PEDIATRIC NURSING

I. Growth & Development

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

Two parameters of Growth

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

6 months-----BW doubles
12 months----BW triples
2-2 ½ yrs-----BW quadrupled

2. Height - Increase by 1”/mo during 1st 6 months, 7-12 months by 1 ½ inch.

- Average increase in height - 1st year = 50%
Stoppage of ht coincide with eruption of wisdom tooth.

*Development - Increase skills or capability to function

- Qualitative

How to measure development:

1. Observe child doing specific task.
2. Role description of child’s progress
3. DDST- Denver development screening test except mental, its I.Q. Test
MMDST (Phil) Metro Manila Developmental Screening Test.

4 Main Rated Categories of DDST

1. Language communication
2. Personal social-interaction
3. Fine motor adapting- prehensile ability to use hand movement
4. Gross motor skills- large body movement

*Maturation- same with development “readiness”

*Cognitive Development –ability to learn and understand from experience, to acquire and retain knowledge, to respond to
a new situation and to solve problems. *Learning---change of behavior

IQ Test- test to determine cognitive development * Average IQ – 90-100

Formula: Mental age x 100 = IQ * Gifted child- > 130 IQ
Chronological age

II. Basic Divisions of Life

1. Prenatal stage from conception- birth

2. Period of Infancy
a. Neonate- 1st 28 days or 1st 4 weeks of life
b. Formal infancy- 29 day – 1 year

3. Early Childhood
a. Toddler – 1-3 yrs
b. Pre school 4-6 years

4. Middle Childhood
a. School age- 7 – 12 yrs

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 5. Late Childhood
a. Pre adolescent 11 – 13 yrs
b. Adolescent 12 - 18 – 21
III. Principles of G & D

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

Patterns of G&D:

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

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

c. Lymphatic system- lymph nodes, spleen, tonsils---grows rapidly- infancy and childhood
-protection against infection
 tonsil adult proportion by 5 years
d. Reproductive system- grows rapidly at puberty

Rates of G&D:
a. Fetal and Infancy – period of most rapid G&D -----*prone to develop anemia
b. Adolescent- period of rapid G&D Toddler- slow growth period
c. Toddler and preschool- alternating rapid and slow
d. School age- slower growth

3. Each child is unique

2 Primary Factors Affecting G&D :
A. Heredity: R – race F- born less in length than M by 1 inch.
I – intelligence F- born less in wt. than M by 1 lb.
S – sex
N - nationality

B. Environment: Q – quality of nutrition

S – socio eco. status
H – health
O – ordinal position in family Eldest- ability in comm. & social skills
P – parent child relationship youngest- more toilet trained

4. G&D occurs in a regular direction reflecting a definitive & predictable patterns or trends.

A. Directional Trends- occur in a regular direction reflecting the development of neuromuscular function.
These apply to physical, mental, social and emotional development and includes.

1. Cephalo-caudal--- “head to toe”

 Occurs along body’s long axis in w/c control over head, mouth & eye
movements & precedes control over upper body torso and legs.
2. Proximo- distal---- “Centro distal”
 From center of body to extremities.
3. Symmetrical----side of body develop on same direction at same time at same rate.
4. Mass Specific “Differentiation”
- Learns simple operations before complex function, from broad general pattern of behavior to a refined pattern.

B. Sequential- involves a predictable sequence of G&D to w/c the child normally passes.

1. Locomotion- creep, crawls, sit then stand.

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 2. Socio & Language skills- solitary games, parallel games
C. Secular- worldwide trend of maturing earlier & growing larger as compared to succeeding generations.

5.Behavior--most compressive indicator of developmental status. *1st cry--oha

6. Universal language of child- play 2nd sound-cooing
7. Great deal of skill and behavior is learned by practice. Practice makes perfect. 3rd sound-ahh(bowel)
9. Neonatal reflexes must be lost 1st before dev’t can proceed. *1st play-solitary
-Plantar reflex shld. disappear before baby can walk
-Moro reflex shld. disappear before baby can roll
*Persistent primitive infantile reflexes- case of cerebral palsy
IV. Theories of G&D
Developmental Tasks- different from chronological age
 skill or growth responsibility arising at a particular time in the individual’s life.
 The successful achievement of w/c will provide a foundation for the accomplishments of future tasks.

Theorists

1. SIGMUND FREUD: (1856-1939) Austrian neurologists----- Founder of Psychoanalysis

- offered personality development, Psychosexual theory

*Phases of Psychosexual Theory*

a.) Oral Phase------------- 0-18 months
- Mouth: site of gratification
-Activity of infant- biting, sucking crying.
-Why do babies suck?- enjoyment & release of tension.
-Provide oral stimulation even if baby on NPO.
-Pacifier.
-Never discourage thumb sucking.

b.) Anal Phase------------- 18 months-3 years

-Anus: site of gratification
-Activity- elimination, retention or defecation of feces must take place
- Principle of holding on or letting go.
-Mother wins or child wins
-Child wins- stubborn, hardheaded anti social. (anak pupu na, child holds pupu, child wins)
-Mother wins- obedient, kind, perfectionist, meticulous--------- OC-anal phase
-Help child achieve bowel & bladder control even if child is hospitalized.

c.) Phallic Phase----------- 3-6 years

- Genitals: site of gratification
- Activity- may show exhibitionism
- Increase knowledge of a sexes
- Accept child fondling his/her own genitalia as normal exploration
- Answer Childs question directly.
- Right age to introduce sexuality – preschool

d.) Latent Phase---------- 7-12 years

-Period of suppression- no obvious development.
-Childs libido or energy is diverted to more concrete type of thinking
-Helps child achieve (+) experience, ready to face conflict of adolescence

e.) Genital Phase--------- 12-18 years

-Genitals: site of gratification
-Achieve sexual maturity
-Learns to establish relationships with opposite sex.
-Give an opportunity to relate to opposite sex.

2. ERIC ERICKSON- Psychoanalysis theory

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

*Stages of Psychosocial Theory*

a.) Trust vs. Mistrust – 0-18 months.

-foundations of all psychosocial task
-to give & receive is the psychosocial theme
-know to develop trust baby
1. Satisfy needs on time
- breastfeed
2. Care must be consistent & adequate
-both parents- 1st 1 year of life
3. Give an experience that will add to security- touch, eye to eye contact, soft music.
b.) Autonomy vs. Shame & Doubt---- 18-3 years
- Independence /self gov’t
- Develop autonomy on toddler ---1. Give an opportunity of decision making, offer choices.
2. Encourage to make decision rather than judge.
3. Set limits
c. Initiative vs. Guilt------------------------ 4-6 years
-Learns how to do basic things
-Let explore new places & events
-activity recommended- modeling clay, finger painting--enhance imagination & creativity
& facilitate fine motor dev’t
d. Industry vs. Inferiority------------------- 7-12 yrs
-Child learns how to do things well
-Give short assignments & projects

e. Identity vs. Role Confusion or Diffusion 12-18 yrs

-Learns who he/she is, what kind of person he/ she will become
by adjusting to new body image and seeking emancipation from parents
-Freedom from parents.

f. Intimacy vs. Isolation-----------------------18-25 yrs. Up to 30 y/o

-looking for a lifetime partner and career focus

g. Generatively vs. Stagnation------------ 30-45 y/o

h. Ego Integrity vs. Despair---------------45-65 & above

3. JEAN PIAGET- Swiss psychologists , pioneer work on dev.t of intelligence in children

-develop reasoning power

*Stages Of Cognitive Development*

A. Sensory Motor------ 0-2 y/o
-“Practical Intelligence”- words & symbols not yet available baby communicates thru senses & reflexes.

Schema (Subdivision) Age Behavior

1. Neonate Reflex 1 month All reflexes
2. Primary Circular Reaction 1-4 months -Activity related to body
-Repetition of behavior (ex. thumb sucking)
3. Secondary Circular Reaction 4-8 months -Activity not related to body
-Discover object & person’s permanence
-Memory traces present
-Anticipate familiar events.
4. Coordination of Secondary Reaction 8-12 months -Exhibit goal directed behavior
- of permanence & separateness (search of lost
toy, knows mom, throw & retrieve)

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5. Tertiary Circular Reaction 12-18 -Use trial & error to discover places & events
months -“ invention of new means”
(1-1 1/2yrs.) -capable of space & time perception
(hits fork, spoon on table or drops fork)
6. Invention of new means thu mental 18-24 -Transitional phase to the pre operational thought
combination---“Symbolic Representation” months process.

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

Schema Age Behavior

1. Preconceptual 2-4 yrs -Thinking basically complete literal & static
-Egocentric- unable to view others viewpoint
-Concept of dying is only now
-Concept of distance is only as far as they can see.
-Concept of Animism: inanimate object is alive
(-) reversibility concept- in every action there’s an opposite reaction or cause & effect
2. Initiative 4-7 yrs Beginning of Causation

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

1. Can find solution to everyday problems with systematic reasoning.
2. *Aware concept of reversibility- cause & effect
3. Concept of Conservation – constancy despite of transformation.
4. Activity recommended- collecting & classifying: stamps, stationeries, dolls, rubber band markers.

D. Formal Operational Thought--------- 12 and up.

1. Cognition achieved its final form
2. Can deal with past present & future
3. Have abstract & mature thoughts & formal reasoning.
4. Can find solutions to hypothetical problems with scientific reasoning.
5. Activity: talk time:-- will sort out opinions & current events.

4. KOHLBERG (1984)
- recognized the theory of moral dev’t as considered to closely approximate cognitive stages of dev’t

*Stages of Moral Development*

A. Infancy – “Amoral, Pre-religious or pre-moral stage

Age Stage Description

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

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V. DEVELOPMENTAL MILESTONES
-Major markers of growth and dev’t

1. Period of Infancy:
*Universal language of child----- Play
a. Play- Solitary plays (non-interactive)
Priority : Safety (toys: age appropriate)
Main goal: Facilitate motor & sensory dev’t
Ex. mobile, teeter, music box, rattle

b. Fear- Stranger anxiety begin 7-8 months: peak 8 months diminishes 9 months

c. Milestones:

 Neonate: >Complete head lag

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

 1 month: > Dance reflex disappears looks at mobile

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

 3 months: >Holds head & chest up when prone

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

 4 months: >Head control complete

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

 5 months: > Turn both ways “roll over”

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

 6 months: >Reaches out in anticipatory of being picked up

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

 7 months: >Transfer object from hand to hand

>Likes object that are good size for transferring

 8 months: >Sits without support

>Peak of stranger anxiety

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 >Planters reflex disappears 8-9 months in prep. for walking

 9 months: > Creeps or crawls, needs space for creeping

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

 10 months: >Pull self to stand

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

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

 12 months: >Stands alone, take 1st step

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

2. Toddler:

a. Play: Parallel play- 2 toddlers playing separately

-Provide with similar toys
Ex. squeaky frog to squeeze, waddling duck to pull, trucks to push-push pull toy,
building blocks, pounding peg, toys to ride on
b. Fear: Separation Anxiety: begin 9 months, peak 18 months
3 Phases Of Separation Anxiety (in order)
P- protect
D- despair
D- denial
-don’t prolong goodbye
-say goodbye firmly to develop trust- say when you will be back

c. Milestones

 15 months: >Plateau stage

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

 18 months: >Height of possessiveness

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

 24 months: >Terrible two’s

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

 30 months or 2 ½ year:
>Makes simple lines or stroke for crosses with a pencil
>Can jump down from chairs
>Knows full name
>Copy a circle
>Holds up finger to show age
>Temporary teeth complete (deciduous teeth -20)

*Posterior Molar- last temporary teeth to appear

>Beginning of toothbrush – 2-2 ½ yrs

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

 36 months or 3 yrs: >Trusting 3

>Unbutton buttons (unbutton before learn to button)
>Draw a +, learns how to share
>Knows full name & sex (gender identity)
>Speaks fluently, 300-900 words
>Nighttime bladder control achieved
>Ride a tricycle
d. Characteristic Traits of Toddler
1. Negativistic- “NO!” -way to search for independence
>Limit questions
>Modify questions to a statement
2. Rigid, ritualistic & stereotype
>Ritualism- to gain mastery
3. Temper Tantrums (most common)
>Head banging, screaming, stamping feet, holds breath
>Ignore behavior
*Protruding abdomen-d/t underdeveloped abdominal muscles
*Physiologic anorexia- d/t preoccupation with environment- food fads, short period of time
>Loves rough & tumbling play
>Loves toilet training
>Failure of toilet training- unreadiness

*Clues For Toilet Readiness:

1.) can stand, squat walk alone
2.) can communicate toilet needs
3.) can maintain dryness for 2 hours
3. Pre-Schoolers:

a. Play : Associative or Cooperative Play Draws by age:

>bahay-bahayan – play house >Role playing 2 1/2

b. Fear : Body Mutilation or Castration 3

>Fear of dark places, witches
>Fear of thunder & lightning 4
>Fear of ghosts
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c. Milestones

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  *4 years old:> Furious 4 , noisy, aggressive, stormy
> Can button buttons
> Copy a square
> Jumps & skips *Laces shoes
> Vocabulary 1,500
> Knows 4 basic colors
> Say songs or poem from memory

 5 years old: > Frustrating 5

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

d. Character Traits of Pre-Schooler:

1. Curious, creative imaginative, imitative
2. Favorite words- “why & how”
3. Complexes- identification to parent of same sex & attachment to parent of
opposite sex
Ex. Oedipal complex- girl to dad/boy to mom
Electra complex- identification to mother (daughter-mother), attachment to father
>Cause of incest marital discord

e. Behavior Problems
1. Telling tall tales d/t over imagination
2. Imaginary friend- to release tension & anxieties
3. Sibling rivalry- jealousy to newly delivered baby.
4. Regression- going back to early stage
Sx: >thumb sucking (should be oral stage only)
>baby talk, bed wetting, fetal position
5. Masturbation- sign of boredom
-divert attention, offer a toy
4. School Age:

a. Play: Competitive play

Ex. Tug of war, track and field, basket ball

b. Fear. 1. School Phobia

-orient to new environment
2. Displacement from school
-teacher and peer of same sex
3. Loss of Privacy
-wants bra
4. Fear of Death: thinks death is reversible as sleep *7-9yrs death is personified
-death as permanent loss of life
c. Significant Person: Teacher, peer of same sex

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

 6 years old: >Temporary teeth begin to fall

>Perm teeth appear- 1st molar
1st temp teeth- 5 months
1st perm teeth- 6 yrs
>Year of constant motion
> Common: green-stick fracture

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 >Recognize all shapes
>1st grade teacher becomes authority figure
>Nail biting
>Begin interest in God.

