NCMA 219 LEC | 2ND Year – 2nd Semester ~ TRANSCRIBED BY: B ~

BACHELOR OF SCIENCE IN NURSING

NCMA 219 LEC Nursing Care of a Family with High-
CARE OF THE MOTHER & CHILD AT RISK Risk Newborn
WEEK 7 Newborn Priorities of First Days of Life
Prof: Mrs. Shiella May Edquibal, Man, RN All newborns have eight (8) priority needs in the first few days
Pediatric Nursing of life:
Classification according size & gestational age
Identification of High-Risk Newborn 1. Initiation and maintenance of respirations
• Premature Infant Effective loud crying is critical for Ductus Arteriosus (will
• Postmature infant be closed by effective crying); connected to maternal
• Small-for-Gestational Age circulation
• Large-for-Gestational Age 2. Establishment of extrauterine circulation
Acute Conditions of the Newborn
• Respiratory Distress Syndrome Perfusion comes from the placenta: once baby is out, s/he
• Meconium Aspiration Syndrome should be able to establish extrauterine circulation
• Apnea of Prematurity (tumitibok ‘yung puso)
• Neonatal Sepsis > Check FHR
• Hyperbilirubinemia 3. Control of body temperature
Diseases of the Newborn
• Necrotizing Enterocolitis
Babies are Non-shivering Thermoregulation
• Retinopathy Other ways to produce heat/ thermoregulate
• Hemolytic Diseases > Breaking down its own serum glucose → hypoglycemia
• Transient Tachypnea of Newborn > Break down Fats –> Ketones –> Acid –> Acidosis
• Trisomy 21 4. Intake of adequate nourishment
> Promote breastfeeding
PEDIATRIC NURSING 5. Establishment of waste elimination
> baby should establish past first stool/ Meconium
Pediatric Nursing or Child Health Nursing 6. Prevention of Infection
Is the nursing specialty of caring for infants, children and 7. Prevention of an infant-parent relationship
adolescents. > promotion of skin-to-skin contact
A nurse who specializes in this area is usually referred to > promote early bonding; baby will be rooming-in
as a pediatric nurse. 8. Developmental care, or care that balances physiologic
needs and stimulation for best development
Roles of the Pediatric Nurse:
❖ Primary Caregiver – provide promotive, preventive, Initiating and Maintaining Respirations
curative and rehabilitative nursing care in all levels of • Resuscitation
health services. > CPR, give oxygen
❖ Coordinator and Collaborator – maintains good • Airway
interpersonal communication with the child, family, and > should be open/ patent
health team members. > use Bulb syringe for
❖ Nurse Advocate – safeguard’s the child’s right, to assist Suctioning (last resort)
and provide the best care from the health care team. • Lung Expansion
❖ Health Educator – provide information to children, • Drug Therapy
parents, and significant others, about the prevention of > if baby is not crying
illness, health promotion, or maintenance. bcos of incorrect
❖ Nurse Consultant – guides parents for maintenance and administration of sedation in the 2nd stage of labor
promotion of health. • Ventilation Maintenance
❖ Nurse Counselor – provides guidance to parents in hazards > w/out oxygen for 3 mins of life it can lead to irreversible
of children and health team for own decision making in fetal death
different situations. Epinephrine/Adrenaline

Establishing Extrauterine Circulation

➢ Although establishing respirations is the usual priority at a
high-risk infant’s birth, lack of cardiac function may be
present concurrently or may develop if respiratory function
cannot be quickly initiated and maintained.
➢ If an infant has no audible heartbeat, or if the cardiac rate
is below 80 beats per minute, closed-chest massage
should be started.
➢ Hold an infant with fingers supporting the back and depress
the sternum with two fingers.

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 NCMA 219 – BSN 2ND YEAR – 2nd SEMESTER // Transcribed by B
➢ Continue to monitor transcutaneous oxygen or pulse ➢ Elevated specific gravity may also be caused by
oximetry to evaluate respiratory function and cardiac inappropriate antidiuretic hormone secretion or kidney
efficiency. If the pressure and the rate of massage are failure because of a primary illness.
adequate, it should be possible, in addition, to palpate a Hypotension (↓ BP) – there’s no enough perfusion in the
femoral pulse. brain, tissue, and organ
➢ If heart sounds are not resumed above 80 bpm after 30 ➢ If an infant has hypotension without hypovolemia, a
seconds of combined positive-pressure ventilation and vasopressor such as dopamine may be given to increase
cardiac compressions, 0.1 to 0.3 mL/kg epinephrine blood pressure and improve cell perfusion.
(1:1000) ➢ If hypovolemia is present, the cause is usually fetal blood
Central line/ Umbilical line to administer epinephrine loss from a condition such as placenta previa or twin-to-
Can also administer epinephrine in the endotracheal tube twin transfusion. With Hypovolemia, typically tachypnea,
pallor, tachycardia, decreased arterial blood pressure,
Maintaining Fluid and Electrolyte Balance decreased central venous pressure, and decreased tissue
➢ After an initial resuscitation attempt, hypoglycemia perfusion of peripheral tissue with a progressively
(decreased blood glucose) may result from the effort the developing metabolic acidosis, will be present.
newborn expended to begin breathing. o give fluids
o increased breastfeeding
demand for ↑ glucose level lead to ↓ blood glucose
o Increase OGT – Oral Gastric Feeding (Oral
Risk for: Hypoglycemia
Gastric Tube)
Problem: ↑ respiration = Dehydration
➢ Dehydration may result from increased insensible water
loss from rapid respirations. Infants with hypoglycemia are Regulating the Temperature of the baby
treated initially with 10% dextrose in water to restore their ➢ All high-risk infants may have difficulty maintaining a
blood glucose level. normal temperature. This is because, in addition to stress
➢ Fluids such as Ringer’s lactate or 5% dextrose in water are from an illness or immaturity, the infant’s body is often
commonly used to maintain fluid and electrolyte levels. exposed during procedures such as resuscitation and blood
Ringer’s lactate – IV Fluids with electrolytes. loss/ drawing.
o Maintain of TFR – Total Fluid Rate Normal Temp: 36.5 – 37.2 or 37.5
o Ex. Maintain TFR of 200mL/24 hours Ways to Regulate Temperature:
o Strict intake and output/monitoring of I and O o Radiant Heat Sources
▪ Make sure that the baby is urinating, weigh the o Incubators
used pad (1g=1ml) o Skin-to-Skin Care
o Dextrose 5% in water Nursing Consideration: Maintain Hydration and close
o Dextrose 10% in water monitoring of I and O due to high temperature.
o Dextrose 50% in water Possible Nursing Diagnosis
If glucose dextrose can’t be established, it can be • Ineffective airway clearance related to presence of mucus
administer in umbilical line (pag natuyo, it can’t be used or amniotic fluid in airway.
na) • Ineffective cardiovascular tissue perfusion related to
Cut down – Periphery area, Central line, via IV, cutting breathing difficulty.
down the area to expose the infant’s vein to directly • Risk for deficient fluid volume related to insensible water
catheter the veins. loss.
o HGT/CBG Test every 3 to 4 hours • Ineffective thermoregulation to newborn status and stress
▪ Normal Blood glucose level is >45mg mg/dl from birth weight variation
▪ <45mg/dl → Alarming baby will be • Risk for imbalanced nutrition, less than body requirements
Hypoglycemic, Notify the physician related to lack of energy for sucking.
➢ The rate of Fluid administration must be carefully • Risk for infection related to lowered immune response in
monitored because a high fluid intake can lead to patent newborns.
ductus arteriosus or heart failure. When using a radiant
• Risk for impaired parenting related to illness in newborns
warmer, there is an increase in water loss from convection
at birth.
and radiation. A newborn on a warmer, therefore, will
• Deficient diversional activity (lack of stimulation) related
require more fluid than if he or she were placed in a double-
to illness at birth.
walled incubator.
• Readiness for developmental care to decrease
Nursing Considerations: Lab Findings overstimulation easily caused by necessary lifesaving
➢ Dehydration monitored by urine output and urine- procedures.
specific gravity measures.
o output less than 2 mL/kg/hr = oliguria
o urine specific gravity greater than 1.015 to 1.020 =
inadequate fluid intake.
Report right away, it can be kidney problem

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 NCMA 219 – BSN 2ND YEAR – 2nd SEMESTER // Transcribed by B
The newborn at Risk because of
ALTERED GESTATIONAL AGE OR BIRTH
WEIGHT
Classification According to Gestational Age
• Premature (preterm) infant – an infant born before the
completion of 37 weeks of gestation, regardless of birth
weight.
• Full-term infant – an infant born between the beginning of
38 weeks and the completion of 42 weeks of gestation,
regardless of birth weight
• Postmature (postterm) infant – an infant born after 42
weeks of gestational age, regardless of birth weight. THE SMALL-FOR-GESTATIONAL-AGE INFANT
➢ An infant is SGA if the birth weight is below the 10th
PRETERM VS. FULL TERM percentile on an intrauterine growth curve for that age.
SGA infants may be born preterm (before 38 weeks of
gestation), term (between weeks 38 and 42), or post term
(past 42 weeks).
➢ SGA infants are small for their age because they have
experienced intrauterine growth restriction (IUGR) or
failed to grow at the expected rate in utero.

Etiology
➢ A woman’s nutrition during pregnancy plays a major role
in fetal growth, so lack of adequate nutrition may be a
major contributor to IUGR. Pregnant adolescents have a
high incidence of SGA infants. Because adolescents must
meet their own nutritional and growth needs, needs of a
growing fetus can be compromised.
➢ However, the most common cause of IUGR is a placental
anomaly; either the placenta did not obtain sufficient
nutrients from the uterine arteries or it was inefficient at
transporting nutrients to the fetus. Placental damage, such
as partial placental separation with bleeding, limits
placental function because the area of placenta that
separated becomes infarcted and fibrosed, reducing the
Classification According to Size placental surface available for nutrient exchange.
• Low-birthweight (LBW) infant o Placental Anomaly:
▪ Partial placental separation
– infant whose birth weight is less than 2,500 grams (5.5
o Mothers with systemic disease
lbs), regardless of gestational age
• Very low birthweight (VLBW) infant
Risk Factor
– An infant whose birth weight is less than 1,500 grams
(3.3 lbs) • Developmental defect in the placenta
• Extremely low birthweight (ELBW) infant • Women with systemic diseases that decrease blood flow to
– An infant whose birth weight is less than 1,000 grams the placenta
(2.2 lbs) o Severe mellitus or pregnancy induced hypertension
(both are diseases in which blood vessel lumens are
• Appropriate for Gestational Age (AGA) infant
narrowed) are at higher risk for delivering SGA babies
– An infant whose weight falls between the 10th and 90th
than others.
percentiles on intrauterine growth curves.
• Women who smoke heavily or use narcotics also tend to
• Small-for-date (SFD) or Small-for-gestational-age (SGA)
have SGA infants.
infant
– An infant whose rate of intrauterine growth was slowed Assessment
and whose birth weight falls below 10th percentile on
• The SGA infant may be detected in utero when fundal
intrauterine growth curves.
height during pregnancy becomes progressively less than
• Intrauterine Growth Restriction (IUGR)
expected. However, if a woman is unsure of the date of her
– Found in infants with those intrauterine growth is last menstrual period, this discrepancy can be hard to
restricted. substantiate.
• Large-for-gestational age (LGA) infant • A sonogram can demonstrate the decreased size.
– An infant whose birth weight falls above the 90 th
percentile on intrauterine growth charts.
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 NCMA 219 – BSN 2ND YEAR – 2nd SEMESTER // Transcribed by B
• A biophysical profile including a nonstress test, placental LARGE FOR GESTATIONAL AGE
grading, amniotic fluid amount, and ultrasound ➢ An infant is LGA (also termed macrosomia) if the birth
examination can provide additional information on weight is above the 90th percentile on an intrauterine
placental function. If poor placental function is apparent growth chart for the gestational age. Such a baby appears
from such determinations, it can be predicted the infant will deceptively healthy at birth because of the weight, but a
do poorly during labor because of periods of relative gestational age examination will reveal immature
hypoxia during contractions may result. development.
• Cesarean birth is the birth method of choice in such ➢ It is important that LGA infants be identified immediately
circumstances. so that they can be given care appropriate to their
• Appearance gestational age rather than being treated as term newborns.
o Generally, an infant who suffers nutritional
deprivation early in pregnancy, when fetal growth Etiology
consists primarily of an increase in the number of body ➢ Infants who are LGA have been subjected to an
cells, is below average in: overproduction of growth hormone in utero. This happens
▪ weight most often to infants of women with diabetes mellitus or
▪ length women who are obese.
▪ head circumference ➢ Extreme macrosomia occurs in fetuses of diabetic women
o An infant who suffers deprivation late in pregnancy, whose symptoms are poorly controlled, because these
who growth consists primarily of an increase in cell fetuses are exposed to high glucose levels.
size, may have only a reduction in weight. ➢ Multiparous women are also prone to have large babies
• Regardless of when deprivation occurs, an infant tends because with each succeeding pregnancy, babies tend to
to: grow bigger.
o Have an overall wasted and old and sick appearance ➢ Other condition associated:
o Small liver, which can cause difficulty regulating o Transposition of the great vessels,
glucose, protein, and bilirubin levels after birth. o Beckwith syndrome (a rare condition characterized by
o Poor skin turgor overgrowth), and
o Head look bigger o Congenital anomalies such as omphalocele.
o Skull sutures may be widely separated
o Hair is dull and lusterless. Assessment
o Abdomen may be sunken. • A fetus is suspected of being LGA when a woman’s uterus
o Umbilical cord appears dry and have yellow staining. is unusually large for the date of pregnancy.
• Laboratory findings: Blood studies at birth usually show a • Abdominal size can be deceptive, however – because a
high hematocrit level (less than normal amounts of fetus lies in a flexed fetal position, he or she does not
plasma in proportion to red blood cells are present because occupy significantly more space at 10 lb than at 7 lb.
of a lack of fluid in utero) and an increase in the total • Sonogram – to see if the fetus is growing at an abnormal
number of red blood cells (polycythemia). rate
o The increase in red blood cells occurs because anoxia • Nonstress Test – assess the placenta’s ability tosustain a
during intrauterine life stimulates the development of large fetus during labor may be performed
red blood cells. The polycythemia that results causes • Lung maturity assessed by amniocentesis – to see if an
increased blood viscosity, a condition that puts extra LGA fetus is mature
work on the infant’s heart because it is more difficult • Fundic height measurement
to effectively circulate thick blood. • Ultrasound
• As a consequence, acrocyanosis (blueness of the hands
and feet) may be prolonged and persistently more marked Appearance
than usual. If the polycythemia is extreme, vessels may • At birth, LGA infants may show immature reflexes and
actually become blocked and thrombus formation can low scores on gestational age examinations in relation to
result. If the hematocrit level is more than 65% to 70%, an their size. They may have extensive bruising or a birth
exchange transfusion injury such as a broken clavicle or Erb-Duchenne
o Exchange transfusion: Done in the umbilical paralysis from trauma to the cervical nerves if they were
cord/central line/carotid, where bad blood (high born vaginally.
hematocrit, high RBC) infuses good blood to defuse • Because the head is large, it may have been exposed to
bad blood. To dilute high viscous blood of the baby more than the usual amount of pressure during birth,
> Done to baby with Hyperbilirubinemia causing a prominent caput succedaneum,
• Because SGA infants have decreased glycogen stores, one cephalhematoma, or molding.
of the most common problems is hypoglycemia (decreased
blood glucose, or a level below 45mg/dL). Such infants
Cardiovascular Dysfunction
may need IV Glucose to sustain blood sugar until they are
able to suck vigorously enough to take sufficient oral ➢ Observe LGA Infants closely for signs of
feedings. hyperbilirubinemia (increased serum bilirubin level),
which may result from absorption of blood from bruising
and polycythemia.

