Nurse's Notes - The Black Book

The Nurse's Notes - Black Book is a compilation of must-know concepts in nursing

education. This will help aspiring nurses to be fully equipped in their future exams
(e.g. Nursing Licensure Exam, NCLEX, CGFNS). Do you want to pass this exams? Of
course! Then we will start our journey to uncover those topics as easy as 1,2,3.
TUESDAY, FEBRUARY 17, 2009

Psychiatric Nursing

PSYCHIATRIC NURSING

BeliefsFeelingsBehavior

Sigmund Freud Father of Psychoanalysis

-structure of personality

Id- impulsive part, pleasure principle

-eat, urinate, have sex
-its all I

Superego small voice of God

-conscience
-should not eat yet, should not eat yet

Ego- arbiter, decision maker

-in touch with reality

Id___________________Superego
EGO

ID DOMINANT needs a superego-needs a conscience

M- manic
A- antisocial serial killer
N- narcissistic

SUPEREGO DOMINANT needs an Id

O- Obsessive Compulsive
A- Anorexia nervosa
EGO impaired reality perception (RN will present reality)
S- schizophrenia- cant distinguish fact from reality

Libido- sexual energy

FREUD - PSYCHOSEXUAL THEORY
ORAL 0-18 months
Cry, suck mouth- survival
Id dominant
Maternal deprivation if not feed, not given milk/water, not kept
warm.

Narcissistic seeks the Id I love myself

Regression return to an earlier stage or earlier level
Fixation stopped in a stage

ANAL- 18 mos-3yrs
Toilet training
Mom is superego.
Superego is being formed
Child is caught in ambivalence pulled in 2 opposing factors

Too much toilet training with punishment will result to a child

who is:

Obedient, organized, clean Rebel, dirty, disobedient

= OC =Anti-social
=anal retentive =anal expulsive

PHALLIC 3-6 yrs old

-penis & vagina
-love of parent of opposite sex
Oedipal-boy loves mom
Electra-girl loves dad

Identification- boy imitates dad

Castration fears- fear that dad is angry at him and will cut off
penis
Penis envy- girls envy little boys

Dr. Karen Horney- detractor of Freud, didnt believe in penis envy.

Freud said that it is maybe in her unconscious mind.
Or repressed.

Conscious- highest level of awareness

Pre-conscious- at tip of tongue
Unconscious forgotten

Repression-kept in unconscious. Unconscious forgotten.

Suppression conscious forgetting

LATENT- 6-12 years old Latent- Logtu = sexual energy asleep

School age School phobia- 1st time to go to school Separation
anxiety
Child is busy with Reading, writing, arithmetic.
Sublimation putting anger into something more productive
putting all energies into schooling
Ex. Angry at life, pour anger in singing.

GENITAL 12 years old Genital-Gising sexual energy

Sexual intercourse most important in this stage!!

PHARMA MOMENTS
Anti-anxiety Drugs (used also for alcohol withdrawal)
Valium Librium Ativan Serax Tranxene
Miltown Equanil Vistaril Atarax Inderal Buspar

ERIK ERIKSON

STAGE (+) (-) FACTOR

0-18 months (Oral) Trust vs Mistrust Feeding
18 mos- 3yrs old (Anal) Autonomy vs
Au-(anal)
To-ilet training
No-No! Favorite word.
My Shame/doubt Toilet training
3-6 yrs old (Phallic) Initiative vs
(Initiate 1st steps)
Phallic-oedipal,electra Guilt anger turned inward
Independence
6-12 yrs old (Latent) Industry vs Inferiority Industry
Induskul
12-20 (Genital) Identity vs Role confusion Peers
20-25 Intimacy vs Isolation Love
25-45 Generativity vs Stagnation Parenting
45 up Ego Integrity vs Despair Reflection

Newly admitted pt- develop trust 1st

-pts are dependent=self care deficit
-develop/teach autonomy
-then pt will develop initiative
-etc

Frontal lobe- personality, learning, judgment, language

Occipital- vision
Temporal- hearing, smell
Parietal-taste, touch

Sensory Integration Motor

Somatic nervous system- voluntary movements

Acetylcholine- responsible for voluntary movements
- on switch of movement

Autonomic nervous system- involuntary movements

-Sympathetic(Anti cholinergic) and parasympathetic (cholinergic)

SYMPATHETIC (alert) PARASYMPATHETIC (relax)

Heart tachycardia bradycardia
Respiratory tachypnea bradypnea
GI (opposite effect) Slow, constipation diarrhea
GU (opposite effect) Slow, oliguria, retention Polyuria, frequency
Dry mouth Moist mouth
Neurotransmitter Epinephrine, Norepinephrine Acetylcholine
(AcH)
Pupils Dilated (dilat when alert) (Midriasis) Constricted (Myotic)
Blood vessels vasoconstriction vasodilated
BP increased decreased

Anti-cholinergic / anti-parasympathetic =effect is sympathetic!

Sympathetic drug classifications:

A- anxiety
P- psychotic
Anti C- cholinergic
D- depressants

MONO AMINE OXIDASE INHIBITORS:

mARplan
nARdil
pARnate

DEFENSE MECHANISMS: coping mechanism from stress:

DISPLACEMENT- -------------Your boss shouts at you, you shout at

your subordinate.
SUBLIMATION - ---------------putting anger into something more
productive or +
putting all energies into schooling
Ex. Angry at life, pour anger in singing.
DENIAL- ----------------------I am not an alcoholic!
DISSOCIATION --------------psychological flight from self. Amnesia.
Ex. Rape, trauma
REGRESSION ----------------RETURN to an earlier developmental
stage
FIXATION ---------------------stuck in a stage of development
REPRESSION -----------------unconscious forgetting
SUPPRESSION ---------------conscious forgetting. Avoidance. I
dont want to talk about it. I dont want to remember it.
RATIONALIZATION -------uses because. Has illogical reasoning.
I drink because I dont want to waste the beer in the ref.
REACTION FORMATION----plastic. Doing opposite of intention.
UNDOING- ----------------------show true feeling/color then feels guilty
after.
IDENTIFICATION -----------models a certain behavior from a
certain role model.
PROJECTION -----------------blame other people, pass load to
others. Looks for a scapegoat. Not me, but them.
INTROJECTION --------------assume another persons trait as your
own. Not just you, me too. Ako din, gusto ko yan.
CONVERSION repression. Anger turned inward to herself.
Converted to physical symptoms.
Sensory-numbness. Motor-paralyzed, tremors.
COMPENSATION -----------defects of the person, overachieve to
cover a defective part.
SUBSTITUTION -----------when you replace a difficult role with a
more accessible one.
Ex.Wants to go to Disneyland but cant afford it. Went to
Enchanted Kingdom instead.

Defense mechanism: Affects/interferes with ADL

Harm to self or others

Behavior Model Ivan Pavlov

Classical Conditioning -behavior learned-repeated (+)

BF Skinner operant conditioning-reinforcement

Confront (-) behavior to make it extinct.
MASLOWS HEIRARCHY OF NEEDS:

5. Self-actualization
4. Self-esteem
3. Love and belonging
2. Safety and security
1. Air, food, water, shelter, clothing, sex Basic physiologic needs

LEVELS OF PREVENTION
PRIMARY SECONDARY TERTIARY
Healthy ill Relapse avoidance
Community teaching Crisis intervention Rehab centers
Community demographics Treatment and diagnosis Al anon

STAGES OF INTERACTION
ORIENTATION WORKING TERMINATION
Assessment Problem solving Evaluation
Establishment of trust Discussion Summarize
Tell patient about termination Patient is most cooperative Say
goodbye
Set contract Grief-ANGER-focus of RN
Patient is resistant Pt might become violent/suicidal

ANTI-PARKINSON DRUGS (Capables) used with anti-psychotics

Anti-cholinergic Dopaminergic ABC PLSE

C- Cogentin
A- Artane
P- Parlodel
A- Akineton
B- Benadryl
L- Larodopa
E- Eldepryl
S- Symmetrel
THERAPEUTIC COMMUNICATION NON- THERAPEUTIC
1. Offer self- Ill stay/sit with you. Dont worry, be happy.
2. Explores use what, when, where, how Why? Puts pt in
defensive position.
3. Silence Change the subject.
4. Active listening-nodding, eye contact, leaning
forward-show active participation. Everythings going to be
alright. giving
False reassurance.
5. Make observations. You see/ I have observed/
I have noticed Ignore the patient.
6. Broad opening- How are you?
You have combed your hair today. Prejudicial. Nice weather
today. value based judgment.
7. Clarification-What do you mean by
ploopplank? Flattery dont use too much adjectives. You have
the most beautiful hair in the ward.
8. Restating-I dont want to eat. (Word per word repetition!) You
dont want to eat? Arguing with the patient
Dont impose your opinion.
9. General leads- And then/What else/Go on
10. Refocusing-We were talking abt the exam
11. Focusing-Tell me more abt this.

ABG ANALYSIS
Ph & PCO2-Respiratory-opposite signs
Ph & HC02-Metabolic same signs

Compensation: Ph is normal=Fully compensated.

C02 & HC03 same signs = Partially compensated

ANXIETY
-vague sense of impending doom. Sympathetic activation.

Assessment: Level of anxiety

MILD-------------------sit restlessly, widened perceptual field,

enhanced learning experience. You seem anxious.
MODERATE----------patient is pacing, selective inattention. Give
PRN meds-Anti-anxiety drugs-valium
SEVERE----------------patient cant make decisions. I dont know
what to do or say. RN directs patient. Sit down on the
chair. Directive.
PANIC- highest level of anxiety. Suicidal. Priority: safety. Stay
with patient. Dont touch pt. Sympathetic activation.
I think Im having a heart attack!

Nrs Dx: -----------------Ineffective Individual Coping

P/I: Decrease anxiety, decrease stimuli
HT: relaxation technique
E: Effective Individual Coping

GENERALIZED ANXIETY DISORDER 6 months excessive

worrying. Patient knows what the problem is.
Cant sleep, concentrate, seat
Fatigue and palpitations

PANIC ATTACK ------------------------------15-30 minutes, happens

without warning. SNS activation.
-with or without agoraphobia -------------------- fear of open space
-social phobia ------------------------------------- fear of public

-provide safety
-Alkalosis-brown bag
-stay with patient
-be directive

POST TRAUMATIC STRESS DISORDER

Victims rape, accident, war zone, disaster, trauma

1. Survivor
2. Flashback > 1 month
3. Memory nightmares

MALINGERING------------------------------------- no organic basis (no tissue

change)
-pretending to be sick, conscious
-decrease anxiety for primary gain
-increase attention from RN secondary gain

SOMATOFORM DISORDER ------------------unconscious, not

pretending, no organic basis
- goes doctor hopping

Nervous system Minor discomfort BODY DYSMORPHIC DISORDER

CONVERSION -Feels like illness -illusion of structural defect
-loss of sensory/motor fx -HYPOCHONDRIASIS -S/sx not real
-s/sx real (biglang nabulag)

PSYCHOSOMATIC DISORDER (Psychophysiologic) real illness,

real s/sx, real pain, with organic basis (with change in tissue)
- stress ulcers, migraine, HPN

PHOBIA---------------------------------------------------------- irrational fear

Etiology knowledge, experience

Immediate nsg intervention: Remove object of fear

(Increase stimuli=increase level of anxiety)
(Decrease stimuli=decrease anxiety)

Belief Feeling Behavior

Object will hurt patient Scared Avoidant=interferes with ADL

Gradual exposure to feared object- SYSTEMATIC

DESENSYTHEZATION

Individual Therapy
1. Hypnosis --------------relaxed state
2. Free association ------ ideas shared to psychoanalyst
3. Catharsis --------------free to express feeling
4. Transterence- -----------patient feels something for psychoanalyst
5. Countertransterence --RN feels something for patient
Green light-Go Epi & Norepinephrine
Red light Stop G-gamma
A-amino
B-butyric
A- acid

Anxiety

Increase GABA Anti-cholinergic S/E

GI-constipation
GU-retention

Effect of GABA:
Drowsy, drink, dont drive, orthostatic hypotension
Anti-anxiety drug

Withdrawal from drug abrupt REBOUND PHENOMENA leads

to seizures. 1 week effect.
Gradual withdrawal tapered dose
Dependence- Cant live without valium

ANTI-PSYCHOTIC AGENTS Sympathetic effect.

Effect 2-4 weeks

STELAZINE CLOZARIL
SERENTIL MELLARIL
THORAZINE HALDOL
TRILAFON PROLIXIN

SCHIZOPHRENIA-------------------------------impaired reality perception.

