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PEDIATRIC NURSING

I. Growth & Development


*Growth - Increase in physical size of a structure or whole.
- Quantitative change.
Two parameters of Growth
1.

Weight- Most sensitive measure of growth, especially low birth rate.


6 months-----BW doubles
12 months----BW triples
2-2 yrs-----BW quadrupled

2. Height - Increase by 1/mo during 1st 6 months, 7-12 months by 1 inch.


- Average increase in height - 1st year = 50%
Stoppage of ht coincide with eruption of wisdom tooth.
*Development - Increase skills or capability to function
- Qualitative
How to measure development:
1. Observe child doing specific task.
2. Role description of childs progress
3. DDST- Denver development screening test except mental, its I.Q. Test
MMDST (Phil) Metro Manila Developmental Screening Test.
4 Main Rated Categories of DDST
1. Language communication
2. Personal social-interaction
3. Fine motor adapting- prehensile ability to use hand movement
4. Gross motor skills- large body movement
*Maturation- same with development readiness
*Cognitive Development ability to learn and understand from experience, to acquire and retain knowledge, to
respond to a new situation and to solve problems.
*Learning---change of behavior
IQ Test- test to determine cognitive development
Formula:
Mental age
x 100 = IQ
Chronological age

* Average IQ 90-100
* Gifted child- > 130 IQ

II. Basic Divisions of Life


1.

Prenatal stage from conception- birth

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

Created by Nia E. Tubio

III. Principles of G & D


1. G&D is a continuous process that begins from conception- ends in death-- Womb to Tomb principle
2. Not all parts of the body grow at the same time or at same rate.-------------Asynchronous Growth principle
Patterns of G&D:
a.
b.

Renal, GIT, musculoskeletal, circulatory----grows rapidly during childhood


Neuromuscular tissue (CNS, brain, S. cord)---grow rapidly 1-2 years of life
Brain achieved its adult proportion by 5 years.
1-2 y/o- very important yrs---if with severe malnutrition--mild mental
retardation

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:

2 Primary Factors Affecting G&D :


R race
F- born less in length than M by 1 inch.
I intelligence F- born less in wt. than M by 1 lb.
S sex
N - nationality

B. Environment: Q quality of nutrition


S socio eco. status
H health
O ordinal position in family
P parent child relationship

Eldest- ability in comm. & social skills


youngest- more toilet trained

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

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*1st cry--oha
2nd sound-cooing
3rd sound-ahh(bowel)
*1st play-solitary

-Moro reflex shld. disappear before baby can roll


*Persistent primitive infantile reflexes- case of cerebral palsy

IV. Theories of G&D


Developmental Tasks- different from chronological age
skill or growth responsibility arising at a particular time in the individuals life.
The successful achievement of w/c will provide a foundation for the accomplishments of future tasks.
Theorists
1. SIGMUND FREUD: (1856-1939) Austrian neurologists----- Founder of Psychoanalysis
- offered personality development, Psychosexual theory
*Phases of Psychosexual Theory*
a.) Oral Phase------------- 0-18 months
- Mouth: site of gratification
-Activity of infant- biting, sucking crying.
-Why do babies suck?- enjoyment & release of tension.
-Provide oral stimulation even if baby on NPO.
-Pacifier.
-Never discourage thumb sucking.
b.) Anal Phase------------- 18 months-3 years
-Anus: site of gratification
-Activity- elimination, retention or defecation of feces must take place
- Principle of holding on or letting go.
-Mother wins or child wins
-Child wins- stubborn, hardheaded anti social. (anak pupu na, child holds pupu, child wins)
-Mother wins- obedient, kind, perfectionist, meticulous--------- OC-anal phase
-Help child achieve bowel & bladder control even if child is hospitalized.
c.) Phallic Phase----------- 3-6 years
- Genitals: site of gratification
- Activity- may show exhibitionism
- Increase knowledge of a sexes
- Accept child fondling his/her own genitalia as normal exploration
- Answer Childs question directly.
- Right age to introduce sexuality preschool
d.) Latent Phase---------- 7-12 years
-Period of suppression- no obvious development.
-Childs libido or energy is diverted to more concrete type of thinking
-Helps child achieve (+) experience, ready to face conflict of adolescence
e.) Genital Phase--------- 12-18 years
-Genitals: site of gratification
-Achieve sexual maturity
-Learns to establish relationships with opposite sex.
-Give an opportunity to relate to opposite sex.
2. ERIC ERICKSON- Psychoanalysis theory
-stresses important of culture & society to the development of ones personality
-environment , culture
*Stages of Psychosocial Theory*

a.) Trust vs. Mistrust 0-18 months.


-foundations of all psychosocial task
-to give & receive is the psychosocial theme
-know to develop trust baby
1. Satisfy needs on time
- breastfeed
2. Care must be consistent & adequate

Created by Nia E. Tubio

-both parents- 1st 1 year of life


3. Give an experience that will add to security- touch, eye to eye contact, soft music.
b.) Autonomy vs. Shame & Doubt---- 18-3 years
- Independence /self govt
- Develop autonomy on toddler ---1. Give an opportunity of decision making, offer choices.
2. Encourage to make decision rather than judge.
3. Set limits
c. Initiative vs. Guilt------------------------ 4-6 years
-Learns how to do basic things
-Let explore new places & events
-activity recommended- modeling clay, finger painting--enhance imagination & creativity
& facilitate fine motor devt
d. Industry vs. Inferiority------------------- 7-12 yrs
-Child learns how to do things well
-Give short assignments & projects
e. Identity vs. Role Confusion or Diffusion 12-18 yrs
-Learns who he/she is, what kind of person he/ she will become
by adjusting to new body image and seeking emancipation from parents
-Freedom from parents.
f. Intimacy vs. Isolation-----------------------18-25 yrs. Up to 30 y/o
-looking for a lifetime partner and career focus
g. Generatively vs. Stagnation------------ 30-45 y/o
h. Ego Integrity vs. Despair---------------45-65 & above
3. JEAN PIAGET- Swiss psychologists , pioneer work on dev.t of intelligence in children
-develop reasoning power
*Stages Of Cognitive Development*
A. Sensory Motor------ 0-2 y/o
-Practical Intelligence- words & symbols not yet available baby communicates thru senses & reflexes.
Schema (Subdivision)
1. Neonate Reflex
2. Primary Circular Reaction

Age
1 month
1-4 months

3. Secondary Circular Reaction

4-8 months

4. Coordination of Secondary Reaction

8-12 months

5. Tertiary Circular Reaction

12-18
months
(1-1 1/2yrs.)

6. Invention of new means thu mental


combination---Symbolic Representation

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.

B. Preoperational Thought---- 2-7 y/o


Schema
1. Preconceptual

Age
2-4 yrs

2. Initiative

4-7 yrs

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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

C. Concrete Operational Thought------ 7-12 years


1. Can find solution to everyday problems with systematic reasoning.
2. *Aware concept of reversibility- cause & effect
3. Concept of Conservation constancy despite of transformation.
4. Activity recommended- collecting & classifying: stamps, stationeries, dolls, rubber band
markers.
D. Formal Operational Thought--------- 12 and up.
1. Cognition achieved its final form
2. Can deal with past present & future
3. Have abstract & mature thoughts & formal reasoning.
4. Can find solutions to hypothetical problems with scientific reasoning.
5. Activity: talk time:-- will sort out opinions & current events.
4. KOHLBERG (1984)
- recognized the theory of moral devt as considered to closely approximate cognitive stages of devt
*Stages of Moral Development*
A. Infancy Amoral, Pre-religious or pre-moral stage
Age
1. Pre-conventional
2-3 yrs
4-7

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

-Orientation to interpersonal relations of mutuality. Child follows


rules cause of a need to be a good person in own eyes
& eyes of others.
-Maintenance of social order fixed rules & authority. Child finds ff.
rules satisfying. Follows rules of authority figures.

3. Post-conventional
Above 12 yrs

Level III
5
6

-Social contract, utilitarian level making perspectives. Follows


standards of society fro the good of the people.
Universal ethical principle orientation. Follows internalized standards
of conduct.

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:

Created by Nia E. Tubio

Neonate:

>Complete head lag


>Largely reflex visual fixation for human race
> Hands fisted with thumbs in
> Cries w/o tears d/t undeveloped lacrimal glands

1 month:

> Dance reflex disappears looks at mobile

Created by Nia E. Tubio

> Alert to sound, regards face


>Looks at mobile, follows to midline
>Holds head up when in prone
>Social smile, cries with tears, baby coos doing sound
>Closure of Frontal Fontanel ( 2-3 months)
>Head lag when pulled to sitting position.
>No longer clenches fist tightly
> Follows object past midline
> Recognizes

2 months:

3 months:

>Holds head & chest up when prone


> Holds hand, open at rest
>Hand regards, follows object past midline
> Grasp & tonic-neck reflexes are fading
> Reaches for familiar people & object
> Anticipates feeding

4 months:

>Head control complete


>Turns front to back, needs space to turn
> Laugh aloud, bubbling sounds

5 months:

> Turn both ways roll over


>Teething rings, handles rattle well
>Moro reflex disappears ( 4-5 months)
> Enjoys looking around environment

6 months:

>Reaches out in anticipatory of being picked up


*>Sits with support
>Uses palmar grasp, handles bottle well
>Eruption of 1st temporary teeth: 6-8 months: 2 lower incisors
>Say vowel sounds ah, oh
> Sucking reflex disappears
>Recognizes strangers (6-7 months) peak 8 months, diminishes 9 months

7 months:

>Transfer object from hand to hand


>Likes object that are good size for transferring

8 months:

>Sits without support


>Peak of stranger anxiety
>Planters reflex disappears 8-9 months in prep. for walking

9 months:

> Creeps or crawls, needs space for creeping


>Neat finger grasp reflex, probes with forefinger (finger feeds)
>Combine 2 syllables mama & dada

