Gliadin
(Toxic to epithelial cells of villi of intestines: Effects is malabsorption syndrome)
Malabsorption
Fats
Vit. D /Calcium
Vit. K
Inadequate blood
coagulation
Steatorrhea
Osteomalasia
Bleeding
Anemia
11. POISONING
- Common in Toddlers: Poisoning
- Common to Infants: Suffocation & falls
Principles :
1.
2.
3.
46
4.
5.
6.
7.
8.
a. LEAD POSIONING
Physiology:
Accumulation Lead
Destroy RBC functioning
Hypochronic Microcytic Anemia
Destroy kidney functioning
Accumulation of Ammonia
Encephalopathy
Sx:
1. Beginning symptoms of lethargy
2. Impulsiveness & Learning difficulties
3. As Lead increases, severe encephalopathy with seizure & permanent mental retardation
Dx:
1.
2.
3.
Blood smear
Abdominal X-ray
Long bones
Mgt:
47
Cause
Sx
Tx
NSG CARE
48
b. NEPHROTIC
SYNDROME
Infectious
c.
AGN
(Acute
Glomerulonephritis)
3
1.
2.
3.
4.
5.
6.
7.
Autoimmune
Grp. A betahemolytic
streptococcus
Or
GABHS
As:
AGN
Autoimmune,
Grp. A Betahemolytic St.
Before:
Sore Throat
*Impetigo
1. Prednisone
2. Diuretic
(Furosemide)
Focus of Care:
1. Monitor edema
Weigh daily
2. Diet:
Moderate CHON
Increase K- OJ, beef
broth, banana
Low Na Diet
Fatigue
Normal to low BP
1. Anti-HPN
drug
(Hydralazine or
Apresoline)
2. Iron
supplements
1. Weigh daily
2. Monitor :
BP
V/S
Neurologic status
3. Diet:
Decrease K
Decrease Na
Complication :
1. Hypertensive encephalopathy
If HPN not treated
2. Anemia
49
Rupture of sac
Prone position
Sterile wet dressing
Uneven hemline
Bend forward & 1 hip higher
1 shoulder blade more prominent than the other
Nsg care:
1. Conservative
Avoid obesity, exercise
2. Preventive
Milwaukee brace : Worn 23 h a day
3. Corrective surgery
Insert Harrington rod
Post operative- How to move : Log Rolling- move client as 1 unit
12. Assessment of the EXTREMITIES:
1. Assess for the # of digits = 20
NOTE FOR:
a. SYNDACTYLY
b. POLYDACTYLY
c. OLIDACTYLY
d. AMELIA
e. POCOMELIA
50
a. ERB-DUCHENNES PARALYSIS
- Paralysis of the brachial plexus injury or brachial palsy
- Birth injury d/t breech delivery & excessive lateral traction
Sx:
1. Unable to abduct arms from shoulders/
Rotate arm externally or supinate forearm
2. Absence or asymmetrical Moro reflex
Mgt:
1. Rotate arms from shoulders with elbow flexed
2. Passive ROM exercises
b. CONGENITAL HIP DISLOCATION
- Head of femur is outside the acetabulum
Types:
Goal of Mgt:
Facilitate abduction
Mgt.
1.
2.
3.
4.
5.
Triple diaper
Carry baby astride
Frejka splint
Pavlik harness
Hip Spica Cast
c. TALIPES or Clubfoot
Types:
a.) EQUINOS
= Plantar flexion (horsefoot)
b.) CALCANEUS = Dorsiflexion: Heel lower that foot/
Anterior portion of foot flexed towards anterior leg
Mgt:
1. Corrective Shoe- Dennis brown shoe, spica cast
2. Cast
13. OTHER TOPICS:
A. CAST
Function of CAST:
1. To immobilize
2. To maintain bone alignment
3. To prevent muscle spasm
Equipments:
1. Stokinette
51
Swing Through
Swing to
No weight bearing are allowed into lower ext
52
1. Move forward to the edge of the chair with the strong leg slightly under the seat
2. Place both crutches in the hand on the side of the affected extremity
3. Push down on the hand piece while raising the body to a standing position
To Go Down Stairs:
1. Walk forward as far as possible on the step
2. Advance crutches to the lower step. The weaker leg is advanced first and then the stronger
extremity shares the work of raising and lowering the body weight with the patients arms.
To Go Up Stairs:
1. Advance the stronger leg first up to the next step.
2. Then advance the crutches and the weaker extremity.
(Strong leg goes up first and comes down last.)
A memory device for the patients is up with the good, down with the bad.
C. WALKER
-Provides more support than a cane or crutches
D. CANE
- Used to help pt. walk with greater balance & support & to relieve the pressure on
weight-bearing joints by redistributing the weight.
- The cane is held in the hand opposite to the affected extremity
Methods of Transferring The Patient from the bed to a wheelchair:
I. Weight-bearing transfer from bed to chair. The patient stands up, pivots his back
is opposite the new seat, and sits down.
II. (Left) Non-weight-bearing transfer from chair to bed. (Right) With legs braced.
III. (Left) Non-weight-bearing transfer, combined method. (Right) Non-weightbearing transfer, pull-up method
E. TRACTION
- Used to reduce dislocation & immobilize fractures
Principles of TRACTION:
1.
2.
3.
4.
Types:
Straight Traction
Skin Traction
Bryants Traction
Bucks Extension
Skeletal Traction
Nursing Responsibilities:
1.
2.
3.
53
F. AUTOIMMUNE SYSTEM
Types of Immunity:
a.
IMMUNITY AGAINST:
= Diphtheria, Pertussis, Tetanus, Polio & Measles last for 9-12
months in babies
b. PASSIVE NATURAL
- Via placenta, breast milk
c.
ACTIVE NATURAL
- Acquired disease & produces memory cells
d. PASSIVE ARTIFICAL
- Receives anti-serum with anti-bodies from host
- Hep. B
e.
ACTIVE ARTIFICIAL
- Receives vaccine & produces memory cells
- All EPI vaccines are active artificial EXCEPT HEP. B
12. NEUROMUSCULAR SYSTEM
Reflexes
A. BLINK REFLEX
- Rapid eyelid closure when strong light is shown
B. PALMAR GRASP REFLEX
- With solid object, baby will grasp object
- Cling to mother for safety
- 6 weeks to 3 months to disappear
C. STEP IN/WALK-IN REFLEX
- Neonate placed on a vertical position with their feet touching a hard
surface will take a few quick, alternating steps.
* PACING REFLEX
Almost the same with step in place reflex only that you are touching
the anterior surface of a newborns leg
D. PLANTAR GRASP REFLEX
When an object touches the sole of a newborns foot at the base of
the toes, the toes grasp in the same manner as the fingers do.
E. TONIC-CLONIC REFLEX
When newborns lie on their backs, their heads usually turn to one
side or the other. The arm on the leg on the side to which the head
turns extend, and the opposite arm and leg contract.
F. MORO REFLEX
Letter C position
- Disappears 4-5 months
- Test for neuro integrity
54
G. MAGNET REFLEX
when there is pressure on the sole of the foot he pushes back
against the pressure
H. CROSSED EXTENSION REFLEX
When the sole of the foot is stimulated by a sharp object, it
causes the foot to rise and the other foot extend
I.
J.
LANDAU REFLEX
While in prone position and the trunk is supported, the baby
exhibit some muscle tone
K. PARACHUTE REACTION
While on ventral suspension, with the sudden change of
equilibrium, it causes extension of the hand and legs
L. BABINSKI REFLEX
When the sole of the foot is stimulated by an inverted J, it
causes fanning of the toes
55