Ego disintegration. Genetic vulnerability. Stress.
-Chose fantasy over reality. Increase dopamine theory. Cause:
unknown.
Increase dopamine, increase schizophrenia.
4 As:
1. Affect---------------------------------------------feelings & emotions (smiles,
laughs). External, readily observable.
Mood, internal, does not match affect. (sad inside)
2. Ambivalence-------------------------------------pulled between 2 opposing
forces
3. Autism --------------------------------------------self absorbed. Trapped in his
own world.Attached to odd objects.Poor eye contact.
4. Associative looseness---------------------------talk about so many
things but unrelated ideas.

Disturbed thought process-------------------------Nsg dx

Content of thought---------------Hallucinations/Illusions------------
ADL----------------------------Harm

Disturbed thought process

Disturbed sensory Self care deficit Self Other
Perception Directed Violence

P/I: Reality/Orient/Safety
Eval: Improved thought process
S & Sx of Schizophrenia:
(-)neg sx (+) positive sx
hypoactive hyperactive flight of ideas
withdrawn restless hallucinations
quiet, flat affect talkative delusions many ideas
poverty of words queen of the world illusions

Types of schizophrenia:

1. Disorganized schizo---------------------------------sad inside, happy

outside inappropriate affect (+)
flat affect no affect (-)
disorganized manner/speech flight of ideas (+)
Hebephrenic- giggling (+)
Sx: both (+) and (-).

2. Catatonic ---------------------------------------------ambivalence anal stage

(-)
No! Negativisim-rebel-anal (-)
Waxy flexibility--------------raise arm of patient. Patients arm
remains up for a long time. (-)
(-) > (+)

3. Paranoid ----------------------------------------------uses projection.

Mistrust Scared/withdrawn/violent Based on history

Develop trust: orientation -Leave door open

-1:1 interaction -Distance from pt: 1 arms length
-consistent approach -stay near door not window
-short/frequent interaction -have visibility:stand halfway in & out
-food: sealed container to be able to call for reinforcement.
-meds: wrapped in tamper resistant foil -calm and firm

4. Unclassified/ Undifferentiated-----------------------cant be classified

anymore.

5. Residual-------------------------------------------------no more (+), (-). Social

withdrawal

THOUGHT PROCESS DISTURBANCE

1. LOOSENESS OF ASSOCIATION----------------topics have connection
but no thought. I am going to the mall. The mall is in
town. The town flies. Flies are here.
2. FLIGHT OF IDEAS ---------------------------------New unrelated topics. I
am going to the mall. Where is the light? I treasure this
chalk. Hurray!
3. AMBIVALENCE-------------------------------------Pulled by 2 opposing
forces.
4. MAGICAL THINKING----------------------------- believes he has magical
powers. I can turn you into a frog.
5. ECHOLALIA------------------------------------------repeat what is said.
Parrots.
6. ECHOPRAXIA----------------------------------------repeats what you do.
Repeats what is seen.
7. WORD SALAD----------------------------------------mixes words that dont
rhyme.
8. CLANG ASSOCIATION----------------------------uses words that rhyme.
Flank, blank, prank.
9. NEOLOGISM------------------------------------------invents new words not in
the dictionary. Ploopplank, pisnok.
10. DELUSIONS-----------------------------------------false belief
Grandeur--------------I am a queen/ king/millionaire!
Persecution------------NBI out to get me!
Ideas of reference-----They talk and write about me!
11. CONCRETE ASSOCIATION-----------------------pilosopo. What will
you wear tomorrow? Clothes!
12. HALLUCINATIONS----------------------ILLUSIONS (with stimuli)
Stimuli N Y
Visual N Y
Auditory N Y
Tactile N Y

Present reality!!! H A R D-Directive. Lets go in the garden.

Acknowledge: I know the voices are real to you. Present reality.

But I cant hear them.
=Assess what voices are saying to know if patient will harm
himself.

Increase Dopamine = increase schizo

Decrease dopamine = decrease schizo

Extra Pyramidal Side Effects (EPSE) (Happens when

acetylcholine is up and dopamine is down)
1. AKATHISIA-------------------------- restless, inability to sit still.
2. AKINISIA ---------------------------- rigidity
3. DYSTONIA--------------------------- affects neck
TORTICOLLIS -------------wry neck
OCULOGYRIC CRISIS fixed stare
OPISTHOTONUS ---------arched back, contracted
4. TARDIVE DYSKINESIA------------lip smacking, tongue is
protruding, puffy cheeks. Irreversible!
5. NEUROLEPTIC MALIGNANT SYNDROME- hyperthermia,
unstable BP, increase CPK, diaphoresis, pallor
-discontinue meds, medical emergency.
6. PHOTOSENSITIVITY------------------wear shades, sunscreen
7. WBC- Agranulocytosis---------------sore throat, fever, malaise,
leukopenia

AUTISM- boys > girls. 1:100 kids gift-autistic savants

-echolalis, poor eye contact, cant express verbally.
Assess:
A- appearance- neat, OC, wants constancy
B- behavior- ritualistic behavior, flat affect, repetitive
C- communication difficulty communicating

Nsg Dx: Impaired social interaction cant form IPR

(Interpersonal relationship)
Impaired verbal communication
Self mutilation cant express anger. Express it inward.
Risk for injury

P/I: constancy, promote safety

Expressive therapy uses art, music, poetry, decreasing risk for
injury, improved social interaction, be able to express feelings.
E: -Safety

ADHD- ATTENTION DEFICIT HYPERACTIVITY DISORDER (can

progress to conduct disorder to anti-social behavior)
Cant focus on anything.
Onset 7 yrs old and below
Duration >6 months
Setting: House & school
ID dominant: Mom or RN will act as superego

Assessment:
A- appearance: dirty
B- behavior: clumsy, impatient, easily distracted
C- talkative

Nsg Dx: High risk for injury

Safety
Structure- provide place to study, eat, play,bath,etc.
Schedule time for everything
Set limits

Residual ADHD grows up not anti-social

Meds: Ritalin, Dexedrine,Pemoline, Adderal

Best time to give meds: If once a day give AFTER MEALS- to
prevent loss of appetite.
Dont give at bedtime-its a stimulant-will cause insomia. Can be
given 6hours before bedtime (if q2d)

ANOREXIA NERVOSA diet, underweight < 85% of expected fat, 3

months amenorrhea, failure to recognize problem.
BULIMIA NERVOSA induce vomiting, takes laxative, normal
weight, irregular menstruation, dental carries, diarrhea
- knows problem but ashamed and embarrassed,

Priority: Fluid volume balance

Weight gain monitor weight, eating pattern, stay 1 hour after
eating, accompany in toilet

Problem: Body image Disturbance

NI: 1. Establish nutrition pattern
2. Teach stress management, journal keeping
3. Monitor eating pattern and weight.
4. Anti-depressant
MANIA needs mood stabilizing agents- Lithium. Group therapy

L- 0.5-1.5 mEq/L (If level is near 2.5-3 mEq/L will cause ataxia
and mental confusion)
I- increase urination
T- tremors
H- H20- 3L/d
I- increase
T- uu
M- mouth dry
N- Na- 135-145 mEq/L to hold water

Check kidney(blood level) before administration of Lithium BUN,

CREA, electrolyte
Lithium toxicity n/v, diarrhea = Diamox

BIPOLAR DISORDER 2 poles, happy (more dominant) & sad

-female, >20 yrs old, stress, obese
Self actualization
Task to decrease self esteem
Family therapy
Risk for injury, risk for other directed violence
Decrease eat, decreased sleep, hyperactive, increase sex
masturbate in front of others

Nsg Dx: High risk for self or other directed violence

Risk for injury

Give task, no group games, any competition will increase anxiety,

water the plants, activities using gross motor skills, escorted
walk, punching bag-displacement.

3 or more signs confirms disorder:

G grandiose, increase risk activities
F flt of ideas
S - sleeplessness
P pressured speech
E exaggerated SE
E extraneous stimuli (easily distracted)
D distractability

PERSONALITY DISORDER

1. Schizoid --------doesnt care about people, believes that he can

stand on his own, never had a best friend
avoid groups & activities no enjoyment
cares more about computers, pets
2. Avoidant ----------avoid group fear criticism, have talent but no
confidence.
3. Anti-social ------as child steal, lie, always get reprimanded
Adult grand robbery, illegal activities against the law.
drug addiction, drives fast, unsafe sex, thrill seeker.
Good talker, charmer, witty, manipulator. Motto I will break the
law

4. Borderline -------Favorite line life is an empty glass. Splitting,

suicidal, superficial relationship, labile-sudden change of
Mood, self mutilation.
(+) (-)
fill glass with friends suicide
have happy moments LABILE AFFECT sad moment

labile- change from good to bad in a split moment

5. Dependent ---------Decrease self esteem, dependent

Poor decision making skills
I cant live if living is without you

6. Histrionics ----------excited, dramatic, manipulative

- CENTER OR ATTENTION
-
7. Narcissistic----------I love myself insensitive, arrogant, self
absorbed
- exaggerated Self esteem, ambitious I am the best
-
8. OC ------------------ perfectionist, organized, constancy in
environment. Provide time to do rituals.

9. Paranoid ----------- always jealous, suspicious, violent

10. Passive aggressive ------always say yes, but resistance is

hidden.

Nsg Intervention: Improve IPR, build trust

A-LCOHOL ABUSE ----------------------happy socializing Narcotic

oversode-give Narcan
-escape from problem Narcotic detox- Methadone
-peer pressure Aversion therapy-Antabuse

B-blackout ---------------- awake but unaware

C-confabulation ---------- invent stories to increase Self-Esteem
D-denial ------------------- I am at not an alcoholic.
D-dependence ------------ I cant live without alcohol.
a. physical tremors, tachycardia, restless
b. psychological craving
E-enabling/codependency (significant others tolerate abusers)

DISULFIRAM
voids alcohol beer
version therapy
ntabuse (DISULFIRAM)
lcoholics anonymous n/v
hypotension
interval of alcohol & antabuse:
12h interval after alcohol intake
B1 Thiamine
Complications wernickes
Encephalopathy
Korsakoff psychosis

Wernickes VROOM Motor sx effect

Korsakoff memory- confabulation

24 72h after alcohol intake

Delirium tremors happens due SNS activation
Tremors, hallucinations, illusions. Well lit room to avoid
hallucinations

ANTI DEPRESSANTS decrease serotonin problem

Anti depressants full stomach
All meds take on a full stomach, except anti anxiety.

ASENDIN TCA
NORPRAMIN TCA
TOFRANIL TCA
SINEQUAN TCA
ANAPRANIL TCA - OC
AVENTYL TCA
VIVACTIL TCA
ELAVIL TCA
PROZAC SSRI
PAXIL SSRI
ZOLOFF SSRI
LUVOX SSRI
Serotonin ---------makes us happy
Decrease serotonin pt becomes sad depression
Increase serotonin antidepressant
SSRI:

Selective S
Serotonin S (decrease S/E)
Reuptake R
Inhibitors I (1 4 weeks)

If SSRI dont work, give TCA

Tri Cyclic Antidepressants ( TCA) ----------2 4 wks has increased

S/E
increased Serotonin & Norephinephrine

MAOI-------------------------- effect 2 6wks

Increase E, NE, serotonin kills serotonin - MAOI
increase MAO = decrease serotonin
* decrease MAO = increase serotonin
give MAOI
Most dangerous, most S/E
Diet avoid tyramine food eat SARIWA, fresh foods
HPN crisis dangerous! Increase CR, diaphoresis

Tyramine rich food:

Avocado Pickles
Alcohol Fermented foods
Beer Eggplant
Chocolate preservatives tocino, bologna,canned meat etc.
Cheese mozerella, swiss cheese
W ine
S soysauce

Anticholinergic = antidepressants antiparasympathetic

Dry, constipation, retention, tachycardia
Male erectile dysfunction

MAOI
mARplan
NARdil
PARnate

DEPRESSION decrease serotonin. If unresponsive to drugs, ECT-

electroconvulsive therapy
Assess:
1. Denial this cant be happening. This cant be real.
2. Anger Why me, why now, why God?!
3. Bargaining If returned, I will give reward.
4. Depression 2 wks or more of sx = clinical depression
5. Acceptance client acts according to situation. Pt prepares
living will.

Increase risk for self directed violence.

Maslows:
5
4 decrease Self-esteem give TASK
3 Pt is withdrawn
2 Risk for self directed violence suicide
1 eat (wt gain) or not eat(wt loss), sleep or not sleep,
hypoactive, decrease sex

SUICIDE CUES:
I wont be a problem any longer
Remember me when Im gone
This is my last day
This is my wedding ring. Give it to my son
- Sudden change in mood.
Pt is suicidal, RN should: D d irect question Are you going to
commit suicide?
I irregular interval of visit to pt room
E early am & endorsement period - time pts commit suicide.

Who will commit suicide?