10 months: >Pull self to stand


>Understands no
>Responds to own name
>Activity: peak a boo, pat a cake, can clap

11 months: >Cruises
>Stands with assistance
>Walking while holding to cribs handle
> One word other than mama & dada

12 months: >Stands alone, take 1st step


>Walk with assistance
>Drink from cup, cooperate in dressing
>Says 2 words mama & dada
>Pots & pans, pull toys, nursery rhymes
>Imitates action, comes when called
>Uses mature pincer grasp, throws object

> Follows one-step with gesture


2. Toddler:
a. Play: Parallel play- 2 toddlers playing separately
-Provide with similar toys
Ex. squeaky frog to squeeze, waddling duck to pull, trucks to push-push pull toy,
building blocks, pounding peg, toys to ride on
b. Fear: Separation Anxiety: begin 9 months, peak 18 months
3 Phases Of Separation Anxiety (in order)
P- protect
D- despair
D- denial
-dont prolong goodbye
-say goodbye firmly to develop trust- say when you will be back
c. Milestones

15 months: >Plateau stage


>Walks alone
*Lateness in walking---mild mental retardation
>Puts small pellets into small bowl
>Holds spoon well
>Seats self on chair, creeps up stairs
>Scribbles voluntarily, say 4 - 6 words

18 months: >Height of possessiveness


>Favorite word- mine
>Bowel control achieved (bowel 1st before bladder)
>No longer rotates spoon
>Can run & jump in place
>Walks up & down stairs holding railing or persons hand
>1-20 words
>Names 1 body part
>Puts both feet on 1 step before advancing.

24 months: >Terrible twos


>Can open doors by turning door knobs
> Turn pages one at a time, removes shoes & pants
>Unscrew lids
>Can walk upstairs alone using both feet on same step at same time
>50-200 words ( 2 words sentences), knows 5 body parts
>Daytime bladder control achieved (daytime 1st , then night time bladder)
> Bring to MD (2-3) or when temporary teeth complete

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)

*Posterior Molar- last temporary teeth to appear


>Beginning of toothbrush 2-2 yrs
>Tooth brushing with little assistance 3 yrs , brushing alone 6 yrs
> The right time to bring to dentist- when temp teeth complete

Created by Nia E. Tubio

36 months or 3 yrs: >Trusting 3


>Unbutton buttons (unbutton before learn to button)
>Draw a +, learns how to share
>Knows full name & sex (gender identity)
>Speaks fluently, 300-900 words

>Nighttime bladder control achieved


>Ride a tricycle
d. Characteristic Traits of Toddler
1. Negativistic- NO! -way to search for independence
>Limit questions
>Modify questions to a statement
2. Rigid, ritualistic & stereotype
>Ritualism- to gain mastery
3. Temper Tantrums (most common)
>Head banging, screaming, stamping feet, holds breath
>Ignore behavior
*Protruding abdomen-d/t underdeveloped abdominal muscles
*Physiologic anorexia- d/t preoccupation with environment- food fads, short period of time
>Loves rough & tumbling play
>Loves toilet training
>Failure of toilet training- unreadiness
*Clues For Toilet Readiness:
1.) can stand, squat walk alone
2.) can communicate toilet needs
3.) can maintain dryness for 2 hours
3. Pre-Schoolers:
a. Play : Associative or Cooperative Play
>bahay-bahayan play house
>Role playing
b. Fear : Body Mutilation or Castration
>Fear of dark places, witches
>Fear of thunder & lightning
>Fear of ghosts

Draws by age:
2 1/2
3
4
5

c. Milestones

*4 years old:> Furious 4 , noisy, aggressive, stormy


> Can button buttons
> Copy a square
> Jumps & skips
*Laces shoes
> Vocabulary 1,500
> Knows 4 basic colors
> Say songs or poem from memory

5 years old: > Frustrating 5


> Copy a triangle
> Draw a 6 part man
> Imaginary playmates
> 2,100 words > Jumps over low objects

d. Character Traits of Pre-Schooler:


1. Curious, creative imaginative, imitative
2. Favorite words- why & how
3. Complexes- identification to parent of same sex & attachment to parent of
opposite sex
Ex. Oedipal complex- girl to dad/boy to mom
Electra complex- identification to mother (daughter-mother), attachment to father
>Cause of incest marital discord
e. Behavior Problems
1. Telling tall tales d/t over imagination
2. Imaginary friend- to release tension & anxieties
3. Sibling rivalry- jealousy to newly delivered baby.
4. Regression- going back to early stage
Sx: >thumb sucking (should be oral stage only)
>baby talk, bed wetting, fetal position

Created by Nia E. Tubio

5. Masturbation- sign of boredom


-divert attention, offer a toy
4. School Age:
a. Play: Competitive play
Ex. Tug of war, track and field, basket ball
b. Fear. 1. School Phobia
-orient to new environment
2. Displacement from school
-teacher and peer of same sex
3. Loss of Privacy
-wants bra
4. Fear of Death: thinks death is reversible as sleep

*7-9yrs death is personified


-death as permanent loss of life

c. Significant Person: Teacher, peer of same sex


d. Significant Development
-boys prone to bone fracture
- mature vision 20/20
e. Milestones

Created by Nia E. Tubio

6 years old: >Temporary teeth begin to fall


>Perm teeth appear- 1st molar
1st temp teeth- 5 months
1st perm teeth- 6 yrs
>Year of constant motion
> Common: green-stick fracture
>Recognize all shapes
>1st grade teacher becomes authority figure
>Nail biting
>Begin interest in God.

7 years old; Age of Assimilation


>Copy a diamond
>Enjoys teasing and playing alone
>Quieting down period

8 years old: Expansive age


>Smoother movement
>Loves to collect objects
>Count backwards
> Normal homosexual

9 years old: >Coordination improves


>Tells time correctly
>Hero worship
>Stealing & lying are common
>Takes care of body needs completely
>Teacher finds this group difficult to handle

10 years old: >Age of Special Talent


>Writes legibly
>Ready for competitive games
>More considerate & cooperative
>Joins orgs.
>Well mannered with adult
>Critical of adults

11-12 y/o:

>Pre-adolescents
>Full of energy & constantly active
>Secret language are common
>Share with friends secrets

>Sense of humor present


>Social & cooperative
f. Character Traits of School Age:
1. Industrious
2. Modest
3. Cant bear to lose- will cheat
4. Love collections- stamps
*SIGNS OF SEXUAL MATURITY*
Girls

Boys

I-inc size breast & genitalia (thelarche- 1st sign sexual at.

A-appearance axillary & Pubic hair

W- widening of hips

D-deepening of voice

A- appearance axillary & pubic hair ( adrenarche)

D- development of muscles

M- menarche- last sign sexual mat. Girls

Iincrease in testes and penis size ( 1st sign sexual mat)


P- production of viable sperm ( last sign sexual maturity)

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.

Created by Nia E. Tubio

Vehicular accident
Smoking
Alcoholism

10

4.
5.

Drug addiction
Pre-marital sex

II. IMMEDIATE CARE OF NEWBORN


1st days of life:
1.
2.
3.
4.
5.
6.
7.
8.

Initiation and maintenance of respiration


Establishment of extra uterine circulation
Control of body temp
Establishment of waste elimination
Intake of adequate nourishment
Prevention of infection
Establishment of an infant-parent relationship
Devt care that balances rest & stimulation or mental devt

1.) Initiation and Maintenance of Respiration


2nd stage of labor- initial airway
-initiation of a /w is a crucial adjustment
-most neonatal deaths w/n 24 h caused by inability to initiate a/w
-lung function begins after birth only
How to initiate a/w :
a. Remove secretions bulb syringe
b. Catheter Suctioning
1.) Place head to side to facilitate drainage of secretions
2.) Suction mouth 1st before nose
-neonates are nasal breathers
3.) Period of time
5-10 sec suctioning, gentle and quick
Prolonged & deep suctioning can lead to : Hypoxia
Laryngospasm, Bradycardia
d/t stimulation of vagal nerve--near esophagus & anus
4.) Evaluate for patency
-cover nostril & baby struggles theres a need for additional suctioning
c. If not effective, requires effective laryngoscopy to open a/w. After deep suctioning an endotracheal tube can be
inserted and oxygen can be administered by (+) pressure bag and mask with 100% oxygen at 40-60b/m.
Nsg alert In O2 Administration:
1. No smoking to prevent combustion
2. Always humidify to prevent drying of mucosa
3. Over dosage of oxygen can lead to scarring of retina leading to blindness
(Retro Lentalfibrolasia or Retinopathy of Prematurity) ROP---prone to:SGA,LBW,Preterm
4. When meconium stained (greenish) never administer oxygen with pressure
(O2 pressure will push mecomium inside)------Atelectasis
2.) Establishing Extra-Uterine Circulation
*Circulation is initiated by lung expansion or pulmo ventilation and completed by cutting of cord.
FETO PLACENTAL CIRCULATION
* Placenta(simple diffusion) oxygenated blood is carried by the umbilical vein- passes liver-ductus venousus- IVCRT atrium 70% blood is shunted to foramen ovale- LT atrium mitral valve LT ventricle- aorta-lower extremities.