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➢ Polycythemia has been caused by an infant’s system • Substernal retractions
attempting to fully oxygenate all body tissues. This effort • Flaring of nares
puts extra stress on the heart, so the heart rate of LGA • Fine respiratory crackles
infants should be carefully observed. • Central cyanosis (late and serious sign)
➢ If cyanosis is present, it may be a sign of transportation of
the great vessels, a serious heart anomaly associated with Diagnostic Evaluation
macrosomia.
• Pulse Oximetry (Determine hypoxia)
Hypoglycemia o Normal: 95 – 100
➢ LGA infants also need to be carefully assessed for • Radiography
hypoglycemia in the early hours of life because infants o Heart anomaly
require large amounts of nutritional stores to sustain their o Chest Xray
weight. • L/S ratio (Lecithin/Sphingomyelin)
➢ If the mother had diabetes that was poorly controlled, the o Normal: 2:1
infant will have had an increased blood glucose level in • TDx Fetal Lung Maturity assay (determines PG level in
utero causing the infant to produce elevated levels of amniotic fluid or neonatal tracheal aspirate)
insulin. o PG – ex. if ↓ Phosphatidyl glycerol/ Phosphatidyl
➢ After birth, these increased insulin levels will continue for choline → ↓ Lung surfactant → Respiratory distress
up to 24 hours of life, possibly causing rebound
hypoglycemia. Therapeutic Management
• Administration of exogenous surfactant
ACUTE CONDITIONS OF THE NEWBORN ▪ Upon intubation endotracheal
Illness of the High-Risk Newborn ▪ Baby preterm w/ respiratory distress, this surfactant
stimulate lung function
Respiratory Distress Syndrome • Nitric oxide (Pulmonary Dilation)
➢ a.k.a Hyaline Membrane Disease • Oxygen therapy (Maintains correct PO2 and pH)
➢ A condition of surfactant deficiency and physiologic • IV therapy (hydration and nutrition)
immaturity of the thorax
➢ Seen almost exclusively in PRETERM infant (multifetal Nursing Management
pregnancies, infants of diabetic mother, C/S delivery, etc) ✓ Close monitoring
Alveoli is the main gas exchange unit of the lungs, without ✓ Keep oxygen consumption as low as possible (handle
the alveoli, there will be no gas exchange infants as little as possible)
o (hindi siya mag i-inhale – exhale nang maayos) Do not hyper-oxygenate! Hyperoxygenation can lead to
Surfactants during the 24th week of AOG Retinopathy (irreversible blindness of the neonate)
If the baby is born before 24th weeks of AOG the baby will ✓ Suction only when necessary (Gently but quickly)
not be able to spontaneously breathe. ✓ Encourage parents to verbalize feelings.
Type 2 cells (work with surfactants) in the lungs, develop
during the 36th weeks AOG Meconium Aspiration Syndrome
Nakalunok/Naka-inhale ng meconium or first poop of the
Pathophysiology baby.
Inadequate inflation ➢ Relaxation of the anal sphincter and passage of meconium
Immaturity of Surfactant
due to increased into amniotic fluid due to intrauterine urine.
the lungs deficiency
surface tension Risk for: Full term/ Post term infants

Hypoxemia (in the Pathophysiology

Atelectasis lungs), and Transudation
(lung
Increased pulmonary (lung injury)
collapsed)
vascular pressure

Lungs become stiffer

(hyaline membrane)

Clinical Manifestations
o Silverman Andersen Index – is the type of assessment to
check for respiratory distress
▪ 0 = no respiratory distress
▪ 10 = severe respiratory distress
• Chest indrawing and retractions
• Tachypnea
• Labored breathing
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 NCMA 219 – BSN 2ND YEAR – 2nd SEMESTER // Transcribed by B
Clinical Manifestations Therapeutic Management
➢ There will be ↑ carbon dioxide in the blood than can lead • Methylxanthines (Aminophylline, theophylline, caffeine)
to respiratory acidosis. o CNS Stimulates to breathing
➢ There will be no enough oxygenation due to lack of inhaled o Observe for Sx of toxicity (Tachycardia at rest,
oxygen vomiting, irritability, diuresis)
o Stained from meconium stool • Cafcit (Caffeine Citrate)
o Tachypneic o Urine output should be closely monitored (mild
o Expiratory grunting, nasal flaring, retractions diuretic effect)
o Initially cyanotic
o Classic Barrel chest Nursing Management
o Respiratory distress with gasping ✓ Observation combine with monitoring is the most effective
means of identifying neonatal apnea
Diagnostic Evaluation
(if apnea begun)
• Laryngoscopy – there will be a scope with video at the end
✓ Gentle tactile stimulation (rubbing the back or chest gently)
down to the larynx to visualize aspirated/meconium in the
✓ Flow-by oxygen and suctioning
area.
✓ Chin is raised gently to open airway
• Chest x-rays
✓ Infant is NEVER SHAKEN
• Pulse Oximetry – check for hypoxemia ✓ Record episodes of apnea
• Echocardiography

Therapeutic Management Sudden Infant Death Syndrome (SIDS)

• Tracheal suctioning (poor respiratory effort, low heart rate, • Sudden death of infant under 1 year of age
poor tone) • “Crib death”
• Ventilatory support Etiology: UNKNOWN (idiopathic)
• Exogenous surfactant administration Contributing Factors:
• IV Fluids
✓ Prone sleep position
• Systemic antibiotics – for prevention of infection
✓ Soft bedding
o Ampicillin – 2x a day
✓ Use of pillow
o Gentamicin – once a day
✓ Brainstem abnormality
✓ Co-sleeping with parents
Nursing management
✓ Maternal smoking
✓ Same with high-risk neonates
Manifestations and Diagnosis
Apnea of Prematurity (AOP) Manifestations:
• Common phenomenon in preterm infants May be seen:
• Characterized by apneic spells • Frothy-blood tinged fluid in the mouth
The baby is not breathing for 20 seconds • Lying face down in the secretions
Preterm baby • Hands clutching in the sheets
Premature is not sensitive to hypoxemia and hypercarbia Diagnosis:
✓ Autopsy
TYPES ✓ Investigation of the Scene
• Central Apnea
o CNS does not transmit signals to the respiratory Nursing Management
muscles. ✓ Allow the parents to say goodbye
• Obstructive Apnea ✓ Encourage to hold their infant
o Airflow ceases due to upper airway obstruction. ✓ Encourage verbalization of feelings
✓ Provide a quiet room with dim lighting
• Mixed Apnea
✓ Explain that the death is due to SIDS and it is not
o Combination of central and obstructive apnea (*most
preventable or predictable
common)
Recommendation in preventing SIDS
Pathophysiology
✓ Place infants on their back when sleeping
Immature respiratory centers (of the (Plagiocephaly: change head position periodically)
brain) ✓ Use firm mattress
✓ Avoid exposure to smoke
Weakness of muscles of the thorax ✓ Offer a pacifier to sleep
and diaphragm

Apneic Episodes

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 NCMA 219 – BSN 2ND YEAR – 2nd SEMESTER // Transcribed by B
Neonatal Sepsis Therapeutic Management
• Handwashing
➢ Generalized bacterial infection in the blood stream. • Antibiotic Therapy
➢ Breastfeeding – has a protective effect.
• Regulation of fluids
➢ Colostrum – contains agglutinins (affective against gram-
• Oxygen therapy
negative bacteria), IgA and iron-binding proteins, as well
as macrophages and lymphocytes.
Sepsis – or septicemia, refers to a generalized bacterial Hyperbilirubinemia
infection in the bloodstream. Neonates are highly susceptible ➢ An excessive level of accumulated bilirubin in the blood
to infection because of diminished nonspecific (inflammatory) and is characterized by jaundice (ICTERUS)
and specific (humoral) immunity. (a yellowish discoloration of the skin, sclera and other
Sources of infection – From the mother itself – Sepsis in the organs)
neonatal period can acquired prenatally across the placenta ➢ Hyperbilirubinemia is a common finding on the newborn
from the maternal bloodstream or during labor from ingestion and in most instance is relatively benign. However, in
or aspiration of infected amniotic fluid. extreme cases, it can indicate a pathologic state.
Early-onset sepsis (<3 days after birth) is acquired in the NOT NORMAL!
perinatal period. Infection can occur from maternal infection. ▪ Jaundice appears in 2nd or 3rd day
Late-onset sepsis (1 to 3 weeks after birth) is primarily ▪ Peaks on 3rd – 5th day
nosocomial (healthcare associated or hospital-acquired ▪ Declines on the 5th – 7th day
infection or HAI), and the offending organisms are usually
o Staphylococci Causes:
o Klebsiella organisms • Physiologic
o Enterococci • Breastfeeding-associated
o E. coli
• Excessive production of bilirubin
o Candida species
• Liver problem
o Coagulase-negative staphylococci – older children and
• Combined overproduction and underexcretion
adults, found to be cause of septicemia in ELBW and
VLBW • Other conditions (G6PD, hypothyroidism, galactosemia,
infant of a diabetic mother)
Pathophysiology • Genetic predisposition to increased production (Native
Americans, Asians)

Pathophysiology

After to 2 – 4 days the The output is

Starts with baby will start to bilirubin
excess RBC destroy or breakdown (Stool and
the excess RBC Urine)

Jaundice Increase
Liver is premature
bilirubin in the
skin and and can’t
yellow blood that will go
metabolize yet
sclera in the tissue
properly
levels
Clinical Manifestations/ Diagnostic Evaluation
NORMAL -PATHOPHYSIOLOGY- PROBLEM
CBC – leukocytosis or leukopenia. (blood)
(↑ WBC) (↓ WBC)
CSF Analysis (Cerebrospinal Fluid)
Blood Culture and sensitivity test (blood)
CRP or C-Reactive Protein test (blood) – determine or
diagnose if there is an inflammation or bleeding in the body
Antibiotic therapy for 7 – 10 days
• Because of sepsis is easy to confuse with other neonatal
distress
• Antibiotic therapy is continued 7 to 10 days if culture are
positive, discontinued in 36 to 48 hours if cultures are
negative and the infant is asymptomatic, and most often
administered via IV infusion. Antifungal and antival
therapies are implemented
• Prognosis
o Infection was assessed early on – GOOD prognosis
o Infection spread out in the brain – POOR prognosis
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Nursing Care Management
✓ Vit. D/ Sunlight – can help dilute the bilirubin so it can be
excreted out in the urine.
✓ Phototherapy (partial sunlight)
▪ Wear eye shield
▪ Genital shield/ Diaper
▪ Clothes
✓ Periodically turn infants (*has not been shown to accelerate
clearance)
✓ Check hydration status
o manifestation of dehydration in infants:
– poor skin turgor (>2 – 3 secs) (N: <2-3 secs)
– sunken eyeball
Clinical Manifestations – sunken fontanel
• Jaundice – the yellowish discoloration primarily of the – ↓ UO
sclera, nails, or skin. – dry & cracked lips
• Appears within 24 hours – Sepsis or HDN or one of the – ↓ capillary refill (> 2 secs) (N: 1-2 secs)
maternally derived diseases such as diabetes mellitus or
infections.
• Appears on the 2nd or 3rd day, peaks at the 3rd to 5th day, and
decline at the 5th to 7th day – Physiologic jaundice
o Serum bilirubin test more than 200 mumol/L
▪ (Normal Level: Below 200 mumol/L)

Complications:
o High Bilirubin levels can lead to Bilirubin
encephalopathy.
o Kernicterus – (bilirubin-induced neurologic
dysfunction) yellow staining of brain cells and brain
necrosis.

Diagnostic Evaluation
• Serum bilirubin
o If more than 200 mumol/L
▪ Normal Level: Below 200 mumol/L
: Unconjugated bilirubin (0.2 to 1.4 mg/dL)
• Transculatenous bilirubinometry
• Hour-specific serum bilirubin levels – GOLD
STRANDARD

Therapeutic Management
• Phototherapy
o consists of exposing the infant’s skin to an
inappropriate light source.
o Light promotes bilirubin excretion by
photoisomerization.
o Alters the structure of bilirubin to a soluble form
(Lumirubin)
o Enhance excretion but not production
• Exchange Transfusion

• Phenobarbital – for infants w/ hemolytic disease

o Effective if given to mother days before the delivery
o Promotes hepatic synthesis of glucuronyl transferase
• Intravenous Immunoglobulin – ABO incompatibility
and Rh isoimmunization
• Early initiation of feeding/ breastfeeding
• Encourage frequent and effective BF
• Monitor early stooling – loose stools may indicate
accelerated excretion (check perineal irritation)

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 NCMA 219 – BSN 2ND YEAR – 2nd SEMESTER // Transcribed by B
DISEASES OF THE NEWBORN Diagnostic Evaluation
❖ Necrotizing Enterocolitis (NEC) • Abdominal X-ray
❖ Retinopathy of Prematurity o See “sausage-like” or sausage-shaped dilation
❖ Hemolytic Disorder
❖ Transient
o Pneumatosis intestinalis – “soapsuds” gas forming
bacteria
NECROTIZING ENTEROCOLITIS (NEC) • CBC
➢ Inflammation and death of intestinal tissue. It may involve just the lining o Anemia (↓ RBC),
of the intestine or the entire thickness of the intestine. In severe cases, the o Leukopenia (↓ WBC) – severe preterm
intestine may even perforate. o Leukocytosis (↑ WBC) – a bit older infants
➢ If this happens, the bacteria normally found only in the intestine can leak
into the abdomen and cause widespread infection.
o Metabolic acidosis
➢ Acute inflammatory disease of the bowel with increased o Electrolyte imbalance
incidence in preterm and other high-risk infants
➢ Cause is uncertain Therapeutic Management
➢ May be due to vascular compromise 1) Prevention
o Intestinal immaturity: o If baby is suspected – Dr order: NPO
▪ Gastrointestinal dysmotility > Oral Feedings withheld for at least 24 – 48 hours
▪ Impaired gastric capacity 2) Breastmilk
▪ Altered anti-inflammatory control o After 24 – 48 hours, u can do breastfeeding
▪ Impaired host defense o Have some passive immunity (IgA), macrophages,
lysozymes.
Necrotize – namamatay, infection, inflamed 3) Maternal steroid administration – promotes early gut
Enterocolitis closure and maturation of gut barriers
↓ ↓ 4) Probiotics
colon infection/ inflammatory
Necrotizing enterocolitis – nabubulok ang small or large Medical Management
intestines due to inflammation. o NPO – nothing per orem
Risk: Premature Infants o DR order:
o It usually develops within two weeks of birth. ▪ Gastric decompression (Lavage);
o 80% occurs in premature babies, 10% of infants who ▪ Drain gastric acid
weigh less than 3 pounds and 5 ounces develop NEC. – Hanggat kaya, it should be empty
o Intravenous Antibiotics
Pathophysiology o Abdominal X-ray – EVERY 4 – 6 HOURS
• Hypoxic event – (di nakakahinga agad yung baby = ▪ If upon Xray, the patient is not improving
vascular compromise sa bituka) ▪ GOAL: To prevent perforation
– Di pumutok ang bituka
• Asphyxia
– If pumutok = Peritonitis
• Vascular compromise – Intestinal ischemia
▪ Do: Bowel Resection (cut) & Anastomosis (dikit)
• Ischemia – there will be bacterial proliferation, – 16 hours OR
inflammation and infection will happen Depends on the extent of injury
(intestinal mucosa will not secrete proteolytic enzyme to
protect the intestine)
Complications:
Risk: not enough IgM & Prematurity
• Fat malabsorption – unable to gain weight, unable to
Clinical Manifestation absorb calories
1. Abdominal distention Nursing Care Management
2. Gastric residuals o Do not put diapers
o To feed: nilalagyan ng OGT (Oral Gastric Tube)
– thru OGT – if may backflow ng milk, it’s a sign RETINOPATHY OF PREMATURITY (ROP)
– Normal: when u feed a baby 30-40 mins, there is no ➢ A disorder involving immature retinal vasculature
gastric residual ➢ Formerly known as the “Retrolental Fibroplasia”
Reto – back
3. Hematochezia Lental – lense
o Blood in the stool Fibro – scar
▪ Milena – black tarry stool = Upper G.I bleed Plasia – proliferation
▪ Hematochezia – fresh blood in the stool = Lower ➢ Proliferation of scar at the back of the lens.
G.I bleed ➢ Occurs when abnormal blood vessels grow and spread
4. Nonspecific Sign throughout the retina, the tissue that lines the back of the
o Lethargy, poor feeding, hypotension, apnea, vomiting eye. These abnormal blood vessels are fragile and can leak,
(bile-stained), decreased urine output, hypothermia scarring the retina and pulling it out of position.
o Onset: between 4 and 10 days
▪ 4 – 10 days after the initiation of feedings.
▪ Especially if preterm has history of hypoxia
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 NCMA 219 – BSN 2ND YEAR – 2nd SEMESTER // Transcribed by B
Etiology Pathophysiology
• Hyperoxemia, Hypoxia, Hypercarbia, Hypocarbia, Rh antibodies
Rh (–)
Prenatal Complicatin, Exposure to light mother
Rh (+) baby enter fetal
Risk: Premature Baby circulation

Pathophysiology
Severe vascular Stimulation of Erythroblastosis RBC
constriction in Hypoxia in vascular fetalis destruction
retinal the area proliferation (Severely Anemia) and hemolysis
vasculature towards the lens

Aqueous and Clinical Manifestations

Retinal
Vitreous humor
edema &
Retinal 1. Jaundice within the 1st 24 hours.
becomes detachment 2. Fetal hydrops (generalize edema)
hemorrhage
TURBID
3. Elevated serum unconjugated bilirubin
4. Anemia – (< hemoglobin)
Irreversible – Hemoglobin
blindness Normal: Female: 12 – 14 mg/dL
: Male: 14 – 16 mg/dL
Severe vascular constriction in retinal vasculature = lead 5. Hepatosplenomegaly
to hypoxia
Hypoxic event – body will try to compensate by Diagnostic Evaluation
proliferating (pinapadami) the vasco chuchuness of Mommy Rh (–) will conduct a blood test
capillaries If she develops antibodies
Risk for: Preterm = The baby is Rh (+)
91 – 94 % 1. Maternal antibody titer (Indirect Coombs test)
Nothing to be alarm of 2. Amniocentesis – test fetal blood type
DON’T INCREASE OXYGEN! 3. Ultrasound/ Ultrasonography