S sex male (more successful)/female (hesitant)

A age 15 24yo or above 45
D depression
P pt with previous attempts will try again
E ETOH (Ethanol) alcoholics
R irrational
S lacks social support
O organized plan greater risk
N no family
S sickness, terminal

Suicide Triad:
- Loss of spouse
- Loss of job
- Aloneness

Best approach for suicide: Direct approach

Nursing Mgt: close surveillance

Hospital area majority suicide happens at: weekends 1 3 am

Sunday
Weekend less staff personnel
Early am every one is asleep

Give simple task. Dont give complex task no jigsaw puzzle

Water the plants
Wash the dishes except sharp objects

SUBSTANCE ABUSE
Type of Addict:
1. Nervous -----tremors
Give downers

Sx of overdose
1. Identify if drug is upper or downer
2. Check effect
3. Sx of withdrawal
If patient takes a downer, all vital signs are down! If he stops
taking it (during withdrawal), patient will experience the opposite
effect of a downer. All his vital signs will shoot up! Same with
uppers.
Ex: Pt had cocaine intoxication. Pt will manifest hyperactivity,
tachypnea, seizure. During withdrawal, pt will manifest
bradypnea or coma.

Substance Abuse Moments

(downer)
A alcohol
B barbiturates
O opiates Antidote
N narcotics - Narcan (narcotic antagonist)
M marijuana

Morph
CODE
HERO

(uppers)

C cocaine
H Hallucinogens
A amphetamines

Uppers Downers
Seizure decrease RR, decrease HR
Tachypnea Para constricted pupil
Moist mouth
Dilated Blood Vessels
Coma
Asleep
Decreased GI constriction
Decrease GU retention
Decrease BP
State of euphoria

Sx of withdrawal reverse of effect

1. Know if upper or downer
2. Opposite of effect

Overdose Withdrawal (opposite of withdrawal is overdose)

Alcohol coma seizure
Morphine bradypnea tachypnea

Detox withdrawal with MD supervision

Methadone

2. Depressed - Sits down on chair

Uppers
Codeine increased heart increase - BP increase, awake
Hallucinogen sympathetic HR increase seizure
Amphetamine pupils- dilate GI - diarrhea
Mouth dry
Decrease appetite - thin

Stop uppers
Tremors crash syndrome Depressed Suicide
Fatigue

LEVELS OF MENTAL RETARDATION

Profound severe moderate mild borderline normal

IQ 20 35 50 70 90 110
Profound Mental retardation IQ <20 =thinks like an INFANT. Cant
be trained. Stay with patient.
Severe MR 20-35
Moderate 35-50 = Can be trained. Mental age is 2-7yo. Pre-
operational stage.
Mild 50-70 = (mild 7) Mental age is 7-12. Educable. Can go to
school.
Borderline- 70-90
Normal- 90-110

JOHN PIAGET COGNITIVE THEORY

0-2 yrs old S-ensory motor. Baby can sense, see, perceive and
hear. Object permanence
2-4 yo- P-reconceptual- language.
4-7 yo- I-ntuitive stage. Unidimentional classification or
unidimentional characteristic.
Child can fix toys according to size, color, height=one at a time
only.
7-12 yo- C-conservation/concrete association. Multidemensional
12yo- F-ormal operation good in abstract thinking. Can interpret
proverbs.

CHILD ABUSE

B=burns, bruises, bone fractures, bungi

Dont bathe child. Dont brush teeth. Body of evidence will be
lost.
Bantay Bata 163

ALZHEIMER
Anomia- dont know name of object
Agnosia problem with senses (smell, taste, hear, touch)
Aphasia cant say it
Apraxia cant do it
Dissociative Fugue- takes a new personality from a tar away
place. New place new identity.
Dissociative Identity Disorder multiple personality
Dissociative Amnesia dont know who/where I am.

DEPERSONALIZATION- believe that they are not persons anymore

PERSEVERATION- kulit. I want to talk about something because
this is something that I want to do. It is something that I need to
talk about. This is something that I want to do.

ELECTROCONVULSIVE THERAPY- sign informed consent. For

depressed pt. If meds dont work, use ECT.

Pre-ECT
N-npo 6 hours
A-atropine sulfate dry mouth
B-barbiturate
S- succinylcholine chloride to relax muscles

Post-ECT
Side-lying- lateral
S/E headache, dizziness, temporary memory loss (distinct
sx)=RN-orient pt.

EXAMS:
Nsg intervention:

Look for words like:

S=safety, support, stay, set limits, assist
Provide safety. Mobilize support system. I will stay with you.
Assist in activity.
Set limit- dont allow patient to misbehave.

Look for words like:

Orient=orient pt post delirium, ECT, pt with dementia
Accept
Seem, observed, noticed, comment, feelings

Group therapy- facilitator is RN.

Rape, battered pt

ALTRUISM Victim becomes a counselor, shares experience to

new victim.

Self-help group=facilitator is the pt themselves. AL ANON groups

Alcoholics Anonymous
Posted by Rey at 6:35:00 PM 1 comments

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Pediatric Nursing

Growth and 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.
Wt doubles 6 months
3x 1yr
4x 2-2 yrs

2. Height- increase by 1/mo during 1st 6 months

- average increase in ht - 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.
MMDST (Phil) Metro Manila Developmental Screening Test.
DDST measures mental

4 main rated categories of DDST

1. Language communication
2. personal social-interaction
3. fine motor adaptive- 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.

IQ test- test to determine cognitive development

Mental age x 100 = IQ
Chronological age

Average IQ 90-100
Gifted child- > 130 IQ

Basic Divisions of Life

I. Prenatal stage from conception- birth

II. Period of infancy

1. Neonatal- 1st 28 days or 1st 4 weeks of life
2. Formal infancy- 29 day 1 year

III. Early childhood

1. Toddler 1-3 yrs
2. Pre school 4-6 years

IV. Middle childhood

1. School age- 7 12 yrs

V. Late childhood
1. Pre adolescent 11 13 yrs
2. Adolescent 12 - 18 21

Principles of G & D
1. G&D is a continuous process
-begins form conception- ends in death
- womb to tomb principles
2. not all parts of the body grow at the same time or at same
rate.
- asynchronism

Patterns of G&D
1. )renal
digestive grows rapidly during childhood
circulatory
musculoskeletal

2. )Neuromuscular tissue (CNS, brain, S. cord)

- grow rapidly 1-2 years of life
- brain achieved its adult proportion by 5 years.

3. )Lymphatic system- lymph nodes, spleen grows rapidly- infancy

and childhood to provide protection -infection
- tonsil adult proportion by 5 years

4. )Repro organ- grows rapidly at puberty

Rates of G&D
1. fetal and infancy most rapid G&D
2. adolescent- rapid G&D
3. toddler- slow G period
4. Toddler and preschool- alternating rapid and slow
5. school age- slower growth

fetal and infancy- prone to develop anemia

3. Each child is unique

2 primary factors affecting G&D

A. Heredity - R race
I intelligence
S sex
N - nationality

Females are born less in weight than males by 1 oz.

Females are born less in length than males by 1 inch

B. Environment
Q quality of nutrition
S socio eco. status
H health
O ordinal pos in family
P parent child relationship

Eldest- skillful in language and social skills

Younger- toilet trained self

4.G&D occurs in a regular direction reflecting a definitive and

predictable patterns or trends.

Directional trends- occur in a regular direction reflecting the

development of neuromuscular function. These apply to physical,
mental, social and emotional development and includes.
a. cephalo-caudal head to tail
- occurs along bodies long axis in which control over head, mouth
and eye movements and precedes control over upper body torso
and legs.
b. proximo- distal Centro distal
- progressing form center of body to extremities.
c. Symmetrical- at side of body develop on same direction at
same time at same rate.
d. Mass specific differentiation
- child learns form simple operations before complex function of
move from a broad general pattern of behavior. To a bore refined
pattern.

B. Sequential- involves a predictable sequence of G&D to which

the child no9rmally passes.
a. locomotion- creep than crawls, sit then stand.
b. socio and language skills- solitary games, parallel games
C. Secular- worldwide trend of maturing earlier and growing
larger as compared to succeeding generations.

5.Behavioral in the 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 us must be lost before one can proceed.
-plantar reflex should disappear before baby can walk
-moro reflex should disappear before baby can roll
persistent primitive infantile reflexes- case of cerebral palsy

Theories of G&D
Developmental tasks- different form chronological age
-skill or growth responsibility arising at a particular time in the
individuals life.
The successful achievement of which will ------- a foundation for
the accomplishments of future tasks.

Theorists
1. Sigmund Freud 1856-1939 Austrian neurologists. Founder of
psychoanalysis
- offered personality development
Psychosexual theory

a.) Oral Phase 0-18 months

- mouths site of gratification
-activity of infant- biting, sucking crying.
-why do babies suck?- enjoyment and release of tension.
-provide oral stimulation even if baby was placed on NPO.
-pacifier.
-never discourage thumb sucking.

b.) ANAL- 18 months-3 years

-site of gratification- anus
-activity- elimination, retention or defecation of feces make 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 and bladder control even if child is
hospitalized.

c.) Phallic- 3-6 years

site of gratification -genitals
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- 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 so ready to face conflict of
adolescence

e.) Genital- 12-18 years

-site of gratification -genitals
-achieve sexual maturity
-learns to establish relationships with opposite sex.
-give an opportunity to relate to opposite sex.

ERIC ERICKSON- psychoanalysis theory

- stresses important of culture and society to the development of
ones personality
- environment
- culture

stages of psychosocial
a.) trust vs mistrust 0-18 months.
-foundations of all psychosocial task
-to give and receive is the psychosocial theme
-know to develop trust baby
1. satisfy needs on time
- breastfeed
2. care must be consistent and adequate
-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 and doubt 18-3 years --- independence

/self govt
develop autonomy on toddler
1. give an opportunity of decision making like offer choices.
2. encourage to make decision rather then judge.
3. set limits

c. initiative vs guilt- 4-6 years

-learns how to do basic things
-let explore new places and events
-activity recommended- modeling clay, finger painting will
enhance imagination and creativity and facilitate fine motor devt

d. industry vs inferiority 7-12 yrs

-child learns how to do things well
-give short assignments and projects

e. Identity vs role confusion or diffusion 12-18 yrs

- learns who he/she is or what kind of person he/ she will become
by adjusting to new body image and seeking emancipation form
parents
-freedom form parents.

f. Intimacy vs isolation 20-40 yrs -looking for a lifetime partner

and career focus

g. generatively vs stagnation 40- 60 45-65 yrs

h. ego integrity vs, despair 60-65
JEAN PIAGET- Swiss psychologists
-develop reasoning power

STAGES OF COGNITIVE DEVELOPMENT

A-Sensory motor 0-2 yrs
-practical intelligence- words and symbols not yet available
baby communicates through senses and reflexes.
(sub div.)

Schema Age Behavior

1.) neonate reflex 1 month All reflexes
2.) primary circular 1-4 months -Activity related to body
-repetition of behavior
ex. thumb sucking
3.) secondary circular reaction 4-8 months -activity not related to
body
-discover obj and persons permanence
-memory traces present
-anticipate familiar events.
Coordination of secondary reaction 8-12 months -exhibit goal
directed behavior
-increase of separateness (will search of lost toy, knows mom)
Tertiary circular reaction 12-18 months -use trial and error to
discover places and events
- invention of new means
-capable of space and time perception
(hits fork, spoon on table or drops fork)
Invention of new means there mental combination 18-24 months
-transitional phase to the pre operational thought period.
Preoperational thought 2-7 years

Schema age Behavior

Preconceptual 2-4 yrs -thinking basically complete literal and
static
-egocentric- unable to view others interrupt
-concept of dying is only now
-concept of distance is only as fat as they can see.
-concept of amenism inanimate object is alive
-not aware of concept of r3eversibility- in every action theories
an opposite reaction or cause and effect
Initiative 4-7 yrs Beginning of causation

Concrete Operational thought 7-12 years

1. able to find solution to everyday problems which systematic
reasoning.
2. have concept of reversibility- cause and effect
3. have concept of longer uation constancy despite of
transformation.
4. 4. activity recommended- collecting and classifying
5. stamps stationeries, dolls, rubber band markers.

Formal Operational thought 12 and up.

1. Cognition achieved its final form
2. can deal with past present and future
3. have abstract and mature thoughts.
4. can find solutions to hypothetical problems with scientific
reasoning.
5. activity ------- will sort out opinions and current events.

