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PRINCIPLES OF IMMEDIATE CARE

I. AIRWAY PATENCY
* Most critical adjustment a newborn must make at birth

TECHNIQUES to maintain patent airway:

 wipe off nose and mouth with sterile gauze
 suctioning with the use of rubber bulb syringe or suction catheter
 positioning
i. if NSD without problem = TRENDELENBURG
ii. traumatic delivery = FLAT
• with head turned towards the side
 stimulating the newborn to cry

II. PROVIDE OPTIMUM TEMPERATURE

POSSIBLE WAYS TO PRODUCE HEAT:
1. SHIVERING
2. METABOLISM OF BROWN FAT
3. GLUCONEOGENESIS

HOW TO PROVIDE WARMTH:

1. Dry, newborn’s skin
2. Wrap, using soft blanket
3. Use of pre heated bassinet or crib, radiant warmer, drop light or floor lamp

III. INITIAL ASSESSMENT OF CONDITION

APGAR SCORING
 was developed by Dr. Virginia Apgar in 1952
 done on the 1st minute, 5 and 10 minutes after
 based on 5 parameters, ranked in order of importance

A. HEART RATE
B. RESPIRATORY EFFORT
C. MUSCLE TONE
D. REFLEX IRRITABILITY
E. COLOR
IV. PROPER IDENTIFICATION

V. PREVENTION OF INFECTION AND INJURY

A. ASEPTIC TECHNIQUE
1. CORD CARE
- Check: Normal = 1 vein and 2 arteries (AVA)
Abnormal = 2 A & 2 V – Mongoloid
2. SKIN CARE
oil bath – high risk premature
soap/water bath – full term
* use mineral oil to remove vernix caseosa on the body
* use skin antiseptic or any mild soap for a regular bath

B. PROPHYLAXIS
1. EYE (Crede’s prophylaxis)
> to prevent ophthalmia neonatorum or gonorrheal conjunctivitis
> use of ophthalmic ointments like terramycin,
tetracycline
TECHNIQUE:
- inner to outer canthus while exposing the lower conjunctival sac

2.HYPOPROTHROMBINEMIA prophylaxis
> prescribed with single dose (1 mg /0.1ml) of Phytonadione solution
(Aquamephyton) per IM, vastus lateralis
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> Aquamephyton, a Vit. K water-soluble preparation – acts as preventive

measure against neonatal hemorrhagic disease

VI. MOTHER – CHILD BONDING

VII. NUTRITION
Purposes:
a. Bonding
b. Involution
c. Breast feeding stimulation

VII. BAPTISM OF INFANT

NORMAL CHARACTERISTICS OF A NEONATE

1. ANTHROPOMETRIC MEASUREMENTS

A. WEIGHT AND LENGTH

Americans - 53 cm (21 inches)
7.7 lbs.
Filipinos - average weight = 6.9 lbs (2500 – 4000gms.)
average length = 48 – 53cm (19 – 21inches)

Newborn loses 5 – 10% or 6 – 9% of his body weight during the first few days of life due to:

a. withdrawal of hormones
b. voiding and passing out of stool
c. limited intake
• will regain weight in 10 – 14 days of age
• later on, he will be gaining 1 lb/month for the 1st 6 mos. Of life thus:
2x @ 6 mos.
3x @ 1 year
4x @ 2 years

B. HEAD CIRCUMFERENCE
- 33 – 35 cm or 13 – 14 inches

C. CHEST CIRCUMFERENCE
- 31 – 33 cm or 12 – 13 inches

D. ABDOMINAL CIRCUMFERENCE
- same as CC

2. VITAL SIGNS
A. TEMPERATURE
- 36.5 – 37 °C or 97.7 – 98 ° F

B. RESPIRATION
- 30 – 60 breaths per minute

C. HEART RATE
- Fluctuates between 120 – 180 beats/minute

E. BLOOD PRESSURE
- High immediately after birth and falls to a minimum within 3 hours after birth.
- 67/41 mmHg – 80/40

2. HEAD TO TOE ASSESSMENT

I. GENERAL APPEARANCE
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II. SKIN
• Pre term – thin, translucent, ruddy skin; with easily seen veins and venules esp. over the
abdomen.
• Term – thick, pinkish, mottled
• Post term – thick, parchment-like with peeling and cracking; few blood vessels over the
abdomen.

III. COLOR
VARIATIONS:
1. Gray - indicative of infection
• Pallor- usually as a result of anemia
2. Cutis Marmorata
3. Acrocyanosis
4. Cyanosis
• cyanotic when quite and grows pink when cries → atelectasis
• with normal color when quite then cyanotic when crying → congenital
heart disease, “ Blue Baby “
5. Harlequin sign
6. Physiologic jaundice or Neonatal hyperbilirubinemia
• Full term = appears after 24°, becomes definite bet 2 – 7 days;
disappears after 7th day
•
Pre term = appears after 18°, becomes definite bet 3 – 10 days;
disappears after the 9th – 10th day
- Serum unconjugated bilirubin does not exceed 12mg/100cc
- Above 20mg/100cc, will cross the blood brain barrier → interfere with chemical synthesis
of brain → permanent cell damage and possible mental retardation, epilepsy, cerebral
palsy → KERNICTERUS
7. OTHERS:
• LANUGO
• VERNIX CASEOSA
• FORCEP MARKS
• MILIA
• NEVI (STORKBITES)
• MONGOLIAN
• ERYTHEMA TOXICUM NEONATORUM
• DESQUAMATION
• HEMANGIOMAS

IV. HEAD
FONTANELS are opening at points of union of skull bones
• Anterior – is diamond shaped, closes @ 12 – 18 mos.
• Posterior – is triangular in shaped, closes @ 2 – 3 mos
VARIATIONS IN THE HEAD:
1. MOLDING
2. CAPUT SUCCEDANEUM
3. CEPHALHEMATOMA
4. CRANIOTABES
EYES
- Normal findings:
• subconjunctival hemorrhage
• edema of eyelids for 2 – 3 days till kidneys are able to excrete urine efficiently
• pseudostrabismus or transient strabismus – cross-eyed
• DOLL’S eyes – eyes do not follow movement of the head. Persists for 10 days,
then disappear
EARS
- shld. be in line with the outer canthus of the eyes
- ears set lower are found in those with chromosomal aberrations like trisomy18 and with
mental retardation
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NOSE
- appears large for his face
- shld. be patent, with thin, white mucoid nasal discharge
- Abnormal: non-patent, bloody nasal discharge, CHOANAL ATRESIA
MOUTH
- shld. open evenly when he cries, tongue appears large
- if one side moves more than the other: CRANIAL NERVE INJURY
- VARIATION:
• EPSTEIN PEARLS – whitish-yellow accumulation of epithelial cells on hard
palate, disappears in a week
- Abnormal:
• Thrush (Candida infection or Moniliasis)
• Cleft lip / palate
• Protruding tongue
• Drooling
• Inability to pass NGT
NECK
- short and chubby (thick) surrounded by skin folds with tonic neck reflex
- Abnormal:
• Nuchal rigidity
• Congenital torticolis – rigidity of neck due to injury to sternocleidomastoid
muscles during birth