 7 years old; Age of Assimilation

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

 8 years old: Expansive age

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

 9 years old: >Coordination improves

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

 10 years old: >Age of Special Talent

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

 11-12 y/o: >Pre-adolescents

>Full of energy & constantly active
>Secret language are common
>Share with friends secrets
>Sense of humor present
>Social & cooperative
f. Character Traits of School Age:

1. Industrious
2. Modest
3. Can’t bear to lose- will cheat
4. Love collections- stamps

*SIGNS OF SEXUAL MATURITY*

Girls Boys

I-inc size breast & genitalia (thelarche- 1st sign sexual at. A-appearance axillary & Pubic hair

W- widening of hips D-deepening of voice

A- appearance axillary & pubic hair ( adrenarche) D- development of muscles

M- menarche- last sign sexual mat. Girls I—increase in testes and penis size ( 1st sign sexual mat)

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

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 5. Adolescent :

a. Fear :
1. Obesity
2. Acne
3. Homosexuality
4. Death
5. Replacement from friends

b. Significant Person: Peer of Opposite Sex

c. Significant Development

1. experiences conflict bet. his needs for sexual satisfaction & societies expectation

*Core Concern: Change of body image & acceptance of opposite sex

* Hallmark of Adolescence: Nocturnal Emission (wet dreams)

2. Distinctive odor d/t stimulation of apocrine glands

3. Sperm is viable by 17 y/o
4. Testes & scrotum increase until age 17
5. Breast & female genitalia increase until age 18

d. Personality Traits Adolescents:

1. Idealistic
2. Very conscious with body image
3. Rebellious
4. Reformers, adventuresome

e. Problems:

1. Vehicular accident
2. Smoking
3. Alcoholism
4. Drug addiction
5. Pre-marital sex

II. IMMEDIATE CARE OF NEWBORN

1st days of life:

1. Initiation and maintenance of respiration

2. Establishment of extra uterine circulation
3. Control of body temp
4. Establishment of waste elimination
5. Intake of adequate nourishment
6. Prevention of infection
7. Establishment of an infant-parent relationship
8. Dev’t care that balances rest & stimulation or mental dev’t

1.) Initiation and Maintenance of Respiration

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 2nd stage of labor- initial airway
-initiation of a /w is a crucial adjustment
-most neonatal deaths w/n 24 h caused by inability to initiate a/w
-lung function begins after birth only

How to initiate a/w :

a. Remove secretions bulb syringe

b. Catheter Suctioning
1.) Place head to side to facilitate drainage of secretions
2.) Suction mouth 1st before nose
-neonates are nasal breathers
3.) Period of time
5-10 sec suctioning, gentle and quick
Prolonged & deep suctioning can lead to : Hypoxia
Laryngospasm, Bradycardia
d/t stimulation of vagal nerve--near esophagus & anus

4.) Evaluate for patency

-cover nostril & baby struggles there’s a need for additional suctioning

c. If not effective, requires effective laryngoscopy to open a/w. After deep suctioning an endotracheal tube can be
inserted and oxygen can be administered by (+) pressure bag and mask with 100% oxygen at 40-60b/m.

Nsg alert In O2 Administration:

1. No smoking to prevent combustion
2. Always humidify to prevent drying of mucosa
3. Over dosage of oxygen can lead to scarring of retina leading to blindness
(Retro Lentalfibrolasia or Retinopathy of Prematurity) ROP---prone to:SGA,LBW,Preterm

4. When meconium stained (greenish) never administer oxygen with pressure

(O2 pressure will push mecomium inside)------Atelectasis

2.) Establishing Extra-Uterine Circulation

*Circulation is initiated by lung expansion or pulmo ventilation and completed by cutting of cord.

FETO PLACENTAL CIRCULATION

* Placenta(simple diffusion) –oxygenated blood is carried by the umbilical vein- passes liver-ductus venousus- IVC- RT
atrium 70% blood is shunted to foramen ovale- LT atrium mitral valve – LT ventricle- aorta-lower extremities.

-Remaining 30%- tricuspid valve- RT ventricle- pulmonary arteries- lungs (for nutrition)--vasoconstriction of lungs pushes
blood to ductus arteriousus to aorta to supply upper extremities.

*3 SHUNTS*

SHUNTS-shortcuts
1. Ductus Venosus- -shunts from liver to IVF (umbilical vein to inferior vena cava)
2. Foramen Ovale- shunts bet 2 atrias
3. Ductus Arteriosus- from pulmonary artery to aorta

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 Decrease PO2, increase PCO2 acidosis

Will cause 1st breath /cry of baby

Decrease Pulmo Artery Pressure

Increase PO2 Decrease blood flow Increase pressure to Left side of

heart

1. Closure of Ductus 2. Closure of Ductus 3. Closure of Foramen Ovale

Arteriosus Venosus & AVA

What will sustain 1st breath- decreased artery pressure

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

4.) 2 Ways to facilitate closure of Foramen Ovale

a.) Tangential Footstep- slap foot of baby----slap---cry---lung expansion

-never stimulate baby to cry if secretions not fully drained to prevent aspiration
-check characteristic of cry
*Normal cry- strong, vigorous and lusty cry *Normal cry of baby boy: lower
cri-du-chat syndrome-chromosomal obliteration cat like cry (meow)

b.) Proper position : Right side lying pos.

-will increase pressure on left and foramen ovale will close
*Foramen Ovale and Ductus arteriosus will begin to close within 24h
*Universal Cry of a Baby: “O-ha”
Obliteration-complete closure
Structure Appropriate Time of Structure Remaining Failure to Close
Obliteration
Foramen Ovale Begins 24 hrs, 1yr Fossa Ovalis Atrial Septal Defect
Ductus Arteriosus Begins 24 hrs., 1 month Ligamentum Arteriosum Patent Ductus Arteriosus
Ductus Venosus 2 months Ligamentum venosum
1.) Lateral umbilical Ligament
Umbilical artery 2-3 months 2.) Interior iliac artery
Umbilical vein 2-3 months Ligamentum Teres ( round ligament of liver)

*Position of infant immediately after birth:

NSD-Trendelenberg/ T position for drainage
contraindication of Trendelenberg position - increase ICP
CS- Supine or crib level position
Signs of Increased ICP
1. Abnormally large head
2. Bulging and tense fontanel Hypertension

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 3. BP and widening pulse pressure Bradycardia Cushing’s Triad of ICP
4. RR & PR Tachypnea
5. Projective Vomiting- sure sign of cerebral irritation
6. High deviation – Diplopia – sign of ICP older child
4-6 months- normal eye deviation if >6 months- lazy eyes
7.) High pitch shrill cry- late sign of ICP

3. Control of Body Temperature : Temp Regulation

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

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

A. Factors Leading to Dev’t of HYPOTHERMIA

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

Effects of Hypothermia ( Cold stress)

1.) Hypoglycemia- 45-55 mg/dl normal ( 50- borderline) d/t utilization of glucose
2.) Metabolic acidosis- catabolism of brown fats (best insulator of newborns body)
will form ketones ( found in chest/back)
3.) High risk for kernicterus- bilirubin in brain leading to cerebral palsy
4.) Additional fatigue to allergy stressful heart

To Prevent Hypothermia:
1. Dry and wrap baby
2. Mechanical pressure – radiant warmer (incubator) *Pre-heat first isolette (or square acrylic sided incubator)
3. Prevent an necessary exposure – cover baby
4. Cover baby with tin foil or plastic
5. Embrace the baby- kangaroo care (skin to skin contact)

4. Establish Adequate Nutritional Intake

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Physiology Breast Milk Production: Physiology of Breast Milk Release:
As you deliver baby, E & P Sucking of the Breast

APG Posterior P. G.
releases: releases

Prolactin Oxytocin
w/c acts on

Acinar Cells/Alveoli Contraction of smooth muscles of the

To Produced foremilk Lactiferous tubules

Stored in lactiferous Tubules Milk Ejection Reflex Let-Down Reflex

(or Collecting Tubules)

*CS- breastfeeding after 4 hours *NSD- breastfeeding asap

*Advantages of Breastfeeding *Store milk- plastic storage container

1. Economical >good for 6 mon. from freezer/ at rm. temp. don’t heat
2. Always available
3. Promotes Bonding
4. Breastfed babies have higher IQ than bottle fed babies.
5. It facilitates rapid involution
6. Decrease incidence of breast cancer.
7. Contents of BREAST MILK: a. Antibodies- IgA
b. Lactobacillius bifidus- interferes w/ attack of pathogenic bacteria in GIT
c. Has macrophages
d. Lactoferrin
e. Lyzozymes
f. Interferons

15
Disadvantages:
1. Possibility of transfer HEP B, HIV ( 30%-39%), cytomegalovirus virus.
2. No iron-----prone to IDA
3. Father can’t feed & bond as well

3 Stages of Breastmilk:

1. Colostrum- 2-4 days post-delivery

content: fats, IgA, CHO, CHON, minerals, fat soluble minerals

2. Transitional milk- 4 – 14 days

content: lactose, water soluble vit., minerals

3. Mature milk- 14 & up (3 L)

content: fats (linoleic acid) – resp for devt of brain & integrity of skin
CHO- lactose – easily digested, baby not constipated.
- responsible of sour milk smelling odor of stool & astringent property of milk

*Lactose Intolerance- deficiency of enzyme LACTASE that digests LACTOSE

—manifestation = Excessive Crying ------substitute-----soy milk
*Decrease CHON- lactalbumin
Contents of Cows milk: fats
CHON – casein- has curd that’s hard to digest
Minerals–traumatic effect on kidneys of babies.
Can trigger stone formation.
Phosphorus
CHO

5. Prevention of Infection:

Health Teachings:
1. Proper hygiene- proper hand washing
Care of breast - cotton balls with lukewarm water (inner to outer)
Caked colostrums- dry milk on breast
2. Best position in breastfeeding – upright sitting -avoid tension!—if w/ tension breast will not properly empty
3. Stimulate & evaluate feeding reflexes
a.) Rooting reflex- by touching the side of lips/cheeks then baby will turn to stimulus. Disappear by 6
weeks- by 6 weeks baby can focus. Reflex will be gone
- Purpose rooting- to look for food.
b.) Sucking – when you touch middle of lips then baby will suck
- Disappears by 6 months
- When not stimulated sucking will stop.
c.) Swallowing- when food touches posterior of tongue then it will be automatically swallowed

d.) Extrusion/ Protrusion reflex

-when food touches anterior portion of tongue then food will be extruded.
Purpose: to prevent from poisoning
Disappear by 4 months & baby can already spit out by 4 months.