Therapeutic Management Therapeutic Management

✓ Strict oxygen management • If mother is nanganak na – give Rh Isoimmunization (Rh
o Maintain oxygen Ig) (Rhoga) is administered at 28 weeks of pregnancy and
o Do not increase oxygen level right away! 72 hrs after birth
o Refer to Doctor o This will deactivate antibodies in mother.
✓ Cryotherapy ablation o Blood type can see if ↓ RBC & h = fetal anemia
o Using cold to kill blood vessels that may cause ROP • Intrauterine Transfusion
✓ Laser Therapy o Ultrasound guided sa umbilical cord
o Using heat as a destroying medium. o Gaano kadaming blood? Depends sa Doctor or sa
Cryotherapy and laser – pinapahinto yung proliferation, gaano karami ang need
slowing or reversing the abnormal growth of blood vessels • Exchange Transfusion
o If nakalabas na si baby from mother
Nursing Care Management o Infant’’s blood is removed in small amounts and
• ↓ constant bright environmental light replaced with compatible blood
• Inform the parents that infants eyelid will be closed and • Phototherapy
edematous post operatively. Risk for: Miscarriage or Preterm labor

HEMOLYTIC DISEASES OF THE NEWBORN Nursing care Management

➢ Term “hemolytic” is derived from the Latin word for • Assessment: see early jaundice, history of Rh
“destruction” (lysis) of red blood cells. incompatibility
➢ Abnormally rapid rate of RBC destruction. • Baby – NPO
➢ Anemia caused by this destruction stimulates the o Monitor for clinical manifestation of blood transfusion
production of RBC. reaction (fever, difficulty of breathing, rashes)
• Phototherapy
Causes:
o Eye shield and Genital shield
• Rh Incompatibility (Fetal anemia) • Urine, Intake and Output
• ABO Incompatibility (can cause jaundice but not really • VS
hemolytic disease)

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 NCMA 219 – BSN 2ND YEAR – 2nd SEMESTER // Transcribed by B
TRANSIENT TACHYPNEA OF NEWBORN Therapeutic Management
➢ Short period of time NO CURE.
➢ Can happen to ALL infants. 1. Therapy
➢ Preterm, term, post term 2. Referral to the Doctor of all at risk complications
Can happen if baby aspirate meconium. • Surgeries to correct congenital anomalies
• Hearing and vision testing/ evaluation
Clinical Manifestations • Thyroid function tests
• Increased RR (Tachypnea)
o Normal RR of newborn: 40 – 60 or 30 – 50 bpm Nursing Care Management
• Retraction • Supporting the family at the time of Diagnosis
• Nasal flaring o Culture has significant effect
• Cyanosis • Assist the Family in Preventing Physical problems

Diagnostic Evaluation If hindi na-diagnose agad…

• T/C Trisomy 21 (Do karyotype)
Determine the cause by:
• At risk of injury, environment should be safe.
• Chest X-ray
• Promote the Child Developmental Progress
• CBC and Blood culture
• Assist in Prenatal Diagnosis and Genetic Counseling.
Therapeutic Management and Outcome
• Oxygenate because after 2 – 3 days, mawawala na

TRISOMY 21
➢ “DOWN SYNDROME”
➢ Physical and cognitive abnormalities
➢ Typical life expectancy 60 YEARS OLD
With proper treatment and therapy
Therapy – as early as 18 months
➢ know thru Karyotyping: The 21st Chromosome instead of
2, it became 3. Attributable to extra chromosome 21.

Etiology: UNKNOWN

➢ Can happen to anyone

➢ Higher incidences with mother who delivers over 35 years
of age.

Clinical Manifestations
PHYSICAL
o Slanted eyes
o Low set ears
o Transverse palmar creases
o Additional fats or skin in neck part
o Flat face, nose, forehead
Other symptoms:
• Intelligence
o Severe – Low average intelligence
o Mild – Moderate range of Cognitive Impairment
• Social Development
• At risk of Congenital abnormalities
o Heart, kidney diseases, muscoskeletal defects
o Cervical spine mobility
• Sensory problems
o Poor muscle strength
• Growth
o Small stature than general
o Weight gain rapid more than normal
• Sexual development
o May be delayed, incomplete, or both
o Female – can have menstruation, ovulation
o Male – genitalia & facial hair – undeveloped
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 NCMA 219 – BSN 2ND YEAR – 2nd SEMESTER // Transcribed by B
NCMA 219 LEC PHENYLKETONURIA (PKU)
CARE OF THE MOTHER & CHILD AT RISK
Phenylalanine – a substance that we get from food we eat
WEEK 8 (meat, milk, eggs)
Prof: Mrs. Shiella May Edquibal, Man, RN Phenylalanine is needed to convert –> tyrosine
Newborn Screening To convert, it needs Phenylalanine hydroxylase
• Congenital Hypothyroidism ➢ Phenylketonuria – NO Phenylalanine hydroxylase
• Phenylketonuria
➢ If there’s no tyrosine, it will lead to neurotransmitter.
• Galactosemia
• G6PD (Glucose-6-Phosphate Dehydrogenase Deficiency)
• Congenital Adrenal Hyperplasia • Increased phenylalanine will lead to:
Infant and Young Problems o Brain injury
• Failure to thrive. o
• Colic
o Seizure
Phenylpyruvic acid in the urine
NEWBORN SCREENING (NBS) – Iniihi mo yung excess Phenylalanin
➢ Has 3 parts
➢ Very important to be done to all babies. Pathophysiology
➢ Should be done to 24 – 48 hours after birth.
↓ tyrosine
➢ Mandatory
➢ Hospital
➢ Health Center
Screening is until 2 days after birth. ↓ Tryptophan ↓ Dopamine ↓ Melanin

Three parts:
Decreases Decreased plasma Fair skin,
1. Blood Spot Screening levels of
level of Blue eyes,
2. Pulse Oximetry Screening (heart condition) serotonin catecholamines Blond hair
3. Hearing Screening (responsible for
o (OAE) stress response)

Where do you get the blood needed for NBS? Therapeutic Management
✓ Heel of the foot • Diet (no to meat!)
o ↓ Phenylalanine : ↑ tyrosine
Diseases that can be diagnoses with NBS o No meat, nuts is an ecemption.
Metabolic Diseases • No medication
CONGENITAL HYPOTHYROIDISM Nursing Management
➢ Thyroid – regulates metabolism, stress response, ability • If the child grow until he can understand anything – s/he
thermoregulate need to know his/ her disease, s/he needs to be aware of it.
➢ Hypothyroidism – ↓ thyroxine • Parent – basic understanding
➢ With congenital hypothyroidism – thyroid is not
functioning at all or not secreting enough thyroxine.
GALACTOSEMIA
Signs and Symptoms ➢ Baby doesn’t have 3 hepatic enzyme. Which is needed
• 1st few days/ months – looks normal convert the galactose to glucose.
• Without proper treatment can lead to: o Galt
o Intellectual disability – developmental delay, o Galk
detoriation o Gale
o Physical deformity ➢ Baby with galactosemia can’t convert galactose to glucose.
➢ What the baby drink (breastfeed), doesn’t have an effect,
Treatment no nutrients
• Levothyroxine (oral medicine) – maintenance drug
Clinical Manifestations
How to feed the baby? • ↑ unmotabolize milk = ↑ sugar, damage the eyes, liver &
o Crash the tablet and mixed it in the breastmilk or brain
formula, bottle feed; • If left untreated = Fetal death
o Given ONCE daily.
If not be able to be given medication right away during Therapeutic Management
infancy, it can lead to Irreversible intellectual disability. • Stop feeding with breastmilk or formula feeding.
• Soymilk products
• Lactose/ Galactose-free formula feedings
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 NCMA 219 – BSN 2ND YEAR – 2nd SEMESTER // Transcribed by B
Nursing Care Management • Ultrasound – to see if the baby has ovaries and uterus
• Diet modification
• Don’t eat food with galactose and lactose INFANT AND YOUNG INFANT PROBLEMS
• Don’t eat – dairy products, cheese FAILURE TO THRIVE
• Mother and children should be aware. Bata – di nag d-develop ng normal, not gaining weight/
doesn’t have the weight appropriate to his/her age.
G6PD (GLUCOSE – 6 – PHOSPHATE Normal: after 6 months = 2x gain weight
DEHYDROGENASE) : 1 year = 3x bigat

➢ RBC – lifespan is up to 120 days Pathophysiology

➢ G6PD – enzyme that can help RBC to sustain life up to 120
1. Inadequate Caloric intake
days until mapalitan
2. Inadequate absorption
➢ G6PD DEFICIENCY
o Chron’s disease, cystic, fibrosis
o No G6PD
3. Increases Metabolism
o Nagh-hemolyze or namamatay agad yung RBC even
o Hyperthyroidism, sickly
before mapalitan ng bago in 120 days
4. Defective Utilization
Complication: Hemolytic Anemia
o Genetic anomaly
Clinical Manifestations
Clinical Manifestations
• Pale skin
• Developmental delay
• Yellow skin, eyes, mouth (jaundice)
• No fear of stranger
• Fever
• Apathy
• Weakness
• Under nutrition
• Dizziness
• Confusion Diagnostic Evaluation
• Dark-colored urine
• Weigh the baby
• Heart murmur
• ↑ RR
Therapeutic Management
• Know the reason
Therapeutic Management
• Iron supplement
COLIC
• Blood/ Iron Transfusion
➢ Paroxysmal Abdominal Pain
➢ “KABAG” in Filipino
CONGENITAL ADRENAL HYPERPLASIA
➢ Most fatal Clinical Manifestation
➢ RARE • Baby is crying for 3 hours a day
➢ Adrenal glands (in the tip of both kidney), produce: • 3x a week for almost a month
o Androgens (steroid hormone) After 3 week, mawawala na.
o Aldosterone (maintain urine ↑ Androgen
production & water reabsorption) ↑ Aldosterone
Etiology
o Cortisol (stress response) ↓ Cortisol
Theories
Hyperplasia – lumalaki • Too rapid breathing
Adrenal hyperplasia – lumalaking adrenal glands
• Overeating
• Swallowing excessive air
Clinical Manifestation
• Ambiguous Genitalia (lumalaki and clitoris) Therapeutic Management
• Precocious Genitalia • Order different kind of milk
• Medication:
Therapeutic Management o Antispasmodics
• Glucocorticoids – suppress the abnormally high secretion o Antihistamines
of ACTH and adrenal androgens o Anti flatulent
o ACTH – Adrenocorticotrophic Hormone
• Ambiguous and Precocious – infertile Nursing Management
o Ambiguous – will not show secondary sex, not • Know what the baby eats, how much, for how long.
develop • Time of day
o Precocious – not develop spermatogenesis • Smoking and nicotine – can cause colic (theory)
• Know the characteristics of …
Nursing Care Management
• Ambiguous – explain to the patient
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 NCMA 219 – BSN 2ND YEAR – 2nd SEMESTER // Transcribed by B
NCMA 219 LEC
CARE OF THE MOTHER & CHILD AT RISK
WEEK 9
Prof: Mrs. Shiella May Edquibal, Man, RN
Problems in toddlers and preschool
• Accidental Poisoning (Lead/Salicylate)
• Falls
• Drowning
• Aspiration and suffocation
• Conjunctivitis
Problems in school age
• Enuresis
• Encopresis
• ADHD
• Bullying
Problems in adolescents
• Amenorrhea
• Dysmenorrhea PATHOPHYSIOLOGY AND CLINICAL MANIFESTATION
• Vaginitis (female)
• Gynecomastia (male)

PROBLEMS IN TODDLERS &PRESCHOOL

LEAD POISONING
Metallic substance, an ingredient that we use to create
paint, metals, that could also be found in soil, environment.
There are toys and things that have lead and toddlers and
preschooler could reach out, and they can ingest those.
➢ The use of lead in paint and leaded gasoline has been
banned in the United States.
In the Philippines, it’s also banned.
➢ After this change in policy, the average blood lead level
(BLL) in the United States for people ages 1 to 74 years
dropped from 12.8 mcg/dl in 1980 to 1.3 mcg/dl in 2010.

Causes of Lead Poisoning

➢ In most instances of acute childhood lead poisoning, the
source is nonintact lead-based paint in an older home or Lead can affect any part of the body including Renal
lead contaminated bare soil in the yard. (kidneys), Hematologic (blood), Neurologic (brain)
Nonintact lead based – daily accumulation/ exposure of the Most common concern for young children – the developing
child to lead. They might touch the materials and put their ___ & nervous system, which are more vulnerable than
hands in their mouth. those of older children and adults.
➢ Microparticles of lead gain entrance into a child’s body Lead in the body moves via equilibration process between
through ingestion or inhalation and, in the case of an the blood, soft tissue, organs, and the bones and teeth.
exposed pregnant woman, by placental transfer. Lead ultimately settles in the bone and teeth wherein it
Lead can transfer from the woman → placenta → baby. remains inert and in storage. This makes up the largest
➢ When measured, a mother’s lead level is nearly the same portion of the body.
as that of her unborn child. However, although the level of At the cellular level, it completes with molecules of
lead may not be harmful to an adult woman, it can be Calcium, interfering with the regulating action of calcium.
harmful to the fetus. In the brain – lead disrupts the biochemical causes and may
➢ Inhalation exposure usually occurs during renovation and have a direct effect on the release of neurotransmitters and
remodeling activities in the home,, ingestion happened may cause alteration in the blood brain barrier and may
during normal day-to-day play and mouthing activities. interfere with regulation of synaptic activity.
➢ Sometimes, a child will actually swallow loose chips of There’s also a relationship between anemia and loid lead
lead-based paint because it has a sweet taste. poisoning. Children who are iron deficient absorbed lead
➢ Water and food may also be contaminated with lead. more readily than those with sufficient iron storage.
➢ A child does not need to eat loose paint chips to be exposed Lead can interfere with binding of iron on to the heme
to the toxin; normal hand-to-mouth behavior, coupled with molecule. This sometimes create a picture of anemia.
the presence of lead dust in the environment that has settled Even though the child isn’t iron deficient, lead toxicity to
over the decades, is the usual method of poisoning. the erythrocytes needs to the release of erythrocyte
If you are living in an environment with a high lead area/ protoporphyrin, which leads to anemia.
houses, those dust settled in your floor and the toddlers and With high levels of lead in the body:
preschoolers can inhale and touch those. Hematologic System:
– (Synthesis of heme – red blood cell production)
– Can interfere with the synthesis of RBC production.
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 NCMA 219 – BSN 2ND YEAR – 2nd SEMESTER // Transcribed by B
– The body will try to increase the erythrocyte o Does your child live in or regularly visit a house built
protoporphyrin (it’s a precursor to RBC production) before 1978 with recent or ongoing renovations or
(u need this enzyme to help w/ production of RBC) remodeling within the past 6 months?
– Your body will work double time to produce RBC and o Does your child have a sibling or playmate who has or
this can lead to anemia. had lead poisoning?
In the Renal System: • Screening should be done at ages 1 and 2 years.
– Proximal tubules in the kidneys helps with • Any child between the ages 3 and 6 years who has not been
reabsorption of substances. With lead poisoning, there previously screened should also be tested.
will be increased permeability in the proximal tubules. • All children with risk factors should be screened more
– Which will urinate glucose, protein, ketones. often.
Decreased Vit. D production.
– Urinate coproporphyrin. This can also damage the Therapeutic Management
teeth and the bone. • The degree of concern, urgency, and need for medical
In the Neurologic System: intervention changes as the lead level increases.
– Most problematic, mostly irreversible. • Education is one of the most important elements of the
– Because if the lead poisoning is treated, the problem in treatment process.
the hematologic and renal system are reversible. Tell them what is lead, how does it affect, the materials with
– Has blood brain barrier – filters materials and things lead, etc.
that can go to the brain. A protective barrier for the • Several areas that the nurse needs to discuss with the family
brain not to receive toxins, chemicals, etc. of every child who has an elevated BLL (≥ 5 mcg/dl)
– If there’s lead poisoning – it increases the permeability include the following:
(there will be more substances that cam enter the brain, o The child’s BLL and what it means.
even the toxins) o Potential adverse health effects of an elevated BLL
o Sources of lead exposure and suggestions on how to
DIAGNOSTIC EVALUATION reduce exposure, such as importance of wet cleaning
• Blood examination – Lead testing of a venous blood to remove lead dust on floors, windowsills, and other
specimen from a venipuncture. surfaces.
2 types: o Importance of good nutrition in reducing the
o Blood test of elevation of erythrocyte protoporphyrin absorption and effects of lead; for persons with poor
o Blood Lead Level (BLL) nutritional.
• Collection process is important. (increased the iron supply for the baby, toddler or
• Blood must be collected carefully to avoid contamination preschool & increased calcium and vitamin D
by lead on the skin. intake)
• Prior to 2012, the level of concern for an elevated BLL had • Chelation Therapy – Chelation is the term used for
dropped from 80 mcg/dl in 1950 to 10 mcg/dl. removing lead from circulating blood and theoretically,
some lead from organs and tissues.
Anticipatory Guidance This attracts magnets or metals like lead to the drug and the
• Most effective prevention of lead exposure is ensuring that patient will urinate it.
environmental exposures are reduced before children are Can be done outpatient.
exposed to the hazards (e.g., paint, soil, dust, water that • Equilibration process between blood, soft tissues, and
contains lead). other sites in the body, there is often a rebound of the BLL
• There has been recent concern regarding toys and other after chelation. After the body burden of lead is reduced
imported items children play with that were found to enough to stabilize the BLL, rebound will cease.
contain lead. • Multiple chelation treatments may be necessary.
• Parents should carefully evaluate the source of the toy The treatment can’t be done once, bcos there’s a risk of
(manufacturer) or item the child may play with and not rebound or it will not be effective if it’s once. There will be
assume it is safe. several chelation treatments to make sure that the lead will
Check if the area that u will go was built in 1980s. if u’re buying toys, flush out from the body.
evaluate the toys if it has lead in it. • Adequate hydration is essential during therapy because
the chelates are excreted via the kidneys.
Screening for Lead Poisoning • Severe lead toxicity (lead level ≥70 mcg/dl) requires
• Targeted screening is acceptable when an area has been immediate inpatient treatment, whether symptoms are
determined by existing data to have less risk. present or not.
• Children should be screened when they live in a high-risk • A less used oral chelating agent, d-penicillamine, is
geographic area or are members of a group determined to sometimes used to treat lead poisoning, but low doses
be at risk (e.g., Medicaid recipients), or if their family should be used in children. Monitoring of renal function
cannot answer “no” to the following personal risk and blood counts during administration is essential.
questions:
o Does your child live in or regularly visit a house that
was built before 1950?