V. CHEST
- Witch’s milk (due to lactating hormone from mother)
- Abnormal:
• Funnel chest – depressed sternum
• Pigeon chest – abnormal prominence of sternum
• Asymmetric chest expansion
VI. LUNGS
- 30 – 60 breaths per minute; chiefly abdominal
- Abnormal: apnea more than 20 secs, dyspnea, rate above 60/min, grunting, see-saw
respiration
VII. HEART
- 100 – 120 beats / minute
- between left nipple and sternum; 3 – 4th ICS
- Abnormal: Cardiomegaly, murmurs, persistent cyanosis
VIII. ABDOMEN
- cylindrical in shape; liver, spleen, kidneys are palpable
- a sunken appearance may indicate missing abdominal contents
- UMBILICAL CORD – appears as a white gelatinous structure during the first hour. Check
for AVA.
• After the first hour = begins to dry, shrink and become discolored
• 2 – 3rd day = turns black
• 6 – 10th day = sloughs off, shld. have no bleeding at site
IX. ANO GENITAL AREA
FEMALE
- vulva may be swollen due to maternal hormones
- urinates within 24 hours
- Variation: PSEUDOMENSTRUATION – blood tinged discharge
- Abnormal:
• enlarged clitoris with urethral meatus at tip
• no vaginal opening
• fecal discharge per vaginal opening
• no urination
MALE
- urethral opening at the tip of the penis; testes palpable at each scrotum
- scrotum usually large, edematous,
- deeply pigmented
- SMEGMA
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- Urinates within 24 hours

- Variations:
• Urethral opening covered by prepuce
• Inability to retract the foreskin (PHIMOSIS)
• Erection or PRIAPISM
• Testes palpable at the inguinal canal

- Abnormal:
• Hypospadia - urethral opening under the penis
• Epispadia – urethral opening @ dorsum of penis
• Cryptochidism
• Inguinal hernia
X. BACK / RECTUM
BACK – spine intact; appears flat in the lumbar / sacral areas
• no openings, mass or prominent curves
RECTUM – patent anal opening; passage of meconium within 24°
- Abnormal:
• Spina bifida (Spinal hernia)
• Imperforate anus
• No meconium within 36 hours
XI. EXTREMITIES
- Variations:
• Webbing (Syndactyly)
• Extra toes and fingers (Polydactyly)
- Major Abnormality:
• Persistent cyanosis of nail beds; fractures; dislocations
• Short arms (Achondroplastic dwarfism)
• Clubfoot (Talipes deformity)
• Absence of extremities (Amelia)
• Short extremities, wherein hands and feet appear to adhere to the body
(Phocomelia)

BLOOD VALUES
1. Blood volume – 80 – 110ml/kg of weight, or about 300ml.
2. RBC - 6 – 8 million/ cu. mm
3. Hgb – average 15 – 20 g/100ml of blood
4. Hct – 45 – 65%
5. Bilirubin level at birth – 1 – 4mg/100ml
6. WBC – 10,000 – 45,000/cu.mm

Stool Characteristics:
1st 24 hours – Meconium
if not, inspect for the possibility of:
a. meconium ileus
b. imperforate anus
c. bowel obstruction
2 – 3rd day – changes color and consistency
- Transitional stool
4th day – if breast fed babies:
• 3 – 4x, golden to light yellow, loose, sweet smelling, non irritating to the skin
- if formula fed:
• 2 – 3x, pale yellow, soft but formed, with noticeable stool odor, irritating to
the skin
VARIATIONS:
• bright green – for those placed under phototherapy for jaundice
• with mucus – milk allergy or other irritants
• clay colored/gray stool – with bile duct obstruction
• black, tarry stool – intestinal bleeding shld be inspected
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REFLEXES – reflects the intactness and maturity of the developing CNS

A. Feeding Reflexes
1. Rooting * 6th week
2. Sucking * 6 mos
3. Extrusion or Spitting up * 4 – 6 mos
4. Swallowing
B. Protective reflexes:
1. Sneezing or Coughing
2. Yawning
3. Blinking
C. Others:
1. Moro or Startle – best index of CNS integrity* 4 – 5th mos
2. Tonic neck / Fencing * 3 – 4 mos
3. Babinski * 3 mos
4. Dancing / Walk or Step in reflex * 3 mos
SENSES
A. Hearing
B. Touch
C. Taste
D. Smell
E. Vision

GROWTH AND DEVELOPMENT

STAGES OF GROWTH AND DEVELOPMENT

A. Prenatal period – conception to birth
B. Infancy period- from birth to 12 months
1. Neonatal: 1-28 days
2. Infancy: 1-12 months
C. Toddler- 1-3 yr
D. Preschool: 3-6 yr
E. Schoolage: 6-12 yr
F. Prepuberty: 10-13 yr
G. Adolescence: 13-18 yr

PRINCIPLES OF GROWTH AND DEVELOPMENT

A. Lifelong Process
B. Critical Periods
C. Proximodistal - midline to peripheral
D. Cephalocaudal - head to tail
A. Mass-to-specific – differentiation

FACTORS THAT CAN INFLUENCE GROWTH AND DEVELOPMENT

A. Genetics
B. Prenatal Influences
C. Gender
D. Family Structure
E. Socioeconomic level
F. Culture
G. Environment
H. Environmental Hazards
I. Nutrition
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TASK AND TASK’S SIGNIFICANT SIGNIFICANT SUPPORTING
SUBTASKS NEGATIVE PERSONS EXPERIENCES
COUNTERPART INFANT (28 days- 1 year)
Infancy (oral) (0-1 Mistrust Primary caregiver Consistency and quality in the care
yr) received
Sense of Trust:
realization of hope
Getting
Tolerating
frustrations in small
doses
Recognizing
mother as distinct
from others and
self
Toddler (anal) (1-3 Shame and Parent(s) Opportunity to attain some self-control
yrs) doubt based on a feeling of self-esteem rather
Sense of than fear
Autonomy:
realization of will
Child will try out
new powers of
speech
Beginning
acceptance of
reality vs. pleasure
principle
Preschool Guilt Basic family Opportunity to do for self with a balance
(Oedipal) (3-6 yrs) between imaginative exploration and set
Sense of Initiative: limits
realization of
purpose
Questioning
Exploring own
body and
environment
Differentiation of
sexes
Schoolage Inferiority Neighborhood; Opportunity to achieve success and
(Latent) (6-12 yrs) schools; same-sex recognition by engaging in manageable
Sense of Industry: peers; adult; non- tasks in the child’s social world so he or
realization of parent idols she can learn responsibility, social and
competence work skills, cooperation, and fair play
Learning to win
recognition by
producing things
Exploring,
collecting
Learning to relate
to own sex
Adolescence Identity diffusion Peer groups and out Opportunity to establish who the child is
(Mature) (12-18 groups; models of and what her or his purpose in society is
yrs) leadership to be through both private and social
Sense of Identity: experiences that build social esteem,
realization of foster increased need for independence
fidelity and cushion periods of feeling of not
Moving towards belonging
heterosexuality
Selecting vocation
Beginning
separation from the
family
Integrating
personality
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Erikson’s Theory of Personality Development

I. Central Task: basic trust vs mistrust; central person: primary caretaker
II. Behavioral indicators
A. Crying is only means of communicating needs
B. Quieting usually means needs are met.
C. Fear of strangers at 6-8 months
III. Parental guidance/ teaching
A. Must meet infant’s needs consistently- cannot “spoil” infant by holding, comforting
B. Neonatal reflexes fade at 4-6 months; replaced with increased in purposeful behavior
C. Fear of strangers is normal- indicates attachment between infant and primary caretaker
D. Infant may repeat over and over newly learned behaviors
E. Weaning can begin around the time child begins walking

Physical Growth
I. Height (length): 50% increased by first birthday
II. Weight
• Doubles by 4-7 months, triples by 1 yr
III. Vital signs
A. HR: 100-140 bpm
B. RR: 25-35 breaths
C. BP: 90/55
IV. Fontanels
A. Posterior--- closed by 6-8 wks
B. Anterior---- remains open through first 12 months
V. Teething
A. Generally begins around 6 mos
B. “Baby” teeth are deciduous (primary) teeth
C. First two teeth: lower central incisors
D. By 1 yr: 6-8 teeth
VI. DDST NORMS

Birth-3 mos
Personal-social: smiles responsively, then spontaneously
Fine motor- adaptive:
Follows 180 degrees, past midline
Grasps rattle
Holds hands together
Language: laughs/ squeals; vocalizes without crying
Gross motor: while on stomach, lifts head 45-90 degrees, able to hold
head steady and erect, rolls over stomach to back