16
Criteria Effective Sucking:
a.) Baby’s mouth is hiked up to areola
b.) Mom experiences after pain.
c.) Other nipple is also flowing with milk.
To prevent from crack nipples & initiate proper production of oxytocin.
- begin 2-3 min at per breast ( 5 – 7 min other authors)
to initiate production of oxytocin
- increase 1 min/ day – until reaching 10 mins per breast or 20 mins/ feeding.
For proper emptying & continuous milk production / feeding
-feed baby on last breast that you feed her with, alternately ( if not emptied - mastitis)

Problems Experienced in Breastfeeding :

1st day post-partum: Breast soft & tender
3RD day changes in breast post partum:
a.)Engorged- feeling of fullness & tension in breast.
- sometimes accompanied by fever known as MILK FEVER-continue BF
Mgt: Warm compress- for breastfeeding mom
Cold compress – for bottle feeding & wear supportive bra.
Contra Indications in Breast Feeding:
a. Maternal Conditions: b. Newborn Condition:
>HIV Inborn errors of metabolism
>CMV Erythroblastosis Fetalis – Rh incompatibility >Hep.
B Hydrops Fetalis, Tay Sachs disease
> Coumadin Phenylketonuria, Galactosemia

6. Establish Waste Elimination

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

Indication of Stool Changes: Jaundice baby – light stool

Under phototherapy – bright green
Mucus mixed with stool - milk allergy
*Clay colored stool – obstruction to bile duct
Chalk clay stool – after barium enema
Black stool – GIT bleeding (melena)
Blood flecked stool - anal fissure.
*Currant jelly stool – intussuseption
*Ribbon like stool – hirschsprung disease
Cult blood – stool exam
*Steatorrhea stool – fatty, bulky foul smelling odor stool
 malabasorption syndrome
(Celiac disease or Cystic fibrosis)
III. ASSESSMENT FOR WELL-BEING

A. APGAR SCORE – Dr. Virginia Apgar

17
 Special Considerations: 1st 1 min – determine general condition of baby
Next 5 min- determine baby’s capabilities to adjust extra uterinely (most important)
Next 15 min – dependent on the 5 min

A- appearance- color – slightly cyanotic after 1st cry baby becomes pink.
P- pulse rate – apical pulse – left lower nipple
G- grimace – reflex irritability- (1) tangential foot slap, (2) catheter insertion
A – activity – degree of flexion or muscle tone
R – respiration

Baby cry – within 30 secs

Failure to cry after 30 secs – asphyxia neonatorum
Resp. depression – d/t mom given Demerol. Administer Naloxone

APGAR Scoring Chart:

0 1 2
HR (most important) Absent <100 >100
Respiratory Effort Absent Slow, irregular, weak Good strong cry
Muscle Tone Flaccid extremities Some flexion Well flexed

Reflex Irritability
Catheter No Response Grimace Cough, sneeze
Tangential Footslap No Response Grimace Cry
Acrocyanosis Pinkish
Color Blue/pale (body- pink
extremities-blue)

APGAR Result:

0 – 3 = severely depressed, need CPR, admission NICU

4 – 6 = moderately depressed, needs add’l suctioning & O2 administration
7 - 10 =good/ healthy

CPR – cardio pulmonary resuscitation or CPR

New: Cardio pulmonary cerebral resuscitation (CPCR)

5 min no O2 – irreversible brain damage

a/w 1. shake, no resp, call for help
2. flat on head, use cardiac board
3. head tilt chin lift maneuver except spinal cord injury over extension may occlude airway

Breathing ( ventilating the lungs)

1. check for breathlessness
if breathless, give 2 breaths- ambu bag
> 1 yr old- mouth to mouth, pinch nose to create a seal
< 1 yr – mouth to nose
Force – different between baby & child
infant – puff

Circulation : Check for pulselessness : carotid- adult

Brachial – infants
CPR – breathless/pulseless
Compression –for infant: 1 finger breath below nipple line or 2 finger breaths or thumb

CPR : Infant 1:5

Adults 2:15

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B. Respiration Evaluation

1. Assessment tool that determines respiration of baby :

Silvermann Anderson Scale
Criteria 0 1 2
Chest movement synchronized Lag on respiration See - saw
Intercostal retraction No retraction Just visible Marked
Xiphoid retraction None Just visible Marked
Nares dilatation None Minimal Marked
Expiratory grunt None Heard on stet only Heard on naked ear
Lowest score – best
Interpretation result:
0 -3 – normal, no RDS
4 – 6 – moderate RDS
7 – 10 – severe RDS

C. Assessment of Gestational Age

1. Clinical Criteria: Ballards & Dobowitz

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

*2. Signs of Preterm Babies

> Born after 20 weeks & before 37 weeks
>Frog leg or lax position
>Hypotonic muscle tone- prone resp problem
>Scarf sign – elbow passes midline pos.
>Square window wrist – 90 degree angle of wrist
>Heel to ear sign Complications: RDS, Hypothermia, ROP
>Abundant lanugo
*Type of Feeding Pre-Term: Gavage Feeding –to prevent aspiration –d/t absence of gag & swallowing reflex

*3. Signs of Post term babies:

> 42 weeks
>Classic sign – old man’s face
>Desquamation – peeling of skin
*Long brittle finger nails
>Wide & alert eyes

IV. Neonates in Nursery

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

19
 >Oil bath – initial : To cleanse baby & spread vernix caseosa
Fx of vernix caseosa : 1. Insulator
2. Bacterio- static
* Babies of HIV + mom – immediately give full bath to lessen transmission of HIV
(13 – 39% possibly of transmission of HIV
*Full bath – safely given when cord fall *Dressing the Umbilical Cord: strict asepsis to prevent tetanus
d. Dressing the Umbilical Cord

1. * 3 Cleans in community

1. Clean hand
2. Clean cord
3. Clean surface
Betadine or Povidone Iodine – to clean cord

2. Check AVA, then draw 3 vessel cord--- if 2 vessel cord—suspect absence of kidneys

- leave about 1 inch” of cord

- if BT or IV infusion – leave 8” of cord
*Best site of blood nerve access: umbilical cord

3. Check cord every 15 min for 1st 6 hrs – bleeding .> 30 cc of blood----hemorrhage

*Excessive bleeding of cord – Omphalagia – suspect hemophilia or blood dyscrasias

*Cord turns black on 3rd day & fall 7 – 10 days

*Failure to fall after 2 weeks- Umbilical granulation (w/o foul smelling odor, pinkish)
Mgt: silver nitrate or cautery
- clean with normal saline solution not alcohol
- don’t use bigkis – air
- persistent moisture-urine, suspect patent uracus – fistula bet
bladder & normal umbilicus

Dx: Nitrazine paper test – if yellow – urine ---if blue – amniotic fluid
- if reddish -- Omphalitis
Mgt: Surgery

e. Credes Prophylaxis – Dr. Crede

Purpose: prevent opthalmia neonatorum or gonorrheal conjunctivitis

* how transmitted – mom with gonorrhea or chlamydia
Drug: erythromycin ophthalmic ointment- inner to outer

Silver nitrate (used before) – 2 drops lower conjunctiva (not used now)
-causes staining of skin, chemical conjunctivitis
- does not give protection against STDs
f. Administer Vit-K

– to prevent hemorrhage R/T physiologic hypoprothrombinemia

- Aquamephyton, phytomenadione or konakion
- .5 – 1.5 mg IM, vastus lateral or lateral ant thigh
- 5 mg preterm baby
*Vit K – synthesized by normal flora of intestine
Vit K – meds is synthetic d/t intestine is sterile

g. Weight-taking

> Normal wt 3.000 – 3400 gms/ 3 – 3.4 kg / 6.5 - 7.5 lbs

20
 > Arbitrary lower limit 2500 gm
> Low birth wt baby delivered < 2500g
> Small for gestational age (SGA) < 10th % rank or born small
> Large for gestational age > 90th % rank or macrosomia >4000 g
> Appropriate for GA – within 2 standard deviation of mean (AGA)
> Physiologic wt loss – 5 – 10% wt loss few days after birth

Small GA < (less) 10

Large GA > (more) 90

V. PHYSICAL EXAM & DEVIATIONS FROM NORMAL

A. Important Considerations:
1. if client is new born, cover areas not being examined to prevent hypothermia
2. if client is infant – the 1st yr of life - get VS – take RR 1st
- begin from least intrusive to the most intrusive area
3. if client is a toddler and preschool, let them handle an instrument like:
- play syringe or stet, security blanket – favorite article.
Let baby hold it, allow bedtime rituals
4. Explain procedure & respect their modesty - school age & adolescent
- by wearing your complete uniform
*Security Blanket--- a transitional object as representation of the parents
B. Components:
1. V/S:
Temp: rectal- newborn – to rule out imperforate anus/assess patency of anus
- take it once only, 1 inch insertion
Imperforate anus
1. Atretic – no anal opening more dangerous
2. Agenetic – no anal opening
3. Stenos – has opening but narrow opening
4. Membranous – has opening
Earliest sign:
1. No mecomium
2. Abdominal destention
3. Foul odor breath
4. Vomitous of fecal matter
5. Can aspirate – resp problem may arise d/t aspiration of intestinal
contents----atelectasis
Mgt: Surgery with temporary colostomy

Cardiac rate: 120 – 160 bpm newborn

Apical pulse – left lower nipple
Radial pulse – normally absent. If present PDA (+) radial pulse
Femoral pulse – normal present. If absent- COA - coartation of aorta

Congenital Heart Diseases:

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

2 Major Types: “AL CR”

1. Acyanotic L to R : Left to Right shunting
2. Cyanotic R to L : Right to Left shunting

21
 I. ACYANOTIC HEART DEFECTS L to R ---------( 8 Types)
*With increased pulmonary blood flow
1. Ventricular Septal Defect (VSD) - opening between 2 ventricles

S&Sx:
a. Systolic murmurs at lower border of sternum and no other significant sign
b. Cardiac catheterization reveals increased o2 saturation @ R side of heart
c. ECG reveals hypertrophy of R side of heart
Nsg Care:
Cardiac catheterization: site – Right femoral vein
1. NPO 6 hrs before procedure
2. Protect site of catheterization. Avoid flexion of joints proximal to site.
3. Assess for complication – infection, thrombus formation – check pedal pulses
Mgt.
1.) *Long term antibiotic – to prevent subacute bacterial endocarditis
2.) Open heart surgery

2.) Atrial Septal Defect (ASD) – Failure of foramen ovale to close

S & Sx:
1. Systolic murmur @ upper border of sternum
2. Result of cardiac catheterization & ECG same with VSD-- O2 sat & hypertrophy
Mgt: Open heart surgery

3.) Endocardial Cushion Defects (ECD) - atrium ventricular - affects both tricuspid & mitral valve

Dx : Confirmed by cardiac catheterization

Mgt: : Open heart surgery
Antibiotics to prevent subacute bacterial endocarditis

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

- should close within 24 h -complete close – 1 month
S & Sx :
1. Continuous machinery like murmurs > outstanding sign of acyanotic HD
2. Prominent radial pulse
3. ECG- hypertrophy Left ventricle
Drug:
1. Endomethacine – prostaglandin inhibitor - facilitate closing of PDA
2. Ligation of PDA by 3-4 y/o via thoracotomy procedure- nakadapa child

*With decrease Pulmonary Blood Flow

5.) Pulmonary Stenosis- narrowing of valve of pulmonary artery

S &Sx:
1. Typical systolic ejection murmur---d/t congestion at the right side of heart
2. S2 sound widely split
3. ECG- R. ventricular hypertrophy
*Normal: Pulmonary Artery = size with aorta*
6.) Aortic Stenosis – narrowing of valve of aorta

S & Sx:
1. If inactive, sx same with angina-like symptoms
2. Typical murmur
3. Rough systolic sound and thrill
4. ECG- Left ventricular hypertrophy
Cardiac catheterization-
Mgt. For Pulmonary Stenosis & Aortic Stenosis---ECMO>Extra Corporeal Membrane Oxygenation
-a lung & heart machine

22
 - return to activity: 3 wks.
1.) Balloon Stenotomy
2.) Surgery

7. Duplication of Aortic Arch- doubling of arch of aorta causing compression to

trachea & esophagus
S & Sx :
1. Dysphagia
2. Dyspnea
3. left ventricular hypertrophy
Mgt: Close heart surgery
*8. Coartation of Aorta – narrowing of arch of aorta
*Outstanding Sx : Absent Femoral Pulse
BP increased on upper extremities & decreased on lower extremities
ECG – hypertrophy Left ventricle ------EPISTAXIS
Mgt: close heart surgery
Monitor BP on 4 extremities
II. CYANOTIC HEART DEFECTS R to L (6)
*With increase Pulmonary Blood Flow
1. Transportation of Great Arteries (TOGA)
- aorta arising from Rt ventricle, pulmo artery arising form Lt ventricle
- direct from RV to aorta w/o oxygenation
Outstanding Sx: 1. Cyanosis after 1st cry (due no oxygenation)
2. *Polycythemia – increased RBC =compensatory d/t O2 supply=viscous blood
*Complications: Thrombus = Embolus = Stroke
3. ECG – cardiomegaly
4. Cardiac cath – decreased O2 saturation
5. Palliative repair – rash kind procedure
6. Complete repair – mustard repair

2.) Total Anomalous Pulmonary Venous Return

– pulmo vein instead of entering Lt atrium, enters Rt atrium or SVC
Increased pressure on Rt so blood goes to Left
Outstanding Sx: Open Foramen Ovale -------so blood L to R
>Mild to moderate cyanosis
>Polycythemia = thrombus = embolus = stroke
>Asplenia- absent spleen
Mgt: Restructuring of heart

3.) Truncus Arteriousus

- aorta & pulmo artery is arising from 1 single vessel or common trunk with VSD
S & Sx 1. Cyanosis
2. Polycythemia – thrombus = embolus = stroke
Mgt: Heart transplant