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 NCMA 219 – BSN 2ND YEAR – 2nd SEMESTER // Transcribed by B
Prognosis danger, immature coordination, and a high center of
• Although most of the pathophysiologic effects of lead are gravity.
reversible, the most serious consequences of both high and ➢ Falling from furniture is a major cause of injury, with
low lead exposure are the effects on the central nervous more children in this age-group sustaining head injuries
system. than older children.
• In children with lead encephalopathy, permanent brain ➢ Gates must be placed at both ends of stairs.
damage can result in ➢ Accessible windows that are left often during warm
o cognitive impairment weather must be guarded with a rail.
o behavior changes ➢ When children reach a height of 89 cm (35 inches), they
o possible paralysis should sleep in a bed rather than a crib. (bcos they can
o seizures already climb the crib)
➢ If a bunk bed is selected, parents should be aware of
• However, low-dose exposure may also cause permanent
possible dangers, including falls from the top bed and the
neurologic deficits.
ladder and head entrapment between the mattress and
• Increased distractibility, short attention span, impulsivity,
guardrail or between the supporting mattress slats.
reading disabilities, and school failure have been
As a caregiver/ parent, remember to keep your eyes always
associated with lead exposure.
in the children.
Nursing Care Management
DROWNING
• Primary goal in lead poisoning – Prevent the child’s initial
One of the leading causes of mortality in children <5 y/o.
or further exposure to lead.
➢ Highest rate of drowning in the years 2000 to 2006 was in
• For children with low level exposure, this requires children ages 0 to 4 years; children ages 12 to 36 months
identifying the sources of lead in the environment. are at higher risk for drowning during the same time period.
• For children who undergo chelation therapy, the nurse ➢ Drowning deaths in infants occur most commonly in the
prepares them for the injections and makes all efforts to bathtub and large buckets.
reduce injection pain. ➢ With well-developed skills of locomotion, toddlers are able
• Chelation Therapy – Chelating agents may be to reach potentially dangerous areas such as:
administered deeply into a large muscle mass. o Bathtubs
o IM – toddlers and preschooler o Toilets
o IV – adults o Buckets,
• Calcium EDTA – medication to help with the calcium o Swimming pools,
deficit and Vit. D problem o Hot tubs, and
o Local anesthetic procaine injected with the drug – to o Ponds or lakes.
lessen the pain from calcium EDTA. ➢ Toddlers’ intense drive for exploration and
• Rotation of sites is essential to prevent the formation of investigation, combined with an unawareness of the
painful areas of fibrotic tissues. danger of water and their helplessness in water, makes
• Because calcium EDTA and lead are toxic to the kidneys drowning always a viable threat.
o Keep records of intake and output ➢ It is also one category of injury that results in death within
o Assess the results of urinalysis to monitor renal minutes, diminishing the chance for rescue and survival.
functioning. If the brain remains unoxygenated for 3 mins, it can cause
Increase oral fluid intake and monitor intake and output irreversible damage. >3 mins = death.
thru your urine monitoring. To determine if the kidneys are ➢ Close adults supervision of children when near any source
still functioning. of water is essential; many drowning in this age-group
occur when a supervising adult becomes distracted.
FALLS ➢ Recommends “touch” supervision for small children; the
➢ Are still a hazard to children in this age-group, although by adult can reach out and touch or grab the child having
the later part of early childhood, gross and fine motor skills difficulty.
are well developed, decreasing the incidence of falls ➢ Teaching swimming and water safety can be helpful but
downstairs or from chairs. cannot be regarded as sufficient protection.
➢ However, playground injuries are common. ➢ Pool fencing although critical, does not always deter fast-
➢ Children need to learn safety at play areas, such as: moving children.
o no horseplay on high slides or jungle gyms,
o sitting on swings ASPIRATION AND SUFFOCATION
o staying away from moving swings. ➢ Small children characteristically explore objects with their
In developmental milestones of toddler – they want to be hands and mouth and are prone to place FBs (foreign
independent. (Erik Erikson – autonomy vs. shame and bodies) into the air passages (nose and mouth).
doubt) ➢ They also place objects such as beads, paper clips, plastic
They would want to roam around, unassisted. toys, small magnets, or food items in the nose, which can
You need to balance their safety while they’re having their easily be aspirated into the trachea.
independence. ➢ Small items may also be placed into the external ear
➢ The climbing and running activity of the typical toddler is canal; small rocks and pebbles appear to be a favorite item
complicated by total neglect for and lack of appreciation of for boys, whereas girls prefer colorful beads.
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 NCMA 219 – BSN 2ND YEAR – 2nd SEMESTER // Transcribed by B
➢ When such objects are placed into the nose or mouth, they 2nd degree or Partial obstruction
can be aspirated into the airway, causing subsequent o Air able to move past the obstruction in one direction
obstruction. only. Air passages enlarge during inspiration and
➢ Ingestion or aspiration of an FB can occur at any age but is diminish during expiration.
most common in older infants and children ages 1 to 3 o Patient can inhale air but the patient can’t exhale the
years. Carbon dioxide which can lead to inflammation,
➢ Severity depends on the location, type of object aspirated, emphysema, respiratory problem.
and extent of obstruction. Complete obstruction
➢ For example, dry vegetable matter, such as seed, nut, o Air unable to move in either direction. FB and
piece of carrot, or popcorn, that does not dissolve and that edematous mucosa obliterate passage.
may swell when moistened creates a particularly difficult o Can lead to death.
problem.
Avoid giving dry vegetable matters to the toddlers. Clinical Manifestations
➢ The high fat content of potato chips and peanuts may cause • Initially, an FB in the air passages produces choking,
the added risk of lipoid pneumonia. gagging, or coughing, but symptoms depend on the site of
➢ “Fun foods” such as hard candy and hot dogs are among obstruction and on the interval between aspiration and
the worst offenders. presentation.
These cannot dissolve easily in the mouth. • Up to half of all children with FB ingestion may be
➢ Offending foods, in order of frequency of aspiration, are asymptomatic.
hot dogs, round candy, peanuts and other types of nuts,
• Laryngotracheal obstruction most commonly causes
grapes, cookies or biscuits, pieces of meat, caramels,
dyspnea, cough, stridor, and hoarseness because of a
carrots, apples, peas, celery, popcorn, fruit and vegetable
decreased air entry.
seeds, cherry pits, gum, and peanut butter.
• Cyanosis may also occur if the obstruction becomes worse.
➢ Round foods are the most frequent offenders.
➢ The first four items together make up more than 40% of all • Bronchial obstruction usually produces cough (frequently
aspirated food items. paroxysmal), wheezing, asymmetric breath sounds,
➢ Other items include plastic or glass beads, button or disk decreased airway entry, and dyspnea.
batteries, burst latex balloons, pen or marker caps, and • In some cases a FB obstruction may be mistaken for croup.
coins. • If the obstruction progresses, the child’s face may become
➢ Objects such as small lithium or cadmium batteries may livid, and sometimes the child becomes unconscious and
cause esophageal or tracheal corrosion. dies of asphyxiation if the object is not removed.
➢ Magnets can trap tissue/ mucosa in between them, which • If obstruction is partial, hours, days, or even weeks may
can result in necrosis of that area. pass without symptoms after the initial period.
➢ A sharp or irritating objects produces irritation and edema. • Secondary symptoms are related to the anatomic area in
A round, pliable object that does not readily break apart is which the FB is lodged and are usually caused by a
more likely to occlude an airway than an object with a persistent respiratory tract infection located distal to the
different shape. obstruction.
➢ A small object may cause little if any pathologic change, • A history of recurrent intractable pneumonia is reason to
whereas an object of sufficient size to obstruct a passage consider an FB in an airway. Often, by the time secondary
can produce various changes, including atelectasis, symptoms appear, the parents have forgotten the initial
emphysema, inflammation, and abscess episode of coughing and gagging.
• The most common symptoms observed in children brought
Mechanism of Airway Obstruction to medical attention ar:
o Stridor,
o Wheezing,
o Sternal Retraction,
o Cough
• When an object is lodged in the larynx, the child is unable
to speak or breath.

Diagnostic Evaluation
• The diagnosis of FB obstruction is usually suspected on the
basis of the history and physical signs.
• Radiographic examination reveals opaque FBs but is of
1st degree
limited value in localizing vegetable matter and some
o Children are a bit symptomatic at first.
plastic items.
o Obstruction allows passage of air in both direction.
• Bronchoscopy is required for a definitive diagnosis and
o Patient can still breath in air and exhale air, bcos the
removal of objects in the larynx and trachea. (video guided)
obstruction is just small.
• Fluoroscopic examination is valuable in detecting FBs in
o Problem – obstruction become bigger, can lead to
the bronchi.
irritation.
o If left untreated – can lead to complete obstruction
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 NCMA 219 – BSN 2ND YEAR – 2nd SEMESTER // Transcribed by B
o On fluoroscopy, a check-valve – obstructed lung • Caution parents about behaviors that their children might
remains expanded, the diaphragm remains low and imitate (e.g., holding foreign objects, such as pins, nails,
fixed on the obstructed side, and the heart and and toothpick, in their lips or mouth).
mediastinum shift to the unobstructed side during
expiration. CONJUNCTIVITIS
o In a stop-valve obstruction, the heart and ➢ “Sore eyes”
mediastinum are drawn to the obstructed side and ➢ Acute conjunctivitis (inflammation of the conjunctiva)
remain there during both inspiration and expiration. occurs from a variety of causes that are typically age
• The diaphragm on the obstructed side remains high, related.
whereas that on the unobstructed side moves normally. • In newborns conjunctivitis can occur from infection during
• Other diagnostic evaluation: birth, most often from Chlamydia trachomatis (inclusion
o Endoscopy conjunctivitis) or Neisseria gonorrhoeae. These
o Bronchoscopy organisms, as well as herpes simplex virus (HSV), cause
o X-ray serious ocular damage.
• In infants, recurrent conjunctivitis may be a sign of
Therapeutic Management nasolacrimal (tear) duct obstruction.
• FB aspiration may result in life-threatening airway ➢ A chemical conjunctivitis may occur within 24 hours of
obstruction, especially in infants because of the small instillation of neonatal ophthalmic prophylaxis; the clinical
diameters of their airways. features include:
• Current recommendations for the emergency treatments of o mild lid edema
the choking child include the use of: o sterile, non-purulent eye discharge.
o Abdominal thrusts (Heimlich maneuver) for • In children, the usual causes of conjunctivitis are viral,
children over 1 year of age bacterial, allergic, or related to a foreign body.
o Back blows and chest thrusts for children less than 1 ➢ Bacterial infection accounts for most instances of acute
year of age. conjunctivitis in children.
• An FB is rarely coughed up spontaneously; therefore, it ➢ Diagnosis is made primarily from the clinical
must be removed by endoscopy or bronchoscopy. manifestations.
• Removal of the FB must be done as soon as possible, since
the progressive local inflammatory process triggered by the Clinical Manifestations of Conjunctivitis
foreign material hampers removal. Bacterial Conjunctivitis (“Pink Eye”)
• In addition, a chemical pneumonia soon develops, and o Purulent drainage
vegetable matter begins to macerate within a few days, o Crusting of eyelids, especially on awakening
further complicating its removal. o Inflamed conjunctivitis
o Swollen lids
Nursing Care Management Viral Conjunctivitis
• Recognize the signs of Foreign Bodies aspiration and o Usually occurs w/ upper respiratory tract infection
implement immediate measures to relieve the obstruction. o Serous (watery) drainage
• All persons working with children should be prepared to o Inflamed conjunctivitis
deal effectively with aspiration of an FB. o Swollen lids
• Choking on food or other material should not be fatal. Allergic Conjunctivitis
• Two simple procedures – can be used by both health o Itching
professionals and lay persons – can save lives. o Watery to thick, stringy discharge
o Back blows o Inflamed conjunctivitis
o Abdominal thrusts o Swollen lids
• It is the nurse’s obligation to learn these techniques and Conjunctivitis Caused by Foreign Body
teach them to parents and other groups. o Tearing
• To aid a child who is choking, nurses need to recognize the o Pain
signs of distress. o Inflamed conjunctivitis
• Not every child who gags or coughs while eating is truly o Usually only one eye affected
choking. Therapeutic Management
• Treatment depends on the cause.
Prevention • Viral conjunctivitis is self-limiting, and treatment is
• Small children should not be allowed access to small limited to removal of the accumulated secretions.
objects that they might please in their nose or mouth. • Bacterial conjunctivitis has traditionally been treated with
• Anticipatory guidance for parents of small children is topical antibacterial agents such as:
essential. Nurses are in a position to teach prevention in a o Polymyxin and bacitracin (Polysporin)
variety of settings. o Sodium sulfacetamide (Sulamyd)
• They can educate parents singly or in groups about hazards o Trimethoprim and polymyxin (Polytrim)
of aspiration in relation to the developmental level of their • However, in one study of children with acute infective
children and encourage them to teach their children safety. conjunctivitis treated by placebo versus topical
chloramphenicol, there was little difference in cure rates;
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 NCMA 219 – BSN 2ND YEAR – 2nd SEMESTER // Transcribed by B
the authors concluded that most children will get better o Primary – bed-wetting in children who have never been dry
without antibiotic treatment. for extended periods.
• Fluroquinolones, approved for children ages 1 year and o Secondary – the onset of wetting after a period of
older, are viewed by ophthalmologists as the best established urinary continence.
ophthalmic antimicrobial agents available ➢ The passage of urine may occur:
fluoroquinolones o Monosymptomatic – only during nighttime sleep,
o Moxifloxacin with the child remaining dry during the day
o Gatifloxacin o Polysymptomatic – where the child has daytime
o Besifloxacin urinary urgency and an occasional daytime accident in
Which provide broad-spectrum coverage, are bactericidal, conjunction w/ other conditions such as sleep apnea,
and are generally well tolerated. urinary tract infection, neurologic impairment,
• Drops – used during the day. constipation, or emotional stressors.
• Ointment – at bedtime.
✓ Ointment preparation remains in the eye longer but blurs ETIOLOGY AND PATHOPHYSIOLOGY
the vision. • No clear etiology has been determined.
• Corticosteroids – avoided because they reduce ocular It is idiopathic. (unknown)
resistance to bacteria. • Predictive factors have been noted:
o Longer duration of sleep in infancy,
Nursing Care Management o A positive family history
• Keeping the eye clean and properly administering o A slower rate of physical development in children up
ophthalmic medication. to 3 years of age.
• Remove accumulated secretions by wiping from the inner • There is a high concordance rate of enuresis in
canthus downward and outward, away from the opposite monozygotic (identical) twins and an even higher one in
eye. dizygotic (nonidentical) twins, which suggests more than a
• Warm, moist compresses, such as a clean washcloth pure generic link in the disorder.
wrung out with hot top water, are helpful in removing the • Approximately 75% of all children w/ enuresis have a first-
crusts. degree relative who has, or has had, the disorder.
• Compresses are not kept on the eye because an occlusive • Enuresis is primarily an alteration of neuromuscular
covering promotes bacterial growth. bladder functioning and as such is benign and self-limiting.
• Instill medication immediately after the eyes have been Self-limiting – as the child grows older, there’s a possibility
cleaned and according to correct procedure. s/he will outgrow it.
• Prevention of infection in other family members is
important consideration w/ bacterial or viral conjunctivitis. • Emotional factors may influence the symptom. Some
• Keep the child’s washcloth and towel separate from those children exhibit temporary regressive behavior resulting in
used by others. enuresis after the birth of a sibling or other trauma.
• Discard tissues used to clean the eye. • Other children, such as those w/ attention deficit
• Instruct the child to refrain from rubbing the eye and to hyperactivity disorder (ADHD), may have occasional
use good hand-washing technique. “accidents” when they become so involved in play that they
are unaware of a full bladder or “forget” to empty the
bladder.
PROBLEMS w/ SCHOOL AGE CHILDREN • In other children, enuresis may be related to attempts to
toilet train before they are developmentally mature enough
ENURESIS
to:
➢ “Bed-wetting”
o Maintain bladder control,
➢ A common disorder that is defined as intentional or
o The emotional atmosphere surrounding the training
involuntary passage of urine in children who are beyond
situation
the age when voluntary bladder control should normally
o An excessive amount of emotional dependence on the
have been acquired.
caregiver.
By the age of toddler period: 16 or 18 months – 3 y/o
• Occasionally, enuresis can be a behavioral manifestation of
A child should be able to have a bit of bladder control. They
a personality disorder.
should be able to wake up in the middle of the night/day to
Several theories have been proposed to explain enuresis.
tell u that they need to pee.
Enuresis happens when a child has already been past the o The Sleep theory stems from parental reports that
age of toddler hood and preschoolers (5 y/o & above), and these children sleep more soundly and are difficult to
they still wet their bed. arouse from sleep.
➢ Medical evaluation is recommended when inappropriate o Another theory related to functional bladder
voiding of urine occurs at least twice a wee for a minimum capacity theory; the volume of urine voided after
of 3 consecutive months and the chronologic or maximum delay of micturition.
developmental age of the child is at least 5 years. o Nocturnal polyuria theory suggests that the kidneys
➢ More common to boys than girls; nocturnal bed-wetting of these children fail to concentrate urine during sleep
usually ceases between 6 and 8 years of age. because of insufficient secretion of antidiuretic
hormone (ADH).
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 NCMA 219 – BSN 2ND YEAR – 2nd SEMESTER // Transcribed by B
The brain cannot secrete enough anti-diuretic hormone. • The baseline information is gathered for 1 to 2 weeks by
The baby at night will always need to urinate that can lead the child and family.
to enuresis. • It usually consists of:
▪ The ADH circadian rhythm may thus be a o Chart or calendar given to the family on which they
significant biologic marker in enuresis, but indicate the date of the incident
additional research must be conducted to clarify o Time of the incident
its role. o Approximate volume of the urinary output
o Dysfunctional detrusor activity theory suggests that • Physical examination may be followed by diagnostic
an unstable bladder detrusor muscle spontaneously evaluation of functional bladder capacity.
contracts to produce bed-wetting, either because of • Functional bladder capacity is determined by having the
abdominal innervation or as a result of other, unknown child hold off voiding until the strongest urgency is felt, at
reasons. which time the child voids into a measurement container.
• Studies to explore theses theories have yielded • Normal bladder capacity (in ounces) is the child’s age + 2
contradictory and inconclusive results; ore research is Normal bladder capacity for:
needed to clarify etiology and address contradictions. o 6 years old = 8 ounces (237 ml)
• A bladder volume of 10 to 12 ounces (300 to 350 ml) is
Clinical Manifestations sufficient for retention of a night’s urine.
• Predominant symptom – immediate urgency that is Ex: urine is <237ml for 6 years old = the child cannot retain
accompanied by: the urine and they will urinate even at night
o Acute discomfort
o Restlessness Therapeutic Management
o Sometimes Urinary frequency. • Conditioning therapy – involves training the child to
• With nocturnal enuresis the child may or may not feel awaken to urinate after a stimulus is given, especially with
urgency. If awareness of the urgency is present, the child a urine alarm.
often reports difficulty awakening to urinate. o The device consists of a moisture-sensitive wire pad
• Spontaneous voiding during sleep occurs, which usually that is placed inside the underpants and is attached to
results in multiple nightly incidents. a bell or buzzer.
• Spontaneous remission of nocturnal enuresis occurs in o When the system detects moisture, the bells or buzzer
approximately 15% of cases. sounds, which fully awakens the child.
• However, is some cause nocturnal enuresis continues into o The child is thus conditioned to awaken at the
adolescence and adulthood. initiation of micturition or to the stimulus of the bell or
buzzer and eventually learns to continue voiding in the
Diagnostic Evaluation toilet.
During the initial phases of evaluation • The urine alarm can be very effective, but children may
relapse once they stop using it.
• Routine physical examination – performed to rule out Relapse is addressed by reinstituting the alarm during
physical causes, such as: sleep.
o Urinary tract infection
• This method is inexpensive compared with drug therapy
o Structural disorders
and has no side effects.
o Major neurologic deficits
• Retention control therapy – developed after the
o Nocturnal epilepsy
observation of reduced functional bladder capacity in
o Disorders that increase the nocturnal output of urine
children who were bed-wetters.
(e.g., diabetes mellitus and diabetes insipidus)
o The child drinks fluids while awake and alert, then
o Disorders that impair the concentrating ability of the
delays urination as long as can be tolerated to stretch
kidneys (e.g., chronic renal failure or sickle cell
the bladder to accommodate increasingly larger
disease)
volumes of urine.
• Routine psychiatric evaluation – is warranted if
• Kegel, or Pelvic muscle, exercises may be helpful in
psychologic difficulties are evident or a personality
children with daytime enuresis.
disorder is suspected.
• History of bed-wetting behavior is obtained, including
• In the waking schedule treatment, the child is awakened
information about the toilet training process.
during the night at intervals to void. This method has been
Ask the parents to check and record the number of times
successful in reducing, but not eliminating, bed-wetting
and the time at night/morning when it occur if the child wet
incidents.
their bed.
• Drug therapy is increasingly being prescribed to treat
• Assessment – important feature
enuresis.
o Parental attitudes – by listening and asking parents
Three types of drugs are used:
how they have attempted to cope w/ the bed-wetting.
o Tricyclic antidepressants – (if emotional stress)
o Baseline count of enuretic incidents
o Antidiuretics – (so pt will not urinate at night)
o Time of the day when each occurs.
o Antispasmodics – (to prevent spasms of the muscle)
• This is necessary not only to establish diagnostic reliability
• The selection depends on the interpretation of the cause.
but also to confirm outcome success after treatment.