4-6 months
Personal-social: works for toy; feeds self (bottle)
Fine motor- adaptive: palmar grasp: reaches for objects
Language: turns toward voice; imitates speech
Gross motor: some weight-bearing on legs; no head lag when pulled to
sitting; sits with support

7-9 months
Personal- social
Indicates wants
Plays pat-a-cake; waves bye-bye
Fine motor-adaptive: takes two cubes in hands and bangs them
together; passes cube hand to hand; makes crude pincer grasps
Language: “dada”, “mama”, nonspecific jabbers
Gross motor: creeps on hands and knees; gets self to sitting; pulls self to
standing; standing holding on
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10-12 months
Personal-social
Plays ball
Imitates activities
Drinks from cup
Fine motor-adaptive: neat pincer grasp
Language: “dada”, “mama”, specific
Gross motor: stands alone well; walks holding on; stoops and recovers

Nursing Interventions/ Parental Guidance

I. PLAY
A. First year- solitary
B. Visual stimulation
C. Auditory stimulation
D. Tactile stimulation
E. Kinetic stimulation

II. SAFETY
A. Aspiration of Foreign Bodies
B. Falls
C. Poisoning
D. Burns
E. Motor vehicles
F. Immunization

TODDLER (1-3 yrs)

Erikson’s Theory of Personality Development

I. Central task: autonomy vs shame and doubt; central persons: parent

II. Behavioral indicators
A. Does not separate easily from parents
B. Negativistic
C. Prefers rituals and routine activities
D. Active physical explorer of environment
E. Begins attempts at self-assertion
F. Easily frustrated by limits
G. Temper tantrums
H. May have favorite “security object”
I. Uses “mine” for everything---does not understand concept of sharing
III. Parental Guidance/ teaching
A. Avoid periods of prolonged separation if possible
B. Avoid constantly saying “no” to toddlers
C. Avoid “yes”/”no” questions
D. Stress that child may use “no” even when he or she means “yes”
E. Establish and maintain rituals
F. Offer opportunities for play, with supervision
G. Allow child to feed self
H. Offer only allowable choices
I. Best method to handle temper tantrums: ignore them
J. Keep security object with child, if so desired
K. Do not force toddler to “share”

Physical Growth

I. Height
A. Slow, steady growth at 2-4 in / yr, mainly in legs rather than trunk
B. Adult height is roughly twice child’s height at 2 yrs
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II. Weight
A. Slow, steady growth, 4-6 lbs/ yr
B. Birth weight quadruples by 2 ½ yrs
III. Vital signs
A. HR=80-120
B. RR=20-30
C. BP=90/56
IV. Anterior fontanel---closes between 12 and 18 months
V. Teething
A. Introduce tooth brushing as a “ritual”
B. By 30 mos: all 20 primary teeth present
C. First dental check-up should be between 12 and 18 mos
VI. Vision
A. Full binocular vision well-developed
B. Visual activity of toddler: 20/40
VII. Posture and gait
A. Lordosis: abdomen protudes
B. Walks like a duck; wide based gait; side-to-side

DDST NORMS

 12-18 months
B. Personal-social
1. Imitates housework
2. Uses spoon, spills little
3. Removes own clothes
4. Drinks from cup
5. Feeds dolls
C. Fine motor-adaptive
1. Scribbles spontaneously
2. Builds tower with 2-4 cubes
D. Language
1. Says 3-6 words other than “mama”, “dada”
2. Points to at least one named body part
E. Gross motor
1. Kicks ball forward
2. Walks up steps

 19-24 months
F. Personal-social
1. Puts on clothing
2. Washes and dries hands
3. Brushes teeth with help
G. Fine motor-adaptive
1. Builds tower with 4-6 cubes
2. Imitates vertical line
H. Language
1. Combines 2-3 words
2. Names one picture
3. Speech is half-understandable
I. Gross motor
1. Throws ball overhand
2. Jumps in place

 2-3 years
J. Personal-social
1. Puts on shirt
2. Can name a friend
K. Fine motor-adaptive
1. Wiggles thumbs
2. Builds Tower of 8 cubes
L. Language
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1. Knows two actions (verbs) and two adjectives

2. Names one color
M. Gross motor
1. Balances on one foot briefly
2. Pedals tricycle

NURSING INTERVENTIONS/ PARENTAL GUIDANCE

I. Play: parallel
II. Toys: stimulate multiple senses simultaneously
III. Safety
A. Accidents-Motor vehicles (Rule of 4)
B. Drowning
C. Burns
D. Poisonings
E. Falls
F. Choking

PRESCHOOLER (3-5 YRS)

Erikson’s Theory of Personality Development

I. Central Task: initiative vs. guilt; central person(s): basic family unit.
II. Behavioral indicators
A. Attempts to perform activities of daily living (ADL) independently.
B. Attempts to make things for self/ others
C. Tries to “help.”
D. Talks constantly: verbal expression of the world (“Why?”)
E. Extremely active, highly creative imagination: fantasy and magical thinking
F. May demonstrate fears: “monsters”, dark rooms, etc.
G. Able to tolerate short periods of separations.
III. Parental Guidance/ teaching
A. Encourage child to dress self by providing simple clothing
B. Remind to go to bathroom (tends to “forget”).
C. Assign simple, small tasks or errands
D. Answer questions patiently, simply; do not offer child more information that he/she is asking for.
E. Normal to have “imaginary playmates”
F. Offer realistic support and reassurance with regards to fears
G. Expose to a variety of experiences: zoo, train, ride, shopping, sleigh riding, etc.
H. Enroll in preschool/ nursery school program; kindergarten at 5 yrs. old

Physical Growth

I. Height and weight

A. Continued slow, steady growth
B. Generally grows more in height than weight.
C. Posture: appears taller and thinner; lordosis of toddler gradually disappears.
II. Vital signs
III. Teeth
IV. Vision
A. Visual acuity: 20/30 at 3-5 yrs. old

Denver development screening test (DDST) Norms

3 yrs.
i. Personal-social
2. Dresses without help.
3. Plays board / card games.
i. Fine motor- adaptive.
4. Picks longer of two lines.
5. Copies circle, intersecting lines.
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6. Draws person with three parts.

i. Language
7. Comprehends “cold,” “tired,” “hungry”
8. Comprehends prepositions: “over,” “under.”
9. Names four colors.
i. Gross Motor
10. Pedals tricycle; hops, skips on alternating feet.
11. Broad jumps, jumps in place.
12. Balances on one foot.

4 yrs.
A. Personal-Social
1. Brushes own teeth, combs own hair
2. Dresses without supervision
3. Knows own age and birthday
4. Ties own shoes.
B. Fine motor- adaptive
1. Draws person with six body parts.
2. Copies a square.
C. Language
1. Learns opposite analogies (2 of 3)
2. Defines seven words.
D. Gross motor
1. Balances on each foot for 5 sec.
2. Can walk heel-to-toe

5 yr.
A. Personal-Social
1. Interested in money.
2. Knows days of the week, seasons.
B. Fine motor-adaptive: prints name
C. Language
1. Counts to ten
2. Verbalizes number sequences (e.g., telephone number)
D. Gross motor
1. Attempts to ride bike
2. Roller skates, jumps rope, bounces ball.
3. Backward heel-toe walk

Nursing interventions/Parental Guidance

I. Play: preschool years-associate and cooperative
II. Safety: Preschoolers are “the great imitators” of parents, who now serve as role models.