KOHLBERG- recognized the theory of moral devt as considered

to closely approximate cognitive stages of devt
-sabay with cognitive dev;t

Stages of Moral devt

Infancy premoral, prereligious, amoral stage

AGE STAGE DESCRIPTION

Pre-conventional Level 1
2-3 yrs 1 -Punishment/ obedience oriented (heteronymous
morality) child does right cause a parent tells him or her to and
to avoid punishment
4-7 2 -Individualism. Instrumental purpose and exch. Carries out
action to satisfy own needs rather than society.
-Will do something for another if that person does something for
the child.
Conventional Level
7-10 3 -Orientation to interpersonal relations of mutuality. Child
followers rules cause of a need to be a good person in own eyes
and eyes of others.
10-12 4 -Maintenance of social order fixed rules and authority.
Child finds ff. rules satisfying. Follows rules of authority figures.
Post-conventional Level III
Above 12 yrs 5 -Social contract, utilitarian level making
perspectives. Followers standards of society.
6 Universal ethical principle orientation. Follows internalized
standards of conduct.

E. DEVT MILESTONES-major markers of growth and devt

1. Period of infancy- universal language of child-play
a.) Play- Infancy- solitary plays
-solo, mom interactive
-facilitate motor and sensory devt
-safety- important age appropriate
solitary play- mobile, teeter, music box, rattle
b.) fear of infancy- stranger anxiety begin 6-7 months peak 8
months diminishes 9 months

1 month- dance reflex disappears looks at mobile

2 months- holds head up when in prone,

social smile,
baby coos doing sound
cry with tears
-closure of frontal fontanel 2-3 months
head lag when pulled to sitting position.

3 months- holds head and chest up when prone

follows obj. past midline
grasp and tonic neck reflex fading
hand regard (looks at hand)
4 months turns form front to back
head control complete
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)

6 months- reaches out in anticipatory of being picked up

-sits with support
-uses palmar grasp
-eruption of 1st temp teeth 6-8 months 2 lower incisors
-say vowel sounds ah, oh
-handles bottle well

7 months- transfer obj. hand to hand

-likes obj that are good size

8 months- sits without support

-peak of stranger anxiety
-planters reflex disappears 8-9 months in prep for walking

9 months - creeps or crawls

-neat finger grasp reflex
- combine 2 syllables mama and papa
- needs space for creeping

10 months pull self to stand

-understands no
-responds to own name
-peak a boo, pat a cake
-can clap

11 months- cruisse
- stands with assistance
12 months- stand alone take 1st step
-walk with assistance
-drink from cup, cooperate in dressing
-says 2 words mama and dada
-pots and pans, pull tay, nursery rhymes

Toddler- parallel play- 2 toddlers playing separately

-provide with similar toys
-squeaky frog to squeeze
waddling duck to pull
trucks to push-push pull toy
building blocks, pounding peg
toys to ride on
fear- separation anxiety
begin 9 months
peak 18 months

3 phases of separation anxiety (in order)

1. P- protect
2. d despair
3. d- denial

-dont prolong goodbye

-say goodbye firmly to develop trust- say when ul be back

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
- 4 - 6 words

18 months- height of possessiveness

favorite word- mine
bowel control achieved (bowel 1st before bladder)
-no longer rotates spoon
-can run and jump in place
walks up and down stairs holding railing or persons hand
-1-20 words
-name, body part
-puts both feet on 1 step before advancing.

24 months- terrible two

-can open doors by turning door knobs
-unscrew lids
-can walk upstairs alone using both feet on same step at same
time
-50-200 words ( 2 words sentences)
-daytime bladder control achieved ( daytime 1st- next nighttime
bladder control)

30 months or 2 years 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
- temp teeth complete

post molar- last temp teeth to appear

how many deciduous teeth -20
beginning of toothbrush 2-2 yrs
tooth brushing with little assistance 3 yrs
tooth brushing alone 6 yrs
right time to bring to dentist- when temp teeth complete

36 months or 3 yrs- trusting 3

- unbutton buttons (unbutton before learn to button)
-draw a +
- learns how to share
-knows full name and sex (gender identity)
- speaks fluently
-nighttime bladder control
-300-900 words
-ride a tricycle

Characteristic Traits of toddler

negativistic- NO! -way to search for independence
limit questions
modify questions to a statement
2.) rigid, ritualistic and stereotype
ritualism- for mastering
3.)Temper tantrums- head banging, screaming, stamping feet,
holds breath
ignore behavior
scaffoid abdominal-due to underdeveloped abdominal muscles
physiologic anorexia- due to preoccupation with environment-
food jag that last for short period of time
loves rough and tumbling play
loves toilet training-
failure of toilet training- unreadiness

Clues of toilet readiness:

1.) can stand, squat walk alone
2.) can communicate toilet needs
3.) can maintain dry for 2 hours

Pre schoolers- associative or cooperative play

1.) bahay-bahayan play house
2.) role playing
3.) fear-body mutilation or castration
fear of dark places witches
fear of thunder and lightning
fear of ghosts

Milestones
4years old- furious 4 , noisy, aggressive, stormy
-can button buttons
-copy a square
-jumps and skips
-laces shoes
-vocabulary 1,500
-knows four basic colors
5 years old- frustrating 5
-copy a triangle
-draw a 6 part man
-imaginary playmates
-2,100 words

Character Traits of Pre-schooler:

1.) curious, creative imaginative, imitative
2.) 2. favorite words- why and how
3.) complexes- word identification to parent of same sex and
attachment to parent of opposite sex
ex. Oedipal complex- boy to mom
Electra complex- girl to dad
Cause of incest marital discord

Death-sleep only

Behavior problems Preschool

1. telling tall tales-over imagination

2. imaginary friend- to release tension and anxieties
3. sibling rivalry- jealousy to newly delivered baby.
4. regression- going back to early stage
-thumb sucking (should be oral stage only)
-baby talk
-bed wetting
-fetal position
5. masturbation- sign of boredom
-divert attention- offer a toy

School Age
Play- competitive play
Ex. Tug of war, track and field, basket ball

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
-7-9yrs death is personified
-death- permanent loss of life

Significant Development
a. boys- prone to bone fracture
b. mature vision 20/20

6 years- temp teeth begin to fall

perm teeth appear- 1st molar
1st temp teeth- 5 months
1st perm teeth- 6 yrs
-yr of constant motion
clensy mout
recognize all shapes
-1st grade teacher becomes authority figure
-nail biting
-begin interest in God.

7 yrs- assimilation age

-copy a diamond
-enjoys teasing and playing alone
-quieting down period

8 yrs- expansive age

-smoother mouth
-loves to collect objects
-count backwards

9 yrs coordination improves

-tells time correctly
-hero worship
-stealing and lying are common
-takes care of body needs completely
-teacher finds this group difficult to handle

10 yrs- age of special talent

-writes legibly
-ready for competitive games
-more considerate and cooperative
-joins orgs.
-well mannered with adult
-critical of adults

11-12 yrs pre adolescents

-full of energy and constantly active
-secret language are common
-share with friends secrets
-sense of humor present
-social and cooperative

Character Traits School Age

1. industrious-
2. modest
3. cant bear to lose- will cheat
4. love collections- stamps

Signs of sexual maturity

GIRLS:
I-inc size breast and genitalia (pelarche- 1st sign sexual mat.
W- widening of hips
A- appearance axillary, pubic ( adrenarch)
M- menarche- last sign sexual mat. Girls

BOYS:
A-appearance axillary, pubic hair ( 1st sign sexual mat)
D-deepening voice
D- development of muscles
I--inc in testes and penis size
P- prod of viable sperm ( last sign sexual maturity)

Adolescent
Fear
1. obesity
2. acne
3. homosexuality
4. death
5. replacement from friends
6. significant person- opp sex.

Significant devt
1. experiences conflict bet his needs for sexual satisfaction and
societies expectation
2. change of body image and acceptance of opp/sex
3. nocturnal emission wet dreams
4. distinctive odor- due to stimulation apocrine glands
5. sperm is viable by 17 yrs
6. testes & scrotum increase until age 17
7. breast and female genitalia increase until age 18

Personality Traits Adolescents

1. idealistic
2. rebellious
3. reformers
4. conscious with body image
5. adventuresome

Problems:
1. vehicular accident
2. smoking
3. alcoholism
4. drug addiction
5. pre marital sex

IMMEDIATE CARE OF NEWBORN

1st days of life

1. initiation and maintenance of respiration

2. establishment of extra uterine circulation
3. control of body temp
4. intake of adequate nourishment
5. establishment of waste elimination
6. prevention of infection
7. establishment of an infant parent relationship
8. devt care that balances rest and 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 with in 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
2,) suction mouth 1st before nose
-neonates are nasal breathers
3.) period of time
-5-10 sec suctioning, gentle and quick
prolonged and deep suctioning can lead to hypoxia, laryngo
spasm, brady cardia due to stimulation vagal nerve

4.) evaluate for patency

-cover nostril and 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 an (+) pressure bag and mask
with 100% oxygen at 40-60b/m.

Nsg alert:
1. No smoking
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)
4. When mecomium stained (greenish) never administer oxygen
with pressure ( O2 pressure will push mecomium inside)

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- IVC- RT atrium 70%
blood is shunted to foramen ovale- LT atrium mitral valve LT
ventricle- aorta-lower extremities.

-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.

SHUNTS-shortcuts
Ductus venosus- -shunts from liver to IVF
Foramen ovale- shunts bet 2 atrias
Ductus arteriosus- from pulmonary artery to aorta

What will sustain 1st breath- decreased artery pressure

What will initiate lung circulation-lung expansion
What will complete circulation- cutting of cord

4.) 2 way to facilitate closure of foramen ovale

a.) Tangential Footstep- slap foot of baby
-never stimulate baby to cry if secretions not fully drained to
prevent aspiration
-check characteristic of cry
normal cry- strong, vigorous and lusty cry
cri-du-chat syndrome-chromosomal obliteration cat like cry
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
Obliteration-complete closure

Structure Appropriate time of obliteration Structure remaining

Failure to close
F. Ovale 1yr Fossa Ovalis Atrial Septal Defect
Ductus Arteriosus 1 month Ligamentum Arteriosum Patent
ductus arteriosus
Ductus Venosus 2 months Ligamentum venosum
Umbilical artery 2-3 months 1.) lateral umb. Ligament
2.) interior iliac artery
Umbilical vein 2-3 months -ligamentum teres ( round ligament of
liver)

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
3.) increase BP and widening pulse pressure #3 & #4 are
Cushings triad of
4.) Decreased RR, decreased PR ICP
5.) projective vomiting- sure sign of cerebral irritation
6.) high deviation diplopia sign of ICP older child
4-6 months- normal eye deviation
>6 months- lazy eyes
7.) High pitch shrill cry-late sign of ICP
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. preterms are born poi kilo thermic- cold blooded
- babies easily adapt to temp of environment due to immaturity of
thermo regulating system of body. Hypothalamus
2. inadequate SQ tissue
3. baby is not capable of shivering
4. 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
earliest sign of hypothermia- increase in RR

Effects of Hypothermia ( Cold stress)

1.) Hypoglycemia- 45-55 mg/dl normal
50- borderline
2.) met acidosis- catabolism of brown fats (best insulator of
newborns body)
will form ketones
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
pre-heated 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

A. Establish Adequate Nutritional Intake

CS- breastfeeding after 4 hours

NSD- breastfeeding asap

Physiology breast milk production

As you deliver baby, decrease Estrogen, decrease Progesterone-
-Anterior Posterior Gland (APG) releases prolactin acts on
acinar cells (or alveoli) produce foremilk stored in lactiferous
tubules ( or collecting tubules)
where breast milk is produced alveoli post-pit.gland

Sucking- PPG oxytocin contraction of lactiferous tubules - milk

ejection reflex- let down reflex.

Advantages of Breastfeeding
1. Economical
2. Always available
3. Breastfed babies have higher IQ than bottle fed babies.
4. It facilitates rapid involution
5. Decrease incidence of breast cancer.
6. Has antibodies- IgA
7. Has lactobacillius bifidus- interferes with attack of pathogenic
bacteria in GIT
8. Has macrophages
Store milk- plastic storage container
Store milk good for 6 months from freezer- put rm temp. dont
heat
Disadvantages:
1. Possibility of transfer HEP B, HIV, cytomegalo virus.
2. No iron
3. Father cant feed & bond as well
Stages of Breastmilk:
1. Colostrum- 2-4 days present
content: decrease fats, increase IgA, dec CHO, dec CHON, inc
minerals,
inc fat soluble minerals
2. Transitional milk- 4 14 days
content: inc lactose, inc water soluble vit., inc minerals
3. Mature milk- 14 & up
content: inc fats (linoleic acid) resp for devt of brain & integrity
of skin
inc CHO- lactose easily digested, baby not constipated.
- resp of sour milk smelling odor of stool.

Lactose intolerance- deficiency of enzyme LACTASE that digest

LACTOSE
Decrease CHON- lactalbumin
Cows milk inc fats-
Dec CHO
Inc CHON casing- has curd thats hard to digest.
Inc mineralstraumatic effect on kidneys of babies. Can trigger
stone formation.
Inc phosphorus

Health Teachings:
1. Proper hygiene- proper hand washing
Care of breast - cotton balls with lukewarm water
Caked colostrum- dry milk on breast
2. Best position in breastfeeding upright sitting -avoid tension!
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
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 @ breast ( 5 7 min other authors)
to initiate production of oxytocin
- increase 1 min/ day until reaching 10 mins @ 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 :

3RD day changes in breast post partum
a.)Engorged- feeling of fullness & tension in breast.
- sometimes accompanied by fever known as MILK FEVER.