Created by Nia E. Tubio

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

Will cause 1st breath /cry of baby

Decrease Pulmo Artery Pressure

Increase PO2

1. Closure of Ductus
Arteriosus

Decrease blood flow

2. Closure of Ductus
Venosus & AVA

Increase pressure to Left side of


heart

3. Closure of Foramen Ovale

What will sustain 1st breath- decreased artery pressure


What will initiate lung circulation-lung expansion
What will complete circulation- cutting of cord
4.) 2 Ways to facilitate closure of Foramen Ovale
a.) Tangential Footstep- slap foot of baby----slap---cry---lung expansion
-never stimulate baby to cry if secretions not fully drained to prevent aspiration
-check characteristic of cry
*Normal cry- strong, vigorous and lusty cry
*Normal cry of baby boy: lower
cri-du-chat syndrome-chromosomal obliteration cat like cry (meow)
b.) Proper position : Right side lying pos.
-will increase pressure on left and foramen ovale will close
*Foramen Ovale and Ductus arteriosus will begin to close within 24h
*Universal Cry of a Baby: O-ha
Obliteration-complete closure
Structure
Appropriate Time of
Structure Remaining
Obliteration
Foramen Ovale
Begins 24 hrs, 1yr
Fossa Ovalis
Ductus
Begins 24 hrs., 1 month
Ligamentum Arteriosum
Arteriosus
Ductus Venosus
2 months
Ligamentum venosum
1.) Lateral umbilical Ligament
Umbilical artery 2-3 months
2.) Interior iliac artery
Umbilical vein
2-3 months
Ligamentum Teres ( round ligament of liver)

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Failure to Close
Atrial Septal Defect
Patent Ductus
Arteriosus

12

*Position of infant immediately after birth:


NSD-Trendelenberg/ T position for drainage
contraindication of Trendelenberg position - increase ICP
CS- Supine or crib level position

Signs of Increased ICP


1. Abnormally large head
2. Bulging and tense fontanel
Hypertension
3.
BP and widening pulse pressure
Bradycardia
Cushings Triad of ICP
4.
RR & PR
Tachypnea
5. Projective Vomiting- sure sign of cerebral irritation
6. High deviation Diplopia sign of ICP older child
4-6 months- normal eye deviation
if >6 months- lazy eyes
7.)
High pitch shrill cry- late sign of ICP
3. Control of Body Temperature : Temp Regulation
-

*Goal in temp regulation is to maintain it not less than 97.7% F (36.5 C)


Maintenance of temp is crucial on preterm and SGA (small for gestational age) - babies prone to
hypothermia or cold stress

A. Factors Leading to Devt of HYPOTHERMIA


1.

2.
3.
4.

Preterms are born PoiKilothermic- cold blooded


Babies easily adapt to temp of environment d/t immaturity of thermo regulating system
of body. >Hypothalamus
Inadequate SQ tissue fats
Baby is not capable of shivering
*Earliest sign of hypothermia- increase in RR
Babies are born wet
PROCESS OF HEAT LOSS
1. Evaporation------body to air (TSB)
2. Conduction------body to cold solid object (cold compress)
3. Convection------body to cooler surrounding air (aircon)
4. Radiation-------- body to cold object not in contact with body

Effects of Hypothermia ( Cold stress)


1.) Hypoglycemia- 45-55 mg/dl normal ( 50- borderline) d/t utilization of glucose
2.) Metabolic acidosis- catabolism of brown fats (best insulator of newborns body)
will form ketones ( found in chest/back)
3.) High risk for kernicterus- bilirubin in brain leading to cerebral palsy
4.) Additional fatigue to allergy stressful heart
To Prevent Hypothermia:
1. Dry and wrap baby
2. Mechanical pressure radiant warmer (incubator) *Pre-heat first isolette (or square acrylic sided incubator)
3. Prevent an necessary exposure cover baby
4. Cover baby with tin foil or plastic
5. Embrace the baby- kangaroo care (skin to skin contact)
4. Establish Adequate Nutritional Intake
Physiology Breast Milk Production:
As you deliver baby,
E &

Physiology of Breast Milk Release:


Sucking of the Breast

APG
releases:
Prolactin

Posterior P. G.
releases
Oxytocin

w/c acts on
Acinar Cells/Alveoli
To Produced foremilk

Created by Nia E. Tubio

Contraction of smooth muscles of the


Lactiferous tubules

13

Stored in lactiferous Tubules


(or Collecting Tubules)

Milk Ejection Reflex

Let-Down Reflex

*CS- breastfeeding after 4 hours


*NSD- breastfeeding asap
*Advantages of Breastfeeding
*Store milk- plastic storage container
1. Economical
>good for 6 mon. from freezer/ at rm. temp. dont heat
2. Always available
3. Promotes Bonding
4. Breastfed babies have higher IQ than bottle fed babies.
5. It facilitates rapid involution
6. Decrease incidence of breast cancer.
7. Contents of BREAST MILK:
a. Antibodies- IgA
b. Lactobacillius bifidus- interferes w/ attack of pathogenic bacteria in
GIT
c. Has macrophages
d. Lactoferrin
e. Lyzozymes
f. Interferons
Disadvantages:
1. Possibility of transfer HEP B, HIV ( 30%-39%), cytomegalovirus virus.
2. No iron-----prone to IDA
3. Father cant feed & bond as well
3 Stages of Breastmilk:
1. Colostrum- 2-4 days post-delivery
content:
fats,
IgA, CHO, CHON, minerals, fat soluble minerals
2. Transitional milk- 4 14 days
content: lactose,
water soluble vit., minerals
3. Mature milk- 14 & up (3 L)
content:
fats (linoleic acid) resp for devt of brain & integrity of skin
CHO- lactose easily digested, baby not constipated.
- responsible of sour milk smelling odor of stool & astringent property of milk
*Lactose Intolerance- deficiency of enzyme LACTASE that digests LACTOSE
manifestation = Excessive Crying ------substitute-----soy milk
*Decrease CHON- lactalbumin
Contents of Cows milk:
fats
CHON casein- has curd thats hard to digest
Mineralstraumatic effect on kidneys of babies.
Can trigger stone formation.
Phosphorus
CHO
5. Prevention of Infection:
Health Teachings:
1. Proper hygiene- proper hand washing
Care of breast - cotton balls with lukewarm water (inner to outer)
Caked colostrums- dry milk on breast
2. Best position in breastfeeding upright sitting -avoid tension!if w/ tension breast will not properly empty
3. Stimulate & evaluate feeding reflexes
a.) Rooting reflex- by touching the side of lips/cheeks then baby will turn to stimulus. Disappear by 6
weeks- by 6 weeks baby can focus. Reflex will be gone
- Purpose rooting- to look for food.
b.) Sucking when you touch middle of lips then baby will suck
- Disappears by 6 months
- When not stimulated sucking will stop.
c.) Swallowing- when food touches posterior of tongue then it will be automatically swallowed
d.) Extrusion/ Protrusion reflex
-when food touches anterior portion of tongue then food will be extruded.
Purpose: to prevent from poisoning

Created by Nia E. Tubio

14

Disappear by 4 months & baby can already spit out by 4 months.


Criteria Effective Sucking:
a.) Babys mouth is hiked up to areola
b.) Mom experiences after pain.
c.) Other nipple is also flowing with milk.
To prevent from crack nipples & initiate proper production of oxytocin.
- begin 2-3 min at per breast ( 5 7 min other authors)
to initiate production of oxytocin
- increase 1 min/ day until reaching 10 mins per breast or 20 mins/ feeding.
For proper emptying & continuous milk production / feeding
-feed baby on last breast that you feed her with, alternately ( if not emptied - mastitis)
Problems Experienced in Breastfeeding :
1st day post-partum: Breast soft & tender
3RD day changes in breast post partum:
a.)Engorged- feeling of fullness & tension in breast.
- sometimes accompanied by fever known as MILK FEVER-continue BF
Mgt: Warm compress- for breastfeeding mom
Cold compress for bottle feeding & wear supportive bra.
*When is involution of breast? - 4 weeks
b.) Sore nipple cracked with painful nipple
Mgt:
Exposure to air remove bra & wear dress, if not, expose to 20 Watt bulb
(12-18 inches away) avoid wearing plastic liner bra
- will create moisture, cotton only----continue BF
c.) Mastitis- inflammation of breast : staphylococcus aureus (common)
Factors:
1. Improper breast emptying
2. Unhealthy sexual practices
-contraindicated for breast feeding
- manually express inflamed breast----- feed on unaffected breast
- give antibiotics can still feed on unaffected breast
Contra Indications in Breast Feeding:
a. Maternal Conditions:
>HIV
>CMV
>Hep. B
> Coumadin

b. Newborn Condition:
Inborn errors of metabolism
Erythroblastosis Fetalis Rh incompatibility
Hydrops Fetalis, Tay Sachs disease
Phenylketonuria, Galactosemia

6. Establish Waste Elimination


A. Different Stools
1. Meconium - physiologic stool
- black green, sticky, tar like, odorless (Sterile intestine)(no bacteria)
will pass w/in 24 36 hrs
*Failure to pass mecomium after 24h- GIT obstruction
ex.
Hirschsprungs disease
Imperforate anus
Mecomium ileus due to Cystic Fibrosis
2. Transitional Stool - (4-14 days)
- green loose & shiny, like diarrhea to the untrained eye (primipara mother)
*3. Breastfed Stool - golden yellow, soft, mushy with sour milk smell, frequently passed
- recur every feeding (orange-yellow)
4. Bottlefed Stool - pale yellow, formed hard with typical offensive odor, seldom passed, 23 x/day
5. Supplementary - with food added -brown & odorous
Indication of Stool Changes:

Created by Nia E. Tubio

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

*Currant jelly stool


*Ribbon like stool
Cult blood
*Steatorrhea stool

intussuseption
hirschsprung disease
stool exam
fatty, bulky foul smelling odor stool
malabasorption syndrome
(Celiac disease or Cystic fibrosis)

III. ASSESSMENT FOR WELL-BEING


A. APGAR SCORE Dr. Virginia Apgar
Special Considerations:

1st 1 min determine general condition of baby


Next 5 min- determine babys capabilities to adjust extra uterinely (most important)
Next 15 min dependent on the 5 min

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

APGAR Scoring Chart:


0
1
Absent
<100
Absent
Slow, irregular, weak
Flaccid extremities
Some flexion

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 :