School-Aged (6-12 yr)

Erikson’s Theory of Personality Development

I. Central task: industry vs. inferiority; central person(s): school, neighborhood friend(s)
II. Behavioral indicators
A. Moving toward complete independence in activities of daily living
B. May be very competitive-wants to achieve in school, at play
C. Likes to be alone occasionally, may seem shy
D. Prefers friends and peers to siblings
III. Parental Guidance/Teaching
A. Be accepting of the child as he or she is
B. Offer consistent support and guidance
C. Avoid authoritative or excessive demands on child.
D. Respect need for privacy
E. Assign household tasks, errands, chores
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Physical Growth
I. Height and Weight
A. Period of slow, steady growth
B. 1-2 in./yr.
C. 3-6 pounds/yr. (Almost double in weight during 6-12 yr.)
D. Girls and boys differ very little in size
II. Teeth
A. Begins to lose primary teeth about sixth birthday
B. Eruption of permanent teeth, including molars; 28 permanent teeth by age 12 yr.
C. Dental screening annually, daily brushing
III. Vision and hearing
A. Should be screened annually-usually in school
B. 20/20 vision well established at 9-11 yr.

Developmental Norms
I. 6-8 yr
A. Dramatic, exuberant, boundless energy
B. Alternating periods: quiet, private behavior
C. Conscientious, punctual
D. Wants to care for own needs but needs reminders, supervision
E. Oriented to time and space
F. Learns to read, tell time, follow map
G. Interested in money-asks for “allowance”
H. Eagerly anticipates upcoming up coming events, trips
I. Can ride bike, swim, play ball
II. 9-11 yr
A. Worries over tasks; takes things seriously, but also develops sense of humor-likes to tell jokes
B. Keeps room, clothes, toys, relatively tidy
C. Enjoys physical activity, has great stamina
D. Very enthusiastic at work and play; has lots of energy-may fidget, drum fingers, tap foot
E. Wants to work to earn money, mow lawn, baby-sit, deliver papers
F. Loves secrets
G. Very well behaved outside own home
H. Uses tools, equipment; follows directions, recipes
I. By 12th birthday; paradoxic stormy behavior, onset of adolescent conflicts.
Nursing interventions/Parental Guidance
I. Play: competitive games
II. Safety

Adolescent (12-18 yr.)

Erikson’s Theory of Personality Development

I. Central Task: Identity vs. role diffusion; central person(s): peer group.
II. Behavioral indicators
A. Changes in body image related to sexual development
B. Awkward and uncoordinated
C. Much interest in opposite sex: girls become romantic
D. Wants to be exactly like peers
E. Becomes hostile toward parents, adults, family
F. Concerned with vocation, life after high school
III. Parental guidance/ teaching
A. Offer firm but realistic limits on behavior
B. Continue to offer guidance, support
C. Allow child to earn own money, control own finances
D. Assist adolescent to develop positive self-image
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Physical Growth
I. Height and weight
A. Adolescent growth spurt lasts 24-36 mo.
B. Growth in height commonly ceases at age 16-17 in girls, age 18-20 in boys
C. Boys gain more weight than girls, are generally taller and heavier
II. Teeth: 32 permanent teeth by 18-21 yr.
III. Sexual changes
A. Girls
1. Changes in nipple and areola; development of breast buds
2. Growth of pubic hair
3. Change in vaginal secretions
4. Menstruation-12.8 yr (average)
5. Growth of axillary hair
6. Ovulation
B. Boys
1. Enlargement of genitalia
2. Growth of pubic, axillary, facial, and body hair
3. Lowering of voice
4. Production of sperm; nocturnal emission

Developmental Norms
I. Motor Development
A. Early (12-15 yr)- awkward, uncoordinated, poor posture; decrease in energy and stamina
B. Later (15-18 yr)- increased coordination, better posture; more energy and stamina

II. Cognitive
A. Academic ability and interest vary greatly.
B. “Think about thinking”- period of introspection
III. Emotional
A. Same sex best friend, leading to strong friendship bonds
B. Highly romantic period for boys and girls
C. May be moody, unpredictable, inconsistent
IV. Social
A. Periods of highs and lows, sociability and loneliness
B. Turmoil with parents- related to changing roles, desire for increased independence
C. Peer group is important socializing agent-conformity increases sense of belonging
D. Friendships: same-sex best friend, advances to heterosexual “relationships”

UPPER RESPIRATORY TRACT INFECTIONS

CHOANAL ATRESIA
-A unilateral or bilateral congenital obstruction of the posterior nares by an obstructing membrane
or bony growth, preventing a newborn from drawing air through the nose and down into the
nasopharynx
Sx
• Dyspnea
• Restlessness
• Fr 8 or 10 catheter can’t pass thru the nares
• Will struggle and become cyanotic during feedings when mouth and nostril occluded
Tx
• IVF
• Oral airways
• Local piercing of the obstructing membrane
• Surgical removal of the bony growth

ACUTE NASOPHARYNNGITIS
• Most frequent infectious disease in children
• 2-3 days incubation period
 15

• Caused by rhinovirus, coxsackie virus, respiratory syncytial virus (RSV), adenovirus,

parainfluenza and influenza virus.
Sx
• Nasal congestion
• Watery rhinitis
• Low grade fever
Tx
• Not specific
• Antibiotics not effective
• Antipyretic for fever
• Rest and fluids

PHARYNGITIS
• Caused by group A B- hemolytic streptococci (GABHS)
• Affected children are at risk for serious sequela such as:
1. Acute Rheumatic Fever (ARF)- an inflammatory disease of the heart, joints and CNS; onset in
about to days
2. Acute Glomerulonephritis (AGN)- acute kidney infection; onset is an average of 18 days.
Sx
• Headache
• Fever
• Abdominal pain
• Usually subsides in 3-5 days
Dx
• Throat culture
Tx
• Oral penicillin (rapid response in 24 hours)
• Analgesics for pain
• Cold/warm compress to the neck to provide relief
• Offer warm saline gargle
• Don’t force child to eat
TONSILLITIS
• Inflammation of palatine tonsils often as a result or a viral or bacterial pharyngitis
• 10% to 15% caused by Group beta hemolytic streptococci
• Adenitis- infection and inflammation of the adenoid (pharyngeal) tonsils
Sx
• Enlarged red tonsils, fever
• Sore throat
• Halitosis, drooling of saliva
• White patches of exudates
• Enlarged cervical lymph nodes
• Lethargy
• Nasal quality of speech
• Difficulty in hearing
Tx
• Antibiotics for bacteria infection, usually penicillin or erythromycin on a 10 day course
• Antipyretic for fever
• Tonsillectomy- tonsillar tissue is removed by ligating the tonsils or by laser surgery; indicated for
chronic tonsillitis; never done if the organs are infected

CROUP
• Inflammation of the larynx, trachea and major bronchi
• 6 months- 3 years-caused by Hemophilus influenza
Sx
• Mild upper respiratory tract infection during the night
• No fever or low grade only
• Barking cough
• Inspiratory stridor
 16

• Retractions
• Wakes up in extreme respiratory distress
Tx
• The child should be brought to the emergency department
• Cool mist air with budesonide, steroid or racemic epinephrine
• Dexamethasone given orally
• IV therapy
EPIGLOTTITIS
• Inflammation of the epiglottis (the flap of tissue that covers the opening of the larynx to keep out
food and fluid during swallowing
• An emergency situation because the swollen epiglottis is unable to rise and allow the airway open.
• 3-6 years of age
• H. influenza type B, pneumococci, streptococci
• Echovirus and RSV
Sx
• Mild URT infection
• Drooling of saliva
• Cherry red epiglottis
• Leukocytosis
Tx
• O2, moist air
• Cefuroxime for H. influenza
• IV administration
• Prophylactic tracheostomy/ endotracheal intubation

FOREIGN OBJECT ASPIRATION

• Inhalation of a foreign object into the airway
• Dislodge the object by purposeful coughing
Mgmt
• For children: Heimlich subdiaphragmatic abdominal thrust
• For infants: back blows and chest thrust
Bronchial obstruction
Sx
• Coughs violently
• Dyspneic
• Hemoptysis
• Fever
• Purulent sputum
• Leukocytosis
• Localized wheezing
Dx
• X-ray
Tx
• Rule: Nuts/Popcorns should not be given to children under school age.
• Bronchoscopy