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: 1.) exposure to air remove bra & wear dress, if not, expose
to 20 Watt bulb
avoid wearing plastic liner bra
- will create moisture, cotton only
c.) Mastitis- inflammation of breast : staphylococcus aureus
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:
Maternal Conditions:
1. HIV CMV
Hepa B Coumadin

Newborn Condition - Inborn errors of metabolism

Erythrobastosis Fetalis Rh incompatibility
Hydrops Fetalis
Phenylketonuria
Galactosemia
Tay Sachs disease

5. Establish of waste elimination

A. Diff stools
1. Meconium - physiologic stool
- black green, sticky, tar like, odorless (Sterile intestine)
will pass with 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 -
- green loose & shiny, like diarrhea to the untrained eye
3. Breastfed stool - golden yellow, soft, mushy with sour milk
smell, frequently passed
- recur every feeding
4. Bottlefed stool
- pale yellow, formed hard with typical offensive odor, seldom
passed, 23 x/day
- with food added -brown & odorous

Jaundice baby light stool

Under phototherapy bright green
Mucus mixed with stool - milk allergy
Clay colored stool obstruction to bile duct
Chalk clay stool after barium enema
Black stool GIT bleeding (melena)
Blood flecked stool - anal fissure.
Currant jelly stool instussusection
Ribbon like stool hirschsprung disease
Steatorrhea stool fatty, bulky foul smelling odor stool
- malabasorption syndrome ( celiac disease or cystic fibrosis)
Cult blood stool exam

III Assessment for Wellbeing

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
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- tangential foot slap, catheter
insertion
A activity degree of flexion or muscle tone
R respiration

Baby cry within 30 secs

Failure to cry after 30 secs asphyxia near the neatorum
Resp. depression due mom given Demerol. Administer Naloxone

APGAR Scoring Chart:

012
HR -absent <100 >100
Resp effort -absent - slow, irreg, weak -good strong cry
Muscle tone - flaccid extremities - some flexion - well flexed
Reflex irritability
Catheter - no response - grimace - cough, sneeze
Tangential Footslap - NR - grimace - cry
Color - blue/pale - acrocyanosis
(body- pink
extremities-blue) - pinkish
APGAR result
0 3 = severely depressed, need CPR, admission NICU
4 6 = moderately depressed, needs addl suctioning & O2
7 - 10 =good/ healthy

CPR cardio pulmonary resuscitation or CPR

Cardio pulmonary cerebral resuscitation

5 min no O2 irreversible brain damage

1. shake, no resp, call for help
2. flat on head
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
< 1 yr mouth to nose
force different between baby & child
infant puff

Circulation
Check for pulslessness :carotid- adult
Brachial infants
CPR breathless/pulseless
Compression inf 1 finger breath below nipple line or 2 finger
breaths or thumb

CPR inf 1:5

Adults 2:15

Assessment tool determines respiration of baby

Silvermann Anderson Index

Respiration Evaluation lowest score best

Criteria 0 1 2
Chest movement synchronized Lag on respiration See - saw
Intercostal retraction No retraction Just visible Marked
Xiphoid retraction None Just visible Marked
Nares dilatation None Minimal Marked
Expiratory grunt None Heard on stet only Heard on naked ear

Interpretation result:
0 -3 normal, no RDS
4 6 moderate RDS
7 10 severe RDS

Assessment of Gestational Age

-Ballards & Dobowitz
Findings Less 36 weeks (Preterm) 37 - 38 39 and up
Sole creases Anterior transverse crease only Occasional creases
2/3 in Covered with creases
Breast nodules 2mm 4mm or 3.5 mm > 5 or 7mm
Scalp hair Fine & fuzzy Fine & fuzzy Coarse & silky
Ear lobe Pliable Some cartilage Thick cartilage
Testes and Scrotum testes in lower canal
Scrotum small few rugae Some intermediate Testes pendulus
Scrotum full extensive rugae

Signs of Preterm Babies

Born after 20 weeks, after 37 weeks
-frog leg or laxed positon
-hypotonic muscle tone- prone resp problem
-scarf sign elbow passes midline pos.
- square window wrist 90 degree angle of wrist
- heal to ear sign-
abundant lanugo-

Signs of Post term babies:

> 42 weeks
- classic sign old mans face
- desquamation peeling of skin
- long brittle finger nails
- wide & alert eyes

Neonates in Nursery
Nsg responsibility upon receiving baby- proper identification
- foot printing, affixing mother thumb print
- take anthropometic 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
Abd 31 33 cm or 12 13

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

3 cleans in community
1. clean hand
2. clean cord
3. clean surface

betadine or povidone iodine to clean cord

check AVA, then draw 3 vessel cord

If 2 vessel cord- suspect kidney malformation

- leave about 1 of cord
- if BT or IV infusion leave 8 of cord best access - no nerve
- check cord every 15 min for 1st 6 hrs bleeding .> 30 cc of
blood
bleeding of cord Omphalagia suspect hemophilia
Cord turns black on 3rd day & fall 7 10 days
Faiture to fall after 2 weeks- Umbilical granulation
Mgt: silver nitrate or catheterization
- clean with normal saline solution not alcohol
- dont use bigkis air
- persistent moisture-urine, suspect patent uracus fistula bet
bladder and normal umbilicus
dx: nitrazine paper test yellow urine
mgt: surgery

Credes Prophylaxis Dr. Crede

-prevent opthalmia neonatorum or gonorrheal conjunctivitis
- how transmitted mom with gonorrhea
drug: erythromycin ophthalmic ointment- inner to outer

silver nitrate (used before) 2 drops lower conjunctiva (not used

now)

Vit-K to prevent hemorrhage R/T physiologic

hypoprothrombinemia
- Aquamephyton, phytomenadione or konakion
- .5 1.5 ml IM, vastus lateral or lateral ant thigh
- 5 ml preterm baby

Vit K synthesized by normal flora of intestine

Vit K meds is synthetic due intestine is sterile

Weight: Normal wt 3.000 3400 gms/ 3 3.4 kg / 6.5 - 7.5 lbs

Arbitrary lower limit 2500 gm

Low birth wt baby delivered < 2500g
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
Physiologic wt loss 5 10% wt loss few days after birth

Small GA < (less) 10

Large GA > (more) 90
Physical Exam and Deviations fr Normal
1. if client is new born, cover areas not being examined
2. if client is infant the 1st yr of life - get VS take RR 1st
- begin fr 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.
4. Explain procedure and respect their modesty - school age and
adolescent

V/S:
Temp: rectal- newborn to rule out imperforate anus
- take it once only, 1 inch insertion

Imperforate anus
1. atretic no anal opening
2. agenetic no anal opening
3. stenos has opening
4. membranous has opening

Earliest sign:
1. no mecomium
2. abd destention
3. foul odor breath
4. vomitous of fecal matter
5. can aspirate resp problem
Mgt:
Surgery with temporary colostomy

Cardiac rate: 120 160 bpm newborn

Apical pulse left lower nipple
Radial pulse normally absent. If present PDA
Femoral pulse normal present. If absent- COA - coartation of
aorta

Congenital Heart Dse

Common in girls PDA, ASD atrial septal
Common in boys TOGA ( transportation of great arteries)
TA tronchus arteriosus
TOF tetralogy of fallot

Causes:
1. familial
2. exposure to rubella 1st month
3. failure of strucute to progress
acyanotic L to R
cyanotic R L

Acyanotic heart defects L to R

1. ventricular septal defect - opening between 2 ventricles

S&Sx
1. systolic murmurs at lower border of sternum and no other
significant sign
2. cardiac catheterization reveals increased o2 saturation @ R
side of heart
3. ECG reveals hypertrophy of R side of heart

Nsg Care:
Cardiac catheterization: site Rt 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
( dorsalis pedis)

Mgt.
1.) long term antibiotic to prevent subacute bacterial
endocarditis
2.) open heart surgery-

2.) 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

Mgt: open heart surgery

3.) endocardial cushion defects - atrium ventricular (AV) - affects
both tricuspid and mitral valve
Dx confirmed by cardiac catheterization
Mgt: - open heart surgery
Antibiotics to prevent subacute bacterial endocarditis

4.) PDA - failure of ductus arteriosus to close

- should close within 24 h -complete close 1 month
S&Sx
1. continuous machinery like murmurs
2. prominent radial pulse
3. ECG- hypertrophy Left ventricle
Drug:
1. endomethazine prostaglandin inhibitor - facilitate closing of
PDA
2. ligation of PDA by 3-4 yo
3. thoracotomy procedure- nakadapa child

5.)Pulmunary Stenosis- narrowing of valve of pulmo artery

S &Sx: 1.) typical systolic ejection murmur
2. S2 sound widely split
3. ECG- Lt ventricular hypertrophy
6.)Aortic Stenosis narrowing of valve of aorta
S & Sx: 1. inactive, sx sme with angina
2. typical murmur
3. rough systolic sound and thrill
4. ECG- Left ventricular hypertrophy

Mgt Pulmo Stenosis & Aortic Stenosis

1.) balloon stenostomy
2.) surgery

Duplication of Aortic Arch- doubling of arch of aorta causing

compression to trachea and esophagus
S&Sx : 1. dysphagia 2. dyspnea
3. left ventricular hypertrophy
Mgt: - close heart surgery

8.) Coartation of Aorta narrowing of arch of aorta

outstanding Sx : absent femoral pulse
BP increased on upper extremities and decreased on lower
extremities
ECG hypertrophy Lft ventricle
Mgt: close heart surgery

CYANOTIC HEART DEFECTS R to L

1. Transportation of Great Arteries (TOGA) - aorta arising from Rt

ventricle pulmo artery arising form Lt ventricle

Outstanding Sx:
1. cyanosis after 1st cry (due no exygenation)
2. polycythemia increased RBC =compensatory due to O2
supply=viscous blood
=thrombus = embolus = stroke
3. ECG cardiomegaly
Cardiac cath decreased O2 saturation
Palliative repair rashkind procedure
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 Lft

Outstanding Sx: Open foramen ovale

Mild to moderate cyanosis
Polycythemia = thrombus = embolus = stroke
asplenia- absent spleen
Mgt: restructuring of heart

3.) Truncus Arteriousus- aorta & pulmo artery is arising fr 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 non fx Left ventricle

1. cynosis
2. polycythemia throm, emb, stroke
Mgt: heart transplant
5.) Tricuspid atresia failure of tricuspid valve to open
S&SX: open foramen ovale
(R to L shunting goes to Lt atrium)
cynosis, polycythemia
Mgt: fontan procedure open tricuspid valve

6.) Tetralogy of Fallot

P pulmonary stenosis
V ventricular SD
O overriding or dextroposition of aorta
R Rt ventricular hypertrophy
S &Sx:
1. Rt ventricular hypertrophy
2. high degree of cyanosis
3. polycythemia
4. severe dyspnea squatting position relief , inhibit venous
return facilitate lung expansion.
5. growth retardation due no O2
6. tet spell or blue spells- short episodes of hypoxia
7. syncope
8. clubbing of fingernails due to chronic tissue hypoxia
9. mental retardation due decreased O2 in brain
10. boot shaped heart x-ray
Mgt:
1. O2
2. no valsalva maneuver , fiber diet laxative
3. morphine hypoxia
4. propranolol decrease heart spasms
5. palliative repair
BLT blalock taussig procedure
Brock procedure complete procedure

ACQUIRED HEART DSE

1. RHD Rheumatic Heart Disease

- inflammation disease ff an infection acquired by group A Beta
hemolytic strepto coccus

Affected body cardiac muscles and valves , musculoskeletal ,

CNS, Integumentary

Sorethroat before RHD

Aschoff rounded nodules with nucleated cells and fibroblasts

stays and occludes mitral valve.

Jones Criteria

Major Minor
1. polyarthritis multi joint pain 1. arthralgia joint pain
2. chorea sydenhamms chores or
st. vetaus dance-purposeless involuntary hand and shoulder with
grimace 2. low grade fever
3. carditis tachycardia
erythema marginatum - macular rashes
SQ nodules 3. all lab results
increase antibody
C reactive protein
erythrocyte sedimentation rate
anti streptolysin
o titer (ASO)
Criteria:Presence of 2 major, or 1 major and 2 minor + history of
sore throat will confirm the dx.

Nsg Care:
1. CBR
2. throat swab culture and sensitivity
3. antibiotic mgt to prevent recurrence
4. aspirin anti-inflammatory. Low grade fever dont give
aspirin.