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 NCMA 219 – BSN 2ND YEAR – 2nd SEMESTER // Transcribed by B
• Tricyclic antidepressant imipramine (Tofranil) – the o Motivating them toward independent control
drug used most frequently, which exerts an anticholinergic • Nurse can provide consistent support through the
action in the bladder to inhibit urination. inconsistent and unpredictable treatment process.
• The dosage and time of administration are individualized, • Children need to believe that they are helping themselves
and the drug is given in amounts sufficient to lighten sleep and to maintain feelings of confidence and hope.
but not to cause wakefulness.
U have to assess first when does enuresis usually happen; ENCOPRESIS
at night or daytime or both. ➢ Repeated voluntary or involuntary passage of feces of
• Some practitioners prescribe low doses, which reduces normal or near-normal consistency in places not
bed-wetting in two thirds of children. appropriate for that purpose according to the individual’s
• However, almost all children relapse when the medication own sociocultural setting.
is stopped. Fetal accidents
o Length of treatment = 6 – 8 weeks They cannot control until they go to the bathroom.
o Gradual withdrawal – over 4 weeks o Occur at least = once a month for a minimum of 3 months
Risk of drug: o Child’s chronologic/ developmental age = at least 4 years.
o Overdosage to continue treatment or add more
medication if enuresis is unresolved. ➢ Fecal incontinence must NOT be caused by physiologic
• Caution parents about safe use and the need to keep effects of a substance (e.g., laxatives) or a general medical
supplies of the drug from the reach of younger siblings. condition EXCEPT through a mechanism involving
• Anticholinergic drugs: oxybutynin constipation.
– Reduce uninhibited bladder contractions and may be ➢ Consistency of stool may vary from:
helpful for children w/ daytime urinary frequency. Normal or near-normal to Liquid
• Desmopressin acetate nasal spray – an analog of ➢ With a more liquid stool seen especially in individuals who
vasopressin have overflow incontinence secondary to fecal retention.
– Success is achieved with this.
– Reduces nighttime urinary output to a volume less than o Primary encopresis – child 4 years of age or older who has
functional bladder capacity. never achieved fecal continence.
– This is more frequently observed as a result of neglect,
Nursing Care Management lax training methods, mental subnormalities, and
• Support both children and parents who are coping w/ the familial causes.
problem of enuresis, the treatment plan, and the difficulties o Secondary encopresis – fecal incontinence occurring in a
they may encounter in the process. child over 4 years of age after a period of established fecal
• Both need encouragement and patience. continence.
• Problem is discussed w/ both the parent and the child – ➢ The disorder is more common in males than in females.
since any treatment involves and require the child’s active
participation. Etiology
• Child: • Constipation – may be precipitated by environmental
o is in charge of the intervention – in some treatments change, such as:
intervention. o Having a new sibling
• Parents: o Moving to a new house
o Must learn to support the child rather than intervene o Changing schools
themselves. o Having to use new or unfamiliar toilet facilities
o Should also be taught to observe for side effects of any • Chronic, severe constipation – tends to impair the usual
medications used. movement and contractions of the colon, which can lead to
o Believe that enuresis – is caused by an emotional fecal obstruction.
disturbance and fear that they have somehow produced Associated w/ Constipation, which can lead to encopresis:
the situation by improper childrearing practices. o Abnormalities in the digestive tract:
o Need reassurance that the bed-wetting is NOT a ▪ Hirschsprung disease
manifestation of emotional disturbance and does not ▪ Anorecta lesions
represent willful misbehavior. ▪ Malformations
o Need to understand that punishment such as scolding, ▪ Rectal prolapse
shaming, and threatening is contraindicated o Medical conditions:
because of their negative emotional impact and limited ▪ Hypothyroidism
success in reducing the behavior. ▪ Hypokalemia
o Encouraged to be patient and understanding and to ▪ Hypercalcemia
communicate love and support to the child. ▪ Lead intoxication
• Communication w/ children is directed toward eliminating ▪ Myelomeningocele
the emotional impact of the problem; ▪ Cerebral palsy
o Relieving feelings of shame, guilt, and the burden of ▪ Muscular dystrophy
parental disapproval ▪ Irritable bowel syndrome
o Building self-confidence
MIDTERMS // honeybunchsugarplum | 21
 NCMA 219 – BSN 2ND YEAR – 2nd SEMESTER // Transcribed by B
• Voluntary retention of stool – may also follow an incident ▪ Sorbitol
of painful defecation (e.g., in a child with anal fissures) ▪ Polyethylene glycol (PEG or MiraLax)
• Involuntary retention – may be produced by emotional ▪ Magnesium hydroxide
problems caused by the encopresis, which sets up a tear -
pain cycle and results in learned abnormal defecation • Customary dosages are usually insufficient to produce a
patterns. therapeutic response.
• Psychogenic encopresis • Mineral oil should be avoided in children who have
o the soiling is caused by emotional problems dysphagia or vomiting to prevent risk of aspiration.
o often related to a disturbed mother-child relationship • Dietary changes are helpful:
Normal: children and adolescents have one or two soft formed o Elimination of milk and dairy products
stools per day. o Consumption of increased amounts of high-fiber foods
• Children with soiling problems tend to form large-bore ▪ Fruits
stools, which are painful to excrete. ▪ Vegetables
o And so, they tend to avoid defecation and withhold ▪ Cereals
stooling. o Increased hydration with water
• Stool help in the rectum and sigmoid colon loses water and • Behavior therapy – eliminate any dear that has developed
progressively hardens, which causes successively more as a result of painful defecation.
painful bowel movements and a stretched rectal vault. • Psychotherapeutic intervention – with the child and
• Over time the child will lose the urge to defecate on his or family.
her own.
• A pain-retention-pain cycle is established. Nursing Care Management
• Leakage around an impaction – suggested when many • Assess the time, date, when it occur.
children have diarrhea or loose leakage in their clothing • Thorough history of the soiling is essential.
and pass small amounts of hard stool. o When soiling began
Children may experience: o How often it occurs.
o Exacerbations w/ transitions in the school setting o Under what circumstance
o For developing retentive tendencies: o Whether the child uses the toilet successfully at all
▪ Fear of using school bathrooms • Direct questioning about the soiling – bcos the parents and
▪ A busy schedule child are reluctant to volunteer information.
▪ Interruption of an established time schedule for • Education of these is prerequisite to a successful outcome.
bowel evacuation o Physiology of normal defecation
o May react to stress w/ bowel dysfunction. o Toilet training as a developmental process
o The treatment outlined for the particular family
Clinical Manifestations • Regimen prescribed for stimulating elimination – is
• Feel ashamed and may wish to avoid social situations explained to the parents.
(camp or school) that might lead to embarrassment. • Essential in treating encopresis or chronic constipation:
• School performance and attendance are affected – the o Bowel retraining with mineral oil
child’s offensive odor becomes a target for scorn and o High fiber diet
derision by classmates. o A regular toileting routine
• Child is not well liked by peers and may be severely
rejected by the parents as a result of the symptom. • Child encouraged to:
o sit on the toilet 10 – 15 minutes after meals.
• Rejection by peers and parents causes further withdrawal
o intervals of 10 minutes
and other behavioral manifestations.
• Placing a footstool below the feet – relax the abdomen
Therapeutic Management and make the child more comfortable.
• Goal: alleviating the cause of the soiling. • Enemas – for impactions, but long-term use prevents the
Is there a problem with physical or anatomy problem or child from assuming responsibility for defecation.
disease or bcos of emotional trauma. • Lubricants – given liberally,
• Detailed medical history and physical examination – to – Stimulant cathartics often cause abdominal cramps
determine the CAUSE. that can frighten the child.
o Rectal examination • Positive reinforcement may encourage child to participate
o Abdominal x-ray film – to determine the SEVERITY in the bowel regimen.
of impaction. o Giving stickers
• Diet, lubricants, and a toilet ritual – encourages the child o Praising the child
to establish normal defecation. o Awarding special activities
• Fecal impaction is relieved by: • Family counseling – directed toward reassurance that most
o Lubricants problems resolve successfully, although the child may have
▪ Mineral oil relapses during periods of stress, such as vacations or
o Osmotic laxatives: illness.
▪ Lactulose