LOWER RESPIRATORY TRACT INFECTIONS

BRONCHITIS (TRACHEOBRONCHITIS)
• Inflammation of large airways (trachea and bronchi)
• Caused by a virus or Mycoplasma pneumoniae
• Preschool and school age children
Sx
• Fever
• Dry, hacking cough worse at night; becomes productive in 2-3 days
• Rhonchi and coarse rales
• Chest X-ray: diffuse alveolar hyperinflation
Tx
• Analgesics
 17

• Antipyretics
• Humidity
• Cough suppressants

BRONCHIOLITIS
• Inflammation of the fine bronchioles and small bronchi
• 2 years, peaking at 6 months of age
• Adenovirus, parainfluenza virus, RSV
Sx
• 1 or 2 days of URTI
• Leukocytosis
• Tachycardia
• Cyanosis
• Chest x-ray: pulmonary infiltrates
• Pulse oximetry
Tx
• Antipyretics
• Adequate hydration
• Rest
• Hospitalization recommended for children with complicating condition or severe stress
• O2 VS, ABG, ventilatory support
• Antibiotics not common
• Nebulize, bronchodilators, steroids
• Positioned on semi-Fowler’s or prone
• IV therapy

PNEUMONIA
• Inflammation of the pulmonary parenchyma
Sx
• High fever
• Whitish sputum
• Tachypnea
• Rhonchi or fine crackles
• Dullness with percussion
• Chest pain
• Retractions
• Nasal flaring
• Pallor to cyanosis
• Chest x-ray-diffuse or patchy infiltrates
• Irritable, restless, lethargic
• Anorexia, vomiting, diarrhea, abdominal pain
Tx
• VS monitoring
• Rest
• IV therapy
• Mist tent with 02
• Antipyretic
• Suctioning
• Postural drainage and CPT
• Antibiotic therapy

SIDS (Sudden Infant Death Syndrome)

• Sudden death of an infant under 1 year of age that remains unexplained after a complete post
mortem examination
 18

• Cause unknown
• A compassionate, sensitive approach to the family during the very first few minutes can help spare
them some of the overwhelming guilt.

ASTHMA
• Immediate hypersensitivity (Type 1) response
Sx
• Wheezing
• Exhausted
• Frightened
• Thick mucus production
• No fever
Tx
• Avoidance of the allergens
• Skin testing and hyposensitization to identified allergen
• Relief of symptoms by the use of pharmacological agents
• Oral fluid intake
• Avoid milk or milk products
• IV therapy

RESPIRATORY DITRESS SYNDROME (HYALINE MEMBRANE DISEASE)

• preterm infants; infants of diabetic mothers, infants born of Caesarean births
• Caused by low level or absence of surfactants, the phospholipid that normally lines the alveoli and
resists surface tension on expiration to keep the alveoli from collapsing on expiration.
Sx
• Altered body temperature
• Nasal flaring
• Sternal and subcostal retractions
• Tachypnea
• Expiratory grunting
• ABG: respiratory acidosis
Tx
• Maintain adequate ventilation and 02
• Maintain acid-base balance
• Maintain a neutral thermal environment
• Maintain an adequate tissue perfusion
• Maintain adequate hydration and electrolyte status
• Administration of exogenous surfactant by endotracheal route

SPECIFIC CARDIAC DISORDERS

ACYANOTIC TYPE
COARCTATION OF THE AORTA (COA)
• localized narrowing near the insertion of the ductus arteriosus, resulting in increased
pressure proximal to the defect (head and upper extremities) and decreased pressure
distal to the obstruction (body and lower extremities)
Sx
• BP and bounding pulses in the upper extremities
• Weak or absent femoral pulses
• Cool lower extremities with lower BP
• Severely acidotic and hypertensive (infants)
• Dizziness, headaches, fainting and epistaxis
• At risk of HPN, ruptured aorta, aortic aneurysm, stroke
Tx
• Balloon angiosplasty
• Resection of the coarcted portion with an end-to-end anastomosis
• Enlargement of the constricted section using a graft of prosthetic material or a portion of the left
subclavian artery
• Post-op HPN treated with IV/oral hypertensive drugs
 19

PATENT DUCTUS ARTERIOSUS (PDA)

• failure of the ductus arteriosus to close, wherein blood will be shunted from the aorta because of
aortic pressure to pulmonary artery, causing a left-to-right shunt
• causes right ventricular hypertrophy and increased pressure in the pulmonary circulation
Sx
• Asymptomatic
• Signs of CHF
• Machinery-like murmur
• Wide pulse pressure
• Low diastolic pressure
• ECG: normal/ventricular enlargement if the shunt is large
Tx
• Administration of oral/IV indomethacin (prostaglandin inhibitor)
1. given repeatedly as many as 3x 12 –24 hours apart
• Surgical ligation of the defect
• Visual assisted thoracoscopic surgery (VATS)

VENTRICULO-SEPTAL DEFECT (VSD)

• most common congenital cardiac defect
• an opening is present in the septum between two ventricles
• results in right ventricular hypertrophy and increased pressure in the pulmonary artery
Sx
• May not be evident at birth
• Loud, harsh systolic murmur along the left sternal border at the 3rd or 4th intercoastalspace
• Echo/ECG/MRI: right ventricular hypertrophy and pulmonary artery dilatation
Tx
• Closes spontaneously
• Interventional cardiac catheterization
• Open heart surgery
• edges of the opening are approximated and sutured in place with a Silastic or Dacron patch to
occlude the space
• post-op complication: arrythmia

ATRIAL SEPTAL DEFECT (ASD)

• abnormal opening between the atria, allowing blood from the higher pressure left atrium to flow into
the lower right atrium
Sx
• may be asymptomatic
• may develop CHF
Tx
• surgical Dacron patch closure
• open CP bypass performed before school age

PULMONIC STENOSIS (PS)

• narrowing at the entrance to the pulmonary artery
• causes RV hypertrophy
• may lead to pulmonary atresia
Sx
• may be asymptomatic
• mild cyanosis or CHF
• murmur
• x-ray: cardiomegaly
• at risk for bacterial endocarditis
Tx
• infants: transventricular(closed) valvotomy (Brock procedure)
• children: pulmonary valvotomy with CP bypass
• balloon angioplasty
 20

AORTIC STENOSIS (AS)

• narrowing or stricture of the aortic valve, causing resistance to blood flow in the left ventricle,
decreased cardiac output, left ventricular hypertrophy, and pulmonary vascular congestion
Sx
• faint pulses
• hypotension
• tachycardia
• poor feeding
• exercise intolerance
• chest pain
• dizziness when standing
• murmur
Tx
• valvotomy

CYANOTIC TYPE

TRANSPOSITION OF THE GREAT VESSELS /ARTERIES

• the pulmonary artery leaves the left ventricle, and the aorta exits from the right ventricle, with no
communication between the systematic and pulmonary circulation
• PDA/ patent foramen ovale/ VSD must be present
Sx
• Severely cyanotic and depressed at birth
• May have symptoms of CHF
• Cardiomegaly
Tx
• Administration of intravenous prostaglandin
• Arterial switch procedure

TETRALOGY OF FALLOT (TOF)

• includes four defects: (1)ventricular septal defect, (2) pulmonic stenosis, (3) overriding aorta and (4)
right ventricular hypertrophy
Sx
• Acutely cyanotic at birth
• Murmur
• Blue spells/tet spells/anoxic spells usually during crying or after feeding
• Clubbing of the fingers
• Squatting
• Poor growth
• Polycythemia
Tx
• Knee-chest position
• Administration of morphine sulfate/beta blocker
• Complete repair (Brock procedure) in the first year of life

TRUNCUS ARTERIOSUS
• failure of normal septation and division of the embryonic bulbar trunk into the pulmonary artery and
aorta, resulting in a single vessel that overrides both ventricles