S/E of aspirin:
- Reyes syndrome encephalopathy- fatty infiltration of organs
such as liver and brain

Respiration
Newborn resp 30-60 cpm, irregular abd or diaphramatic with
short period of apnea without cyanosis.
< 15 secs normal apnea newborn

Resp Check
Newborn 40 90
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:

1.) VESICULAR soft, low pitched, heard over periphery of lungs,
inspiration longer then expiration -Normal

2.) BRONCHOVESICULAR- 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 snoring sound made by air moving through mucus

in bronchi. Normal
5.) RALES-or crackles like cellophane made by air moving
through fluid in alveoli.
Abnormal- asthma, foreign body obstruction.
6.) WHEEZING- whistling on expiration made by air being pushed
through narrowed bronchi .Abnormal asthma, foreign body
obstruction
7.) STRIDOR- crowing or ropster life sound air being pulled
through a constricted larynx. Abnormal resp obstruction
Asthma- pathognomonic sign expiratory wheezing
Pet fish. Sport swimming
Drugs amynophylline monitor bp, may lead to hypotension

Laryngo Tracheo Bronchitis LTB

- inspiratory stridor pathognomonic sign

RDS respiratory dist synd or hyaline membrane dis

Cause- lack of surfactant for lung expansion
Hypotonia, Post surgery, Common to preterm
Fibrine hyaline
Sx definite with in 1st of life
Increase RR with retraction
Inspiratory grunting pathognomonic
7 10 severe RDS (silvermenn Anderson index)
cyanosis due to atelectasis
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

6. CPAP- continuous + a/w pressure

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

LARYNGOTRACHEOBRONCHITIS
LTB most common Creup -viral infection of larynx, trachea &
bronchi
outstanding sx - croupy cough or barking
pathognomonic - stridor
- labored resp
- resp acidosis
- end stage death
Lab:
1. ABG
2. neck and throat culture
3. dx- neck x-ray to rule out epiglotitis
Nsg Mgt:
1. bronchodilators
2.increase o2 with humidity
3. prepair tracheostomy set

BRONCHOLITIS- Inflammation of bronchioles tenatious mucus

Causative agaent RSV - Resp sincytial viruses
Sx: flu like sx
Increased RR
Drug: Antiviral Ribavirin
End stage epiglotitis

EPIGLOTITIS - infl of epiglottis

- emer. Condition of URTI
Sx: sudden onset
Tripod position leaning forward with tongue protrusion
- never use tongue depressor
prepare tracheotomy set
< 5 yo 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

BP 80/46 mmHg newborn

BP after 10 days- 100/50
BP taking begins by 3 yo
COA take BP on 4 extremities

SKIN:
Acrocyanosis
BIRTHMARKS:
1. Mongolian spots stale gray or bluish discoloration patches
commonly seen across the sacrum or buttocks due to
accumulation of melanocytes. Disappear by 1 yr old
2. MIlla plugged or unopened sebaceous gland . white pin point
patches on nose, chin or cheek.
3. Lanugo fine, downy hair common preterm
4. Desquamation peeling of newborn, extreme dryness that
begin sole and palm.
5. Stork bites (Talengeictasi nevi) pink patches nape of neck
hair will grow as child grows old
6. Erythema Toxicum (flea bite rash)- 1st self limiting rash
appear sporadically & unpredictably as to time & place.
7. Harlequin sign dependent part is pink, independent part is
blue
(side lying bottom part is dependent pink)
8. Cutis Marmorato transitory mottling of neonates skin when
exposed to cold.
9. Hemangiomas vascular tumors of the skin

3 types 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 yo.
c.) Cavernous hemangiomas communication network of venules
in SQ tissue that never disappear with age. - MOST DANGERIOUS
intestinal hemorrhage
Skin color blue cyanosis or hypoxia
White edema
Grey inf
Yellow jaundice , carotene
Vernix Caseosa white cheese like for lubrication, insulator

BURN TRAUMA injury to body tissue caused by excessive heat.

INFANT 5-9 yo
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
Genital 1 1
@ buttocks 2.5@ 2.5 @
Thigh 2.75 2.75 4 4
Leg 2.5 2.5 3 3
foot 1.75 1.75 1.75 1.75

DEPTH
1st degree partial thickness superficial epidermis - erythema,
dryness, PAIN
-sunburn, heals by regeneration from 1 10 days
2nd degree epidermis & dermis- erythema, blisters, moist,
extremely painful
scalds
3rd degree full thickness- epidermis, dermis, adipose tissue,
fascia, muscle & bone
lethargy, white or black, not painful nerve endings destroyed
ex. lava burns

Mgt:
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
d.) cover burn with sterile dressing

2.) a/w
a.) suction PRN, o2 with increased humidity
b.) endotracheal intubation
c.) tracheostomy
3.) Preventiuon of shock & F&E imbalance
a. colloids to expand bld 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
a.) cleaning & debriding of wound
b.) open or close method of wound care
c.) 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.

ATOPIC DERMATITIS- infantile eczema (galis)

Papulo vesicular erythematus lesions with weeping & crusting
Cause food allergies: milk, citrus juice, eggs, tomatoes, wheat
Sx: - extreme pruritus, linear excoriation, weeping crusting; scaly
shiny and white lechenification

Goal of care: decrease pruritus avoid food allergens

Diet: Prosobi or Isomil
Hydrate skin, borow solution 1% hydrocortisone cream
Prevent infection proper handwahsing, trim nails

IMPETIGO- skin disease.

Causative agent grp A beta Hemolytic streptococcus
- papulovesicular surrounded by localized erythema becomes
purulent , oozes a honey colored crust
Pediculosiscapitis KUTO
- Mgt: proper hygiene wash soap and H2o, oral penicillin
bactroban ointment
Can lead to acute glomerulonephritis AGN

ACNE- adolescent problem

- self limiting infl dis sebaceous gland comedones sebum
causing white heads
- sebum- lipids causing acne bulgaris
Mgt: - proper hygiene- mild soap or sulfur soap- antibacterial retin
A or tretinoi

ANEMIA-pallor
Causes:
1.)early cutting of cord preterm cut umb cord ASAP
fullterm cut umb cord when pulsation stops
2.) Bleeding disorders blood dyscrasias

HEMOPHILIA deficiency of clotting factor. X linked recessive

inherited
If mom carrier, son affected
If father carrier- transmitted to daughter

Hemophilia A deficiency of coagulation component factor 8

Hemophilia B or christmas disease, deficiency of clotting factor
9
Hemophilia C deficiency of clotting factor 11

Assessment:
- umphalagia earliest sign
- newborn receive maternal clotting factor
- newborn growing sudden bruising on bump area- marks
earliest sign
- continuous bleeding hematrosis damage or bleeding 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
just change gauge of needle
Falls immobilized , elevate affected part, apply pressure-not
more then 10 min
cold compress
-determine case before doing invasive procedure

LEUKEMIA- grp of malignant disease

- rapid proliferation of immature WBC
- WBC protection from infection, soldiers of body

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

S&Sx:
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
b.) epistaxis
c.) blood in urine/ emesis
signs of anemia
a.) pallor , body malaise , constipation

2. from invasion of body organ- hepato spenomegaly abd pain ,

CNS affectation, increase ICP
Dx Tests:
1. PBS- peripheral blood smear determine immature RBC
2. CBC determine anemia, leukocytosis, thrombocytopenia
neutropenia
3. lumbar puncture (LP) determine CNS involvement. Before LP,
fetal pos.- avoid flexion of neck will cause a/w obstruction.C
position or shrimp position only.
4. bone marrow aspiration determine blast cells,
- common site- iliac crest
- post BMA s/effect bleeding
- apply pressure. Put pt on affected side to prevent hemorrhage
5. Bone scan determine bone involvement
6. CT scan determine organ involvement

Therapeutic Mgt:
TRIAD:
1. surgery
2. irradiation
3. chemotheraphy
Focus Nsg Care: prevent infection

4 LEVELS OF CHEMOTHERAPHY
1. induction goal of tx; to achieve remission
meds: IV vincristine
L- agpariginase
Oral predinisone
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
-adm of methotrisate do weekly WBC check

4. Reinductin 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: alteration in nutrition less body

requirement.
Based on Maslows heirarchy
S/Effect of Chemotherapy
1. N/V adm antiemetic drugs 30 mins before chemo until 1 day
after chemo
2. Ulcerations / stomatitis / abscess of oral mucosa- (alteration
nutrition less body req)
- 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 hair
-give emotional support to parents

ABO incompatibility
Most common incompatibility ( mom) O ( fetus) A
Most severe incompatibility (Mom) O (Fetus) B
Can affect 1st pregnancy

Hydrops (h20) Fetalis edematous on lethal state with pathologic

jaundice
Within 24 h

Mgt:
1. initiate breastfeeding to get colostrum
2. Temp suspension of breastfeeding
- content breast milk pregnanedioles that delays action of
glucoronil transferees
liver enzymes converts in direct bilirubin to become direct
bilirubin
3. Needs phototherapy
4. needs exchange therapy

Hyperbilirubinemia - > 12 mg/dL of indirect bilirubin among full

term
Normal 0-3 mg/dL
- bilirubin encephalopathy
- Kemicterus - > 20 mg/dL among full term &
>12 mg /dl of indirect preterm
=can lead to cerebral palsy-

Physiologic jaundice jaundice within 48 -72 h (2-3 days) expose

morning sunlight
Pathologic Jaundice within 24h. Jaundice during delivery.

Breastfeeding jaundice caused by pregnanediole

Assessment of Jaudice :
1. Blanching neonates forehead, nose or sternum
- yellow skin & sclera
- color of stool light stool
- color of urine dark urine

Mgt: Phototheraphy photo oxygenation

Nsg Resp:
1. cover eyes prevent retinal damage
2. cover genitals prevent priapism painful continuous erection
3. change position regularly even exposed to light
4. increase fld intake due prone to dehydration
5. monitor I&O weigh baby
6. monitor V/S avoid use of oil or lotion due- heat at
phototherapy
= bronze baby syndrome-transient S/E of phototherapy
weigh diaper 1gm = 1cc

Head largest part of baby

of its length
Craniostenosis or craniosinustosis premature closing of
fontanel
Hydrocephalus ant fontanel open after 18 mos
Microcephaly small growing brain due- alcohol & HIV mom
Anencepahly absence of cerebral hemisphere
Craniotabes localized softening cranial bone. Common 1st
born child
-due early lightening (2 weeks prior to EDD)
Rickets of Vit B deficiency soft cranial bone in older children
Caput Succedaneum edema of scalp due prolonged pressure at
birth
Char:
1. present at birth
2. crosses suture lines
3. disappear after 2-3 days

Cephalhematoma- collection of blood due to rapture of pericostal

capillaries
Char :
1. present after 24 h
2. never cross suture line
3. disappear after 4-6 weeks
4. monitor for developing jaundice

Seborrheic Dermatitis craddle 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
- baby oil

Hydrocephalus excessive accumulation of CSF

1. communicating extra ventricular hydrocephalus
2. non-communicating- intraventricular hydrocephalus or
obstructive hydrocephalus
due to tumor obstruction
Sx ICP abnormally large head, bulging fontanel
- cushings triad
- high pitched cry
older child diplopia eye deviation, projectile vomiting
- fontanel bossing prominent forehead
- - prominent skull vein
- sunset eyes
Mgt: position to lessen ICP low semi-fowlers 30 degree angle
Administer- osmotic diuretic Mannitol/ Osmitrol , Diamex- Azetam
Decrease CSF production
Shunting AV shunt or Vp shunt (ventriculoperitoneal shunt)
Shave hair in OR to prevent growth of micro org.