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 NCMA 219 – BSN 2ND YEAR – 2nd SEMESTER // Transcribed by B
• Reevaluated condition – if encopresis persists beyond • Sex linked factor – may be operating bcos the disorder is
occasional relapses. much more common in boys than in girls.
• Behavior modification techniques are explained.
• Family is assisted with a plan suited to particular situation. Clinical Manifestation
• Behaviors exhibited are not unusual aspects of child
ATTENTION DEFICIT HYPERACTIVE DISORDER behavior.
(ADHD) • Difference lies in the:
➢ Refers to developmentally inappropriate degrees of o Quality of motor activity
inattention, impulsiveness, and hyperactivity. o Developmentally inappropriate inattention
➢ Most common neurobehavioral disorder of childhood and o Impulsivity
often persists into adulthood. o Hyperactivity that the child displays
➢ Prevalence rates for ADHD vary depending on whether o Degree of severity
they are based on school samples or community samples. • May be numerous or few, mild, or sever, and vary with the
➢ The National Survey of Children’s Health found the child’s developmental level.
estimated prevalence of parent-reported ADHD among • Mild manifestations – apparent in at least two settings
children aged 4 – 17 years was 9.5%, representing 5.4 o Educational
million children. o Family environments
➢ The rates of diagnosis have been increasing an estimated Every child with ADHD is different from all other children
2% to 3% per year. with ADHD.
➢ ADHD is seen more in boys than girls.
➢ Early 1900s – first recognize symptoms. • Most behavioral manifestations – apparent at an early age,
Several different names have been applied to the disorder. • Learning disabilities – may not become evident until the
➢ Difficulties associated w/ ADHD are most often: child enters school.
o School related or academic.
• Distractibility – major c.m
➢ Family and social relationship – if aggressive behavior and
• Stimuli may come from – External or Internal Sources
mood liability w/ peer relationship, cause difficulties in
social interactions, or make discipline difficult. • Children frequently demonstrate immaturity relative to
Risk for: chronologic age.
There is a developmental/ mental delay (ex. child is 5 or 6
• Conduct disorders
y/o but acting like 2 or 3 y/o), they cannot understand and
• Oppositional defiant disorders
follow instructions to stay still and listen to what others are
• Depression
saying.
• Anxiety disorders
• Selective attention – is often seen; the child has difficulty
• Developmental disorders: speech and language delays and attending to “nonpreferred” tasks, such as:
learning disabilities – Completing chores
– Finishing homework
➢ Early identification of affected children is important –
• Child may not consider the consequences of behavior
characteristics of ADHD significantly interfere w/ the
o Take excessive physical risks (often beginning early in
normal course of emotional and psychologic development.
life)
➢ Many children develop maladaptive behavior patterns that o May demonstrate inappropriate social skills.
hinder psychosocial adjustment.
• In families of children w/ ADHD, there is an increased:
ADHD can cause problems with social development. Since
o Incidence of substance abuse
they want to go and roam around, they cannot stay still,
o Conduct disorders
they have problems with communication and mingling
o Learning disabilities
with other people.
o Depression
➢ Their behavior evokes negative responses from others, and
o Antisocial personality disorder
repeated exposure to negative feedback adversely affects
the child’s self-concept.
Diagnostic Evaluation
Etiology • Complete and thorough multidisciplinary evaluation of
the child
• Exact cause is UNKNOWN.
o incorporating the efforts of the primary pediatric
• A combination of organic, genetic, and environmental
health care provider and the family
factors is probably involved.
o possible support from a Psychologist, Developmental
• Factors that put a child at risk for symptoms of ADHD: Pediatrician, Neurologist, Pediatric Nurses, Classroom
o Family history of ADHD Teachers, and Administrators.
o Especially the father, brother, or uncle. • Clinicians and professionals – must first determine whether
• Implicated in ADHD the child’s behavior is age appropriate or truly problematic.
o Chromosomal or genetic abnormalities
• Complete medical and developmental history – obtained
▪ Fragile X syndrome
prior to diagnosis.
▪ Klinefelter syndrome
• Detailed descriptions of the child’s behavior:
o In the home
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 NCMA 219 – BSN 2ND YEAR – 2nd SEMESTER // Transcribed by B
o In school o Children who receive stimulants should be monitored
o In social situations carefully for side-effects of medication.
From many observes of the child as possible, particularly ▪ Decreased appetite/ appetite loss
with those involved in the child’s care: ▪ Abdominal pain
o Parents ▪ Headaches
o Teachers ▪ Sleep disturbances
o Caregiver ▪ Growth velocity
o Administrator o Stimulants are avoided in children who have a history
• Physical examination of Tics-like behavior or Tourette syndrome.
o Vision and hearing screening o Tricyclic antidepressant an extended-release
o Detailed neurologic evaluation Clonidine can be used as another therapy for ADHD.
• Psychologic testing – Projective tests ▪ Primarily for children with co-existing condition
o identify visual-perceptual difficulties, such as sleep disturbances.
o problem with spatial organization, and other
phenomena that suggest cortical or diencephalic Nursing Care Management
involvement, • School nurses are active participants in all aspects of
o helps to identify the child’s intelligence and managements of the child w/ ADHD.
achievement levels. • Nurses in the community setting work with families in the
• Behavioral checklist and adaptive scales – be completed home on a long-term basis to help plan and implement
by the child’s caregivers and educators and scored by the therapeutic regimens and to evaluate the effectiveness of
primary care provider. therapy.
• These assessment tools are also helpful in measuring social • Medication
adaptive functioning and behavioral concerns in children o Stimulants, Nonstimulants, Antidepressants
with ADHD, as well as providing benchmarks for • Environmental Manipulation
evaluation of improved or worsening behavioral changes o Encourage families to learn how to modify the
once therapy has begun. environment to allow the child to be more successful.
• Psychiatric disorders, medical problems, and traumatic o Consistency – important for children w/ ADHD.
experiences are ruled out, including: Consistency between families and teachers in terms of
– Lead poisoning reinforcing the goals is essential.
– Seizures o Fostering improve organizational skills required a
– Partial hearing loss more highly structured environment than most
– Psychosis children need.
– Witnessing of sexual activity o The child should be encouraged to make more
– Violence appropriate choices and to take responsibilities for
his/her actions.
Therapeutic Management ▪ (u let them choose & decide to help them boost
• Behavior therapy and Psychotherapy their self-esteem)
o Behavior Therapy – focuses on the prevention of o Other helpful intervention include: Teaching parents to
undesired behavior. Families help to identify new make organizational charts, listing all activities that
appropriate contingency and reward system to meet must be performed before leaving for school.
the child’s developing needs. They may also receive ▪ (so they can have a structured environment and
instruction in effective parenting skills such as: they know what are the things that need to be
delivering positive reinforcement, rewarding small done, and to follow before going out)
___ of desired behavior and providing age-appropriate o Suggesting how to decrease distraction in the
consequences like time-out, etc. environment:
o Through collaborative teamwork (parents, doctors, ▪ Child completing homework: turn off tv; have a
nurses, teachers); A parent learn techniques to help the consistent study area w/ the supplies needed so the
child become more successful at home and in school. child will not go around; have schedule
• Pharmacologic Therapy (Medication) o Helping parents to understand ways to model positive
o Most effective and frequently used medication are behaviors and problem solving; the focus is on
stimulants: strategies to help the child succeed and cope with
▪ Methylphenidate hydrochloride deficits while emphasizing strengths.
▪ Dextroamphetamine • Appropriate Classroom Placement
o Non stimulant medication including norepinephrine o Children with ADHD need an orderly predictable and
reactive inhibitors and adrenergic agonist – consistent classroom environment with clear and
effective with fewer side effects with school age and consistent rules.
adolescents’ children. o Homework and classroom assignments may need to be
o Children are given a small dosage initially, and dosage reduced and more time may need to be allotted to
is gradually increased until the desire respond is allow the child to complete test/task.
achieved. o Verbal instruction should be accompanied by visual
references such as little instruction in the chalk board.

MIDTERMS // honeybunchsugarplum | 24
 NCMA 219 – BSN 2ND YEAR – 2nd SEMESTER // Transcribed by B
o Schedules may need to be arrange, so academic o Feelings of insecurity
subjects are taught in the morning when the child is o Loneliness
experiencing the effect of morning dose of the o Poor academic performance
medication. o Psychosomatic complaints: feeling tense, tired or
o Low interest and high interest classroom activity dizzy
should be integrated to maintain the child’s attention.
o Regular and frequent breaks in activities are helpful, ➢ Bullying can be reduced or prevented through:
because sitting in one place for an extended period of o Supportive relationships with family
time may be difficult for patient with ADHD. o Intervention of school personnel
– Ice breakers o Involvement with positive peer groups
– Short snack break ➢ Many school districts have developed bullying prevention
o Computers are helpful for children who have difficulty programs; however, results are mixed. Some programs
in written assignments and fine motor skills. reporting positive results and others showing little to no
o If learning disabilities exist, special learning activities impact.
may be accompanied in self-contain classes, limited to ➢ All states have antibullying laws and/ or policies that
6 – 8 children only. include definitions of bullying and procedures for
• Psychiatric, Psychologic, and Social Therapies reporting, investigating, and responding to bullying.
o Refer the parents to counseling therapy. Bullying can happen to all ages.
o Counseling can be very helpful with children who
demonstrate signs of anxiety or depression. PROBLEMS WITH ADOLESCENTS
o Therapy can help the child develop a healthier self-
AMENORRHEA
esteem and practice problem solving.
The adolescent is not menstruating.
o Adolescents may benefit from group work focusing on
➢ The absence of menstrual flow, a clinical sign of a variety
social skills development.
of disorders.
o Parents of children with ADHD can cause a lot of
➢ Generally, the following circumstances should be
stress and therapy may be indicated for parent and
evaluated:
family members.
(1) the absence of both menarche and secondary sexual
characteristics by age 13 years
BULLYING (2) the absence of menses by age 16.5 years, regardless of
➢ The infliction of repetitive physical, verbal, or emotional normal growth and development (primary amenorrhea)
abuse by one or more individuals to harm or bother another (3) a 6-month or more cessation of menses after a period of
individual in order to establish power over someone who is menstruation (secondary amenorrhea)
perceived as being less physically or psychologically
dominant than the aggressor(s). ➢ A moderately obese girl (20% to 30% above ideal weight)
➢ Can occur in varying degrees of severity in a physical, may have early-onset menstruation
social, or emotional context. ➢ Delay of onset is known to be related to malnutrition
➢ Can occur in any setting, it usually takes place in school (starvation such as that with anorexia)
hallways or on the playground where supervision is ➢ Girls who exercise strenuously before menarche can have
minimal, but peers are present to witness attack. delayed onset of menstruation until about age 18.
Cyberbullying ➢ Although amenorrhea is not a disease; it is often SIGN of
➢ Involves an electronic medium to harm or bother another disease.
individual. ➢ May occur from any defect or interruption in the
➢ Can be more harmful than traditional bullying because the hypothalamic-pituitary-ovarian-uterine axis.
attach can instantly reach a wider audience, while allowing ➢ May result from anatomic abnormalities such as:
the bully to remain anonymous. o Endocrine disorders such as:
▪ Hypothyroidism
Bullies and victims of bullying are at risk for long-term ▪ Hyperthyroidism
psychologic disturbances and psychiatric symptoms. o Chronic diseases
▪ Type 1 diabetes
Future problems of bullies include a higher risk for: o Medications
o Conduct problems ▪ Phenytoin (Dilantin)
o Hyperactivity o Illicit drug abuse (e.g., opiates, marijuana, cocaine)
o School dropout o Eating disorders
o Unemployed o Strenuous exercise
o Participation in criminal behavior o Emotional stress
o Oral contraceptive use
Victims of bullying are at increased risk for: ➢ Secondary amenorrhea is commonly result of pregnancy.
o Low self-esteem
o Anxiety
o Depression

MIDTERMS // honeybunchsugarplum | 25
 NCMA 219 – BSN 2ND YEAR – 2nd SEMESTER // Transcribed by B
➢ Exercise-associated amenorrhea – can occur in women • Deep breathing exercise and relaxation techniques –
undergoing vigorous physical and athletic training and is simple yet effective stress-reduction measures.
thought to be associated w/ many factors, including: • Referral for biofeedback or Massage therapy.
o Body composition (height, weight, and percentage of • Referrals for psychotherapy (in some instances)
body fat)
• If an adolescent’s exercise program is thought to contribute
o Type, intensity, and frequency of exercise
to her amenorrhea, several options exist for management.
o Nutritional status
o May decide to decrease the intensity
o Presence of emotional or physical stressors
o Decrease the duration of her training
o Modify her diet to include the appropriate nutrition for
Greater risk: Women who participate in sports emphasizing
her age
low body weight:
*accepting these alternative may be difficult for one who is
• Sports in which performance is subjectively scored (dance,
committed to a strenuous exercise regimen.
gymnastics)
• Nurse – point out the connection between low bone density
• Endurance sports favoring participants with low body
and stress fractures.
weight (distance running, cycling)
– Because many young female athletes may not
• Sports in which body contour-revealing clothing is worn understand the consequences of low bone density or
(swimming, diving, volleyball) osteoporosis
• Sports with weight categories for participation (rowing,
martial arts) DYSMENORRHEA
• Sports in which prepubertal body shape favors success ➢ Pain during or shortly before menstruation.
(gymnastics, figure skating) ➢ One of the most common gynecologic problems in women
of all ages.
Assessment ➢ Many adolescents have dysmenorrhea in the first 3 years
after menarche.
• Begins w/ thorough history and physical examination.
➢ Pain is usually located in the suprapubic area or lower
• Specific components of the assessment process depend on
abdomen.
a patient’s:
➢ Women describes pain:
o age
o Sharp
o adolescents, young adult, or perimenopausal
o Cramping
o whether she has menstruated previously
o Gripping
o Steady, dull ache
Nursing Care Management
➢ For some women, Pain radiates to the lower back or
You have to first know whether it’s primary or secondary
upper thighs.
amenorrhea.
• Amenorrhea caused by hypothalamic disturbances: Primary Dysmenorrhea
o Nurse – ideal health professional to assist women ➢ A condition associated with ovulatory cycles.
because many of the cause are potentially reversible ➢ Research – show that primary dysmenorrhea has a
(stress, weight loss for nonorganic reasons) biochemical basis and arises from the releases of
• Counseling and Education – primary interventions and prostaglandins with menses.
appropriate nursing roles. ➢ During the luteal phase and subsequent menstrual flow
• Addressing the stressors – initial management when a = prostaglandin F2-alpha (PGF2α) is secreted.
stressor is known to predispose a woman to hypothalamic Which lead to uterine contraction, vasospasm and ischemia
amenorrhea is identifies. which can lead to abdominal cramps or dysmenorrhea.
• The adolescent and nurse plan:
➢ Excessive release of PGF2α
o How the woman can decrease or discontinue
– increases the amplitude and frequency of uterine
medications known to affect menstruation
contractions and causes vasospasm of the uterine
o Correct weight loss
arterioles
o Deal more effectively w/ psychologic stress
– resulting in ischemia and cyclic lower abdominal
o Address emotional distress
cramps.
o Alter an exercise routine
➢ Systemic responses to PGF2α include:
o Backache
• Nurse and adolescent: o Weakness
o Work together to help her identify, cope with, and o Sweats
eliminate sources of stress in her life. o Gastrointestinal symptoms
o May have several sessions before the woman elects to ▪ Anorexia
try exercise reduction. ▪ Nausea
o Should investigate other factors that may be ▪ Vomiting
contributing to the amenorrhea and develop plans for ▪ Diarrhea
o Central nervous system symptoms
altering lifestyle and decreasing stress.
▪ Dizziness
▪ Syncope
▪ Headache
▪ Poor concentration
MIDTERMS // honeybunchsugarplum | 26
 NCMA 219 – BSN 2ND YEAR – 2nd SEMESTER // Transcribed by B
Pain usually: • Exercise
• Begins at the onset of menstruation. o Helps relieve menstrual discomfort through increased
• Lasts 8 to 48 hours vasodilation and subsequent decreases ischemia.
o Releases endogenous opiates (beta-endorphins)
Primary dysmenorrhea o Suppresses prostaglandins.
• Appears 6 to 12 months after menarche when ovulation is o Shunts blood flow away from the viscera = reduced
established. pelvic congestion.
If you are not ovulating, prostaglandins cannot be secreted. o Pelvic rocking
Hence, dysmenorrhea will not occur. • Decreased salt and refined sugar intake 7 – 10 days
before expected menses – may reduce fluid retention.
Anovulatory bleeding • Natural diuretics – helps reduce edema and related
discomforts
o Common in the few months or years after menarche
o Asparagus
o Painless
o Cranberry juice
➢ Because both estrogen and progesterone are necessary for
o Peaches
primary dysmenorrhea to occur, it is experienced only w/
o Parsley
ovulatory cycles.
o Watermelon
➢ More common among women in their late teens and
early twenties than in women in older age-groups; the • Low-fat vegetarian diet – help minimize dysmenorrheal
incidence declines with age. symptoms.
➢ Psychogenic factors – may influence symptoms • NSAIDs
– But symptoms are definitely related to ovulation and o Most effective if started several days before menses or
do not occur when ovulation is suppressed. at least by the onset of bleeding.
o All NSAIDs have potential gastrointestinal side
Nursing Care Management effects:
• Medications ▪ Nausea
o Buscopan ▪ Vomiting
o Hyoscine-N-butylbromide ▪ Indigestion
* Warn all women taking them to report dark-colored stool
(this may be an indication of gastrointestinal bleeding)
• Mgt of Primary dysmenorrhea – depends on the severity
of the problem and the individual woman’s responses to
various treatments. Secondary Dysmenorrhea
• Information and support ➢ Menstrual pain that develops later in life than primary
dysmenorrhea – typically after age 25. (adult women)
Because menstruation is so closely linked to reproduction and ➢ Associated with pelvic pathology such as:
sexuality, menstrual problems such as dysmenorrhea can have o Adenomyosis (myoma)
a negative influence on sexuality and self-worth. o Endometriosis
• Nurse can provide facts about what is normal – to correct o Pelvic inflammatory disease
myths and misinformation about menstruation and o Endometrial polyps
dysmenorrhea. o Submucous or intestinal myomas (fibroids)
• Adolescent and young women need support to foster their
feelings of positive sexuality and self-worth. ➢ Pain is often characterized by:
• Heat (heating pad or hot bath) or warm compress to the o Dull
lower abdominal area, minimizes cramping by: o lower abdominal aching that radiates to the back or
o increasing vasodilation and muscle relaxation thighs.
o minimizing uterine ischemia ➢ Often women experience feelings of bloating or pelvic
fullness.
• Massaging the lower back – can reduce pain by:
o Relaxing paravertebral muscles
Therapeutic Management
o Increasing the pelvic blood supply
• Physical examination – careful pelvic examination
• Soft, rhythmic rubbing of the abdomen (effleurage) –
useful bcos it provides distraction and an alternative focal • Diagnosis may be assisted by ultrasound examination
point. • Dilation and curettage (D&C) – Raspa
• Endometrial biopsy
• Used to decrease menstrual discomfort (evidence is sufficient • Laparoscopy
to determine the effectiveness)
o Biofeedback • Treatment is directed toward – removal of the underlying
o Transcutaneous electrical nerve stimulation pathology.
(TENS) – help relax the muscle of uterus • Many of the measures described for pain relief of primary
o Progressive relaxation dysmenorrhea are also helpful for women w/ secondary
o Hatha yoga dysmenorrhea.
o Acupuncture
o Medication
MIDTERMS // honeybunchsugarplum | 27
 NCMA 219 – BSN 2ND YEAR – 2nd SEMESTER // Transcribed by B
VAGINITIS Genitourinary syndrome of menopause (vaginal
Inflammation on vaginal tract. atrophy)
➢ “Abnormal vaginal discharge” • Estrogen – in the form of vaginal creams, tablets or rings
➢ An infection caused by a microorganism. – can treat this condition.
➢ Most common vaginal infections:
o Bacterial vaginosis (BV) Noninfectious vaginitis
o Candidiasis • Need to pinpoint the source of the irritation and avoid it.
o Trichomoniasis It can be bcos of external environment, poor hygienic processes,
➢ Group B Streptococcus is considered normal vaginal underwear, etc.
flora, it may also cause infection. • Possible sources include new soap, laundry detergent,
➢ Vulvovaginitis (inflammation of the vulva and vagina) – sanitary napkins or tampons.
may be caused by vaginal infection:
o Copious leukorrhea GYNECOMASTIA
▪ Can causes maceration of tissues ➢ Some degree of bilateral or unilateral breast enlargement
o Chemical irritants, allergens, and foreign bodies occurs frequently in young boys during puberty.
▪ May produce inflammatory reactions ➢ Approx. half of adolescent boys have transient
gynecomastia, which usually lasts less than 1 year.
Signs and Symptoms ➢ If gynecomastia persists or is extensive enough to cause
• An itchy or sore vagina. embarrassment – plastic surgery is indicated for cosmetic
• Vaginal discharge that’s a different colour, smell or and psychologic reasons.
thickness to usual. ➢ Administration of testosterone – has NO effect on breast
• Vaginal dryness. development or regression and may even aggravate the
• Pain when peeing or having sex. condition.
• Light vaginal bleeding or spotting.
• Sore, swollen or cracked skin around your vagina. Nursing Care Management
Consists of assuring the adolescent and his parents that this
Diagnostic Evaluation situation is benign and temporary.
But all adolescents w/ gynecomastia should receive a
• Perform a pelvic exam.
careful medical evaluation to rule out pathologic causes.
– Pap smear – to check the cervix/ vaginal tract or canal
Maybe there is cyst or tumor.
– u can also check the discharge – to know what type of
Do ultrasound.
bacterial infection invaded the vaginal tract
X-ray
• Collect a sample for lab testing. Adolescent may benefit from the knowledge that it occurs
• Perform pH testing. in more than 50% of his peers.
– Acidic discharge – manifestation of vaginitis. Common in male esp. during the onset of puberty.