Sx
• Moderate to severe CHF
• Poor growth
• Cyanosis
• Activity intolerance
• At risk of brain abscess and bacterial endocarditis
 21

Tx
• Modified Rastelli procedure
Post-op complication
1. persistent heart failure
2. bleeding
3. pulmonary artery HPN
4. dysrythmias
5. residual VSD

ACQUIRED

RHEUMATIC FEVER/ RHEUMATIC HEART DISEASE

• -inflammatory disease affecting the heart, joints, CNS, and subcultaneous tissues
• follows a previous infection with group A streptococci
Sx
• carditis
• polyarthritis
• erythematous macules (erythma marginatum)
• chorea (St.Vitus Dance, Sydenham Chorea)
• arthralgia
• fever
• elevated ESR/ C-reactive protein
• positive throat culture to streptococci
Tx
• bed rest
• penicillin therapy
• oral salicylates
• corticosteroids
• Phenobarbital

KAWASAKI’S DISEASES
• mucocutaneous lymph nodes syndrome
• vasculitis is the principal life-threatening finding
• unknown cause though genetic predisposition possible

Sx
• conjunctivitis*
• “strawberry” tongue and red cracked lips*
• rashes often confined to the diaper area*
• enlarged cervical lymph nodes*
• desquamation of palms and soles*
Tx
• administration of salicylic acid
• IV gammaglobulin
• Steroids are contraindicated
• Observe for signs of heart failure
• Supportive nursing interventions

CHILD WITH HEMATOLOGIC DISORDERS

ANEMIAS
not a disease itself but a manifestation of an underlying pathologic condition; ↓ RBC or Hgb
Etiology
1. excessive blood loss
2. destruction of erythrocytes
3. decreased or impaired production of erythrocytes or its components
 22

Sx
• muscle weakness
• easy fatigability
• frequent resting
• headache
• dizziness
• irritability
• slowed thought processes
• ↓ BP and CVP
Tx
• Treat the underlying cause
• Make-up for any deficiency in blood/ blood products
• O2 therapy
• Bed rest
• Replacement of intravascular volume with IV fluids

IRON DEFICIENCY ANEMIA

• an inadequate supply of iron
• impaired iron absorption
• increased body’s need for iron, and anything that may affect the synthesis of Hgb
Tx
• iron fortified infant formula/cereal
• oral iron supplements for 3 months
• parenteral iron
• blood transfusions

HEMOLYTIC DISEASE OF THE NEWBORN (HDN)

- also called as erythroblastosis fetalis
- abnormally rapid rate of RBC destruction

Rh Incompatibility (isoimmunization)
- In the 1st pregnancy, if the mother’s blood type is Rh (-) and the fetal blood type is Rh (+), the
introduction of the fetal blood cause sensitization to occur, and the mother begins to form
antibodies against the antigen
- after this sensitization, in the 2nd pregnancy, there will be a high level of antibody circulating in the
mother’s blood stream, which acts to destroy the fetal RBC if the fetus is Rh (+)

ABO Incompatibility
- major blood group antigens of the fetus are different from those of the mother
- most common incompatibility: mother with blood group “O” and an infant with “A” or “B” blood
group

Sx
• jaundice within 24 hours after birth
• elevated serum level of unconjugated bilirubin
• anemia
• hypoglycemia
Tx
• Administration of Rho immune globulin (RhIg) within 72 hours (as long as 3-4 weeks) after
the 1st delivery and repeated after subsequent ones or at 26-28 weeks of gestation
• Intrauterine infusion of Rh O- negative packed RBC via the umbilical vein
• Exchange transfusion with fresh whole blood which is typed and crossmatched to the
mother’s serum

THALASSEMIA
- anemias associated with abnormalities of the beta chain of adult Hgb
 23

Dx
• RBC : hypochromic and microcytic
• Hgb level : less than 5 g/ 100 ml
• ↑ serum iron level
Sx
• anemia (before diagnosis)
• fever
• poor feeding
• greatly enlarged spleen
• headache
• precordial and bone pain
• small stature
• delayed sexual maturation
• bronzed, freckled complexion
• bone changes
Tx
• digitalis, diuretics, and a low Na diet
• hypertransfusion therapy with PRBC every 2-4 weeks
• administration of desferoxamine/SQ over 6-8 hours
• splenectomy/ bone marrow transplantation
PURPURA
- hemorrhagic rash or small hemorrhages occurring in the superficial layer of the skin
Idiopathic Thrombocytopenic Purpura
- unknown cause; increased rate of platelet destruction due to an antiplatelet antibody
- occurs 2 weeks after a viral infection
Sx
• miniature petechiae
• asymmetric ecchymosis over the legs
• epistaxis
• bleeding over joints
• thrombocytopenia
• touniquet test: > 2 petechiae marks on an area on the forearm 2 cm square
Tx
• administration of prednisone
• platelet transfusion
• splenectomy
• do not give salicylates for pain
• IV gamma globulin

Henoch-Schonlein Syndrome (anaphylactoid purpura)

- caused by increased vessel permeability
- hypersensitivity reaction to an invading allergen
- history of mild infection
Sx
• rash on buttocks, posterior thighs, extensor surface of the arms and legs, tips of ears
• tender, swollen joints
• abdominal pain, vomiting, or blood in stool
• normal platelet count;↑ESR, WBC, eosinophil count
Tx
• steroid therapy
• nose and throat cultures
• urinalysis for protein and glucose

HEMOPHILIA
- group of bleeding disorders in which there is a deficiency of one of the factors necessary
for the coagulation of the blood
 24

- Types:
1. factor VIII deficiency (hemophilia A, or classic hemophilia)
2. factor IX deficiency (hemophilia B, or Christmas disease)
3. factor XI deficiency (hemophilia C)
4. Von Willebrand disease (Vwd)
Sx
• Prolonged bleeding anywhere from or in the body
• Hemorrhage from any trauma
• Excessive bruising
• Subcutaneous and intramuscular hemorrhages
• Hemarthrosis
• Hematomas- pain, swelling, and limited motion
• Spontaneous hematuria
Dx
• History of bleeding episodes
• X-linked inheritance
• Laboratory findings
• DNA testing
Tx
• No cure for hemophilia
• Replacement of the missing clotting factor
• Corticosteroids
• Physical activity within reasonable limits
• Transfusion of plasma and platelet concentrates

LEUKEMIA
- distorted and uncontrolled proliferation of WBC
- cancer of the blood-forming tissues

Acute Lymphocytic Leukemia

- the malignant cell involved is the lymphoblast, which is an immature lymphocyte
- unknown cause

Acute Myelogenous Leukemia

- non-ALL or ANLL
- in its chronic form, it is the most common type of leukemia in adulthood
- overproliferation of granulocytes
Sx
• pallor
• lethargy
• low-grade fever
• bleeding from oral mucous membrane
• petechiae
• abdominal pain, vomiting and anorexia
• bone and joint pains
• headache and unsteady gait
• variable leukocyte count
• bone marrow aspiration: > 25% blast cells present
Tx
• Chemotherapy ( vincristine, prednisone, L- asparaginase, doxorubicin or daunorubicin)
a. induction phase- achieving a complete remission or absence of
leukemic cells
b. sanctuary phase- preventing leukemia cells from invading or
growing in the CNS
c. maintenance phase- maintaining the original remission
• allopurinol
• adequate hydration
• intrathecal administration of methotrexate, dexamethasone, cytarabine and ara-C
 25