Check for pulselessness : carotid- adult


Brachial infants

Created by Nia E. Tubio

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

*2. Signs of Preterm Babies


> Born after 20 weeks & before 37 weeks
>Frog leg or lax position
>Hypotonic muscle tone- prone resp problem
>Scarf sign elbow passes midline pos.
>Square window wrist 90 degree angle of wrist
>Heel to ear sign
Complications: RDS, Hypothermia, ROP
>Abundant lanugo
*Type of Feeding Pre-Term: Gavage Feeding to prevent aspiration d/t absence of gag & swallowing reflex
*3. Signs of Post term babies:
> 42 weeks
>Classic sign old mans face
>Desquamation peeling of skin
*Long brittle finger nails
>Wide & alert eyes

IV. Neonates in Nursery


1. Special & Immediate Interventions:
a. Nsg responsibility upon receiving baby- proper identification
- Foot printing, affixing mother thumb print
b. Take anthropometric measurement
normal length- 19.5 21 inch or 47.5 53.75cm, average 50 cm
head circumference 33- 35 cm or 13 14
Hydrocephalus - >14
Chest 31 33 cm or 12 13 (Average 32 cm)

Created by Nia E. Tubio

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:

Nitrazine paper test if yellow urine ---if blue amniotic fluid


- if reddish -- Omphalitis
Mgt: Surgery
e. Credes Prophylaxis Dr. Crede
Purpose: prevent opthalmia neonatorum or gonorrheal conjunctivitis
* how transmitted mom with gonorrhea or chlamydia
Drug: erythromycin ophthalmic ointment- inner to outer
Silver nitrate (used before) 2 drops lower conjunctiva (not used now)
-causes staining of skin, chemical conjunctivitis
- does not give protection against STDs
f. Administer Vit-K
to prevent hemorrhage R/T physiologic hypoprothrombinemia
- Aquamephyton, phytomenadione or konakion
- .5 1.5 mg IM, vastus lateral or lateral ant thigh
- 5 mg preterm baby
*Vit K synthesized by normal flora of intestine
Vit K meds is synthetic d/t intestine is sterile
g. Weight-taking
> Normal wt 3.000 3400 gms/ 3 3.4 kg / 6.5 > Arbitrary lower limit 2500 gm
> Low birth wt baby delivered < 2500g

Created by Nia E. Tubio

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

Congenital Heart Diseases:


*Common in girls PDA, ASD , Atrial Septal (Acyanotic HD)
*Common in boys TOGA ( Transposition of great arteries)
TA Tronchus arteriosus
TOF Tetralogy of Fallot
*Causes:
1. Familial
2. Exposure to rubella 1st month of pregnancy
3. Failure of heart structure to progress

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:

Created by Nia E. Tubio

19

a. Systolic murmurs at lower border of sternum and no other significant sign


b. Cardiac catheterization reveals increased o2 saturation @ R side of heart
c. ECG reveals hypertrophy of R side of heart
Nsg Care:
Cardiac catheterization: site Right femoral vein
1. NPO 6 hrs before procedure
2. Protect site of catheterization. Avoid flexion of joints proximal to site.
3. Assess for complication infection, thrombus formation check pedal pulses
Mgt.
1.) *Long term antibiotic to prevent subacute bacterial endocarditis
2.) Open heart surgery
2.) Atrial Septal Defect (ASD) Failure of foramen ovale to close
S & Sx:
1. Systolic murmur @ upper border of sternum
2. Result of cardiac catheterization & ECG same with VSD-- O2 sat & hypertrophy
Mgt: Open heart surgery
3.) Endocardial Cushion Defects (ECD) - atrium ventricular - affects both tricuspid & mitral valve
Dx
Mgt:

: Confirmed by cardiac catheterization


: Open heart surgery
Antibiotics to prevent subacute bacterial endocarditis

4.) Patent Ductus Arteriosus - Failure of ductus arteriosus to close


- should close within 24 h -complete close 1 month
S & Sx :
1. Continuous machinery like murmurs > outstanding sign of acyanotic HD
2. Prominent radial pulse
3. ECG- hypertrophy Left ventricle
Drug:
1. Endomethacine prostaglandin inhibitor - facilitate closing of PDA
2. Ligation of PDA by 3-4 y/o via thoracotomy procedure- nakadapa child
*With decrease Pulmonary Blood Flow
5.) Pulmonary Stenosis- narrowing of valve of pulmonary artery
S &Sx:
1. Typical systolic ejection murmur---d/t congestion at the right side of heart
2. S2 sound widely split
3. ECG- R. ventricular hypertrophy
*Normal: Pulmonary Artery = size with aorta*
6.) Aortic Stenosis narrowing of valve of aorta
S & Sx:
1. If inactive, sx same with angina-like symptoms
2. Typical murmur
3. Rough systolic sound and thrill
4. ECG- Left ventricular hypertrophy
Cardiac catheterizationMgt. For Pulmonary Stenosis & Aortic Stenosis---ECMO>Extra Corporeal Membrane Oxygenation
-a lung & heart machine
- return to activity: 3 wks.
1.) Balloon Stenotomy
2.) Surgery
7. Duplication of Aortic Arch- doubling of arch of aorta causing compression to
trachea & esophagus
S & Sx :
1. Dysphagia
2. Dyspnea
3. left ventricular hypertrophy

Created by Nia E. Tubio

20

Mgt: Close heart surgery


*8. Coartation of Aorta narrowing of arch of aorta
*Outstanding Sx : Absent Femoral Pulse
BP increased on upper extremities & decreased on lower extremities
ECG hypertrophy Left ventricle ------EPISTAXIS
Mgt: close heart surgery
Monitor BP on 4 extremities
II. CYANOTIC HEART DEFECTS R to L (6)
*With increase Pulmonary Blood Flow
1. Transportation of Great Arteries (TOGA)
- aorta arising from Rt ventricle, pulmo artery arising form Lt ventricle
- direct from RV to aorta w/o oxygenation
Outstanding Sx:
1. Cyanosis after 1st cry (due no oxygenation)
2. *Polycythemia increased RBC =compensatory d/t O2 supply=viscous blood
*Complications: Thrombus = Embolus = Stroke
3. ECG cardiomegaly
4. Cardiac cath decreased O2 saturation
5. Palliative repair rash kind procedure
6. Complete repair mustard repair
2.) Total Anomalous Pulmonary Venous Return
pulmo vein instead of entering Lt atrium, enters Rt atrium or SVC
Increased pressure on Rt so blood goes to Left
Outstanding Sx: Open Foramen Ovale -------so blood L to R
>Mild to moderate cyanosis
>Polycythemia = thrombus = embolus = stroke
>Asplenia- absent spleen
Mgt: Restructuring of heart
3.) Truncus Arteriousus
- aorta & pulmo artery is arising from 1 single vessel or common trunk with VSD
S & Sx 1. Cyanosis
2. Polycythemia thrombus = embolus = stroke
Mgt: Heart transplant
4.) Hypoplastic Left Heart Syndrome a non- functioning Left ventricle
S & Sx:
1. Cyanosis
2. Polycythemia thrombosis, embolus, stroke
Mgt: Heart Transplant
*With decrease Pulmonary Blood Flow
5.) Tricuspid Atresia Failure of tricuspid valve to open
S&SX:
1. Open Foramen Ovale-----pressure increase in right so open FO
(R to L shunting goes to Lt atrium)
2. Cyanosis, Polycythemia
Mgt: Fontan procedure to open tricuspid valve
6.) Tetralogy Of Fallot (TOF)
P pulmonary stenosis
V ventricular SD
O overriding or dextroposition of aorta
R Rt ventricular hypertrophy
S &Sx:
1.
2.
3.
4.
5.
6.
7.
8.

Created by Nia E. Tubio

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.

Boot shaped heart revealed by x-ray

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

ACQUIRED HEART DISEASES


1. Rheumatic Heart Disease (RHD)
- inflammation disease ff an infection acquired by group A Beta hemolytic streptococcus
(GABHS)
a. Affected body cardiac muscles and valves , musculoskeletal , CNS, Integumentary
b. Suspect : Sorethroat before RHD -----candidate babies---eating lots of sweets
c. Aschoff rounded nodules with nucleated cells & fibroblasts stays that occludes mitral valve.
d. To Diagnose RHD uses the Jones Criteria

*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:

Created by Nia E. Tubio

Snoring sound made by air moving through mucus in bronchi. Normal


or crackles like cellophane made by air moving through fluid in alveoli.
Abnormal- pneumonia, pulmonary edema

22

6. WHEEZING:
7. STRIDOR:
8. RESONANCE:
9. HYPERRESONANCE:

Whistling on expiration made by air being pushed through narrowed bronchi


Abnormal asthma, foreign body obstruction
Crowing or rooster life sound air being pulled through a constricted larynx.
Abnormal resp obstruction, inspiratory stridor
Loud, low tone, percussion sound over normal lung tissue
Louder, lower sound than resonance, a percussion sound over hyperinflated lung
tissue

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.