Treatment
Bacterial vaginosis
• Health care provider might prescribe
o Metronidazole tablets (Flagyl) – taken by mouth
o Metronidazole gel (MetroGel) – apply to the affected
area
• Clindamycin (Cleocin) cream – apply to the vagina
• Clindamycin tablets – taken by mouth or capsules put in
the vagina.
• Tinidazole (Tindamax) or Secnidazole (Solosec) – taken
by mouth
Yeast Infections
• Usually are treated with an over-the-counter antifungal
cream or suppository, such as:
o Miconazole (Monistat 1)
o Clotrimazole (Lotrimin AF, Mycelex, Trivagizole 3)
o Butoconazole (Gynazole-1)
o Tioconazole (Vagistat –1)
• Prescription of oral antifungal medication = Fluconazole
(Diflucan)
Trichomoniasis
• Health care provider may prescribe tablets like:
o Metronidazole (Flagyl)
o Tinidazole (Tindamax)
MIDTERMS // honeybunchsugarplum | 28
 NCMA 219 – BSN 2ND YEAR – 2nd SEMESTER // Transcribed by B
NCMA 219 LEC Classification of Congenital Heart Defect (CHD)
CARE OF THE MOTHER & CHILD AT RISK
WEEK 10
Prof: Mrs. Shiella May Edquibal, Man, RN
Alterations in Oxygenation
• Responses to Altered Cardiac and Tissue Perfusion
Congenital Heart Defects (CHD)
Congestive Heart Failure
Rheumatic Fever
Kawasaki Disease
LEGENDS:
➢ From ppt in canvas
✓ From ppt in canvas
Notes taken from what ma’am said in f2f class
• Notes taken from “ f2f

How does the NORMAL heart of the baby work?

Atrium – receive
Ventricle – release/ away from the heart Cyanotic – show manifestations of cyanotic episode
Acyanotic – newborn not showing symptom of cyanosis
Normal heart:
UNOXYGENATED blood from Superior vena cava (from ACYANOTIC
upper body) & Inferior vena cava (from lower body) → unoxy
Defects w/ INCREASED PUMONARY BLOOD FLOW
will all empty → RA (unoxy) → Tricuspid valve → RV →
Pulmonic valve → Pulmonary artery → Lungs ATRIAL SEPTAL DEFECT
➢ Idiopathic
OXYGENATED blood from Lungs → Pulmonary vein → LA ➢ Abnormal opening between atria →
→ Mitral valve → LV → Aortic valve → Aorta → Body blood from higher pressure (LA) to
flow into lower pressure (RA).
TPMA ➢ Increase O2 blood into R side of
T – Tricuspid valve heart
P – Pulmonic valve ➢ RA & RV enlargement
M – Mitral (Bicuspid) valve ➢ Cardiac failure is unusual in
A – Aortic valve uncomplicated ASD

Muscles that separates the diff. chambers May butas/ hole sa Atrial septum (muscle that separate the
o Ventricular Septum – separates the R and L Ventricle R and L atrium)
o Atrial Septum – separates the R and L Atrium Left side = need ↑ pressure – to pump blood away from
the heart to go to the body
Baby inside mother’s womb – lungs are not functional; the Right side = ↓ pressure – only receives unoxy blood;
fetal heart does not have to pump blood to the lungs to pick pumping is adjacent to the lungs
up oxygen. “Shunting” – movement or flow
The fetal heart does not need a separate pulmonary artery – There will be shunting from the left side → right side
and aorta, they are connected.
The umbilical cord – connected to the baby’s heart with two Clinical Manifestation
holes: Acyanotic – may lumalabas pa ring oxygenated blood
o Ductus Arteriosus – another valve (butas) Asymptomatic if small defect
▪ which connects the pulmonary artery and the If small – baby can still live normally.
aorta. 30 – 40 y/o – possible lalabas na mga symptoms
o Foramen ovale – muscle separation (butas) – bcos over the decades of working, the R side of heart
▪ located in the atrial septum will get tired;
These 2 should be OPEN when the baby is inside mother’s Right side will have:
womb; these 2 holes bypass the lungs. o Hypertrophy
o Increase pressure in R atrium.
CONGENITAL HEART DEFECTS (CHD) o Pulmonary artery will have Pulmonary Hypertension
❖ Incidence: 1% of or about 40,000 births per year o Can develop Right Side Heart failure.
❖ Most common anomaly is VSD.
❖ 25% of babies with CHD are critical and generally needs Problem – additional workload
surgery or other procedures in their 1st year of life (CDC) Complication: lumalaki yung CHAMBER not the
❖ 15% of CHD are associated with genetic conditions. opening, because of workload/ ↑ pressure
❖ 28% of kids with CHD have another recognized anomaly
(trisomy 21)

MIDTERMS // honeybunchsugarplum | 29
 NCMA 219 – BSN 2ND YEAR – 2nd SEMESTER // Transcribed by B
Signs and Symptoms Hole is in the ventricular septum
Hear “murmur” sound. Complication:
Hollow systolic murmur o mas mabilis lumala ‘yung sakit bcos Ventricle has ↑
Subtle signs: pressure
✓ Dyspnea o mas madami and blood flow na mapupunta dito
✓ Fatigue and poor growth o Acyanotic blues – meron pa ring lalabas na oxygenated
✓ Soft systolic murmur in pulmonic area (splitting S2) blood
✓ May develop CHF
Clinical Manifestations
Laboratory/ Diagnostic Examination
• Murmur sound
DR order: 2D Echo – heart ultrasound • Hollow systolic murmur
– reveals enlarged right side of the heart and ↑
• Mas mabilis mag manifest – school age/ preschool pa lang
pulmonary circulation
– can have heart failure if left untreated.
✓ Cardiac catheterization – demonstrates separation of RA
and the↑ O2 saturation in the RA
Symptoms
✓ Tachypnea, dyspnea
Surgical Treatment
✓ Poor growth, reduced fluid intake
If detected early – can have surgery. ✓ Palpable thrills
• Surgical Dacron patch closure (pericardial patch) ✓ Systolic murmur at left lower sternal border
– Open repair with C-P bypass during school age ✓ May develop CHF
• Direct closure w/ double suture
Surgical Treatment
Non-surgical Treatment • Pulmonary artery bandaging (if not too large) or Patch
• May be closed using devices during cardiac – Support to pulmonary artery
catheterization.
• Same to VSD Non-surgical Treatment
• Same to ASD
Prognosis of ASD (and CHD) • Catheterization
• if treated, detected, have surgery early on – GOOD. o In femoral artery (singit)– ipapasok catheter papunta
• if hindi agad nadetect/ surgery – BAD can have failure. sa heart (may device sa dulo) → irrelease like an
umbrella – para takpan ‘yung butas/defect.
Nursing Management
✓ Explain to parents the purpose of tests and procedures Prognosis
✓ Teach parents ways to support nutrition, reduce stress on • If detected early on – GOOD.
heart, promote rest, and support growth and development • If left undetected/ untreated – DEATH.
during preoperative period
✓ Teach parents signs of congestive heart failure and Treatments:
infection ✓ Medications:
✓ Prepare parents and child for surgery by visiting intensive o Furosemide: a diuretic which removes excess fluid out
care unit, explaining equipment and sounds of the body
✓ Prepare older child for post-operative experience, o Digoxin: helps the heart pump more forcefully
including coughing and deep breathing and need for o Angiotensin-converting enzyme (ACE) inhibitor:
movement relaxes blood vessels and help heart to pump more
✓ Teach need for antibiotic prophylaxis to prevent subacute easily
bacterial endocarditis ✓ Surgical repair with bypass (procedure of choice)

VENTRICULAR SEPTAL DEFECT (VSD) PATENT DUCTUS ARTERIOSUS (PDA)

➢ Idiopathic ➢ Ductus SHOULD close by about age
➢ An abnormal opening between the R 15 hours after birth
and L ventricle ➢ Some shunting of blood may occur
➢ Defect in ventricular septum – error up to 24 hours of life
in early fetal development ➢ DUCTUS closes because increase in
➢ 20-25% of all CHDs are VSD arterial oxygen concentration that
➢ Pressure LV → RV and systemic follows initiation of pulmonary
arterial circulation resistance → function
pulmonary circulation, blood flows ➢ Prostaglandin E leads to closure of
through the defect and into the pulmonary artery PDA
➢ RV becomes enlarged (Hypertrophied), over time the RA ➢ Allows blood to flow from left to right and pulmonary
may also become distended blood flow

MIDTERMS // honeybunchsugarplum | 30
 NCMA 219 – BSN 2ND YEAR – 2nd SEMESTER // Transcribed by B
Ductus Arteriosus – opening/ connection in between the COARCTATION OF AORTA
Aorta (oxygenated) and Pulmonary Artery (unoxygenated) ↑ pressure sa taas
Ductus Arteriosus is maintained by Prostaglandin E. ↓ pressure pababa
If baby is inside mother’s womb – it’s okay if it’s open. ➢ The aorta is narrowed near the
In PDA – If baby is OUT from mother’s womb – open na yung insertion of the ductus arteriosus
ductus arteriosus. which result in increased
Crying of the baby will expand the lungs → Pressure will pressure proximal to the defect
close/ seal the patency → If ‘di nag close – ‘yung blood na and decreased pressure distal to
nasa Aorta ay bumabalik sa Pulmonary artery the obstruction (body).

Clinical Manifestations Signs and Symptoms

• Acyanotic – meron pa ring oxygenated blood na lalabas. • Hypertension – high BP in UPPER body and extremities
• Asymptomatic: small PDA • Bounding pulses in arms
✓ Bounding peripheral pulses • Weak or absent femoral pulses
✓ Widened pulse pressure (>25) • Cool lower extremities with low BP
✓ Complication for Large PDA: CHF with tachypnea, ✓ Patient at risk for ruptures aorta, aortic aneurysm, or stroke
dyspnea, and hoarse cry
Clinical Manifestations
Signs and Symptoms • Decreased/ diminish/ absent femoral pulses
• Machinery- like murmur • ↓ pressure
o Loud machine-like murmur at upper left sternal border • Cool extremity
(Left intraclavicular area)
Surgical Treatment
Nursing Care Management
Treatment of choice – For infants younger than 6 months
• Refer to the DR A. Resection and end – end anastamosis
o DR order – 2D Echo B. Grafting (luter positioning graft)
• Medication C. Patch Angioplasty
o To close the opening D. Subclavian Flap
o Prostaglandin E. Inhibitor
▪ INDOMETHACIN to close PDA’s – (IV) ✓ Surgical: does not require bypass since defect is outside
pericardium
Surgical Treatment ✓ Post-op complication is hypertension.
• Thoracotomy ✓ Usually done before age 2 yrs.
✓ Surgical ligation if meds fail. ✓ Risk of recurrence
✓ Surgery >> between age 1 – 2 years
Non-surgical Treatment
OBSTRUCTIVE BLOOD FLOW • Balloon Angioplasty
➢ Blood flow in heart meets an area of anatomic narrowing – Usually, effective.
(stenosis) → obstruction to blood flow – Pinapadaan sa femoral artery paakyat sa heart
➢ Pressure in ventricle & great arteries before – Ginagawa PANANDALIAN – i-inflate ‘yung balloon
obstruction is increased; pressure in area beyond hanggang masanay na dilated then id-deflate and
obstruction is decreased remove. Hoping it will remain dilated.
➢ Location of narrowing near the valve of the obstructive – May tendency na bumalik sa coarctation.
defect:
o Valvular: site of valve itself
AORTIC STENOSIS
o Sub valvular: narrowing in vent below valve
(ventricular outflow tract) ➢ Narrowing of aortic valve
o Supravalvular: narrowing in great art above valve usually malformed in BI-
➢ (+) pressure load on ventricle – decrease CO rather than Tricuspid valve
➢ s/s – CHF ➢ Causes ↑ resistance of blood
➢ Mild obstruction: asymptomatic flow in left ventricle, ↓
➢ Severe stenosis: hypoxemia (rare) Cardiac Output, Left
ventricular hypertrophy and
Stenosis – narrowing hindi harang pulmonary vascular
Stricture – narrowing congestion
Obstruction palabas ng puso ➢ Left ventricular wall is
hypertrophied>> increased pulmonary vascular resistance
& pulmonary hypertension
➢ LVH >> decrease coronary artery perfusion & increase risk
of MI.

MIDTERMS // honeybunchsugarplum | 31
 NCMA 219 – BSN 2ND YEAR – 2nd SEMESTER // Transcribed by B
Stenosis in the aortic valve or aorta. Clinical Manifestations
Hypertrophy – lalaki ‘yung left ventricle • Asymptomatic/ Acyanotic – may lumalabas pa ring
↑ Left Atrial pressure oxygenated blood
Connected to pulmonary vein that lead to pulmonary • Progressive narrowing causes increased symptoms.
vascular congestion → Lungs → Pulmonary edema
• Cyanotic – if sobrang narrow
(magtutubig and puso)
• Characteristic Murmur
>> can lead to: Left side heart failure
or worse: Death • Cardiomegaly
• Xray
Clinical Manifestations
Treatment of Choice:
• Acyanotic – may lumalabas pa ring oxygenated blood • Balloon Angioplasty – to dilate the pulmonary artery.
• Newborns are critical. • Valvotomy (resect stenosis)
• ↓ Cardiac output:
▪ Faint pulse Balloon angioplasty has better outcome to pulmonic
▪ Hypotension stenosis compared to doing it in the coarctation of aorta.
▪ Tachycardia
▪ Poor feeding
✓ Murmur; exercise intolerance CYANOTIC
✓ Chest pain, dizziness with standing Defects w/ DECREASED PULMONARY BLOOD
FLOW
Non-surgical Treatment Obstructed pulmonary blood flow + anatomic defect (ASD
• Balloon Angioplasty or VSD) between the Right and Left side of the heart are
present.
Surgical Treatment Difficulty of blood exiting R heart via pulmonary artery
→ Pressure on the right side of the heart increases →
• Artificial Heart Valve – after balloon angioplasty; can do
exceeding pressure on the left side → allows
if school age na
desaturated blood to shunt right to left → desaturation
• Implantable heart devices – Heart Valve in the left side of the heart and in the systemic
circulation
✓ Surgery: Konne procedure (valve replacement)
✓ May require repeat procedures
TETRALOGY OF FALLOT
PULMONIC STENOSIS Involves 4 heart defects:
o Ventricular Septal Defect
➢ Pulmonary artery is stenosed. (VSD)
➢ Narrowing at entrance to pulmonary artery → o Pulmonic stenosis
resistance to blood flow >> R ventricular hypertrophy o Overriding aorta
and decreased pulmonary blood flow. o Right ventricular hypertrophy
➢ Extreme form of PS: Pulmonary atresia (total fusion of the
commissures and no blood flow to lungs) Cyanotic
➢ PS >> RVH, R ventricular failure >> R atrial pressure 1. May pulmonic stenosis.
increases and may reopen foramen ovale 2. Kulang na ‘yung dugo na pumupunta sa baga from
➢ Shunts unoxygenated blood to L atrium >> systemic oxygenation → pagbalik na oxygenated, naghahalo ‘yung
cyanosis. oxygenated and unoxygenated blood → lumalabas
➢ May lead to CHF. desaturated blood
➢ Often have PDA as well
➢ Cardiomegaly on CXR ➢ Hemodynamics vary widely.
– Depends on extent of pulmonic valve stenosis & size
Problems in pulmonary artery of VSD.
Narrowing at the entrance to the pulmonary artery. – If VSD is large, pressures are equal in R and L
ventricles. Blood is shunted in the direction of the least
Complication: resistance (pulmonary or systemic vascular resistance)
Hypertrophy ➢ PVR is > than systemic vascular resistance, shunt will be R
↑ pressure of Left Atrium to L
Systemic circulation >> overload – may tumatakas na
additional fluid pabalik sa katawan Clinical Manifestations
– Edematous
• Cyanotic
– Mamamaga ‘yung liver
• Over the years w/o surgery – lumalala ‘yung VSD
• When they cry & eating/ feeding – exhibit bluish skin.
= TET SPELLS or BLUE SPELLS
= specific C.M: “Blue Baby”