4.) Hypoplastic Left Heart Syndrome – a non- functioning Left ventricle

S & Sx:
1. Cyanosis
2. Polycythemia – thrombosis, embolus, stroke
Mgt: Heart Transplant
*With decrease Pulmonary Blood Flow
5.) Tricuspid Atresia – Failure of tricuspid valve to open
S&SX:
1. Open Foramen Ovale-----pressure increase in right so open FO
(R to L shunting – goes to Lt atrium)
2. Cyanosis, Polycythemia
Mgt: Fontan procedure – to open tricuspid valve

6.) Tetralogy Of Fallot (TOF)

23
 P – pulmonary stenosis
V – ventricular SD
O – overriding or dextroposition of aorta
R – Rt ventricular hypertrophy
S &Sx:
1. Rt ventricular hypertrophy
2. High degree of cyanosis
3. Polycythemia
4. Severe dyspnea – squatting position – relief , inhibit venous return, facilitate lung
expansion.
5. Growth retardation – due no O2------ Mental retardation –d/t O2 in brain
6. Tet spell or blue spells- short episodes of hypoxia—blue baby esp. when crying
7. Syncope
8. Clubbing of fingernails – due to chronic tissue hypoxia
9. Boot shaped heart – revealed by x-ray
Mgt:
1. O2 administration after 1 month old—to wait for the complete closure of the ductus arteriosus
2. No valsalva maneuver , fiber diet laxative
3. Morphine – hypoxia , Propanolol – decrease heart spasms
4. Palliative repair – BLT >Blalock taussig procedure
Brock procedure – complete procedure
ACQUIRED HEART DISEASES
1. Rheumatic Heart Disease (RHD)
- inflammation disease ff an infection acquired by group A Beta hemolytic streptococcus
(GABHS)
a. Affected body – cardiac muscles and valves , musculoskeletal , CNS, Integumentary

b. Suspect : Sorethroat before RHD -----candidate babies---eating lots of sweets

c. Aschoff – rounded nodules with nucleated cells & fibroblasts – stays that occludes mitral valve.

d. To Diagnose RHD uses the Jones Criteria

*Jones Criteria*
Major Minor
1. Polyarthritis – multi joint pain 1. Arthralgia – joint pain
2. Chorea – Sydenhamms Chores or St. Vitous Dance 2. Low grade fever
-purposeless involuntary hand and shoulder with grimace
3. Carditis – characterized by tachycardia 3. All Dx Test & Lab results
antibody
4. Erythema marginatum - macular rashes C reactive protein
Erythrocyte sedimentation rate
5. SQ nodules Anti streptolysin O titer (ASO)

*Criteria: Presence of 2 major, or 1 major & 2 minor + history of sore throat will confirm the dx.
Mngt: Supportive only
Nsg Care:
1. CBR , avoid contact sports
2. Throat swab – culture & sensitivity for antibiotic therapy
3. *Antibiotic mgt – to prevent recurrence
4. Aspirin ( ASA therapy)– anti-inflammatory. Low grade fever – don’t give aspirin.

S/E of aspirin: if given to children continuously w/ bacterial infection:

*Reyes syndrome – encephalopathy- fatty infiltration of organs such as liver & brain

2. Respiration
Newborn resp – 30-60 cpm, irregular abd or diaphramatic with short period of apnea w/o cyanosis.

24
 If < 15 secs – normal apnea –newborn , if >15 secs. ---dead already
Resp Check: Newborn – 40 – 90 bpm
1 yr - 20 – 40
2-3yr 20 – 30
5 yrs 20 – 25
10 yrs 17 – 22
15 & above 12- 20

BREATH SOUNDS HEARD DURING ASCULTATION:

Sound Characteristics
1. VESICULAR : Soft, low pitched, heard over periphery of lungs, inspiration longer then expiration -Normal

2. BRONCHOVESICULAR: Soft, medium pitched, heard over major bronchi, inspiration equals exp. Normal

3. BRONCHIAL SOUNDS: Loud high pitched, heard over trachea, expiration longer than inspiration. Normal

4. RHONCHI : Snoring sound made by air moving through mucus in bronchi. Normal
5. RALES: or crackles – like cellophane – made by air moving through fluid in alveoli.
Abnormal- pneumonia, pulmonary edema
6. WHEEZING: Whistling on expiration made by air being pushed through narrowed bronchi Abnormal –
asthma, foreign body obstruction
7. STRIDOR: Crowing or rooster life sound – air being pulled through a constricted larynx. Abnormal –
resp obstruction, inspiratory stridor
8. RESONANCE: Loud, low tone, percussion sound over normal lung tissue
9. HYPERRESONANCE: Louder, lower sound than resonance, a percussion sound over hyperinflated lung tissue
1. Asthma
Pathognomonic Sign: Expiratory wheezing
Pet – fish. Sport – swimming
Drugs – Aminophylline – monitor BP, may lead to hypotension
Allergens: dust
Food allergens: seafood, chocolate,
Climate Changes

2. Respiratory Distress Syndrome (RDS) or Hyaline Membrane

Cause- lack of surfactant – for lung expansion ----------------end stage: Atelectasis
Hypotonia, Post surgery, Common to preterm

Fibrine Hyaline : Sx----definite with in 1st 4 hrs. of life ---d/t lack of surfactant
Tachypnea with retraction -------earliest sign
*Inspiratory Grunting – Pathognomonic Sx
> 7 – 10 severe RDS (Silverman Anderson Index), respiratory acidosis
end stage: Cyanosis d/t atelectasis *Chromolin Sodium---prevents asthmatic attack
before attack administer
> if with asthma attack ----bronchodilator---Aminophylline—monitor BP
Mgt:
1. Surfactant replacement and rescue
2. Pos- head elevated
3. Proper suctioning
4. O2 with increase humidity- to prevent drying of mucosa
5. Monitor V/S skin color , ABG------R.A.

6. *CPAP- continuous (+) a/w pressure

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

3. LaryngoTracheo Bronchitis (LTB)

Pathognomonic Sign: Inspiratory Stridor
LTB – most common Creup -viral infection of larynx, trachea & bronchi
Outstanding Sx : Croupy cough or barking

25
 - Labored respiration
- Respiratory acidosis
- End stage – death
Lab:
1. ABG
2. Neck and throat culture
3. Dx- neck x-ray to rule out epiglotitis
4. CBC- to determine leukocytosis
Nsg Mgt:
1. Bronchodilators
2. Humidified oxygen
3. Prepare tracheostomy set
4. Corticosteroids
4. Broncholitis
Inflammation of bronchioles characterized by production of thick, tenacious mucus
*Causative agent – RSV - Resp sincytial virus
Sx: Flu-like sx
Increased RR---Monitor: Tachypnea of >90 bpm =RDS
Drug: Antiviral – Ribavirin
End stage – epiglotitis

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

3. Skin / Integumentary

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

26
 3 Types of Hemangiomas
a.) Nevus Flammeus – port wine stain – macular purple or dark red lesions seen on face or thigh.
NEVER disappear. Can be removed surgically
b.) Strawberry hemangiomas – nevus vasculosus – dilated capillaries in the entire dermal or
subdermal area. Enlarges, disappears at 10 y/o.
c.) Cavernous hemangiomas – comm. network of venules in SQ tissue that never disappear with age.
MOST DANGERIOUS – intestinal hemorrhage
10. Vernix Caseosa – white cheese like for lubrication, insulator

Skin Color & its significance: Blue – cyanosis or hypoxia Ringworm Infestation:
White – edema Tinea Pedia : foot (athelte’s foot)
Grey – infection Tinea Capites: head
Yellow – jaundice , carotinemia Tinea Cruris: singit
Pale – anemia Tinea Corporalis – body

Representative Problems of the Skin:

1. Burn Trauma – injury to body tissue caused by excessive heat.

INFANT 5-9 y/o
ANTERIOR POSTERIOR Ant Post
Head 9.5 9.5 6.5 6.5
Neck 1 1 1 1
Upper arm 2 2 2 2
Lower arm 1.5 1.5 1.5 1.5
Hand 13 1.25 1.25 1.25
Trunk 13 13
Back 13 13
Genital 1 1
@ buttocks 2.5@ 2.5 @
Thigh 2.75 2.75 4 4
Leg 2.5 2.5 3 3
foot 1.75 1.75 1.75 1.75

DEPTH:
1st degree – Partial thickness – superficial epidermis - erythema, dryness, PAIN
Ex. Sunburn, heals by regeneration from 1 – 10 days
2nd degree – Epidermis & portion of dermis- erythema, blisters, moist, extremely painful
 scalds
3rd degree – Full thickness- All skin layers: epidermis, dermis, adipose tissue, fascia, muscle & bone
 lethargy, white or black, not painful – nerve endings
destroyed
 ex. lava burns

Mgt: Emergency: Prioritization depend on area of burn

*1.) 1st aid a.) Put out flames by rolling child on blanket
b.) Immerse burned part on cold H2o
*c.) Remove burned clothing of with sterile material, if none in the hosp. only
d.) Cover burn with sterile dressing
2.) A/W
a.) Suction PRN, o2 with increased humidity
b.) Endotracheal intubation
c.) Tracheostomy
3.) Prevention of shock & F&E imbalance : Burns: Hyperkalemia—MD will give insulin—
for K to go back to cells
a. colloids to expand blood volume
b. isotonic saline to replace electrolytes
c. dextrose & H2o to provide calories

27
 4.) Tetanus Toxoid Booster
5.) Relief of pain – IV analgesic MORPHINE SO4 – needed for 2nd degree – very painful
6.) 1st defense of body – intact skin
Prevention of Wound infection
i. Cleaning & debriding of wound
ii. Open or close method of wound care
iii. Whirlpool therapy – drum with solution
7.) Skin grafting – 3rd degree – thigh or buttocks (autograft), pigs/ animals – xenograft
frozen cadaver – hallow graft
8.) Diet – increase CHON, increase calories.

2. ATOPIC DERMATITIS - Infantile eczema (hika ng balat) (asthma of the skin)

Papillovesicular erythematus lesions with weeping & crusting
Usual Cause : Food allergies: milk, citrus juice, eggs, tomatoes, wheat
Sx:
> Extreme pruritus---linear excoriation----weeping crusting----- scaly shiny & white to ------
-------Lichenification

Goal of Care: 1. Decrease pruritus – avoid food allergen

2. Diet: Prosobi or Isomil
3. Hydrate skin w/ burrow solution
4. Topical Steroids ---1% hydrocortisone cream
5. Prevent infection – proper hand washing, trim nails/cut short
3. IMPETIGO- skin disease.
Causative agent – Grp. A beta Hemolytic streptococcus (GABHS), possibly staphylococcus
> Papulovesicular surrounded by localized erythema
becomes purulent & oozes a honey colored crust

4. PEDICULOSISCAPITIS –“KUTO”
Mgt: proper hygiene – wash soap and H2o, oral penicillin – bactroban ointment
*Can lead to acute glomerulonephritis AGN ---common to children with this type

5. ACNE- adolescent problem

>Self limiting inflammatory disease – sebaceous gland
*Comedones – sebum causing white heads
*Sebum- lipids of cholesterol causing acne bulgaris
Mgt: Proper hygiene- mild soap or sulfur soap- antibacterial retin A or tretinoi
Liver clearance before using Retin a: C/I to pregnant women
6. ANEMIA -pallor
Causes:
1.) Early cutting of cord – preterm – cut umbilical cord ASAP
Full term – cut umbilical cord when pulsation stops
2.) Bleeding disorders – blood dyscrasias
Ex.
a. Hemophilia – deficiency of clotting factor.
Pattern of Inheritance : X linked recessive
Usual carrier : mother (with X chromosome carrying the disease)
Usually affected children: Son
If mom – carrier, son – affected
If father carrier- transmitted to daughter
3 Types:
Hemophilia A – Deficiency of coagulation component factor 8 (classic/most common)
Hemophilia B –or Christmas disease, deficiency of clotting factor 9
Hemophilia C – deficiency of clotting factor 11

Assessment:
>Omphalagia – earliest sign >30cc in newborn
>Newborn receive maternal clotting factor –reason why late Dx of hemophilia

28
 >Newborn growing – sudden bruising on bump area- marks earliest sign >Continuous
bleeding – Hemarthrosis
>damage or repeated bleeding of synovial membrane

Dx test :
PTT = Partial thromboplastin time – reveals deficiency in clotting factor
*Long Term Goal- prevention of injury

Nsg Dx: Increase risk of injury

HT: avoid contact sport, swimming only, don’t stop immunization – change gauge of needle
Falls –1st splint then immobilized , elevate affected part, apply pressure-not more then 10 min
Of cold compress to prevent necrosis
> Determine case before doing invasive procedure
> No Aspirin
> BT : Fresh frozen plasma or cryoprecipitate
> Long-Term Goal: Prevention of Injury