*CPAP- continuous (+) a/w pressure


PEEP - + end expiratory pressure
Purpose of #6-7- to maintain alveoli partially open & alveoli collapse

3. LaryngoTracheo Bronchitis (LTB)


Pathognomonic Sign: Inspiratory Stridor
LTB most common Creup -viral infection of larynx, trachea & bronchi
Outstanding Sx : Croupy cough or barking
- Labored respiration
- Respiratory acidosis
- End stage death
Lab:
1. ABG
2. Neck and throat culture
3. Dx- neck x-ray to rule out epiglotitis
4. CBC- to determine leukocytosis
Nsg Mgt:
1. Bronchodilators
2. Humidified oxygen
3. Prepare tracheostomy set
4. Corticosteroids
4. Broncholitis
Inflammation of bronchioles characterized by production of thick, tenacious mucus
*Causative agent RSV - Resp sincytial virus
Sx:
Flu-like sx
Increased RR---Monitor: Tachypnea of >90 bpm =RDS
Drug: Antiviral Ribavirin
End stage epiglotitis
5. Epiglotitis
Inflammation of epiglottis

Created by Nia E. Tubio

23

*Emergency: Condition of URTI


Sx:
*Sudden onset
*Tripod Position leaning forward with tongue protrusion
*Never use tongue depressor
>Prepare tracheotomy set
*< 5 y/o unable to cough out, put on mist tent (humidifier o2) or croupe tie
Nsg Care:
Check edges tucked on mist tent
Provide washable plastic material
No toys with friction due O2 on
No hairy toys due moist environment medium for bacterial growth
No smoking
2.Blood Pressure
BP
80/46 mmHg newborn
BP after 10 days- 100/50
BP taking begins by 3 y/o
COA take BP on 4 extremities
3. Skin / Integumentary
*Acrocyanosis
Birthmarks:
1.
2.
3.
4.
5.
6.
7.
8.
9.

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

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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

Partial thickness superficial epidermis - erythema, dryness, PAIN


Ex. Sunburn, heals by regeneration from 1 10 days
Epidermis & portion of dermis- erythema, blisters, moist, extremely painful
scalds
Full thickness- All skin layers: epidermis, dermis, adipose tissue, fascia, muscle & bone
lethargy, white or black, not painful nerve endings
destroyed
ex. lava burns

Mgt: Emergency: Prioritization depend on area of burn


*1.) 1st aid

a.) Put out flames by rolling child on blanket


b.) Immerse burned part on cold H2o
*c.) Remove burned clothing of with sterile material, if none in the hosp. only
d.) Cover burn with sterile dressing

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:

1. Decrease pruritus avoid food allergen


2. Diet: Prosobi or Isomil
3. Hydrate skin w/ burrow solution
4. Topical Steroids ---1% hydrocortisone cream
5. Prevent infection proper hand washing, trim nails/cut short

3. IMPETIGO- skin disease.


Causative agent Grp. A beta Hemolytic streptococcus (GABHS), possibly staphylococcus
> Papulovesicular surrounded by localized erythema
becomes purulent & oozes a honey
colored crust
4. PEDICULOSISCAPITIS KUTO
Mgt:
proper hygiene wash soap and H2o, oral penicillin bactroban ointment
*Can lead to acute glomerulonephritis AGN ---common to children with this type

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5. ACNE- adolescent problem


>Self limiting inflammatory disease sebaceous gland
*Comedones sebum causing white heads
*Sebum- lipids of cholesterol causing acne bulgaris
Mgt: Proper hygiene- mild soap or sulfur soap- antibacterial retin A or tretinoi
Liver clearance before using Retin a: C/I to pregnant women
6. ANEMIA -pallor
Causes:
1.) Early cutting of cord preterm cut umbilical cord ASAP
Full term cut umbilical cord when pulsation stops
2.) Bleeding disorders blood dyscrasias
Ex.
a. Hemophilia deficiency of clotting factor.
Pattern of Inheritance : X linked recessive
Usual carrier : mother (with X chromosome carrying the disease)
Usually affected children: Son
If mom carrier, son affected
If father carrier- transmitted to daughter
3 Types:
Hemophilia A Deficiency of coagulation component factor 8 (classic/most common)
Hemophilia B or Christmas disease, deficiency of clotting factor 9
Hemophilia C deficiency of clotting factor 11
Assessment:
>Omphalagia earliest sign >30cc in newborn
>Newborn receive maternal clotting factor reason why late Dx of hemophilia
>Newborn growing sudden bruising on bump area- marks earliest sign
>Continuous bleeding Hemarthrosis
>damage or repeated bleeding of synovial membrane
Dx test :
PTT = Partial thromboplastin time reveals deficiency in clotting factor
*Long Term Goal- prevention of injury
Nsg Dx: Increase risk of injury
HT:
avoid contact sport, swimming only, dont stop immunization change gauge of needle
Falls 1st splint then immobilized , elevate affected part, apply pressure-not more then 10 min
Of cold compress to prevent necrosis
> Determine case before doing invasive procedure
> No Aspirin
> BT : Fresh frozen plasma or cryoprecipitate
> Long-Term Goal: Prevention of Injury
7. LEUKEMIA - group of malignant disease characterized by
> Rapid proliferation of immature WBCs
Ratio: 500 RBC:1 WBC
> WBC protection from infection, soldiers of body
> Immature WBC takes the nutrients from mature WBC
Classification :
1. Lympho affects lymphatic system
2. Myelo affects bone marrow
3. Acute / blastic- affects immature cells
4. Chronic/ cystic- affects mature cells
Most common cancer = (ALL) Acute Lymphocytic Leukemia
*Main cause of Anemia: Failure of bone marrow to produce RBC
S & Sx: TRIAD
1. From invasion of bone marrow
Signs of Infection:
a. Fever
b. Poor wound healing
c. Bone weakness & causes fracture
Signs of Bleeding :
a.) Petecchiae-small, round, flat, dark red spot

Created by Nia E. Tubio

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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.

PBS- peripheral blood smear determine immature WBC


CBC determine anemia, leukocytosis, thrombocytopenia neutropenia
>done weekly during maintenance phase of therapy
Lumbar puncture (LP) determine CNS involvement. Before LP, Fetal position
Best: Avoid flexion of neck will cause a/w obstruction.C position or shrimp.
Bone marrow aspiration determine blast cells or immature WBC
> *Common site for BMA = Iliac crest
> Post BMA s/effect bleeding apply pressure.
Put pt on affected side to prevent hemorrhage
Bone scan determine bone involvement
CT scan determine organ involvement, CNS affectation

Therapeutic Mgt:
TRIAD FOR CANCER:
1.
2.
3.

Surgery
Irradiation
Chemotherapy

Focus Nsg Care: Prevent infection


4 LEVELS OF CHEMOTHERAPHY---Goal of Tx: Achieve remission
1. Induction: every level is 1 session
Meds: IV vincristine
L- agpariginase
Oral prednisone
2. Sanctuary- Treat leukemic cells that invaded testes & CNS
*Give: Methotrixate- adm. intrathecally via CNS or spine
cytocine, Arabinoside, steroids with irradiation
3. Maintenance- to continue remission
Give: Oral Methotrisate check WBC/ CBC order 1st before administering drug
Adm. of methotrisate do weekly WBC check
4. Reinduction treat leukemic cells after relapse occurs. Meds same as induction
Give antigout agents: allopurinol or Zyloprim- treat or prevent hyperurecemic nephropathy.
Nsg mgt:

Outstanding Nsg Dx:

1. High risk for infection


2. Alteration in nutrition less body requirement.
3. Alteration in Body image
4. Anticipatory grieving for family & parents
Based on Maslows hierarchy

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:

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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.

Hemolysis = destruction of RBC

Rh Incompatibility
> Rhesus means foreign body
> mother (-), fetus & father (+)
> 4th baby severely affected
> if (-) or no antigen : CHON factor
> (+) has antigen : CHON factor

Erythroblastosis Fetalis = hemolysis or destruction of RBC d/t

O2 carrying capacity

S & Sx: Intrauterine growth retardation w/ pathologic jaundice w/in 24 hrs.


b. ABO Incompatibility
Most common incompatibility ( mom) O ( fetus) A
Most severe incompatibility
(Mom) O (Fetus) B
Assessment:
Can affect 1st pregnancy
RBC - 20 days lifespan
O = universal donor
AB = universal recipient
Dx: Coombs Test
Indirect: mother ----- normal result is (-)
Direct : from baby---normal result is initially (-)
Drug Of Choice: Rhogam Vaccine given to mothers (-) w/in 72 hrs. post-exposure to fetal RBCs to
destroy fetal RBCs, then preventing Rh sensitization or antibody formation
> given only w/in 72 hrs. once only 1st pregnancy
9. Hydrops (h20) Fetalis edematous on lethal state with pathologic jaundice
Within 24 h
Mgt. for both:
1. Initiate feeding
2. Temporary suspension of breastfeeding to prevent kernicterus
>content breast milk pregnanedioles that delays action of glucoronyl
transferasea liver enzymes that converts indirect bilirubin to become
direct bilirubin
3. Needs phototherapy
4. Needs exchange therapy
10. Hyperbilirubinemia - > 12 mg/dL of indirect bilirubin among full term
*Normal Value: 0-3 mg/dL
- bilirubin encephalopathy
11. Kernicterus - > 20 mg/dL among full term & >12 mg /dl of indirect for pre-term----lead to cerebral palsy
*Physiologic Jaundice (Icterus Neonatorum) jaundice within 48 -72 h (2-3 days)------ NORMAL
-- just expose to morning sunlight
*Pathologic Jaundice (Icterus Gravis) jaundice w/n 24h or Jaundice during delivery
d/t small Rh/edematous ABO
*Breastfeeding Jaundicecaused by pregnanediole (6-7th day)
Pathophysiology: ------------------- Destroyed RBCs
releases
Heme

Globin
brokendown

Created by Nia E. Tubio

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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)

Direct Bilirubin (water-soluble)


Assessment of Jaundice :
*1. Blanching neonates forehead, nose or sternum (use 2 thumbs to separate skin folds)
- yellow skin & sclerae
- color of stool light stool
- color of urine dark urine
Mgt: Phototherapy or photo oxygenation (Normal HT: 18-20 inch.)
Nsg Resp:
1. Cover eyes prevent retinal damage
2. Cover genitals prevent Priapism a painful continuous erection
3. Change position regularly even exposure to light
4. Increase fluid intake prone to dehydration
5. Monitor I&O weigh baby
diaper 1 g= 1cc
6. Monitor V/S avoid use of oil or lotion due- heat at phototherapy
> Bronze baby syndrome------transient S/E of phototherapy

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.