• bone marrow transplantation

CHILD WITH GASTROINTESTINAL DISORDERS

CLEFT LIP
- The failure of the maxillary and median nasal processes to fuse which should normally occur
between 5-8 weeks of intrauterine life
CLEFT PALATE
- An opening in the palate which usually closes at approximately 9-12 weeks of intrauterine life,
is usually in the midline and may involve just the anterior hard palate, or the posterior palate
Tx
- Surgery: Cleft lip- shortly after birth
Cleft palate- 18-24 months
Preoperatively
• Feed the child in an upright position using a commercial cleft lip/ palate nipple (Haberman/ Breck
feeder)
• Burping should be done after feeding
• Offer small sips of fluids
• Solid foods offered should be soft
Postoperatively
• NPO for at least 4 hours
• Introduce plain water gradually to prevent vomiting
• No tension should be placed on the suture line
• Breastfeeding/ bottle-feeding contraindicated
• If on solid foods, do not use spoon
• Offer the child clear water to rinse the suture line
• Observe for respiratory distress
• Suction PRN without touching the suture line
• Do not lie the infants on their abdomen
• A Logan bar (a wire bow taped to both cheeks) should be used to hold the suture line in place
• Infants should not be allowed to cry
• Nothing hard or sharp should touch the suture line
• Use elbow restraints
• Administer analgesics as ordered
• Clean suture line
• Observe for signs of otitis media
• Speech therapy

DENTAL CARIES
- The number one health problem in school-age children
- The child may not be able to chew and digest thoroughly the food that they eat
Tx/Px
- Remind the child to brush their teeth daily
- Use of soft toothbrush, fluoride based toothpaste, dental floss
- offer high-protein foods for snacks instead of candies
- If the child eats candies, offer types that can be eaten quickly and dissolves quickly such as
chocolate bars

TRACHEO-ESOPHAGEAL FISTULA/ ESOPHAGEAL ATRESIA

- abnormalities found in infants if the trachea and esophagus are affected by some teratogens
that does not allow the esophagus and trachea to separate normally and should take place
between 4-8 weeks of intrauterine life
Sx
• Excessive salivation and drooling
• 3 C’s of TEF: coughing, choking, cyanosis
• Apnea
• Increased respiratory distress after feeding
• A firm catheter cannot pass through the infant’s esophagus to the stomach
 26

• No gastric content can be aspirated

• Flat plate x-ray of the abdomen reveals distended stomach
• Barium swallow/bronchial endoscopy: blind-end esophagus and fistula
Tx
• Gastrostomy tube drained to gravity
• Antibiotics as ordered
• Surgery: closure of the fistula and anastomosis of the esophageal segments

GASTROESOPHAGEAL REFLUX DISEASE/ CHALASIA

- Neuromuscular disturbance in which the gastroesophageal (cardiac) sphincter and the lower
portion of the esophagus are lax and, therefore, allow easy regurgitation of gastric contents
into the esophagus
Sx
• Effortless and non-projectile vomiting
• pH of secretions are acidic
• Fiber-optic endoscopy/esophagography will reveal lax sphincter
Tx
• Feed infants a formula thickened with rice cereal (1 tbs cereal per 1 oz of formula)
• Hold in upright position 1 hour after feeding; placed on their left side
• Antacid as ordered to reduce possibility of the stomach acid contents irritating the esophagus
• Cisapride as ordered to hurry gastric emptying
• Surgery: Nissen fundoplication

PYLORIC STENOSIS
- Hypertrophy or hyperplasia of the muscle surrounding the pyloric sphincter, thereby making it
difficult for the stomach to empty
Sx
• Projectile vomiting as much as 3-4 feet
• Sour-smelling vomitus
• Signs of dehydration
• Alkalosis; hypopnea
• Ultrasound/endoscopy: hypertrophied sphincter
Tx
• Correction of fluid and electrolyte imbalance, dehydration, and starvation by administration of
intravenous fluids
• Surgery: pyloromyotomy (Fredet-Ramstedt operation)

INTUSSUSCEPTION
- Invagination of one portion of the intestine into another
- Surgical emergency because necrosis of the invaginated portion of the bowel may occur
Sx
• Draws up their legs and cry when in severe pain, then after the discomfort, will be symptom free
• Bilous vomitus
• Blood in the stools
• Abdominal distention
• ↑ Temp., peritoneal irritation, ↑ WBC, rapid pulse
• Sonogram: (+) intussusception

Tx
• Surgery to straighten the invaginated portion
• Reduction by a water-soluble solution, barium enema, or air (pneumatic insufflation)
• Kept on NPO pre and post-operatively
• IV therapy
• NGT in place while suture line is healing
• Comfort measures to alleviate the pain

VOLVULUS
- Twisting of the intestines which leads to obstruction of the passage of feces and compromise
the blood supply to the loop of the intestines involved
 27

Sx
• Intense crying and pain
• Pulling up of legs
• Abdominal distension
• Vomiting
• Abdominal mass
• Sonogram/ lower barium radiograph: obstruction
Tx
• Surgery to relieve the volvulus and reattach the bowel

NEC (NECROTIZING ENTEROCOLITIS)

- Condition wherein the bowel develops necrotic patches, interfering with digestion and possibly
leading to paralytic ileus
Sx
• Abdominal distension
• Delayed gastric emptying
• Stool positive for occult blood
• ↓ BP, unstable temp
• Abdominal x-ray: air invading the abdominal wall
Tx
• Feedings discontinued
• IV therapy/ TPN
• Antibiotic as ordered
• Surgery: colostomy/removal of the portion of the bowel invoved

MECKEL DIVERTICULUM
- Presence of an omphalomesenteric fistula (a fibrous band connecting the small intestines to
the umbilicus)
- Most common congenital malformation of the GI tract
Sx
• Recurrent, vague abdominal pain similar to appendicitis
• Painless, bloody stools with mucus
• Severe anemia/ shock
Tx
• Surgical removal of the diverticulum
• Blood replacements, IV therapy, oxygen
• Antibiotics as ordered
• Monitor VS, I&O
• Bed rest

HIRSCHSPRUNG’S DISEASE
- Also called congenital aganglionic megacolon
- Mechanical obstruction caused by inadequate motility of a part of the intestine
Sx
Newborn
• Failure to pass meconium within 24-48 hours after birth
• Reluctance to ingest milk
• Bile-stained vomitus
• Abdominal distention
Infancy
• Failure to thrive
• Constipation
• Abdominal distension
• Explosive, watery diarrhea and vomiting
• Fever
Children
• Constipation
• Ribbon like foul-smelling stools
 28

• Abdominal distention
• Visible peristalsis
• Fecal masses easily palpable
• Poorly nourished and anemic
Tx
• Surgery to remove the aganglionic portion of the bowels and to return the normal bowel motility and
function of the anal sphincter

IMPERFORATE ANUS
- Stricture of the anus
- Minor, requiring surgical incision of the persistent membrane
- Severe, involving sections of the bowels that are inches apart with no anus
Sx
• No anal formation upon inspection
• Failure to insert a catheter or thermometer into the anal canal
• No stools
• Abdominal distention
• “Wink reflex” not present
• X-ray/ sonogram: blind pouch of the bowel

Tx
• Surgery depending on the extent of the problem

CHILD WITH RENAL OR URINARY DISORDERS

CONGENITAL DEFECTS

BLADDER EXTROPHY
- A midline closure defect that occurs during the embryonic period of gestation, usually on
the 1st 8 weeks, wherein the bladder lies open and exposed on the abdomen
Sx
• No anterior bladder wall
• No skin covering on the lower anterior abdomen
• Bright red bladder
• Continuous drainage of urine
• Epispadias- opening of the urinary meatus on the dorsal or superior surface of the penis
Tx
• Surgical closure of the bladder and the anterior abdominal wall
• Creation of urethra
• Surgical removal of the bladder, then construction of a continent urinary reservoir or an artificial
bladder

HYPOSPADIAS
-Urethral defect in which the urethral opening is not at the end of the penis but on the ventral
(lower) aspect of the penis

EPISPADIAS
-Similar defect in which the opening is on the dorsal surface of the penis
Sx
• Hypospadias with chordee- a fibrous band that causes the penis to curve downward (cobra-head
appearance)
• Cryptorchidism (undescended testes)
Tx
• Circumcision not done
• Meatotomy- a surgical procedure in which the urethra is extended to a normal position