7. LEUKEMIA - group of malignant disease characterized by

> Rapid proliferation of immature WBCs Ratio: 500 RBC:1 WBC
> WBC – protection from infection, soldiers of body
> Immature WBC takes the nutrients from mature WBC
Classification :
1. Lympho – affects lymphatic system
2. Myelo – affects bone marrow
3. Acute / blastic- affects immature cells
4. Chronic/ cystic- affects mature cells
Most common cancer = (ALL) Acute Lymphocytic Leukemia
*Main cause of Anemia: Failure of bone marrow to produce RBC
S & Sx: TRIAD
1. From invasion of bone marrow
Signs of Infection: a. Fever
b. Poor wound healing
c. Bone weakness & causes fracture
Signs of Bleeding :
a.) Petecchiae-small, round, flat, dark red spot
b.) Epistaxis
c.) Blood in urine & emesis
Signs of Anemia :
a.) Pallor , body malaise , constipation
2. From invasion of body organ:
a. Hepatosplenomegaly
b. Abdominal pain
c. CNS affectation & increase ICP
Dx Tests:
1. PBS- peripheral blood smear – determine immature WBC
2. CBC – determine anemia, leukocytosis, thrombocytopenia neutropenia
>done weekly during maintenance phase of therapy
3. Lumbar puncture (LP) – determine CNS involvement. Before LP, Fetal position
Best: Avoid flexion of neck – will cause a/w obstruction.“C” position or shrimp.
4. Bone marrow aspiration – determine blast cells or immature WBC
> *Common site for BMA = Iliac crest
> Post BMA s/effect – bleeding apply pressure.
Put pt on affected side to prevent hemorrhage
5. Bone scan – determine bone involvement
6. CT scan – determine organ involvement, CNS affectation

Therapeutic Mgt:
TRIAD FOR CANCER:
1. Surgery

29
 2. Irradiation
3. Chemotherapy
Focus Nsg Care: Prevent infection

4 LEVELS OF CHEMOTHERAPHY---Goal of Tx: Achieve remission

1. Induction: every level is 1 session
Meds: IV vincristine
L- agpariginase
Oral prednisone
2. Sanctuary- Treat leukemic cells that invaded testes & CNS
*Give: Methotrixate- adm. intrathecally via CNS or spine
cytocine, Arabinoside, steroids with irradiation

3. Maintenance- to continue remission

Give: Oral Methotrisate – check WBC/ CBC order 1st before administering drug
Adm. of methotrisate – do weekly WBC check

4. Reinduction – treat leukemic cells after relapse occurs. Meds – same as induction

Give antigout agents: allopurinol or Zyloprim- treat or prevent hyperurecemic nephropathy.

Nsg mgt: Outstanding Nsg Dx: 1. High risk for infection

2. Alteration in nutrition less body requirement.
3. Alteration in Body image
4. Anticipatory grieving for family & parents
Based on Maslow’s hierarchy
S/E of Chemotherapy
1. N/V – adm anti-emetic drugs 30 mins before chemo until 1 day after chemo
2. Ulcerations / stomatitis / abscess of oral mucosa: Nsng. Dx: Altered oral mucus membrane
> Oral care – alcohol free mouthwash , betadine mouthwash
> Don’t brush – use cotton pledgets
> Topical xylocaine before meals
> Diet- soft, bland diet according to child’s preference

Temporary S/E of Chemo:

Alopecia – altered body image
Hirsutism – abnormal growth of hair to other body parts
-give emotional support to parents, always repeat instructions
Irradiation Management:
3 principles: 1. Time
2. Distance
3. Shielding
> with visitors but not more than 10

New Management: Chemotherapy or Bone Marrow Transplant

8. Hemolytic Disorders: Hemolysis = destruction of RBC

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

Erythroblastosis Fetalis = hemolysis or destruction of RBC d/t O2 carrying capacity

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

30
 b. ABO Incompatibility
Most common incompatibility – ( mom) O – ( fetus) A
Most severe incompatibility (Mom) O– (Fetus) B
Assessment: Can affect 1st pregnancy
RBC - 20 days lifespan
O = universal donor
AB = universal recipient

Dx: Coomb’s Test

Indirect: mother ----- normal result is (-)
Direct : from baby---normal result is initially (-)
Drug Of Choice: Rhogam Vaccine given to mothers (-) w/in 72 hrs. post-exposure to fetal RBC’s to
destroy fetal RBC’s, then preventing Rh sensitization or antibody formation
> given only w/in 72 hrs. once only 1st pregnancy

9. Hydrops (h20) Fetalis – edematous on lethal state with pathologic jaundice

Within 24 h
Mgt. for both:
1. Initiate feeding
2. Temporary suspension of breastfeeding to prevent kernicterus
>content breast milk pregnanedioles – that delays action of glucoronyl
transferase—a liver enzymes that converts indirect bilirubin to become direct
bilirubin
3. Needs phototherapy
4. Needs exchange therapy

10. Hyperbilirubinemia - > 12 mg/dL of indirect bilirubin among full term *Normal Value: 0-3 mg/dL
- bilirubin encephalopathy
11. Kernicterus - > 20 mg/dL among full term & >12 mg /dl of indirect for pre-term----lead to cerebral palsy

*Physiologic Jaundice –(Icterus Neonatorum) jaundice within 48 -72 h (2-3 days)------ NORMAL
-- just expose to morning sunlight

*Pathologic Jaundice – (Icterus Gravis) jaundice w/n 24h or Jaundice during delivery
d/t small Rh/edematous ABO
*Breastfeeding Jaundice—caused by pregnanediole (6-7th day)

Pathophysiology: ------------------- Destroyed RBCs

releases

Heme Globin
brokendown
Iron Protoporphyrin
(removed in the body) broken down
(not involved in jaundice)
Indirect Bilirubin (fat-soluble converted by kidney)

Converted by Glucoronyl Transferase (liver enzyme)

Direct Bilirubin (water-soluble)

Assessment of Jaundice :
*1. Blanching neonates forehead, nose or sternum (use 2 thumbs to separate skin folds)
- yellow skin & sclerae
- color of stool – light stool
- color of urine – dark urine

Mgt: Phototherapy or photo oxygenation (Normal HT: 18-20 inch.)

31
Nsg Resp:
1. Cover eyes – prevent retinal damage
2. Cover genitals – prevent Priapism – a painful continuous erection
3. Change position regularly – even exposure to light
4. Increase fluid intake – prone to dehydration
5. Monitor I&O – weigh baby diaper – 1 g= 1cc
6. Monitor V/S – avoid use of oil or lotion due- heat at phototherapy
> Bronze baby syndrome------transient S/E of phototherapy

4. Head
– largest part of baby , ¼ of its length
Normal head : 33-35 cm or 13-14 inches
Size: Anterior Fontanel 1 x 1
Posterior Fontanel 3 x 4

A. Cephalo-caudal Assessment:

Noticeable Structures of the Head:

1. Craniostenosis or Craniosyntosis – premature closing of anterior fontanel

2. Microcephaly – small, slow growing brain d/t alcohol & HIV mom
>5th percentile
3. Anencephaly – absence of cerebral hemisphere

4. Craniotabes – localized softening of cranial bone. Common – 1st born child (normal)
-d/t early lightening (2 weeks prior to EDD)
Rickets’ d/t Vit. B deficiency – soft cranial bone in older children

5. Caput Succedaneum – edema of scalp d/t prolonged pressure at birth

Characteristics:
1. Present at birth
2. Crosses suture lines
3. Disappear after 2-3 days

6. Cephalhematoma- collection of blood due to rapture of periosteal capillaries

Characteristics :
1. Present after 24 hours
2. Never cross suture line
3. Disappear after 4-6 weeks
4. Monitor for developing jaundice

7. Seborrheic Dermatitis – ‘Cradle Cap”

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

2 Types:

32
 1. Communicating – extra ventricular hydrocephalus
2. Non-communicating-
a. Intraventricular hydrocephalus
b. Obstructive hydrocephalus d/t tumor obstruction

Nsg. Dx: High Risk For Injury

Dx For Seizure Activity : EEG

Sx:
a. Abnormally large head, bulging fontanel –Earliest Sx of ICP
b. Cushing’s Triad----- Hyper, bradypnea,bradycardia
c. High pitched cry
d. For older children & >6 months
– Diplopia – eye deviation, projectile vomiting---earliest sx
e. Fontanel bossing – prominent forehead
f. Prominent skull vein
g. Sunset eyes

Mgt:
a. Position to lessen ICP – low semi-fowlers 20-30 degree angle
b. Administer- osmotic diuretic Mannitol/ Osmitrol , Diamex- Azetam
c. Decrease CSF production ----drug: acetazolamide or Diamox
d. Shunting – AV shunt or Vp shunt (ventriculoperitoneal shunt)
Shave hair – in OR – to prevent growth of micro org.
e. Hyperventilate child

Nsg Care:
1.) Post VP shunt –position: immediately after---supine then after anesthesia
--- side lying on non operated site
- to prevent increase ICP
Monitor for good drainage in catheter: good sign is a sunken fontanel
if bulging fontanel – blocked shunt
Catheter change as child is growing

5. Senses

A. Assessment of Eyes:

1. Check for symmetry

2. Sclera – normal color – light blue then become dirty white
3. Pupil – round- adult size
4. Cornea – round & adult size

* If large – Congenital Glaucoma

NOTE FOR:

*Coloboma- part of iris is missing (notching)

Sign: Key hole pupil

*Brushfields Spots -----iris black with white spots

*Congenital Cataract-----Whiteness & Opacity of lens

33
 COMMON TESTS

Age Common Tests

1. Newborn *DOLL’S EYES TEST------ Test for blindness

= Done on the 10th day
General Appearance: = Pupil go to opposite direction when head is moved
 Can only see 10-12 inches
 Visual Acuity 20 /200 to 20/ 800 *GLOBELLAR’S TEST -------Test for Blink Reflex.
= Points near nose & the baby should blink

Infant & Children * Test the ability to follow object past midline

2. 3 years old to School Age *ALLEN CARDS -----------Test for Visual Acuity
= Show common pictures 20 ft away

*ISHIHARAS PLATES = Test for Color Blindness

3. Preschool *E CHART ------ Test for Stereopsi of depth perception

* COVER TESTING TEST ----- Test for Strabismus

= Cover 1 eye for 10- 15 minutes. Then remove.
Note For:
ESOTROPIA = inward movement of eye ball
EXOTROPIA = outward movement of eye

4. School Age To Adult * SNELLENS TEST ------- Test for normal vision
* E CHART

DISEASES:

1. RETINOBLASTOMA = Malignant tumor of the retina

Outstanding Sign: Cat’s Eye Reflex – the whitish glow of pupil

- With red painful eye
- Can lead to blindness
Mgt.
a. Surgery: Enucliation – the removal of the eyeball & replacement of artificial aye

B. Assessment of the NOSE (Sense Of Smell)

 Normal color of nasal membrane: Pinkish

1. Check for presence of creases & pale color of nasal membrane

 Indicative of Chronic Rhinitis
2. Check if inflamed & reddened
 Indicative of infection

3. Check for Flaring of Alenase

 A case of RDS
4. Check for Cyanosis at rest
 Indicative of CHOANAL ATRESIA = The posterior nares obstructed with bone or membrane

Sx:
a. Resistance during catheter insertion in suctioning
b. Emergency---- Surgery within 24 hrs
5. Check for sense of smell = Blindfold the child & let him common foods

34
 5.Check for presence of hair in nose: Cilia
 Adolescent with no hair with ulceration of nasal mucosa: Cocaine user
NOTE FOR:

a. EPISTAXIS or Nosebleed
N.I:
Position: Sit upright, head slightly forward to facilitate drainage & prevent aspiration
Put Cold compress & apply gentle pressure
Give Epinephrine

*Most developed sense of newborn – SENSE OF TOUCH

The way the baby can identify the mother

C. Assessment of the Ears: (Sense of hearing)

*1st sense to develop & last to disappear – HEARING

* Normal Color of the Tympanic Membrane : Pearly Gray

1. Check for symmetry

 If ears not properly aligned with the outer cantus of eyes or low set ears: Suspect

A. KIDNEY MALFORMATION:

1. RENAL AGINESIS = the absence of kidney

2 Types: a. Unilateral = only 1 is present

b. Bilateral = absence of 2 kidneys

Sign in uterus : Oligohydramnios

Sign in newborn: 2 vessel cord

Sx: Failure to void within 24 hrs

Mgt: Kidney Transplant

2. PRUNE BELLY SYNDROME

The newborn has a wrinkled abdomen that looks like a prune d/t abdomen swelled with
fluid in the womb, then lost that fluid after birth, leading to puckering of excess skin.

B. CHROMOSOMAL ABERRATIONS:

Cause: Advance maternal age >35 y/o

1.NONDISJUNCTION = Uneven division of chromosome

a. TRISOMY 21 or “DOWN SYNDROME”

= Extra #21 chromosome
= Related to advance paternal age: 47xx + 21
Sx:
Low set ears
Mongolian slant
Broad, flat nose
Epicanthal Fold = extra fold of eyelids
Brushfield’s Spot = black & white specks in the iris
Pectum Excavatum = sunken sternum
Puppy’s neck

35
 Hypotonic = muscle tone prone to URTI
Simian crease = a single transverse line on palm.
Alert:
Always check PR for tachycardia d/t hypotonia
Check for respiration
Check for mental retardation----educable
b. TRISOMY 18 or “ENDVARD SYNDROME”

- Affecting more girls than three times as boys.