Craniostenosis or Craniosyntosis premature closing of anterior fontanel

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

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7. Seborrheic Dermatitis Cradle Cap


Scaling, greasy appearing salmon colored patches seen on scalp behind ears and
umbilicus
Cause: - improper hygiene
Mgt:
1. Proper hygiene
2. Put oil night before shampoo (use baby oil or virgin oil)
3. Use of fine-toothed comb
8. Hydrocephalus excessive accumulation of CSF d/t anterior fontanel open after 18 months
2 Types:
1.
2.

Communicating extra ventricular hydrocephalus


Non-communicatinga. Intraventricular hydrocephalus
b. Obstructive hydrocephalus d/t tumor obstruction
Nsg. Dx: High Risk For Injury
Dx For Seizure Activity : EEG

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:

1. Check for symmetry


2. Sclera normal color light blue then become dirty white
3. Pupil round- adult size
4. Cornea round & adult size
* If large Congenital Glaucoma
NOTE FOR:
*Coloboma- part of iris is missing (notching)

Created by Nia E. Tubio

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Sign: Key hole pupil


*Brushfields Spots -----iris black with white spots
*Congenital Cataract-----Whiteness & Opacity of lens

COMMON TESTS
Age

Common Tests

1. Newborn
General Appearance:
Can only see 10-12 inches
Visual Acuity 20 /200 to 20/ 800

*DOLLS EYES TEST------ Test for blindness


= Done on the 10th day
= Pupil go to opposite direction when head is moved
*GLOBELLARS TEST -------Test for Blink Reflex.
= Points near nose & the baby should blink

Infant & Children

* Test the ability to follow object past midline

2. 3 years old to School Age

*ALLEN CARDS -----------Test for Visual Acuity


= Show common pictures 20 ft away
*ISHIHARAS PLATES = Test for Color Blindness

3. Preschool

*E CHART ------ Test for Stereopsi of depth perception


* COVER TESTING TEST ----- Test for Strabismus
= Cover 1 eye for 10- 15 minutes. Then remove.
Note For:
ESOTROPIA = inward movement of eye ball
EXOTROPIA = outward movement of eye

4. School Age To Adult

* SNELLENS TEST ------- Test for normal vision


* E CHART
DISEASES:

1. RETINOBLASTOMA
Outstanding Sign:

= Malignant tumor of the retina


Cats Eye Reflex the whitish glow of pupil
- With red painful eye
- Can lead to blindness

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)

Normal color of nasal membrane: Pinkish

Check for presence of creases & pale color of nasal membrane


Indicative of Chronic Rhinitis
Check if inflamed & reddened
Indicative of infection
Check for Flaring of Alenase
A case of RDS
Check for Cyanosis at rest

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Indicative of CHOANAL ATRESIA = The posterior nares obstructed with bone or


membrane
Sx:

a. Resistance during catheter insertion in suctioning


b. Emergency---- Surgery within 24 hrs
5. Check for sense of smell = Blindfold the child & let him common foods
5.

Check for presence of hair in nose: Cilia


Adolescent with no hair with ulceration of nasal mucosa: Cocaine user
NOTE FOR:
a. EPISTAXIS or Nosebleed
N.I:
Position: Sit upright, head slightly forward to facilitate drainage & prevent aspiration
Put Cold compress & apply gentle pressure
Give Epinephrine
*Most developed sense of newborn SENSE OF TOUCH
The way the baby can identify the mother
C. Assessment of the Ears: (Sense of hearing)
*1st sense to develop & last to disappear HEARING
* Normal Color of the Tympanic Membrane : Pearly Gray
1. Check for symmetry

If ears not properly aligned with the outer cantus of eyes or low set ears: Suspect
A. KIDNEY MALFORMATION:
1.

RENAL AGINESIS = the absence of kidney


2 Types: a. Unilateral = only 1 is present
b. Bilateral = absence of 2 kidneys
Sign in uterus : Oligohydramnios
Sign in newborn: 2 vessel cord
Sx: Failure to void within 24 hrs
Mgt:

Kidney Transplant

2. PRUNE BELLY SYNDROME


The newborn has a wrinkled abdomen that looks like a prune d/t abdomen swelled
with fluid in the womb, then lost that fluid after birth, leading to puckering of
excess skin.
B. CHROMOSOMAL ABERRATIONS:
Cause: Advance maternal age >35 y/o
1.NONDISJUNCTION = Uneven division of chromosome
a. TRISOMY 21 or DOWN SYNDROME
= Extra #21 chromosome
= Related to advance paternal age: 47xx + 21
Sx:
Low set ears
Mongolian slant
Broad, flat nose

Created by Nia E. Tubio

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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

- Affecting more girls than three times as boys.


- Caused by the presence of an extra number 18 chromosome
Sx:
Pecan Carinatum (protruding sternum)
Small Jaw (micrognathia)
Hypoplastic (underdeveloped) fingernails
c. TRISOMY 13 PATAU SYNDROME
- Associated w/ multiple abnormalities, including defects of the
brain that lead to seizures, apnea, deafness, and eye
abnormalities.
Sx:
Coloboma
Cleft lip & cleft palate
Low set ears
d. TURNERS

Monosomy X Syndrome/Bonnevie-Ullrich Syndrome


- Occurs only in females
- The girl's cells are missing an X chromosome, or part of an X
chromosome. Sx evident during puberty

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

*Turner Tina Turner female

2. DELETION ABNORMALITIES = deletion of the genes on chromosomes


a. CRI-DU-CHAT SYNDROME or Chromosome 5p deletion syndrome
- Results from a missing piece of chromosome # 5.
Sx:
Severe mental retardation outstanding sx
Wide-set eyes (hypertelorism)
Downward slant of the eyes (palpebral fissures)
All other sx of down syndrome
b. FRAGILE X SYNDROME or Marker X Syndrome

Created by Nia E. Tubio

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- Changes in the long arm of the X chromosome


- Most common cause of inherited mental retardation in males
- A fragile area on the X chromosome (called FMR1) has repeats
in the genetic code. The more repeats, the more likely there is to
be a problem. Boys and girls can both be affected, but because
boys have only one X chromosome, a single fragile X is likely to
affect them more severely.
Sx:

Same with other chromosomal abnormalities

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:

Created by Nia E. Tubio

During Otoscopic Exam:


Bulging tympanic membrane
Absence of light reflex
Observe for passage of milky, purulent foul smelling odor discharge
Observe for URTI

34

Nsg Care:

1. Position: Side-lying on affected aside to facilitate drainage


2. Supportive Care- Bed rest, increase fluid intake
Med Mgt:
1. Massive dosage antibiotic to prevent complication of Bacterial Meningitis
2. Apply ear ointment
3. Mucolytics
How? School age : Pull pinna up & down
< 3 y/o = down & back
> 3 y/o = up & back
Small child = down & back ( no age)
4. Surgery :
Myringotomy w/ Tympanostomy Tube Insertion:
Prevents permanent hearing loss
Nsg. Care:
Post surgery: Position on affected side for drainage
When taking a bath put ear plugs on both ears
If tympanous tube falls healed already- usually 6 months
D. Assessment of the Mouth & Tongue
1. Check for Symmetry
NOTE FOR:
a. BELLS PALSY:
- Facial nerve injury to the Cranial Nerve #7 w/c causes paralysis d/t forcep delivery
Sx:
1.

Continuous drooling of saliva


*Drooling Indicates 2 disorder:

2.
Mgt:

Bells Palsy & TEF/TEA

Inability to open the eye & close the other eye at the same time---monitor for dryness

Refer to PT

b. TRACHEOESOPHAGEAL FISTULA/ATRESIA ( TEF /TEA)


- TEF there is a thin connection bet. the esophagus & stomach
- TEA there is no connection bet. the esophagus & stomach

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

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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:

Administer Drug: Aspirin


Gamma Globulin

E. Assessment of the Lips


1. Check for symmetry
NOTE FOR:
a. *CLEFT LIP
- Failure of median maxillary nasal processes to fuse by 5-8 wks of pregnancy
- Common to boys
- Unilateral
b. *CLEFT PALATE
- Failed palate to fuse by 9 12 wks of pregnancy
- Common to girls
- Unilateral or bilateral
Sx:
1. Evident at birth
2. Milk escapes to nostril during feeding
3. Frequent colic & otitis media or URTI
Nsg Care:
1. Provide soft & large nipples---cross cut
2. Burp baby often

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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

Condition that warrants suspension of operation:


COLDS & PHARYNGITIS = can lead to generalized infection TO SEPTICEMIA

Post Operative Nsg Care:


1. Airway:
Position post-cheilopasty : Side lying to facilitate drainage
Post-uranoplasty (tonsillectomy): Prone position to increase mucus secretion
Avoid using straw,spoon,fork
2. Assess for RDS & signs of bleeding
3. Assess for bleeding: Frequent swallowing 6-7 days after surgery indicates bleeding
4. Proper nutrition
Post-NPO: Children- offer first sterile water before clear liquid
Clear liquids: Gelatin except red or brown color it may mask bleeding
(Popsicle- not ice cream)
Full liquid
Soft diet
Regular diet
5. Maintain integrity of suture line such as:
Logan bar wash strength Hydrogen Peroxide & saline solution:
Bubbling effect traps microorganism
Prevent crusting & scarring by putting sterile gauze + NSS
- Prevent baby form crying give analgesic for pain
6. Assessment of the Neck
1. Check for symmetry
NOTE FOR:
a. CONGENITAL TORTICOLIS or Wryneck

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- Congenital shortening or Birth injury of sternocleidomastoid muscle during


delivery d/t excessive traction at cephalic delivery
Mgt:
Daily passive stretching exercise
Surgery
Complication : Scoliosis
2. Check the thyroid gland for basal metabolism

b. CONGENITAL CRETINISM
- Absence or non functioning thyroid glands or Hypothyroidism
Reasons for Delayed Dx:
1.
2.
3.