HYDRONEPHROSIS
- Enlargement of the pelvis of the kidney with urine as a result of backpressure in the ureter
 29

- Caused by obstruction, either of the ureter or of the point where the ureter joins the
bladder
- Occurs in the 1st 6 months
Sx
• Asymptomatic
• Repeated UTI
• ↑ BP
• Flank/abdominal pain
• Abdominal mass
• IVP/sonogram: enlarged pelvis and a point of obstruction
Tx
• Surgical correction of the obstruction

POLYCYSTIC KIDNEY
- Large, fluid-filled cysts have formed in place of normal kidney tissue
- Inherited as an autosomal recessive trait
- The mother had oligohydramnios during pregnancy
Sx
• Kidneys are large and feel soft and spongy
• If bilateral, the child may not be able to pass out urine
• “Potter facies” appearance
• Transillumination/ sonography: fluid-filled cysts
• Liver is filled with identical cysts
• ↑ Portal circulation
• Oliguria if unilateral
• Abdominal mass can be palpated
• Systemic hypertension
Tx
• Surgical removal of a kidney if only one is cystic
• Renal transplantation

INFECTIOUS CONDITIONS

URINARY TRACT INFECTION

- Involves the urethra, bladder, ureters, renal pelvis, calyces, and renal parenchyma
- Occurs most often in females because the urethra is shorter in girls and is located close to
the vagina and anus
- Escherichia coli- most common causative agent
Sx
• Pain in urination
• Frequency
• Hematuria
• Low/high-grade fever
• Mild abdominal pain
• Enuresis (bedwetting)
• Vomiting
• Malaise
• Alkaline urine
Tx
• For the 1st UTI, oral administration of antibiotics specific to the causative agents for 10 days
• Encourage to drink a large quantity of fluids
• Mild analgesic
• Urinalysis at 72 hours
• For recurrent UTI’s, prophylactic antibiotics for 6 month

GLOMERULONEPHRITIS
 30

- Inflammation of the glomeruli of the kidney

- Occurs as an immune complex disease after an infection with nephritogenic streptococcus

Acute Glomerulonephritis
- Ages 5-10 years
- More common in boys
- Has a history of recent URTI (within 1-2 weeks) or impetigo (within 3 weeks)
Sx
• Sudden onset of hematuria and proteinuria
• Tea- colored, reddish-brown, or smoky urine
• Oliguria
• ↑ Urine specific gravity
• Hypertension
• Low grade fever
• Edema
• Cardiac involvements- orthopnea, cardiac enlargement, enlarged liver, pulmonary edema, galloping
heart rhythm, inverted T wave and longer PR interval
• Cerebral symptoms caused by cerebral ischemia- encephalopathy, headache, irritability,
convulsions, vomiting, coma, lethargy, paralysis
• Hypoalbuminemia
• Increased ESR
• Increased BUN creatinine
• Elevated antistreptolysin O

Tx
• Antibiotics/diuretics not effective
• Palliative therapy
• High protein, low salt diet
• Weigh daily
• I &O

Chronic Glomerulonephritis
- May follow AGN or nephritic syndrome
- Results in either diffuse or local nephron damage
*Alport’s syndrome- a progressive chronic glomerulonephritis inherited as an autosomal
dominant disorder
Sx
• Proteinuria
• Edema
• Hypertension
• RBC/WBC in urine
• Below normal urine specific gravity
• Increased BUN creatinine
• Renal biopsy: permanent destruction of glomeruli membranes
Tx
• Antihypertensive
• Diuretics
• Corticosteroids
• Dialysis
• Kidney transplantation

NEPHROSIS (NEPHROTIC SYNDROME)

- Altered glomeruli permeability due to fusion of the glomeruli membrane surfaces, which
causes abnormal loss of protein in urine
- May be caused by a hypersensitivity to an antigen-antibody reaction or an autoimmune
process (T-cell dysfunction)
Sx
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• Proteinuria
• Edema
• Low serum albumin
• Hyperlipidemia
Tx
• Steroid therapy to reduce edema/ proteinuria
• Diuretics not commonly used
• IV albumin
• Cyclophosphamide-to prevent relapse of the disease
• High protein, low sodium, high potassium diet
• Weigh daily
• I&O
• VS monitoring
• Prevent infection
• Frequent change in positioning
• Kidney transplantation

NEUROLOGICAL DISORDERS

SEIZURE DISORDER
- Disturbances in normal brain function resulting in abnormal electrical discharges in the brain:
a. Generalized seizures
b. Partial seizures
c. Status epilepticus
d. Infantile spasm
Etiology
- Prenatal or perinatal hypoxia, infections
- Congenital malformations
- Metabolic disturbances
- Lead poisoning/Head injuries
- Drug abuse/Alcohol misuse
- Tumors
- Medication/Toxins
- Idiopathic
Sx
• loss of consciousness
• uncontrolled body movements
• changes in behavior and sensation
• changes in the autonomic nervous system
• EEG- abnormal activity

NURSING MANAGEMENT
1. Assess the child and obtain a thorough history
2. Administer prescribed medications
3. Prevent injury
4. Document all seizure activity
a. trigger factor
b. behavior before the seizure/ aura
c. time seizure began and ended
d. clinical manifestations of the seizure
e. postseizure behavior and symptoms
5. Help prevent seizures
6. Promote optimal growth and development and minimize child’s anxiety
7. Prepare the family for alternative treatments when necessary
8. Provide child and family teaching

HYDROCEPHALUS
- an imbalance in either absorption or production of cerebrospinal fluid within intracranial cavity
- congenital or acquired
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- unknown etiology
- diagnosed at birth or within 2-4 months of life
Sx
INFANT
- increased head circumference
- tense bulging anterior fontanel
- distended scalp veins
- high pitched cry
- irritability
- feeding problems
- discomfort when held
OLDER CHILD
- headache
- vomiting especially in the morning
- diplopia/blurred vision
- behavioral changes
- decreased motor function
- decreased level of consciousness
- seizures

Dx
- Clinical signs of increased intracranial pressures
- CT scan
Tx
- Pressure relieved by surgical insertion of a shunting device
- VP/ VA shunts
- Complications include shunt failure (lethargy, irritability, vomiting) and infection
Nursing interventions
(1) Preoperatively: assess neuro functions; always measure HC by obtaining occipito-frontal
measurement
(2) Postoperatively
a. neuro assessment with daily HC
b. position on non-operative site: Check anterior fontanel to determine positioning
of the head; do not pump shunt without physician’s orders
(3) Strict fluid limits ( no more than 70-80% of daily fluid requirement)
(4) Control environmental stimuli; seizure precautions

MYELOMENINGOCOELE (NEURAL TUBE DEFECTS)

CHARACTERISTICS
a. Failure of posterior laminae to fuse
b. Usually associated with other neuro defects
c. Unknown etiology
d. Neural elements and meningeal covering protrude through opening in sac

PATHOLOGY
a. partial to complete paralysis determined by location of defect
b. musculoskeletal problems such as clubfoot, scoliosis or congenital hip dysplasia
c. bowel and bladder problems which includes constipation, incontinence or neurogenic bladder

Tx
a. decision to correct the defect or not is difficult as well as controversial
b. early surgical closure is advocated to preserve neural function, reduced risk of infection and control
hydrocephalus

NURSING INTERVENTIONS
• Prevent rupture of the sac which would predispose the newborn to infection
• Promote healing and reduce neurological complications
• Parents should be taught the Credes maneuver
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• Intermittent self-catheterization can be performed as early as 5-6 years of age

• Hydration and early detection of UTI should be stressed
• Neuro checks with daily HC
• Monitor signs and symptoms of increased ICP
• Instruct family regarding recognition of shunt infection/ malfunction
• Nursing strategies should be directed towards maintaining skin integrity and preventing
decubiti
• Assess family support and available resources
• Offer support