- Caused by the presence of an extra number 18 chromosome
Sx:
Pecan Carinatum (protruding sternum)
Small Jaw (micrognathia)
Hypoplastic (underdeveloped) fingernails

c. TRISOMY 13 “ PATAU SYNDROME”

- Associated w/ multiple abnormalities, including defects of the brain

that lead to seizures, apnea, deafness, and eye abnormalities.
Sx:
Coloboma
Cleft lip & cleft palate
Low set ears

d. TURNER’S “Monosomy X Syndrome/Bonnevie-Ullrich Syndrome”

- Occurs only in females
- The girl's cells are missing an X chromosome, or part of an X
chromosome. Sx evident during puberty
Sx:
Short height
Lack of developing ovaries
Sterile

e. KLINEFELTER’S SYNDROME

- 47XXY or XXY syndrome is a condition caused by a chromosome

nondisjunction in males; affected individuals have a pair of X sex
chromosomes instead of just one
- Has male genitalia
- No deepening of voice
- Small testes, penis -sterile

*Klinefelter – Calvin Kline – male *Turner – Tina Turner – female

2. DELETION ABNORMALITIES = deletion of the genes on chromosomes

a. CRI-DU-CHAT SYNDROME or “Chromosome 5p deletion syndrome”

- Results from a missing piece of chromosome # 5.

Sx:
Severe mental retardation – outstanding sx
Wide-set eyes (hypertelorism)
Downward slant of the eyes (palpebral fissures)
All other sx of down syndrome

b. FRAGILE X SYNDROME or “Marker X Syndrome”

36
 - Changes in the long arm of the X chromosome
- Most common cause of inherited mental retardation in males
- A fragile area on the X chromosome (called FMR1) has repeats in
the genetic code. The more repeats, the more likely there is to be a
problem. Boys and girls can both be affected, but because boys have
only one X chromosome, a single fragile X is likely to affect them
more severely.

Sx: Same with other chromosomal abnormalities

3. TRANSLOCATION ABNORMALITIES
- Abnormalities in chromosome structure follow a chromosome break
& during the repair process, the reunion of the wrong segments of the
chromosome.
- Involves two nonhomologous chromosomes (e.g., chromosome 2 and
chromosome 6). Following a break in each of the chromosomes & subsequent
reunion, a segment of chromosome 2 becomes attached to chromosome 6 and
vice versa.

a. BALANCED TRANSLOCATION CARRIER

- When there is no loss or gain of chromosomal material & the individual is

mentally & physically normal. However, there is an increased risk of having
chromosomally abnormal offspring because individuals who carry balanced
chromosome rearrangements may produce chromosomally unbalanced gametes.

b. UNBALANCED TRANSLOCATION SYNDROME

- Happens if following repair, there is a loss or gain of chromosomal

material . There are significant clinical consequences for this type.

4. Others

a. MOSAICISM
– a situation where the nondisjunction of chromosomes occurs during the
mitotic cell division after fertilization results to diff. cells contains different #
of chromosomes.
- Where an individual has two or more cell populations that differ in genetic
makeup. This situation can affect any type of cell, including blood cells,
gametes (egg and sperm cells) & skin.

b. ISOCHROMOSOMES
– a situation w/in the chromosomes instead of dividing vertically it divides
horizontally

NOTE FOR:

*OTITIS MEDIA
= Inflammation of middle ear
Common to children d/t wider & shorter Eustachian tube

Causes :
1. Bottle propping w/c may also lead to dental carries
2. Cleft lip/ cleft palate

37
 Sx: During Otoscopic Exam:
Bulging tympanic membrane
Absence of light reflex
Observe for passage of milky, purulent foul smelling odor discharge
Observe for URTI

Nsg Care:
1. Position: Side-lying on affected aside – to facilitate drainage
2. Supportive Care- Bed rest, increase fluid intake

Med Mgt:
1. Massive dosage antibiotic to prevent complication of Bacterial Meningitis
2. Apply ear ointment
3. Mucolytics
How? School age : Pull pinna up & down
< 3 y/o = down & back
> 3 y/o = up & back
Small child = down & back ( no age)
4. Surgery :
Myringotomy w/ Tympanostomy Tube Insertion:
Prevents permanent hearing loss

Nsg. Care:
Post surgery: Position on affected side for drainage
When taking a bath put ear plugs on both ears
If tympanous tube falls – healed already- usually 6 months

D. Assessment of the Mouth & Tongue

1. Check for Symmetry

NOTE FOR:

a. BELL’S PALSY:
- Facial nerve injury to the Cranial Nerve #7 w/c causes paralysis d/t forcep delivery

Sx:
1. Continuous drooling of saliva

*Drooling Indicates 2 disorder: Bell’s Palsy & TEF/TEA

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

Mgt: Refer to PT

b. TRACHEOESOPHAGEAL FISTULA/ATRESIA ( TEF /TEA)

- TEF – there is a thin connection bet. the esophagus & stomach

- TEA – there is no connection bet. the esophagus & stomach

Outstanding Sx: 4 C’s

C
Coughing
Choking
Continuous drooling
Cyanosis

38
 Mgt: Emergency surgery

c. EPSTEIN PEARL :
- White glistering cyst at palate & gums r/t hypercalcemia ( 1-2 small shiny mass)

d. NATAL TOOTH
- Tooth at birth d/t Hypervitaminosis of mother during pregnancy
- If movable remove with a clean gauze

f. NEONATAL TOOTH
- Appearance of temporary teeth w/n the 28 days of life instead of 6 months

* ANODONTIA – No eruption of temporary teeth even at 5 y/o

g. ORAL MONILIASIS or ORAL THRUSH “Oral Candidiasis”

- White cheese-like substances & curd like patches that coats tongue
CA: Candida Albicans
Nsg Care:
Do not remove, wash mouth with cold boiled water
Administer meds: Nystatin / Mycostatin: Antifungal
g. *KAWASAKI DISEASE or “Mucocutaneous Lymphnode Syndrome”

- A Strawberry tongue, originated in Korea

- Dr. Kawasaki discovered it
- Common in Japan

Criteria For Diagnosis Of Kawasaki Disease

1. Fever lasting more than 5 days

2. Bilateral Conjunctivitis
3. Changes of lips & oral cavity
- Dry, red fissure of lips
- Strawberry tongue
- Diffuse erythema of hands & feet

4. Changes of Peripheral Extremities

- Erythema of the hands & soles
- Indurative edema of the hands & feet
- Membranous desquamation from fingertips
5. Polymorphous rash
6. Acute nonpurulent swelling of cervical lymph node to > 1.5 cm in diameter

Complication: Myocardial Infarction in Children ( only MI in children)

Mgt: Administer Drug: Aspirin

Gamma Globulin

E. Assessment of the Lips

1. Check for symmetry

NOTE FOR:

a. *CLEFT LIP
- Failure of median maxillary nasal processes to fuse by 5-8 wks of pregnancy
- Common to boys
- Unilateral

39
b. *CLEFT PALATE
- Failed palate to fuse by 9 – 12 wks of pregnancy
- Common to girls
- Unilateral or bilateral
Sx:
1. Evident at birth
2. Milk escapes to nostril during feeding
3. Frequent colic & otitis media or URTI
Nsg Care:
1. Provide soft & large nipples---cross cut +
2. Burp baby often
Mgt:
1. Surgery : Depends on the Rule of 10
10 wks. Old
10 grams HgB
10 lbs. weight

a. Cleft Lip Repair = Cheiloplasty

- Done 1-3 months to save sucking reflex (lost in 6 months )
b. Cleft Palate Repair = Uranoplasty
- Done 4-6 months to save speech
Pre- Operative Care:

1. Provide emotional support especially to mom

2. Provide Proper nutrition to prevent colic
Feeding : Upright seating position
Burp frequently :
2x at middle & after feeding in a prone position& in a lower to upper tap

3. Orient parents to type of feeding

Rubber tipped syringe = Post-cheiloplasty
Paper cup/ soup spoon/ plastic cup = Post-uranoplasty

4. Apply restraints; Elbow restraints pre-opt so baby can adjust post op & decrease movement
5. 7-8 years after: Velopharyngeal Flap Operation: To fix nostril & pharynx

 ALL Operation for mouth (adenoidectomy, tonsillectomy):

MOST IMPORTANT DIAGNOSTIC TEST TO CHECK: CLOTTING TIME

 Condition that warrants suspension of operation:

COLDS & PHARYNGITIS = can lead to generalized infection TO SEPTICEMIA

Post Operative Nsg Care:

1. Airway:
Position post-cheilopasty : Side lying to facilitate drainage
Post-uranoplasty (tonsillectomy): Prone position to increase mucus secretion
Avoid using straw,spoon,fork

2. Assess for RDS & signs of bleeding

3. Assess for bleeding: Frequent swallowing 6-7 days after surgery indicates bleeding
4. Proper nutrition
Post-NPO: Children- offer first sterile water before clear liquid
Clear liquids: Gelatin except red or brown color it may mask bleeding
(Popsicle- not ice cream)
Full liquid
Soft diet

40
 Regular diet

5. Maintain integrity of suture line such as:

Logan bar – wash ½ strength Hydrogen Peroxide & saline solution:
Bubbling effect traps microorganism
Prevent crusting & scarring by putting sterile gauze + NSS
- Prevent baby form crying give analgesic for pain

6. Assessment of the Neck

1. Check for symmetry

NOTE FOR:

a. CONGENITAL TORTICOLIS or “ Wryneck”

- Congenital shortening or Birth injury of sternocleidomastoid muscle during

delivery d/t excessive traction at cephalic delivery
Mgt:
Daily passive stretching exercise
Surgery
Complication : Scoliosis

2. Check the thyroid gland – for basal metabolism

b. CONGENITAL CRETINISM

- Absence or non functioning thyroid glands or Hypothyroidism

Reasons for Delayed Dx:

1. Thyroid glands covered by sternocleidomastoid muscles in newborn

2. Baby received maternal thyroxin
3. Baby sleeps 16 – 20 hrs a day

Earliest Sign:
1. Change in Sucking -1st
2. Change in Crying – 2nd –decrease sound
3. Sleep excessively
4. Constipation d/t decrease peristalsis
5. Edema – moon face
Late Sign:
1. Mental Retardation
Prognosis: Mental retardation preventable when Dx is early
New Born Screening: it is included in the 6 diseases to be tested
Dx:
1. PBI- Protein Bound Iodine
2. RIA - Radioimmunoassay Test
3. Radioactive Iodine Uptake

Mgt:
Synthroid (Sodium Levothyrosin) = Synthetic thyroid given lifetime
Check PR before giving synthroid
Tachycardia = Sx of Hyperthyroidism

7. Assessment of the Chest

41
 1. Check for Symmetry

NOTE FOR:

a. WITCH MILK
- Transparent fluid coming out from newborn r/t hormonal changes

b. Respiratory Distress Syndrome (RDS)

- Retroactive chest

c. PECTUS EXCAVATUM
- Sunken Sternum

d. BRONCHCOLITIS
- Distention of the alveoli
- Viral in origin
Sx:
- Respiratory Distress
- Increase RR > 60/minute
- Wheezing: high-pitch on expiration

8. Assessment of the Abdomen

1. Assess in order:

a. Inspection I
b. Auscultation A
c. Percussion P
d. Palpation P =Last to perform because it will change bowel sounds

*Normal contour of the abdomen = Slightly protruding

NOTE FOR:

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

Sx:
1. Sunken abdomen
2. Signs of RDS
3. R to L shunting

Mgt:
1. Emergency surgery within 24h
Diaphragmatic Repair w/ the use of Teflon Patch while place on
(ECMO) Extra Corporal Membrane Oxygenation
2. Continuous CPAP & CPPB

b. OMPHALOCELE
– Protrusion of stomach contents in bet. junction of abdominal wall & umbilicus.

Mgt:
Very small surgery – return the stomach contents
If large: Suspension surgery - Let the baby grow more to accommodate the
stomach content
Nsg Mgt:
1. Protect the sac with sterile wet dressing
2. Apply silver sulfadiazine ointment to prevent infection

42
 c. GASTROCHISIS
- Absence of the abdominal wall exposing all the stomach contents
Nsg Mgt:
1. Provide sterile wet dressing

2. FUNCTION OF THE GIT

a. Assists in maintaining F&E & acid base balance

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

Newborn: Gastric Capacity – 1-2 oz

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

3. RECOMMENDED DAILY ALLOWANCE

Calories : 120 cal / Kbw/day or 360 – 380 cal/ day

CHON = 2.2g /Kbw/day
Fluids = 16-20 cc/kg/day
4. PRINCIPLES IN SUPPLEMENTARY FEEDING

*Supplementary Feeding usually at 6 months

*Supplementary feeding can be given as early as 4 months
*Weaning starts at 6-9 months or when shortening the nursing time
*Never wean a child when in crisis

a.) Solid food offered to baby in the ff. sequence!