Thyroid glands covered by sternocleidomastoid muscles in newborn


Baby received maternal thyroxin
Baby sleeps 16 20 hrs a day
Earliest Sign:
1.
2.
3.
4.
5.
Late Sign:

Change in Sucking -1st


Change in Crying 2nd decrease sound
Sleep excessively
Constipation d/t decrease peristalsis
Edema moon face

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.

PBI- Protein Bound Iodine


RIA - Radioimmunoassay Test
Radioactive Iodine Uptake

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

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8. Assessment of the Abdomen


1. Assess in order:

a.
b.
c.
d.

Inspection
Auscultation
Percussion
Palpation

I
A
P
P =Last to perform because it will change bowel sounds

*Normal contour of the abdomen = Slightly protruding


NOTE FOR:
a. DIAPHRAGMATIC HERNIA
- Sunken abdomen or the protrusion of stomach content thru a defective diaphragm
d/t failure of pleuroperitoneal canal to close (located at the left postero-lateral side)
Sx:
1.
2.
3.

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.

Assists in maintaining F&E & acid base balance


Processes & absorbs nutrients to maintain metabolism & support G & D
Excrete waste products from digestive process

Newborn:

Created by Nia E. Tubio

Gastric Capacity 1-2 oz


Gastric Emptying every 2-3 hrs.
Normal Body Weight 3,000 to 3,500 grams

39

3. RECOMMENDED DAILY ALLOWANCE


Calories : 120 cal / Kbw/day or 360 380 cal/ day
CHON = 2.2g /Kbw/day
Fluids = 16-20 cc/kg/day
4. PRINCIPLES IN SUPPLEMENTARY FEEDING
*Supplementary Feeding usually at 6 months
*Supplementary feeding can be given as early as 4 months
*Weaning starts at 6-9 months or when shortening the nursing time
*Never wean a child when in crisis
a.) Solid food offered to baby in the ff. sequence!
1st - Cereals rich in ironReserves is catabolized already by 6 months
2nd - Fruits
3rd - Vegetables
4th - Meat
b.) Begin with small quantities
c.) Finger foods offered 6 months
d.) Soft table food modified family menu given by 1 year
e.) Dilute fruit juices & offered by 6 months
Ratio of fruits to water 1:4 (1 squeeze orange = 1 ounce)
f.) Never give half cooked eggs usually causes of Salmonellosis/Gastroenteritis
g.) Dont give honey may cause Infant Botulism
h.) Offer new food one at a time interval of 4 7days or 1 week
To determine food allergens
5. MAJOR CONCEPTS OF FLUID & ELECTROLYTE BALANCE
Total Body Fluids: Comprises 65 - 85% of body wt of infants & children
Where fluids are greater in infants: ECF reason why babies prone to develop dehydration
6. ACID BASE BALANCE
Dependent on the ff:
a. Chemical buffers
b. Renal & Respiratory system involvement
c. Dilution of strong acids & bases in blood
IMBALANCE:
a. RESPIRATORY ACIDOSIS = Carbonic acid excess
Causes:
Hypoventilation
RDS
COPD

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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

a. VOMITING = Forceful expulsion of stomach content


Sx:

1.
2.
3.
4.

Nausea
Dizziness
Facial flushing
Abdominal cramping

Assessment:
Mgt:

Amount, Frequent & force


Projectile Vomiting Indicates Increase ICP or Pyloric Stenosis
BRAT DIET
B banana
R rice
A- apple sauce
T- toast

b. DIARRHEA Exaggerated excretion of intestinal contents


Types:
1. ACUTE DIARRHEA/ INFECTIOUS
- Associated with the ff:
a. Gastroenteritis
b. Salmonellosis
c. Dietary indiscretions
d. Antibiotic use (Ampicillin, Tetracycline)
CA:

Bacteria (salmonella, shigella)


Virus (Rotavirus- most common)
Prozoan (Entamoeba histolytica)

2. CHRONIC-NON SPECIFIC DIARRHEA/NON-INFECTIOUS


Cause:
a. Food intolerance
b. Excessive fluid intake
c. CHO, CHON malabsorption (abnormality)
d. Allergy
e. Irritable colon
Assessment:
Frequency, Consistency, Appearance of green colored stool
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*Best criteria to determine diarrhea : Consistency


Complication:
1. DEHYDRATION
Mild dehydration
Moderate dehydration
Severe dehydration

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.

Barium Enema Reveals narrowed portion of bowel


Rectal Biopsy Reveals absence of ganglionic cells
Abdominal X-ray Reveals dilated loops on intestine
Rectal manometry Reveals failure of intestine sphincter to relax

Therapeutic Mgt/Nsg care


1. NGT feeding:
Measure tube from nose to ear to midline of xyphoid & umbilicus
2. Surgery
a.) Temporary colostomy
b. Anastomosis & pull through procedure
Pre-opt:
Provide Enema everyday

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Use NSS: Isotonic ( 1 tsp. sugar + 500 cc of H20)


Not tap water: Hypotonic
Can be absorbed by the cells----Circulatory Overload
3. Diet:
Increase CHON
Increase calories
Decrease residue Ex. Offer pasta, spaghetti, chicken
No corn, raisins ---may lead to aspiration
b. GASTROESOPHAGEAL REFLUX (GER) or CHALASIA
- Presence of stomach contents in the esophagus
Assessment :
1.
2.

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

a.) Betanicole (Urecholine) To increase esophageal tone & peristaltic activity


b.) Metachloporomide (Reglam) To decrease esophageal pressure by relaxing
pyloric & duodenal segments
Increase peristalsis w/o stimulating secretions
c.) H2 Histamine Receptor Antagonist To decrease gastric acidity & pepsin
secretion
Ex. Zimetidine, Ranitidine (Zantac) take 30 min before meals
d.) Antacid To neutralizes gastric acid between feedings. Ex. Maalox
Surgery:

Nissen Funduplication
- Creation of a valve mechanism by wrapping the greater curvature of the stomach

Nsg Care:

For Chronic vomiting:


1. Thickened feeding with baby cereals to prevent vomiting
- effective if without vomiting
2. Feed slowly, burp often every 1 ounce
3. Positioning:
< 9 months supine on infant seat
> 9 months prone w/ head of mattress slightly elevated 30
degree angle

9. OBSTRUCTIVE DISORDERS
a. PYLORIC STENOSIS
Hypertrophy of the muscles of pylorus causing narrowing & obstruction
- Progressive thickening of the muscular layer of the pylorus

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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.

Pyloromyotomy - incision of the pyloric muscle


Fredret-Ramstedt Procedure separation of hypertrophied muscle w/o incision

Nsg Care:
1. Serum electrolyte: Increase Na & K, Decrease chloride
2. If on enteral feeding, provide pacifier
Pre-Opt:
Post-Opt:

Thickened feedings (regular formula + Cereal)


Monitor feedings
(Clear liquid 24 hrs.)
(Diluted Formula)

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:

Person who eats too fast


Too much activities involving the movement of the stomach

Complication:

Invagination
O2 supply
Necrosis
Swelling-----burst -------Peritonitis: An emergency

Sx:

1.)
2.)
3.)
4.)

Persistent paroxysmal abdominal pain


Vomiting
Currant Jelly Stool: d/t bleeding & inflammation
Palpable sausage shaped mass

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
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- Due to deficient liver enzymes


a. PHENYLKETONURIA (PKU)
- Genetic disorder that is characterized by an inability of the body to utilize the
essential amino acid, phenylalanine d/t deficiency of liver enzymes (PHT)
Phenylalaninehydroxylase Transferase :
The liver enzyme that converts Phenylalanine to tyroxine or CHON to amino acid
9 Amino Acids:
1. Valine
2. Isolensine
3. Tryptophase
4. Lysine
5. Phenylalanine
6. Thyronine: Decrease melanin production
Sx:
a. Fair complexion
b. Blond hair
c. Blue eyes
7. Thyroxin: decrease basal metabolism
-Accumulation of Phenyl Pyruvic acid leads to:
a. Atopic dermatitis
b. Musty / mousy odor urine
c. Seizure: Mental retardation
Dx:
1. GUTHRIE TEST: Use blood as specimen
Preparation: Increase CHON intake
- Test if CHON will convert to amino acid
2. Specimen urine mixed with pheric chloride
- Presence of green spots at diaper a sign of PKU
Nsg Care:
1. DIET:
Low phenylalanine diet:
Food C/I : Meats, chicken, milk, legumes, cheese, peanuts
Give Lofenalac: Milk with synthetic protein
b. GALACTOSEMIA
- Deficiency of liver enzyme GUPT: Galactose Urovil Phosphatetranferase
Converts galactose to phosphate tranferase glucose
Galactose will destroy brain cells if untreated death within 3 days
Dx:
1. Beutler Test = Get blood after 1st feeding
Presence of glucose in blood: Sign of galactosemia
Nsg Care:
1. Diet: Galactose free diet for lifetime
2. Give Neutramigen : Milk formula
c. CELIAC DISEASE
- Gluten enteropathy
Assessment:
Early Sx:

a. Diarrhea: Failure to gain weight following diarrheal episodes


b. Constipation
c. Vomiting
d. Abdominal Pain: Protuberant abdomen even if with muscle wasting
e. Steatorrhea
Late Sx:

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1.
2.