MIDTERMS // honeybunchsugarplum | 32
 NCMA 219 – BSN 2ND YEAR – 2nd SEMESTER // Transcribed by B
• Characteristic murmur Therapeutic Management
• Episode of cyanosis • Give Prostaglandin E
• Hypoxia • To keep the Ductus Arteriosus open
Hindi tumatagal ‘gang pre-school unless masurgery agad. • Atrial Septostomy – if maliit ang septum opening;
✓ Anoxic after feeding or with crying. bubutasan
✓ RISK of: emboli, LOC, sudden death, seizures Note: If lumabas si baby as cyanotic – give Prostaglandin E
AGAD; then do 2D Echo
Surgical Treatment ✓ Continuous infusin of PGE 1 until Sx
A. Palliative Shunt
o Blalock Taussig Shunt (BTS) Surgical Treatment
– Maglalagay ng artificial graft deretso sa • Pulmonary – to – Systemic Artery Anastomosis
pulmonary artery – gumagawa ng artificial way para – If the ASD is small – Atrial Septostomy – palalakihin
makapunta ‘yung dugo sa pulmonary artery. ‘yung butas ng ASD or ‘yung pulmonary artery
 (Gore-Tex graft) ✓ Pulmonary artery bandaging
– Connecting subclavian artery to pulmonary artery ✓ Modified Fontan procedure
branch
– Pansamantala; can have multiple surgery. MIXED DEFECTS
B. Complete Repair Fully saturated systemic blood flow mixes with the
o Closure of VSD desaturated blood flow, causing a desaturation of the
o Repair of the pulmonic stenosis systemic blood flow.
✓ Usually in 1st year of life ➢ Survival on postnatal period depends on mixing of blood
✓ Resect stenosed area from pulmonary systemic circulation within cardiac
✓ Patch R ventricular outflow chambers.
➢ Cardiac output decreases because of volume load on
TRICUSPID ATRESIA ventricle
Atresia – wala/ didn’t develop ➢ Signs of desaturation, cyanosis, and
Walang valve only ligament/ harang CHF, but variable depending on
ASD, VSD, PDA anatomy
– Need these defects to be present for baby to survive. ➢ Degree of cyanosis not always
– Lagyan ng butas visible & signs of CHF
ASD – need to open AS or manatiling open ang foramen – TGA: severe cyanosis in 1st day
ovale. of life → CHF (later)
VSD – need para lumipat ‘yung dugo sa RA paakyat sa – Truncus arteriosus: severe CHF
pulmonary artery 1st few weeks of life and mild desaturation
Deoxygenated and oxygenated blood → (mixing) → L
Atrium → LV → RV → lalabas sa PDA or aorta TRANSPOSITION OF THE GREAT ARTERIES or
= Complete mixing (may desaturation) TRANSPOSITION OF THE GREAT BLOOD VESSELS
GOAL: Oxy Saturation = until 75% RV – connected to aorta
< 80% LV – connected to Pulmonary
Note: without ASD, VSD & PDA – DEATH Artery
The pulmonary artery leaves
➢ Failure of tricuspid valve to develop the L ventricle and the Aorta
➢ No communication from R atrium to R ventricle exits from the R ventricle with
➢ Blood flows thru an ASD or a patent FO to L side of the no communication between
heart thru a VSD to R ventricle to lungs the systemic and pulmonary
➢ Complete mixing unO2 and O2 blood in L side of the heart circulation.
→ systemic desaturation, pulmonary obstruction →
decrease pulmonary blood flow 2 Circuits
➢ At birth: presence of patent FO (or ASD) is required to 1. Oxygen poor blood (Aorta)
permit blood flow across septum into L atrium o circulates through the body by passing the lungs.
– PDA allows blood flow to pulmonary artery for Deoxygenated blood
oxygenation – unoxygenated blood → Aorta unoxygenated ulit
2. Oxygen rich blood (Pulmonary Artery)
Clinical Manifestations o Circulated from the heart to the lungs and back.
✓ Cyanosis – Pulmonary artery is oxygenated → pulmonary
✓ Tachycardia vein oxygenated pabalik
✓ Dyspnea
✓ Hypoxemia
✓ Clubbing
✓ AT RISK FOR: Bacterial endocarditis, Brain abscess,
Stroke
MIDTERMS // honeybunchsugarplum | 33
 NCMA 219 – BSN 2ND YEAR – 2nd SEMESTER // Transcribed by B
Pathophysiology CONGESTIVE HEART FAILURE
• Associated defects such as septal defects or PDA must be ➢ Inability of the heart to pump an adequate amount of blood
present to permit blood to enter the systemic circulation or to the systemic circulation at normal filling pressures to
the pulmonary circulation for mixing of saturated and meet the metabolic demands of the body.
desaturated blood. ➢ Due to structural deformity in children (septal defects) →
o Most common defects associated: increased blood volume & pressure in the heart →
– Patent foramen ovale or ASD MYOCARDIAL FAILURE
• TGA/ TGV = PDA & Foramen ovale are not open. ➢ Can occur with cardiomyopathy, dysrhythmia, severe
• For baby to survive: there should be an opening to electrolyte imbalances
Patent Ductus Arteriosus & Foramen Ovale. ➢ Could also be due to excess demands on a normal cardiac
– For the unoxygenated blood in the R atrium → L muscle (sepsis / severe anemia)
atrium → L ventricle → Pulmonary artery → left Cause: PEDIA = structural abnormalities
lung → Pulmonary vein (helpful ang PDA) → What happens?
Mixing of blood in Aorta → palabas o Ventricular emptying
• If foramen ovale is not open → ASD o Stroke volume
Therapeutic Management o Residual volume
• Medication: 2 Types:
o Prostaglandin E • Left Side Heart Failure
– IV
• Right Side Heart Failure
– Panandalian; to maintain the opening
Surgery Management Signs and symptoms of CHF
• Balloon Atrial Septostomy ✓ Each side of the heart depends on the adequate function of
– Bubuksan Septal Defect the other
• Artificial Graft in Aorta ✓ Failure of one chamber affects the opposite chamber
✓ If not corrected, it may lead to cardiac damage →
Lifetime mixing of deoxy and oxy blood inadequate CO → decreased supply to the kidneys → Na
Desaturated patient and H2O resorption → hypervolemia, increased workload
GOAL: at least 75 % oxy saturation on the heart, pulmonary and systemic congestion
HYPOPLASTIC LEFT HEART SYNDROME (HLHS)
Hypoplastic = maliit LEFT SIDE HEART FAILURE
Underdevelopment of the Problem = Pulmonary Congestion
left side of the heart ➢ LV unable to pump blood to the systemic circulation →
resulting in Hypoplastic increased LA pressure and pulmonary artery → congestion
left ventricle & Aortic in lungs → increased pulmonary pressure → pulmonary
atresia. edema → pulmonary HPN
Most blood from the L OR
atrium flows across the LV → (-) SYSTEMIC CIRCULATION → ↑LA → ↑PA → lung
patent foramen ovale → R congestion/ pulmonary edema
atrium → L ventricle → out
to pulmonary artery. Signs and Symptoms of LSCHF
The descending aorta receives blood from the PDA to • Respiratory malfunctions
supply the systemic blood flow. • Dyspnea (Paroxysmal Nocturnal Dyspnea)
Walang lumalabas na dugo from LV and aorta. • Orthopnea
unoxy blood → RA → RV → Pulmonary Artery → Lung • Rales/ Crackles
→ pabalik → need ASD or Foramen ovale → need PDA – • Blood-Tinged Frothy Sputum
para lumabas ‘yung blood through the body • Wheezing
Therapeutic Management • Dizziness
• Prostaglandin E • Syncope
– Infusion to keep the ductus open • Weakness
• Heart Transplant – best and last option.
Surgical Treatment RIGHT SIDED HEART FAILURE
Problem = Systemic Circulation Overload
✓ Norwood procedure to create a new aorta using the main ➢ RV unable to pump blood to Pulmonary Artery →
pulmonary artery and creation of large ASD. increased pressure in RA and in the systemic venous
✓ Bidirectional Glenn Shunt at 6-9 months age to reduce circulation → Systemic venous HPN →
volume load on the R ventricle. hepatosplenomegaly.
✓ Modified Fontan procedure, similar to Tricuspid atresia OR
repair.
RV → (-)PA → ↑RA → ↑systemic circulation →
✓ Transplant may be an option for some parts. Mortality rate
is very high (30%- 50%) hepatosplenomegaly → edema
MIDTERMS // honeybunchsugarplum | 34
 NCMA 219 – BSN 2ND YEAR – 2nd SEMESTER // Transcribed by B
Signs and Symptoms of RSCHF Therapeutic Management
• Edema GOALS:
• Fatigue 1. Improve Cardiac Function
• Neck vein engorgement o Digitalis therapy
• Ascites ▪ Increased CO, decreased size and venous
• Enlarged liver & spleen pressure, relieve edema
• Peripheral edema ▪ Lanoxin (Digoxin) – (Pedia) – more rapid in onset
• Leg varicosities  Oral / IV doses x 24 hours followed by
• Weight gain (bcos of additional fluids) maintenance dose (BID) to maintain blood
levels (Digitalizing Dose)
If not corrected…  Help heart contractility.
 Inotropic effects
↓Blood flow → KIDNEY → ↑ABSORPTION → hypervolemia  Chronotropic effects
→ ↑workload → DAMAGE TO HEART MUSCLES
o ACE Inhibitors (Capoten/ Enalapril)
This will lead to the three groups of manifestation for CHF ▪ (-) normal function of R-A system in kidney
1. Impaired myocardial function (L & R) ▪ Blocks conversion of AI to AII (Vasodilator)
– ‘di na titibok nang maayos ‘yung puso ▪ Captopril – can be given smaller doses
2. Pulmonary congestion (L) Asess:
3. Systemic venous congestion (R) • Heart Rate before administration if below 60 or above 120
= DO NOT GIVE Lanoxin or Digoxin; refer to doctor
s/s of Impaired Myocardial Function • If given it can lead to Bradycardia or rebound Tachycardia
• Contractility of heart
• Tachycardia Digitalis Toxicity
• ↓ urine output • Bradycardia
• Fatigue • GI manifestations:
• Weakness o Anorexia
• Restlessness o Nausea and Vomiting
• Anorexia o Diarrhea
• Pale, Cool extremities • Dysrhythmias (most dangerous)
• ↓ BP • Altered visual perceptions (Halos)
• Weak peripheral pulse 2. Remove accumulated fluid/ sodium
• Cardiomegaly • To decrease cardiac workload by reducing circulating
volueme thereby reducing preload
s/s of Pulmonary Congestion o DIURETICS – pampaihi
• Respiratory problems 1. Furosemide (Lasix)
• Tachypnea 2. Thiazides (Diuril)
• Dyspnea 3. Potassium sparing (Aldactone)
• Retractions Assess:
• Flaring of nares Pt is at risk for electrolyte imbalance.
• Exercise intolerance • Hypokalemia (↓ potassium) = < 3.5 mmol/L
• Cough – DO NOT GIVE furosemide and thiazide
• Cyanosis Normal: 3.5 – 5 mmol/L
• Wheezing
Management:
s/s of Systemic Venous Congestion • If hypokalemia:
o Hook the patient to Cardiac Monitor; refer to DR
• Weight gain and hold the medication.
• Hepatomegaly (Large liver)
• DR order:
• Peripheral and periorbital edema o Potassium sparring – muscle electrolyte; will
• Ascites reabsorb potassium to go back to circulation
• Neck vein distention o Give Diuretics – best in EARLY MORNING/
EARLY AFTERNOON
Diagnostic Evaluation
3. Decrease Cardiac Demand
• Chest X-ray – to determine kung lumalaki ‘yung puso
1. Reduce metabolic needs (Diet)
• Electrocardiogram (ECG) – to determine if u have
2. Limited physical activity
arrythmia, dysrhythmia or short abnormal heart rhythm
3. Preserving body temperature
4. Positioning
5. Sedation
MIDTERMS // honeybunchsugarplum | 35
 NCMA 219 – BSN 2ND YEAR – 2nd SEMESTER // Transcribed by B
4. Improve tissue oxygenation and Decrease O2 Nursing Management
consumption 1. Encourage compliance to treatment
• Supplemental humidifies oxygen is given. o Encourage adherence to tx’c plan
• DR order: Oxygen therapy o (+) poor compliance: monthly injections
2. Facilitates recovery from the illness
For L and R side heart failure: 3. Provide emotional support
4. Prevent the disease
• Vasodilators – to dilate the vessels to maintain normal
blood pressure
o Captopril (Capoten) KAWASAKI DISEASE
o Hydralazine (Apresoline) ➢ MUCOCUTANEOUS LYMPH NODE SYNDROME
o Nifedipine (calcium channel blocker w/ vasodilator ➢ Acute systemic vasculitis
effects) ➢ <5 y/o (Peak: toddlers)
➢ This in itself is SELF-LIMITING.
RHEUMATIC FEVER (RF) ➢ w/o treatment the child can develop Cardiac Problems
➢ Acute inflammatory disease
➢ Has significant effect in the: ETIOLOGY
o Heart ➢ UNKNOWN
o CNS • Infectious
o Joints • Geographical
o Subcutaneous tissues • Seasonal outbreaks
Rheumatic Heart Diseases
PATHOPHYSIOLOGY
➢ Damages the mitral valves
• Extensive inflammation of the arterioles, venules, and
ETIOLOGY capillaries
➢ Group A streptococci • Formation of coronary artery aneurisms
➢ Development of RF within 2 – 6 weeks • Coronary thrombosis
– Upon exposure to Group A streptococci bacteria • Stenosis
Diagnostic Criteria for RF • Severe scar formation of the main coronary artery
Can happen if left untreated.
• Modifications of the Jones criteria
o 2 Major Manifestations and 2 Minor Manifestations
Signs and Symptoms
• If with evidence of STREP INFECTION
• Pink eye
o 1 major and 2 minor manifestation
• Oral mucosal change
5 MAJOR CRITERIA of Jones • Enlarged lymph nodes
1. Polyarthritis • Patchy rash
2. Carditis • Peeling skin
3. Subcutaneous nodules
4. Erythema marginatum • Small and medium vessel vasculitis
5. Sydenham’s chorea • Mnemonic: “Warm CREAM”
MINOR
• Fever Needs:
• Polyarthralgia • Warm – fever >5d (5 days)
• History of RF
• Increase ESR PLUS 4 of 5:
• Antecedent strep infection 1. Conjunctivitis – bilateral, non-purulent
2. Rash – erythematous, maculopapular, morbilliform
Therapeutic Management 3. Erythema palms and soles – with swelling
1. Eradication of Hemolytic Streptococci 4. Adenopathy, cervical – 1 unilateral node
o Penicillin G – IM x 1 5. Mucous Membrane – dry, red, strawberry tongue
o Penicillin V – oral x 10 days
o Sulfa – oral x 10 days Diagnostic Criteria for KD
o Erythromycin (if allergic to above) - oral x 10 days
1. Fever for 5 or more days
2. Prevention of Permanent Cardiac Damage 2. Bilateral conjunctival inflammation without exudation
3. Palliation of other symptoms 3. Changes in the oral mucous membrane “strawberry tongue”
o Salicylates (ASA) – control inflammatory process esp. 4. Changes in the extremities (EDEMA and PEELING)
joints, dec fever and discomfort 5. Polymorphous rash
o Bed rest – during febrile phase but need not be strict 6. Cervical lymphadenopathy (one lymph node >1.5cm)
o Should be followed medically x 5 years
4. Prevention or recurrence of RF

MIDTERMS // honeybunchsugarplum | 36
 NCMA 219 – BSN 2ND YEAR – 2nd SEMESTER // Transcribed by B
3 Phases Clinical Manifestations
1. Acute phase
o ABRUPT ONSET FEVER
o Very irritable
2. Subacute phase
o Begins with resolution n of the fever
o Lasts until all clinical signs of KD disappear
o GREATEST RISK FOR THE DEVT OF
CORONARY ARTERY ANEURISMS
o Still irritable
3. Convalescent phase
o All clinical signs of KD have disappeared but LAB
values not normal

Therapeutic Management
1. High doses of IV Gamma Globulin
o 2 g/kg of BW over 10 – 12 hours
2. ASPIRIN
o Anti-inflammatory dose 80 – 100 mg/ kg/ day
o Antiplatelet dose 3 – 5 mg/ kg/ day
3. COUMADIN
o 1 of GIANT Aneurisms

• Prognosis
o Curable and full recover after treatment
• Death
o Sec to THROMBOSIS

Nursing Care Management

• Help the family adjust to the disorder
• Educated the family about the disorder
• Help the family manage the illness at home
• Prepare the child and family for invasive procedures
• Provide Postoperative care
• Provide Emotional support
• Plan for discharge and home care

Surgical Intervention
• Open-Heart
• Closed heart procedures
• Staged procedures
• Prepare child and family for procedures

MIDTERMS // honeybunchsugarplum | 37