1st - Cereals – rich in iron—Reserves is catabolized already by 6 months

2nd - Fruits
3rd - Vegetables
4th - Meat
b.) Begin with small quantities
c.) Finger foods – offered 6 months
d.) Soft table food – “modified family menu” given by 1 year
e.) Dilute fruit juices & offered by 6 months
Ratio of fruits to water 1:4 (1 squeeze orange = 1 ounce)
f.) Never give half cooked eggs – usually causes of Salmonellosis/Gastroenteritis
g.) Don’t give honey may cause Infant Botulism
h.) Offer new food one at a time – interval of 4 – 7days or 1 week
To determine food allergens

43
5. MAJOR CONCEPTS OF FLUID & ELECTROLYTE BALANCE

Total Body Fluids: Comprises 65 - 85% of body wt of infants & children

Where fluids are greater in infants: ECF – reason why babies prone to develop dehydration

6. ACID BASE BALANCE

Dependent on the ff:

a. Chemical buffers
b. Renal & Respiratory system involvement
c. Dilution of strong acids & bases in blood
IMBALANCE:

a. RESPIRATORY ACIDOSIS = Carbonic acid excess

Causes:
Hypoventilation
RDS
COPD
Laryngotracheobronchitis (LTB)

b. RESPIRATORY ALKALOSIS = Carbonic acid deficit

Causes:
Hyperventilation
Fever
Encephalopathy

c. METABOLIC ACIDOSIS = Base HCO3 deficit

Causes:
Diarrhea
Severe dehydration
Malnutrition
Celiac crisis

d. METABOLIC ALKALOSIS = Base HCO3 excess

Alkalosis Up
Causes:
Uncontrolled vomiting Acidosis Down
NGT aspiration
Gastric lavage
7. CONDITIONS THAT PRODUCES F & E IMBALANCE

a. VOMITING = Forceful expulsion of stomach content

Sx:
1. Nausea
2. Dizziness
3. Facial flushing
4. Abdominal cramping
Assessment:
Amount, Frequent & force
Projectile Vomiting – Indicates Increase ICP or Pyloric Stenosis
Mgt: BRAT DIET

B – banana
R – rice
A- apple sauce
T- toast

44
 b. DIARRHEA – Exaggerated excretion of intestinal contents

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

CA: Bacteria (salmonella, shigella)

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

2. CHRONIC-NON SPECIFIC DIARRHEA/NON-INFECTIOUS

Cause:
a. Food intolerance
b. Excessive fluid intake
c. CHO, CHON malabsorption (abnormality)
d. Allergy
e. Irritable colon
Assessment:
Frequency, Consistency, Appearance of green colored stool
*Best criteria to determine diarrhea : Consistency
Complication:
1. DEHYDRATION
Mild dehydration 5% wt loss
Moderate dehydration 10% wt loss
Severe dehydration 15 % wt loss

Signs of Dehydration
Hypotension
Early Signs Tachycardia ---- 1st sign in newborn
Tachypnea
+ Fever

Weight loss -----Best criteria to determine dehydration

Sunken fontanel & eyeballs
Scanty & dark urine
Absence of tears
Poor skin turgor

Severe dehydration:
Marked Oliguria & Prolonged capillary refill time > 3 sec.
Mgt:
1. Acute Diarrhea = NPO (to rest the bowel )
With fluid replacement – IV
Oresol : 1 glass & 1 tsp. of sugar, 1 pinch of salt
Prone to Hypokalemia : Give K chloride
Before administering of K chloride : Check if baby can void
If cannot void = Hyperkalemia
Drug: Na HCO3 : Administer slowly to prevent cardiac overload

8. GASTRIC MOTILITY DISORDER: (Lower GIT Obstruction)

a. HIRSCHPRUNGS DISEASE
- Congenital aganglionic megacolon
- Aganglionic: Absence of ganglion cells needed for peristalsis

45
Earliest Sign in Neonate:
1. Failure/Delayed passage of mecomium after 24h
2. Abdominal distension
3. Vomitus of fecal material ---lead to aspiration----Atelectasis
4. Foul-smelling breath

Signs in Early Childhood:

1. Ribbon like stool
2. Foul smelling stool
3. Constipations
4. Diarrhea

Dx:
1. Barium Enema – Reveals narrowed portion of bowel
2. Rectal Biopsy – Reveals absence of ganglionic cells
3. Abdominal X-ray – Reveals dilated loops on intestine
4. Rectal manometry – Reveals failure of intestine sphincter to relax

Therapeutic Mgt/Nsg care

1. NGT feeding:
Measure tube from nose to ear to midline of xyphoid & umbilicus
2. Surgery
a.) Temporary colostomy
b. Anastomosis & pull through procedure
Pre-opt: Provide Enema everyday
Use NSS: Isotonic ( 1 tsp. sugar + 500 cc of H20)
Not tap water: Hypotonic

Can be absorbed by the cells----Circulatory Overload

3. Diet:
Increase CHON
Increase calories
Decrease residue Ex. Offer pasta, spaghetti, chicken
No corn, raisins ---may lead to aspiration

b. GASTROESOPHAGEAL REFLUX (GER) or CHALASIA

- Presence of stomach contents in the esophagus
Assessment :
1. Chronic vomiting
2. Failure to Thrive Syndrome
2 Types:
a. Organic - d/t abnormality in the body/affected organ
b. Non-organic – d/t abuse
3. Esophageal bleeding manifested by Melena or Hematemesis
Complication:
1. Aspiration pneumonia
2. Esophagitis
3. Inflammation
4. Esophageal cancer (Organic type)
Dx Procedure:
1. Barium Esophogram – reveals reflux
2. Esophageal Manometry – reveals lower esophageal sphincter
pressure
3. Intraesophageal pH content – reveals pH of distal esophagus.
Medication For GERD

46
 1. Anti-cholinergic

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

b.) Metachloporomide (Reglam) – To decrease esophageal pressure by relaxing

pyloric & duodenal segments
Increase peristalsis w/o stimulating secretions
c.) H2 Histamine Receptor Antagonist – To decrease gastric acidity & pepsin
secretion
Ex. Zimetidine, Ranitidine (Zantac) – take 30 min before meals

d.) Antacid – To neutralizes gastric acid between feedings. Ex. Maalox

Surgery: Nissen Funduplication

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

Nsg Care: For Chronic vomiting:

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

9. OBSTRUCTIVE DISORDERS

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

Assessment:
1.) Outstanding Sx: Projectile vomiting d/t pressure from narrowed pylorus

Nursing Alerts:

a. Vomiting is an Initial Sign of Upper GI obstruction

b. Vomitus of upper GI can be blood tinged not bile streaked. (with blood)
c. Vomitus of lower GI is bilous ( with pupu)
d. Projectile vomiting – increase ICP or GI obstruction
e. Abdominal distension – Major Sign of Lower GIT Obstruction

2.) Metabolic Alkalosis

3.) Failure to gain weight
4.) Olive shaped mass – On palpation (almond-shaped mass)
5.) Peristaltic wave visible from L to R across epigastrum
6.) Always hungry, irritable

Dx:
1. Ultrasound
2. X-ray of upper abdomen with barium swallow reveals a “STRING SIGN”
Mgt:
1. Pyloromyotomy - incision of the pyloric muscle
2. Fredret-Ramstedt Procedure – separation of hypertrophied muscle w/o incision

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

47
 Pre-Opt: Thickened feedings (regular formula + Cereal)
Post-Opt: Monitor feedings (Clear liquid 24 hrs.)
(Diluted Formula)

b. INSTUSSUSCEPTION

- Invagination or telescoping of position of bowel to another

- Common Site: Ilio-Cecal junction (Junction bet. the small intestine)
Cecum is bigger than the ileum
- Not congenital

Prone People: Person who eats too fast

Too much activities involving the movement of the stomach

Complication: Invagination

O2 supply

Necrosis

Swelling-----burst -------Peritonitis: An emergency

Sx:
1.) Persistent paroxysmal abdominal pain
2.) Vomiting
3.) Currant Jelly Stool: d/t bleeding & inflammation
4.) Palpable sausage shaped mass
Dx:
1.) X-ray with Barium Enema – reveals “Staircase Sign” (coiled spring)
Mgt:
1.) Hydrostatic Reduction with barium enema
2.) Anastomosis & pull thru procedure

10. INBORN ERRORS OF METABOLISM

- Due to deficient liver enzymes

a. PHENYLKETONURIA (PKU)

- Genetic disorder that is characterized by an inability of the body to utilize the

essential amino acid, phenylalanine d/t deficiency of liver enzymes (PHT)
Phenylalaninehydroxylase Transferase :
The liver enzyme that converts Phenylalanine to tyroxine or CHON to amino acid

9 Amino Acids:
1. Valine
2. Isolensine
3. Tryptophase
4. Lysine
5. Phenylalanine
6. Thyronine: Decrease melanin production
Sx:
a. Fair complexion
b. Blond hair
c. Blue eyes
7. Thyroxin: – decrease basal metabolism
-Accumulation of Phenyl Pyruvic acid leads to:
a. Atopic dermatitis
b. Musty / mousy odor urine

48
 c. Seizure: Mental retardation
Dx:
1. GUTHRIE TEST: Use blood as specimen
Preparation: Increase CHON intake
- Test if CHON will convert to amino acid
2. Specimen urine mixed with pheric chloride
- Presence of green spots at diaper a sign of PKU
Nsg Care:
1. DIET:
Low phenylalanine diet:
Food C/I : Meats, chicken, milk, legumes, cheese, peanuts
Give Lofenalac: Milk with synthetic protein

b. GALACTOSEMIA
- Deficiency of liver enzyme GUPT: Galactose Urovil Phosphatetranferase
Converts galactose to phosphate tranferase glucose
Galactose will destroy brain cells if untreated – death within 3 days

Dx:
1. Beutler Test = Get blood after 1st feeding
Presence of glucose in blood: Sign of galactosemia
Nsg Care:
1. Diet: Galactose free diet for lifetime
2. Give Neutramigen : Milk formula

c. CELIAC DISEASE
- Gluten enteropathy

Assessment:
Early Sx:
a. Diarrhea: Failure to gain weight following diarrheal episodes
b. Constipation
c. Vomiting
d. Abdominal Pain: Protuberant abdomen even if with muscle wasting
e. Steatorrhea
Late Sx:
1. Behavioral changes: Irritability & Apathy
2. Muscle wasting & loss of subcutaneous fats

Celiac Crisis: Exaggerated vomiting with bowel inflammation

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

49
PATHOPHYSIOLOGY:

Gluten – Glutamine (Normal Absorption)

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

Malabsorption

Fats CHON & CHO Vit. D /Calcium Vit. K Iron folic acid
peripheral edema &
malnutrition

Inadequate blood
coagulation

Steatorrhea Osteomalasia Bleeding Anemia

11. POISONING
- Common in Toddlers: Poisoning
- Common to Infants: Suffocation & falls

Principles :

1. Determine the substance taken & Assess LOC

2. Unless poison is corrosive, caustic (strong alkali such as lye) or a hydrocarbon, INDUCE
VOMITING is the most effective way to remove poison.
3. Give SYRUP OF PECAC: oral emetic to cause vomiting after drug overdose/poisoning
15 ml : Adolescent, school age & pre school
10 ml to infant
4. UNIVERSAL ANTIDOTE: Charcoal, Milk Of Magnesia & Burned Toast
5. Never administer the charcoal before syrup of pecac
6. Antidote for Acetaminophen Poisoning: N – Acetylcyctein (Mucomyst)
7. For Caustic poisoning like Muriatic Acid:
Give vinegar to neutralize acid . Don’t vomit prepare tracheostomy set
8. For Gas poisoning :
Give mineral oil to coat the intestine & prevent absorption of gas---go to stool

a. LEAD POSIONING

Physiology: Accumulation Lead

Destroy RBC functioning

Hypochronic Microcytic Anemia

Destroy kidney functioning

50
 Accumulation of Ammonia

Encephalopathy
Sx:
1. Beginning symptoms of lethargy
2. Impulsiveness & Learning difficulties
3. As Lead increases, severe encephalopathy with seizure & permanent mental retardation
Dx:
1. Blood smear
2. Abdominal X-ray
3. Long bones
Mgt:
1. Remove child from the source
2. If lead is > 20 ug/dL: Need Chelation Therapy : Binds with lead & excreted by kidney
Ex. BAL (Dimercaprol)
Ca EDTA ( Edetate Ca Disodium)
A chelating agent must be administered in a large muscle group VIA DEEP IM
Check urine specific gravity (Normal: 1.003-1.030)
S/E: Nephrotoxic
N.I: Warm compress post-chelation to relieve pain