Nsg Care:
1.) post VP shunt side lying on non operated site - to prevent
increase ICP
-monitor for good drainage - sign sunken fontanel
-bulging fontanel blocked shunt
-change fontanel as child is growing
SENSES
EYES: Assessment
1. check for symmetry
2. sclera normal color light blue then become dirty white
pupil round- adult size
coloboma- part of iris is missing
sign: key hole pupil
-whiteness & opacity of lens congenital cataract
cornea round & adult size
large congenital glaucoma

Test for blindness common tests

1. newborn general appearance
- can only see 10 12
- visual acuity 20 /200 to 20/ 800
Dolls eyes test- test for blindness
- done 10th day
- pupil goes opposite to direction when head is moved
Globellars test test for blink reflex. Points near nose baby
should blink
2. Infant & children
- appearance
- ability to follow object past midline

3. 3 yrs school age

- general appearance
Allen cards test for visual acuity. Show picture 20 ft away

Ishiharas plates test for color blindness

Prechool E chart - test for stereopsi of depth perception
Cover testing test cover 1 eye for 10 15 min. Then remove. Test
for strabismus

4. School age adult

- general appearance
- snellens test

Retinobastoma malignant tumor of retina

Outstanding sign : oats eye reflex-whitish glow of pupil
- red painful eye
- blindness
surgery Enucliation removal of eyeball put artificial aye

NOSE:
1. flaring alenase case of RDS
2. cyanosis at rest choanal atresia - post nares obstructed with
bone or membrane
Sx:
1. resistance during catheter insertion
2. emer. Surgery within 24 h
normal color nasal membrane pinkish
rhinitis presence of creases & pale
check sense of smell blindfold smell

Hair in nose cilia

Adolescent no hair with ulceration of nasal mucosa suspect
cocaine user

Epistaxis nosebleed
- sit upright, head slightly forward to facilitate drainage
- cold compress , apply gentle pressure, epinephrine

most developed sense of newborn sense of touch

1st sense to develop & last to disappear hearing

EARS:
1. Properly aligned with outer cantus of eyes
low set ear kidney malformation
ex. Renal aginesis absence of kidney
sign in uterus : oligohydramnios
sign in newborn: 2 vessel cord
failure to void within 24 h

Mgt: kidney transplant

Chromosomal aberrations : -advance maternal age

1. non disjunction uneven division

Trisomy 21 - down syndrome - extra chromosome

47xx + 21 - related to advance paternal age
Sx:
Mongolian slant
Broad flat nose
Protruding neck
Puppys neck
Hypotonic prone to resp problem
Simean crease single transverse line on palm.

Trisomy 18 edward syndrome

Trisomy 13- patau syndrome
Turner Monosomy of X synd.
- 45x0
- affected girls
- signs evident during puberty
- has poorly developed 2dary sexual char.
- Sterile

Klinefelters Syndrome- has male genitalia - 47 XXY

- poorly devt secpndary sexual characteristics
- no deepening of voice
-small testes, penis -sterile

Klinefelter Calvin Kline male

Turner Tina Turner female

Otitis Media inflammation of middle ear. Common children due

to wider & shorter Eustachian tube
Causes
1.) bottle propping
2.) Cleft lip/ cleft palate
Sx: Otitis
1. bulging tympanic membrane, color pearly gray
2. absence light reflex
3. observe for passage of milky, purulent foul smelling odor
discharge
4. observe for URTI
Nsg Care:
1. position side lying on affected aside to facilitate drainage
2. supportive care- bedrest, increase fld intake
Med Mgt:
1. Massive dosage antibiotic
Complication bacterial meningitis
2. Apply ear ointment

School age up and down

< 3 yo down & back
> 3 yo up & back
Small child down & back ( no age)
surgery (to prevent permanent hearing loss) otitis media
myringotmy with tympanostomy tube
post surgery position affected side for drainage
both put ear plug
if tympanous tube falls healed na

Bells Palsy- facial nerve #7 paralysis R/T forcep delivery

Sx.
1. Continuous drooling saliva
2. inability to open , eye & close either eye
Mgt:
Refer to PT

TEF (Tracheoesophageal Fistula)-TEA- no connection bet

esophagus and stomach

Outstanding Sx Coughing
Choking
Continuous drooling
Cyanosis
Mgt:: Emergency surgery

Epstein pearl white glistering cyst at palate & gums related to

hypercalcemia

Hypervitaminosis
Natal tooth tooth at birth. Move with gauze
Neonatal tooth tooth within 28days of life

Moniliasis oral candidiasis

- white cheese like, curd like patches that coats tongue
- oral thrush
- Nsg Care dont remove, wash with cold boiled H2o
Meds nystatin / Mysnastatin antifungal

Kawasaki Dse--strawberry tongue - originated in Korea

- Dr. Kawasaki discovered it
- common in Japan
- mucocutaneous Lymphnode Syndrome
Sx:
-persistent fever 5 days
-strawberry tongue ,
-desquamation of palm & sole
- lymph adenopathy > 1.5 cm
Drug: aspirin
Can lead to MI

LIPS- symmetrical
Cleft lip failure of median maxillary nasal process to fuse by 5-8
wks of pregnancy
- common to boys
- unilateral

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

Mgt:
1. Surgery
cleft lip repair Cheiloplasty =done 1-3 months to save sucking
reflex (lost in 6 months )
Cleft Palate- uranoplasty = done 4-6 months to save speech

Pre op care
1. emotional support especially to mom
2. proper nutrition
3. prevent colic
feed upright seating or prone pos
burp frequently 2x at middle and after feeding-lower to upper tap
4. orient parents to type of feeding
rubber tipped syringe cheiloplasty
paper cup/ soup spoon/ plastic cup urano plasty
5. apply restraints elbow restraints
so baby can adjust post op

Condition that warrants suspension of operation

- colds & pharyngitis = can lead to generalized infection
septicemia

Post Op Nsg Care :

1. airway positon post cheilopasty side lying for drainage
post uranoplasty (tonsillectomy)- prone
2. assess for RDS sx bleeding
3. assess for bleeding freq swallowing. 6-7 days after surgery
bleeding
4. proper nutrition
- clear liquids- ( gelatin except red or brown color due 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 baby form crying
for pain- analgesic

NECK-
1.) check symmetry
Congenital torticolis- wryneck-burn injury of
sternocleidomsstoid muscle during
delivery due to excessive traction at cephalic delivery

Mgt: passive stretching exercise , Surgery

Complication scoliosis

THYROID gland for basal metabolism

Congenial cretinism absence or non functioning thyroid glands

reasons for delaying dx:

1. Thyroid glands covered by sternocleidomastoid muscles in
newborn
2. baby received maternal thyroxine
3. baby sleeps 16 20 h a day
earliest sign:
1. change in crying
2. change in sucking
3. sleep excessively
4. constipation
5. edema moon face
late sign
1. mental retardation
prognosis : mental retardation preventable when Dx is early
Dx:
1. PPI-protein
2. radioimmunoassay test
3. radioactive iodine uptake

Mgt: synthroid sodium Levothyrosine -synthetic thyroid given

lifetime
- check pulse rate before giving synthroid
- tachycardia Sx of hyperthyroidism

CHEST
1. symmetry
2. breast - transparent fluid coming out from newborn related to
hormonal changes-
3. chest has retroactive RDS
4. sternum sunken pectus excavation

ABDOMEN (in order)

1. inspection I
2. Auscultation A
3. percussion P
4. Palpation P = Will change bowel sounds, so do last

Normal contour of abd slightly protruding

Sunken abd- diaphramatic hernia protrusion of stomach content
through a defective diaphragm due to failure of puroperitoneal
canal to close.
Sx:
1. sunken abd
2. Sx of RDS
3. R to L shunting
Mgt:
Emergency surgery within 24h

Omphalocele protrusion of stomach contents in between

junction of abd wall and umbilicus.

Mgt- very small surgery

If large suspension surgery
Nsg Mgt: protect sac- sterile wet dressing
Gastrochisis absence of abd wall
Nsg Mgt: sterile wet dressing

Fx of GIT
1. assists in maintaining F&E & acid base balance
2. Processes & absorbs nutrients to maintain metabolism &
support G & D
3. excrete waste products from digestive process

Recommended Daily Allowance

Calories : 120 cal / Kbw/day (kilo body wt)
360 380 cal/ day

CHON_ 2.2g /Kbw/day

Principles in Supplementary Feeding

Supplementary Feeding usually 6 mos
Supplementary feeding given 4 mos.

a.) solid food offered to ff sequence!

1. cereals rich in iron
2. fruits
3. veg
4. meat
b.) begin with small quantities
c,) finger foods offered 6 months
d.) soft table food modified family menu given 1 yr
e.) dilute fruit juices 6 mos
f.) never give half cooked eggs usually causes of salmoneliosis
g.) dont give honey infant botulism
h.) offered new food one at a time interval of 4 7days or 1
week determines food allergens

Total Body Fluids- comprises 65 - 85% of body wt of infants &

children
Where fluids are greater in infants
Extracellular fld prone to develop dehydration

Acid Base Balance dependent on the ff:

a. chemical buffers
b. renal & resp system involvement
c. dilution of strong acids and bases in bld
Resp Acidosis carbonic acid excess
- hypoventilation
- RDS
- COPD
- Laryngotracheobronchitis (LTB)
Resp Alkalosis carbonic acid deficit
- hyperventilation
- fever
- encephalopathy
Met. Acidosis base HCO3 deficit
- diarrhea
- severe dehydration
- malnutrition
- ciliac crisis
Met Alkalosis base HCO3 excess
- uncontrolled vomiting
- NGT aspiration
- Gastric lavage

PROBLEMS LEADIING TO F&E IMBALANCE

1. vomiting forceful expulsion of stomach content
Sx:
1. nausea
2. dizziness
3. facial flushing
4. abd cramping

assess: amt, freq, force

projectile vomiting= increase ICP or pyloric stenosis

Mgt: BRAT diet - banana, rice cereal, apple sauce, toast

2. Diarrhea exaggerated excretion of intestinal contents

Types:
Acute diarrhea related to gastroenteritis, salmoneliosis
- dietary indiscretions
- antibiotic use
Chronic non specific diarrhea
Cause:
1. food intolerance
2. excessive fld intake
3. CHO, CHON malabsorption

Assess: freq, consistency, appearance of given colored stool.

Best criteria to determine diarrhea : consistency

Complication = dehydration
Mild dehydration 5% wt loss
Moderate dehydration 10% wt loss
Severe dehydration 15 % wt loss

Earliest sx of dehydration
tachycardia increase temp weight loss
tachypnea sunken fontanel & eyeballs scanty urine
hypotension absence of tears

Severe dehydration:
Oliguria , Prolonged capillary refill time

Mgt:
Acute NPO ( rest the bowel )
- with fluid replacement IV
- prone to Hypokalemia give K chloride
before adm of K chloride check if baby can void, if cant void
hypokalemia
Drug: Na HCO3 adm slowly to prevent cardiac overload

Gastric Motility Disorder:

HIRSCHPRUNGS DISEASE congenital aganglionic megacolon
Aganglionic absence of ganglion cells needed for peristalis

Earliest sign
1. failure to pass mecomium after 24h
2. abd distension
3. vomitus of fecal material
early childhood ribbon like stool
foul smelling stool
constipations
diarrhea
Dx:
1. Barium enema reveals narrowed portion of bowel
2. Rectal Biopsy reveals absence of ganglionic cells
3. abd x-ray reveals dilated loops on intestine
4. rectal manometry revels failure of intestine sphincter to relax

Therapeutic Mgt/Nsg care

1. NGT feeding measure tube fr nose to ear to midline of
xyphoid & umbilicus
2. surgery
a.) temp colostomy
b.) anastomosis & pull through procedure
Diet:
Increase CHON, increase calories , decrease residue pasta

GER- Gastroesophageal Reflux

Chalasia presence of stomach contents to esophagus
Will lead to esophagitis complication aspiration pneumonia

Esophageal cancer
Assessment :
1. chronic vomiting
2. faiture to thrive syndrome
3. organic organ affected
4. melena or hematemesis esophageal bleeding
Dx procedure
1. barium esophogram reveals reflux
2. esophageal manometry reveals lower esophageal sphincter
pressure
3. intra esophageal pH content reveals pH of distal esophagus.
Meds of GERD
Anti-cholinergic
a.) Betanicol ( urecholine) increase esophageal tone &
peristaltic activity
b.) Metachloporomide (Reglam) decrease esophageal pressure
by relaxing pyloric & duodenal segments
- increase peristalsis without stimulating secretions
c.) H2 Histamine Receptor Antagonist decrease gastric acidity
& pepsin secretion
- Zimetidine, Ranitidine (Zantac) take 30 min before meals
d.) antacid neutralizes gastric acid between feedings - Maalox

Surgery: Nissen funduplication :

Chronic vomiting
- thickened feeding with baby cereals - effective if without
vomiting
- feed slowly, burp often every 1 ounce
- positioning
< 9 months infant sit with infant supine
> 9 months prone with head of mattress slightly elevated 30
degree angle

OBSTRUCTIVE DISORDERS
A. PYLORIC STENOSIS hypertrophy of muscles of pylorus
causing narrowing &
obstruction.
1.) outstanding Sx- projectile vomiting
- vomiting is an initial sx of upper GI obstruction
- vomitus of upper GI can be blood tinged not bile streaked. (with
blood)
- vomitus of lower GI is bilous ( with pupu)
- projectile vomiting increase ICP or GI obstruction
- abd distension major sx of lower GIT obst
2.) met alk
3.) failure to gain wt
4.) olive shaped mass on palpation
5.)serum electrolyte increase Na & K, decrease chloride
6.) ultrasound
7.) x ray of upper abd with barium swallow reveal string sign