Behavioral changes: Irritability & Apathy


Muscle wasting & loss of subcutaneous fats

Celiac Crisis: Exaggerated vomiting with bowel inflammation


Dx:

1. Laboratory Studies : Stool analysis


2. Serum Antigliadin & Antireticulin Antibodies: Confirmatory Dx of the disease
3. Sweat Test
Nsg Care:
1. Gluten-free diet for lifetime
2. All brow food not allowed: Intolerance
Common Gluten food:
B- barley
R- rye
O- oat
W- wheat
3. Allowed to eat rice & corn
Mgt:
1. Vitamin supplements
2. Mineral supplements
3. Steroids
PATHOPHYSIOLOGY:
Gluten Glutamine (Normal Absorption)

Gliadin
(Toxic to epithelial cells of villi of intestines: Effects is malabsorption syndrome)

Malabsorption

Fats

CHON & CHO


peripheral edema &
malnutrition

Vit. D /Calcium

Vit. K

Iron folic acid

Inadequate blood
coagulation

Steatorrhea

Osteomalasia

Bleeding

Anemia

11. POISONING
- Common in Toddlers: Poisoning
- Common to Infants: Suffocation & falls
Principles :
1.
2.
3.

Created by Nia E. Tubio

Determine the substance taken & Assess LOC


Unless poison is corrosive, caustic (strong alkali such as lye) or a hydrocarbon,
INDUCE VOMITING is the most effective way to remove poison.
Give SYRUP OF PECAC: oral emetic to cause vomiting after drug overdose/poisoning

46

4.
5.
6.
7.
8.

15 ml : Adolescent, school age & pre school


10 ml to infant
UNIVERSAL ANTIDOTE: Charcoal, Milk Of Magnesia & Burned Toast
Never administer the charcoal before syrup of pecac
Antidote for Acetaminophen Poisoning: N Acetylcyctein (Mucomyst)
For Caustic poisoning like Muriatic Acid:
Give vinegar to neutralize acid . Dont vomit prepare tracheostomy set
For Gas poisoning :
Give mineral oil to coat the intestine & prevent absorption of gas---go to stool

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:

1. Remove child from the source


2. If lead is > 20 ug/dL: Need Chelation Therapy : Binds with lead & excreted by kidney
Ex. BAL (Dimercaprol)
Ca EDTA ( Edetate Ca Disodium)
A chelating agent must be administered in a large muscle group VIA DEEP IM
Check urine specific gravity (Normal: 1.003-1.030)
S/E: Nephrotoxic
N.I: Warm compress post-chelation to relieve pain
9. Assessment of the Reproductive Organ
NOTE FOR:
a. ANOGENITAL
1. Female:
a. PSEUDOMENSTRUATION:
- Slight bleeding on vagina R/T hormonal changes
b. RAPE/CHILD ABUSE or BATTERED CHILD SYNDROME
- Tearing of fourchette with blood
Rape: Report within 48 h to brgy. Captain
R.A. 7610 CHILD ABUSE LAW
- Non-accidental injury
Characteristics of Abusive Parents:
1. Experience of childhood abuse
2. Too concerned, too many questions
Sx:
1. Wound in different stages of healing

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2. Identical marks of wounds


2. Male:
Assessment:
1. Assess scrotum with warm hands & warm room
2. Baby should pee w/in 24 hrs.
NOTE FOR:
a. UNDESCENDED TESTES or CRYPTORCHIDISM
- Common to preterm (descend in 7 months)
Surgery:
Orchidopexy
Complication: Sterility
3. Check for the arch of urination
b. EPISPADIAS
- Urinary meatus located dorsal or above glans penis
c. HYPOSPADIAS
- Urinary meauts located ventral or below glans penis
Hypospadias w/ Chordee: Fibrous band causing penis to curb downward
Mgt:
Surgery
d. PHIMOSIS = A tight foreskin
Mgt:
Circumcision
e. PARAPHIMOSIS = loosened foreskin
f. BALANITIS = Infection of glands penis d/t smegma
g. TESTICULAR TORSION = Twisted testicle
h. HYDROCEL

= Fluid -filled scrotum


Dx:
Transillumination with use of flashlight - glowing sign

i. VARICOCELE = Enlarged vein of epididymis


(Girls = Valvular varicosities)
10. Assessment of the Urinary Tract
NOTE FOR:
a. WILMS TUMOR or NEPHROBLASTOMA
- A neoplasm of the kidneys that typically occurs in children.
- Most common type of kidney tumor
- It is more common among some siblings and twins, which suggests a
possible genetic cause.
Sx:
- Absence of the iris (aniridia)
- Hemihypertrophy (enlargement of one side of the body)
Alert:
- No palpation or percussion----metastasis may occur
Mgt:
- Triad Treatment of Cancer
Renal Disorder

Created by Nia E. Tubio

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

Anasarca: General edema


Massive protenuria
Microscopic or no hematuria

1. Prednisone
2. Diuretic
(Furosemide)

Focus of Care:
1. Monitor edema
Weigh daily

Serum CHON decreased

2. Diet:

Serum lipid increased

Moderate CHON
Increase K- OJ, beef
broth, banana
Low Na Diet

Fatigue
Normal to low BP

1. (PPP) Primary Peripheral


Periobital Edema
2. Moderate protenuria
3. Gross Hematuria
(Sign: Smokey urine)
4. Serum K increased
5. Fatigue
6. *Increase BP Outstanding Sx

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

11. Assessment of the BACK


1. Check for flatness & symmetry
*Spina Bifida From L5 to S1
NOTE FOR:
a. OPEN NEURAL TUBE DEFECT
- Decreased Folic Acid intake of mother & those during pregnancy undergoes
steam bath/spa
2 Types:
1. SPINA BIFIDA OCCULTA
- Failure of post laminae of vertebrae to fuse
Sx:
Dimpling of the back
Abnormal tufts of hair
2. SPINA BIFIDA CYSTICA
- Failure of post laminae of vertebrae to fuse with a sac
Types:
1.* MENINGOCELE
- Protrusion of CSF & Meninges
- No alteration in function
2. MYELOMENINGOCELE
- Protrusion of CSF & Meninges & Spinal Cord
- Most dangerous type
- On the back : under illumination shows a half glow
3. ENCEPHALOCELE

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- CNS complication : Hydrocephalus--Cranial meningocele or


Myelomeningocele
Most Common Problem :
a.
b.
c.

Rupture of sac
Prone position
Sterile wet dressing

Most Common Complication: Infection


1. For Myelomeningocele : Genitourinary & Fecal Incontinence
2. Orthopedic complication: Paralysis of lower extremities
Sx:
a. Weakness, paralysis of lower extremities
b. Cold to touch
c. Ulceration
d. Absence of spontaneous movement
e. Bladder dribbling of urine
g. Bowel no control
Dx:
1. During pregnancy thru MAFEP
Mgt:
Surgery just to prevent infection, will not cure
Pre-opt Protect the sac, use sterile doughnut ring
Post op prone position
Nsg Care:
Always check diaper
b. SCOLIOSIS
- Lateral curvature of the spine
- Common to adolescence
2 Types:
1. Structural
d/t Wry neck
2. Postural
d/t improper posture or heavy bags
Sx:
1.
2.
3.

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

- Webbing of digits (ginger-like foot)


- Extra digits
- Lack of digits

d. AMELIA
e. POCOMELIA

- Total absence of digits


- Absence of distal part of extremities
Both d/t use of anti-emetic in Pregnancy or Thalidomides

2. Assess for movement of extremities

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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:

1. Subluxated : Most common type


2. Dislocated
Sx:
1.
2.
3.
4.
5.

Shortening of affected leg


Asymmetrical gluteal fold
Limited movement earliest sx
(+) Ortolanis sign abnormal clicking sound during abduction (away)
When able to walk child limps Late Sx: Trendelenburg Sign

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

c.) VARUS = Foot turns in


d.) VALGUS
= Foot turns out
e.) EQUINOS VARUS = Most common (Combination)
Assessment:
1.

Straighten legs & flexing them at midline position

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

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51

2. Lead pencil to mark area to be amputated


3. Plaster of Paris
Nsg Care To Patients with CAST:
1. Cold H20 will hasten setting process
2. Hot H20 will slow setting process
3. After cast application :
How to move pt:
-Use open palm not fingers- fingers will cause indention
4. Dry cast with natural air not blower
5. If Cast with bleeding
- Mark with ball pen edge of blood to know if bleeding is on going
6. sign that cast is dry: Resonant sound, cast cold to touch
7. Do petaline: making rough surface of cast smooth
8. Priority check : Neurovascular check:
C - circulation
M - motion
S - sensation
9. Assess for circulation impairment:
B - blueness or coldness
L - lack of peripheral pulses
E - edema not corrected by elevation
P pain on casted area
T tingling sensation
B. CRUTCHES
Function:
1. To maintain balance
2. To support the weakened leg
Principles In CRUTCHES:
1. Weight of body on palm!
2. Brachial Pulsing if weight of body in axilla
3. Do palm exercise- squeeze ball
4. Measure Crutches:
2 inches across bar of axilla
6 inches in front of the big toe
Different Crutch Gaits:
1.
2.

Swing Through
Swing to
No weight bearing are allowed into lower ext

3. Three point Gait


- wt bearing is allowed in 1 ext
4. Four point gait
5. Two point Gait
- Weight bearing allowed in 2 lower extremities
Other Crutch-Maneuvering Techniques
To sit down:
1. Grasp the crutches at the hand pieces for control
2. Bend forward slightly while assuming a sitting position
3. Place the affected leg forward to prevent weight-bearing and flexion
To stand up:

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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.

The client should be in dorsal or supine position


For every traction there is always a counter traction
Line of pull should be in line with deformity
For traction to be effective, it must be continuous

Types:
Straight Traction
Skin Traction
Bryants Traction
Bucks Extension
Skeletal Traction
Nursing Responsibilities:
1.
2.
3.

Created by Nia E. Tubio

Assess for circulation and neurologic impairment


It can lead to hypertension
Be careful in carrying out nursing functions by not moving the weights

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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

Created by Nia E. Tubio

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.

TRUNK INCURVATION REFLEX


While in prone position & the paravertical area is stimulated, it
causes flexion of the trunk and swing his pelvis towards the touch

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

Created by Nia E. Tubio

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