9. Assessment of the Reproductive Organ

NOTE FOR:

a. ANOGENITAL

1. Female:

a. PSEUDOMENSTRUATION:
- Slight bleeding on vagina R/T hormonal changes

b. RAPE/CHILD ABUSE or BATTERED CHILD SYNDROME

- Tearing of fourchette with blood
Rape: Report within 48 h to brgy. Captain
R.A. 7610 – CHILD ABUSE LAW
- Non-accidental injury

Characteristics of Abusive Parents:

1. Experience of childhood abuse
2. Too concerned, too many questions
Sx:
1. Wound in different stages of healing
2. Identical marks of wounds

2. Male:

Assessment:
1. Assess scrotum with warm hands & warm room
2. Baby should pee w/in 24 hrs.
NOTE FOR:

a. UNDESCENDED TESTES or “CRYPTORCHIDISM”

- Common to preterm (descend in 7 months)
Surgery: Orchidopexy
Complication: Sterility

3. Check for the arch of urination

51
 b. EPISPADIAS
- Urinary meatus located dorsal or above glans penis

c. HYPOSPADIAS
- Urinary meauts located ventral or below glans penis
Hypospadias w/ Chordee: Fibrous band causing penis to curb downward
Mgt: Surgery
d. PHIMOSIS = A tight foreskin
Mgt:
Circumcision

e. PARAPHIMOSIS = loosened foreskin

f. BALANITIS = Infection of glands penis d/t smegma

g. TESTICULAR TORSION = Twisted testicle

h. HYDROCEL = Fluid -filled scrotum

Dx:
Transillumination with use of flashlight - glowing sign

i. VARICOCELE = Enlarged vein of epididymis

(Girls = Valvular varicosities)

10. Assessment of the Urinary Tract

NOTE FOR:

a. WILMS TUMOR or NEPHROBLASTOMA

- A neoplasm of the kidneys that typically occurs in children.
- Most common type of kidney tumor
- It is more common among some siblings and twins, which suggests a
possible genetic cause.
Sx:
- Absence of the iris (aniridia)
- Hemihypertrophy (enlargement of one side of the body)
Alert:
- No palpation or percussion----metastasis may occur
Mgt:
- Triad Treatment of Cancer

Renal Disorder Cause Sx Tx NSG CARE

b. NEPHROTIC Infectious 1. Anasarca: General edema 1. Prednisone Focus of Care:

SYNDROME 2. Massive protenuria 2. Diuretic 1. Monitor edema
3. Microscopic or no hematuria (Furosemide) Weigh daily
4. Serum CHON decreased
5. Serum lipid increased 2. Diet:
6. Fatigue
7. Normal to low BP Moderate CHON
Increase K- OJ, beef
broth, banana
Low Na Diet

c. AGN Autoimmune 1. (PPP) Primary Peripheral 1. Anti-HPN 1. Weigh daily

52
 (Acute Grp. A beta- Periobital Edema drug 2. Monitor :
Glomerulonephritis) hemolytic 2. Moderate protenuria (Hydralazine or BP
streptococcus 3. Gross Hematuria Apresoline) V/S
3 A’s: Or (Sign: Smokey urine) Neurologic status
GABHS 4. Serum K increased 2. Iron
AGN 5. Fatigue supplements 3. Diet:
Autoimmune, Before: 6. *Increase BP – Outstanding Sx Decrease K
Grp. A Betahemolytic St. Sore Throat Decrease Na
*Impetigo Complication :
1. Hypertensive encephalopathy
If HPN not treated

2. Anemia

11. Assessment of the BACK

1. Check for flatness & symmetry

*Spina Bifida – From L5 to S1

NOTE FOR:

a. OPEN NEURAL TUBE DEFECT

- Decreased Folic Acid intake of mother & those during pregnancy undergoes steam
bath/spa

2 Types:

1. SPINA BIFIDA OCCULTA

- Failure of post laminae of vertebrae to fuse
Sx:
Dimpling of the back
Abnormal tufts of hair

2. SPINA BIFIDA CYSTICA

- Failure of post laminae of vertebrae to fuse with a sac

Types:
1.* MENINGOCELE

- Protrusion of CSF & Meninges

- No alteration in function

2. MYELOMENINGOCELE

- Protrusion of CSF & Meninges & Spinal Cord

- Most dangerous type
- On the back : under illumination shows a half glow

3. ENCEPHALOCELE

- CNS complication : Hydrocephalus--Cranial meningocele or

Myelomeningocele
Most Common Problem :
a. Rupture of sac
b. Prone position
c. Sterile wet dressing

Most Common Complication: Infection

1. For Myelomeningocele : Genitourinary & Fecal Incontinence

53
 2. Orthopedic complication: Paralysis of lower extremities
Sx:
a. Weakness, paralysis of lower extremities
b. Cold to touch
c. Ulceration
d. Absence of spontaneous movement
e. Bladder – dribbling of urine
g. Bowel – no control
Dx:
1. During pregnancy thru MAFEP
Mgt:
Surgery just to prevent infection, will not cure
Pre-opt – Protect the sac, use sterile doughnut ring
Post op – prone position

Nsg Care:
Always check diaper
b. SCOLIOSIS
- Lateral curvature of the spine
- Common to adolescence

2 Types:
1. Structural – d/t Wry neck
2. Postural – d/t improper posture or heavy bags

Sx:
1. Uneven hemline
2. Bend forward & 1 hip higher
3. 1 shoulder blade more prominent than the other

Nsg care:
1. Conservative – Avoid obesity, exercise
2. Preventive – Milwaukee brace : Worn 23 h a day
3. Corrective surgery – Insert Harrington rod
Post operative- How to move : Log Rolling- move client as 1 unit

12. Assessment of the EXTREMITIES:

1. Assess for the # of digits = 20

NOTE FOR:

a. SYNDACTYLY - Webbing of digits (ginger-like foot)

b. POLYDACTYLY - Extra digits
c. OLIDACTYLY - Lack of digits

d. AMELIA - Total absence of digits

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

2. Assess for movement of extremities

a. ERB-DUCHENNES’ PARALYSIS
- Paralysis of the brachial plexus injury or brachial palsy
- Birth injury d/t breech delivery & excessive lateral traction
Sx:
1. Unable to abduct arms from shoulders/
Rotate arm externally or supinate forearm

54
 2. Absence or asymmetrical Moro reflex
Mgt:
1. Rotate arms from shoulders with elbow flexed
2. Passive ROM exercises

b. CONGENITAL HIP DISLOCATION

- Head of femur is outside the acetabulum

Types:
1. Subluxated : Most common type
2. Dislocated
Sx:
1. Shortening of affected leg
2. Asymmetrical gluteal fold
3. Limited movement – earliest sx
4. (+) Ortolanis sign – abnormal clicking sound during abduction (away)
5. When able to walk – child limps – Late Sx: Trendelenburg Sign

Goal of Mgt:
Facilitate abduction
Mgt.
1. Triple diaper
2. Carry baby astride
3. Frejka splint
4. Pavlik harness
5. Hip Spica Cast

c. TALIPES or “Clubfoot”

Types:

a.) EQUINOS = Plantar flexion (horsefoot)

b.) CALCANEUS = Dorsiflexion: Heel lower that foot/
Anterior portion of foot flexed towards anterior leg
c.) VARUS = Foot turns in
d.) VALGUS = Foot turns out

e.) EQUINOS VARUS = Most common (Combination)

Assessment:
1. Straighten legs & flexing them at midline position
Mgt:
1. Corrective Shoe- Dennis brown shoe, spica cast
2. Cast

13. OTHER TOPICS:

A. CAST

Function of CAST:
1. To immobilize
2. To maintain bone alignment
3. To prevent muscle spasm
Equipments:
1. Stokinette
2. Lead pencil to mark area to be amputated
3. Plaster of Paris

55
 Nsg Care To Patients with CAST:
1. Cold H20 will hasten setting process
2. Hot H20 will slow setting process
3. After cast application :
How to move pt:
-Use open palm not fingers- fingers will cause indention
4. Dry cast with natural air not blower
5. If Cast with bleeding
- Mark with ball pen edge of blood to know if bleeding is on going
6. sign that cast is dry: Resonant sound, cast cold to touch
7. Do petaline: making rough surface of cast smooth
8. Priority check : Neurovascular check:

C - circulation
M - motion
S - sensation

9. Assess for circulation impairment:

B - blueness or coldness
L - lack of peripheral pulses
E - edema not corrected by elevation
P – pain on casted area
T – tingling sensation
B. CRUTCHES

Function:
1. To maintain balance
2. To support the weakened leg

Principles In CRUTCHES:
1. Weight of body on palm!
2. Brachial Pulsing – if weight of body in axilla
3. Do palm exercise- squeeze ball
4. Measure Crutches:
2 inches across bar of axilla
6 inches in front of the big toe
Different Crutch Gaits:

1. Swing Through
2. Swing to
No weight bearing are allowed into lower ext

3. Three point Gait

- wt bearing is allowed in 1 ext

4. Four point gait

5. Two point Gait
- Weight bearing allowed in 2 lower extremities

Other Crutch-Maneuvering Techniques

To sit down:

1. Grasp the crutches at the hand pieces for control

2. Bend forward slightly while assuming a sitting position
3. Place the affected leg forward to prevent weight-bearing and flexion

56
To stand up:

1. Move forward to the edge of the chair with the strong leg slightly under the seat
2. Place both crutches in the hand on the side of the affected extremity
3. Push down on the hand piece while raising the body to a standing position

To Go Down Stairs:

1. Walk forward as far as possible on the step

2. Advance crutches to the lower step. The weaker leg is advanced first and then the stronger
extremity shares the work of raising and lowering the body weight with the patient’s arms.

To Go Up Stairs:

1. Advance the stronger leg first up to the next step.

2. Then advance the crutches and the weaker extremity.
(Strong leg goes up first and comes down last.)
A memory device for the patients is “up with the good, down with the bad.”

C. WALKER
-Provides more support than a cane or crutches

D. CANE
- Used to help pt. walk with greater balance & support & to relieve the pressure on
weight-bearing joints by redistributing the weight.
- The cane is held in the hand opposite to the affected extremity

Methods of Transferring The Patient from the bed to a wheelchair:

I. Weight-bearing transfer from bed to chair. The patient stands up, pivots his back is
opposite the new seat, and sits down.

II. (Left) Non-weight-bearing transfer from chair to bed. (Right) With legs braced.

III. (Left) Non-weight-bearing transfer, combined method. (Right) Non-weight-bearing

transfer, pull-up method

E. TRACTION
- Used to reduce dislocation & immobilize fractures

Principles of TRACTION:

1. The client should be in dorsal or supine position

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

Types:

Straight Traction
Skin Traction
Bryant’s Traction
Buck’s Extension
Skeletal Traction

Nursing Responsibilities:

57
 1. Assess for circulation and neurologic impairment
2. It can lead to hypertension
3. Be careful in carrying out nursing functions by not moving the weights

F. AUTOIMMUNE SYSTEM

Types of Immunity:

a. IMMUNITY AGAINST:
= Diphtheria, Pertussis, Tetanus, Polio & Measles last for 9-12
months in babies

b. PASSIVE NATURAL
- Via placenta, breast milk

c. ACTIVE NATURAL
- Acquired disease & produces memory cells

d. PASSIVE ARTIFICAL
- Receives anti-serum with anti-bodies from host
- Hep. B

e.
ACTIVE ARTIFICIAL
- Receives vaccine & produces memory cells
- All EPI vaccines are active artificial EXCEPT HEP. B
12. NEUROMUSCULAR SYSTEM

Reflexes

A. BLINK REFLEX
- Rapid eyelid closure when strong light is shown

B. PALMAR GRASP REFLEX

- With solid object, baby will grasp object
- Cling to mother for safety
- 6 weeks to 3 months to disappear
C. STEP IN/WALK-IN REFLEX
- Neonate placed on a vertical position with their feet touching a hard
surface will take a few quick, alternating steps.

* PACING REFLEX
– Almost the same with step in place reflex only that you are touching the
anterior surface of a newborn’s leg

D. PLANTAR GRASP REFLEX

– When an object touches the sole of a newborn’s foot at the base of the
toes, the toes grasp in the same manner as the fingers do.

E. TONIC-CLONIC REFLEX

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 – When newborns lie on their backs, their heads usually turn to one side
or the other. The arm on the leg on the side to which the head turns
extend, and the opposite arm and leg contract.

F. MORO REFLEX
– Letter “C” position
- Disappears 4-5 months
- Test for neuro integrity

G. MAGNET REFLEX
– when there is pressure on the sole of the foot he pushes back against
the pressure

H. CROSSED EXTENSION REFLEX

– When the sole of the foot is stimulated by a sharp object, it causes
the foot to rise and the other foot extend

I. TRUNK INCURVATION REFLEX

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

J. LANDAU REFLEX
– While in prone position and the trunk is supported, the baby exhibit
some muscle tone

K. PARACHUTE REACTION
– While on ventral suspension, with the sudden change of
equilibrium, it causes extension of the hand and legs

L. BABINSKI REFLEX
–When the sole of the foot is stimulated by an inverted “J”, it causes
fanning of the toes

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