Mgt:
1. Pyleromyotomy
2. Fredet Ramstedt procedure
INSTUSSUSCEPTION- invagination or telescoping of position of
bowel to another
Common site ilio-secal junction
Prone pt: person who eats fat
Complication peritonitis emergency
Sx:
1.) persistent paroxysmal abd pain
2.) vomiting
3.) currant jelly stool- dye bleeding & inflammation
- palpate sausage shaped mass
Mgt:
1.) Hydrostatic reduction with barium enema
2.) Anastomosis & pull thru procedura

Inborn Errors of Metabolism- deficient liver enzymes

PHENYLKETONURIA (PKU) deficiency of liver enzymes (PHT)
Phenylalaninehydroxylase Transferase liver enzyme that
converts CHON to amino acid

9 amino acids:
valine isolensine tryptophase
lysine phenylalanine

Thyronine decrease malanine production

1.) fair complexion
2.) blond hair
3.) blue eyes
Thyroxine decrease basal metabolism
- accumulation of Phenyl Pyruvic acid
4.) Atopic dermatitis
5.) musty / mousy odor urine
6.) seizure mental retardation

Test GUTHRIE TEST specimen blood

- preparation increase CHON intake
- test if CHON will convert to amino acid
specimen and urine
mixed with pheric chloride, presence of green spots at diaper a
sign of PKU
DIET:
Low phenylalanine diet- food contraindicated- meats, chicken,
milk, legumes, cheese, peanuts
Give Lofenalac- milk with synthetic protein

Galactosemia deficiency of liver enzyme

- GUPT Galactose Urovil Phosphatetranferase
- Converts galactose to phosphate tranferace glucose
Galactose will destroy brain cells if untreated death within 3
days

Dx:
Beutler test get blood -done after 1st feeding
presence of glucose in blood sign of galactosemia
galactose free diet lifetime
neutramigen milk formula

CELIAC DISEASE gluten enteropathy

Common gluten food:
Intolerance to food with brow
B- barley
R- rye
O- oat
W- wheat

Early Sx:
1. diarrhea failure to gain wt ff diarrheal episodes
2. constipation
3. vomiting
Late Sx:
1. abd pain protruberant abd even if with muscle wasting
2. steatorrhea

Celiac Crisis- exaggerated vomiting with bowel inflammation

Dx:
1. lab studies stool analysis
2. serum antiglyadin confirmatory of disease
gluten free diet lifetime
all BROW not allowed
ok rice & corn

Mgt:
1. vitamin supplements
2. mineral supplements
3. steroids

POISONING- common in toddlers. (falls- common to infant)

1. determine substance taken, assess LOC
2. unless poison is corrosive, caustic (strong alkali such as lye)
or a hydrocarbon, vomiting is the most effective way to remove
poison.
- Give syrup 1 pecac to induce vomiting
3. 1 pecac oral emetic
- 15 ml adolescent, school age & pre school
- 10 ml to infant
4. UNIVERSAL ANTIDOTE- charcoal, milk of magnesia & burned
toast
5. Never adm charcoal before 1 pecac
6. antidote for acetaminophen poisoning acetylsysterine
( mucomyst)
7. caustic poisoning ( muriatic acid ) neutralize acid by giving
vinegar . Dont vomit prepare tracheostomy set
8. Gas- mineral oil will coat intestine

Lead poisoning
Lead = Destroy RBC functioning = Hypochornic Microcytic
Anemia = Destroy kidney functioning
Accumulation of anemia = Encepalopathy

Sx:
1. beginning sx of lethargy
2. impulsiveness, learning difficulties
3. as lead increases, severe encepalopathy with seizure and
permanent mental retardation
Dx:
1. Blood smear
2. abd x ray
3. long bones
Mgt:
1. remove child from source
2. if > 20 ug/dL need chelation therapy = binds with led &
excreted by kidney
=nephrotoxic

Amogenital
Female:
Pseudomenstration slight bleeding on vagina related to hormonal
changes

Tearing of fourchette with blood rape/ child abuse

Rape- Report within 48 h
Shape pubic hair in inverted triangle ( female)

Male:
Undescended testes cyrptorchidism -common to preterm
surgery orchidopexy
assess scrotum- warm room & hands

baby pee within 24 h

-check for arch of urination
Epispadias- urinary meatus located dorsal or above glans penis
Hypospadias- urinary meauts loc ventral or below glans penis

Hypospadias with chordee- fibrous band causing penis to curb

downward

Mgt:
Surgery

Phimosis- tight foreskin

Balanitis-infection of glands penis due smegma

Mgt:
Circumsicion

Hydrocele fld filled scrotum

Tst of Dx:
Transillumination with use of flashlight - glowing sign

Varicocele enlarged vein of epididimis ( girls- vulvular

varicosities)

BACK- check for flatness & symmetry

Open Neural Tube Defect- decreased Folic Acid intake

SPINA BIFIDA OCCULTA- failure of post laminae of vertebrae to

fuse
Sx: dimpling of back , Abnormal tufts of hair

SPINA BIFIDA CYSTICA- failure of post laminae of vertebrae to

fuse with a sac

Types:
1. Meningocele protrusion of CSF & Meninges
2. Myelomeningocele protrusion of CSF & Meninges & spinal
cord ( most dangerous)
3. Encephalocele ( CNS complication hydrocephalus) cranial
meningocele or myelomeningocele
Most common problem
- rupture of sac
- prone pos
- sterile wet dressing
Most common complication - infection
Myelomeningocele genitourinary complication- urinary & fecal
incontinence
Nsg care: always check diaper
Orthopedic complication paralysis of lower extremities
Surgery to prevent infection
Post op prone position

SCOLIOSIS- lateral curvature of the spine

2 types:
1. structural rye neck
2. postural improper posture

Dx:
1. uneven hemline
2. bend forward- 1 hip higher
1 shoulder blade more prominent
Nsg care:
1. conservative avoid obesity, exercise
2. preventive Milwaukee brace - worn 23 h a day
3. corrective surgery insert Harrington rod
post op- how to move
log rolling- move client as 1 unit

EXTREMITIES:
check # of digits = 20
1. syndactyly webbing of digits
2. polydactyly extra digits
3. olidactyly lack of digits
4. Amelia total absence of digits
5. pocoamelia- absence of distal part of extremities

ErQ duchennes paralysis- brachial plexus injury or brachial

palsy
- birth injury caused by lateral & excessive traction during a
breech injury
Sx:
1. unable to abduct arms from shoulders, rotate arm externally or
supinate forearm
2. absence or asymetrical moro reflex
Mgt:
1. abduct arm from shoulders with elbow flex.
CONGENITAL HIP DISLOCATION head of femur is outside
acetabulum
Types;
1. subluxated most common type
2. dislocated
Sx:
1. shortening of affected leg
2. asymmetrical gluteal fold
3. limited movement earliest sx
4. (+) ortolanis sign abnormal clicking sound
5. when able to walk child limps late sx- trendelenburg sign
Goal of Mgt:
Facilitate abduction
Mgt.
1. triple diaper
2. carry baby astride
3. Frejka splint
4. Pavlik harness
5. Hip Spica Cast

TALIPES clubfoot
a.) Equinos plantar flexion horsefoot
b.) Calcaneous dorsiflexion heal lower that foot anterior
posterior of foot flexed towards anterior leg
c.) Varus- foot turns in
d.) Valgus- foot turns out
Equino varus- most common

Assessment:
1. Straighten legs & flexing them at midline pos
Mgt:
1. Corrective shoe- Dennis brown shoe, spica cast
Fx: of cast
- to immobilize
- bone alignment
- prevent muscle spasm
lead pencil mark area to be amputated
cold H20 hasten setting process
hot H20- slow setting process

After cast application how to move pt:

- use open palm not fingers- fingers will cause indention
- dry cast natural air not blower
- priority check : neurovascular check
C- circulation
M- motion S- sensation

Cast with bleeding

- mask with ball pen edge of blood to know if bleeding is on going

sign cast is dry = resonant sound, cast cold to touch

do petaling making rough surface of cast smooth

CRUTCHES
Fx: To maintain balance
- To support weakened leg

Principles in crutches
- wt of body on palm!
- Brachial pulsing if wt of body in axila
Renal Disorder Cause Sx Tx NSG CARE
NEPHROTIC
SYNDROME infectious 1. Anasarca- gen edema
2. massive protenuria
3. microscopic or no hematuria
4. serum CHON decreased
5. serum lipid increased
6. fatigue
7. normal or decreased BP Prednisone
Diuretic Focus of care: monitor edema
-weigh daily
Diet:
Increase CHON
Increase K- OJ, beef broth, banana
Decrease Na
AGN ( acute Glomerulo Nephritis)
3As;
AGN,
autoimmune,
Grp A Autoimmune
Grp A beta hemolytic streptococcus 1. (PPP) primary peripheral
periobital edema
2. moderate protenuria
3. gross hematuria ( smokey urine)
4. serum K increased
5. fatigue
6. increase BP
Complication :
1. hypersensive encephalopathy
2. anemia 1. anti HPN drug
- hydralazine or apresoline
2. iron 1. weigh daily
2. monitor BP & neurologiuc status
3. Diet: decrease K, decrease Na
- Do palm exercise- squeeze ball
Different crutch Gaits:
1. Swing Through
2. 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
- wt bearing allowed in 2 lower ext
Posted by Rey at 6:34:00 PM 2 comments

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Obstetrical Nursing

MATERNAL/OB NOTES

Human Sexuality
A. Concepts
1. A persons sexuality encompasses the complex behaviors,
attitudes emotions and preferences that are related to sexual
self and eroticism.
2. Sex basic and dynamic aspect of life
3. During reproductive years, the nurse performs as resource
person on human sexuality.
B. Definitions related to sexuality:

Gender identity sense of femininity or masculinity

2-4 yrs/3 yrs gender identity develops.
Role identity attitudes, behaviors and attributes that
differentiate roles

Sex biologic male or female status. Sometimes referred to a

specific sexual behavior such as sexual intercourse.

Sexuality - behavior of being boy or girl, male or female man/

woman. Entity life long dynamic change.
- developed at the moment of conception.

II. Sexual Anatomy and Physiology

A. Female Reproductive System
1. External value or pretender
a. Mons pubis/veneris - a pad of fatty tissues that lies over the
symphysis pubis covered by skin and at puberty covered by pubic
hair that serves as cushion or protection to the symphysis pubis.

Stages of Pubic Hair Development

Tannerscale tool - used to determine sexual maturity rating.
Stage 1 Pre-adolescence. No pubic hair. Fine body hair only
Stage 2 Occurs between ages 11 and 12 sparse, long, slightly
pigmented & curly hair at pubis symphysis
Stage 3 occurs between ages 12 and 13 darker & curlier at labia

Stage 4 occurs between ages 13 and 14, hair assumes the

normal appearance of an adult but is not so thick and does no
appear to the inner aspect of the upper thigh.
Stage 5 sexual maturity- normal adult- appear inner aspect of
upper thigh .
b. Labia Majora - large lips longitudinal fold, extends symphisis
pubis to perineum
c. Labia Minora 2 sensitive structures
clitoris- anterior, pea shaped erectile tissue with lots sensitive
nerve endings sight of sexual arousal (Greek-key)

fourchette- Posterior, tapers posteriorly of the labia minora-

sensitive to manipulation, torn during delivery.
Site episiotomy.

d. Vestibule an almond shaped area that contains the hymen,

vaginal orifice and bartholenes glands.

1. Urinary Meatus small opening of urethra, serves for urination

2. Skenes glands/or paraurethral gland mucus secreting subs
for lubrication
3. hymen covers vaginal orifice, membranous tissue
4. vaginal orifice external opening of vagina
5. bartholenes glands- paravaginal gland or vulvo vaginal gland -2
small mucus secreting subs secrets alkaline subs.
Alkaline neutralizes acidity of vagina
Ph of vagina - acidic
Doderleins bacillus responsible for acidity of vagina
Carumculae mystiformes-healing of torn hymen
e. Perineum muscular structure loc lower vagina & anus
Internal:
A. vagina female organ of copulation, passageway of mens &
fetus, 3 4inches or 8 10 cm long, dilated canal
Rugae permits stretching without tearing

B. uterus- Organ of mens is a hollow, thick walled muscular

organ. It varies in size, shape and weights.
Size- 1x2x3
Shape: nonpregnant pear shaped / pregnant - ovoid
Weight - nonpregnant 50 -60 kg- pregnant 1,000g
Pregnant/ Involution of uterus:
4th stage of labor - 1000g
2 weeks after delivery - 500g
3 weeks after delivery - 300 g
5-6 weeks after delivery - returns to original, state 50 60

Three parts of the uterus

1. fundus - upper cylindrical layer
2. corpus/body - upper triangular layer
3. cervix - lower cylindrical layer
* Isthmus lower uterine segment during pregnancy
Cornua-junction between fundus & interstitial
Muscular compositions: there are three main muscle layers whi