St. Jude College Dimasalang Dimasalang cor. Don Quijote St. Sampaloc, Manila
Nursing Enhancement Program PEDIATRIC NURSING VI. THE NEW BORN A. CARE OF OF THE NEWBORN NEWBORN IN THE DELIVERY DELIVERY ROOM
5. Maint Maintai ain n paten patentt airwa airway y a. Drai Drain n secr secret etio ions ns Put the baby in a trendelenburg position for drainage except when signs of increase ICP is observed: bulging fontanelles, high-pitched cry (earli (earliest est sign), sign), vomiti vomiting ng (sure (surest st sign) sign),, increas increase e BP, decrea decrease se PR, decrease RR. •
a. Suct Suctio ion n new newbo born rn Suction the mouth first before the nose to prevent aspiration Sunctioning should be gentle to prevent laryngospasm • It should not be more than 1 minute otherwise, it will stimulate vagus nerve causing bradycardia. •
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a. Occlude Occlude one nostril nostril at a time to test test for patency patency since since newborns newborns are nasal nasal breathers b. Observe Observe characteri characteristics stics of respiratio respirations ns
c. Admini Administe sterr oxygen oxygen as needed needed Oxygen Oxygen concen concentra tratio tion n should should be <40% <40% to preven preventt retina retinall scarr scarring ing which may lead to blindness (retrolental fibroplasia). Oxygen is best administered thru a tent •
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5. Keep Keep the the new newbo born rn warm warm The body temperature temperature of the newborn newborn at birth is 37.2 C (99 F). Shortly Shortly • after birth, if falls below normal because of the immature temperatureregulating mechanism and heat loss. In addition, the cold temperature of the delivery room contributes to this. A newborn losses heat thru the following mechanisms: ○ Conduction: heat is transferred to a cooler solid object in contact with the body ○ Convection: heat flows from the body surface to a cool surrounding air Evapor Evaporati ation: on: heat heat los loss s thru thru conver conversio sion n of liquid liquid to vapor vapor (wet (wet ○ skin). ○ Radiation: heat is transferred to a cooler solid object but not in contact with the body •
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Subcutaneous fats to act as insulators. Shivering is also not present at birth birth becaus because e of this, this, they they are prone prone to col cold d stress stress which which may cause cause metabo metabolic lic acidos acidosis is as fatty fatty acids acids acc accumu umulat late e due to the breakdown breakdown of brown fat Dry newborn immediately Wrap in a blanket Place under a radiant warmer or isolette with a temp of 33-34 C. Place under a droplight which should be 12-18” far from the newborn
5. Take Take the the Apga Apgarr sco score re Done at 1 minute after birth to know the conditions of the newborn. Then at 5 minutes after to determine how well the newborn is adjusting to extrauterine life. •
Sign
Score Pediatric Nursing Page 1 of 46
S T J U D E C O L L E G E S T J U D E C O L L E G E
Heart rate Respiratory effort
0 Absent Absent
Muscle tone Reflex irritability Color
Limp flaccid No response Blue, pale
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0-3 0-3 =
Well flexed extremities Cry, withdrawal of foot Completely pink
This This may indi indica cate te sever evere e resp respir irat ator ory y & CNS CNS depr depres essi sion on.. The The baby baby is in serious danger needing immediate resuscitation Condit Condition ion is guar guarded ded & may may need need more more suct suction ioning ing & oxyg oxygena enatio tion n Routin Routine e care care only only,, no specia speciall care care need needed ed
4-6 = 7-10 7-10 =
5. Asse Assess ss ges gesta tati tion onal al age age Clinical criteria for gestational age assessment Finding Sole creases Breast nodule diameter Scalp hair Ear lobe Testes scrotum
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0-36 WKS Anterior transverse only 2 mm
GESTATIONAL AGE 37-38 WKS crease Occa Occasi sion onal al crea crease ses s anterior 2/3 4 mm
Fine & fuzzy Pliable, no cartilage
Fine & fuzzy Some cartilage
Testes in lower canal, small scrotum, few rugae
Intermediate
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39 WKS Sole covered creases 7 mm
7. Cord care are Inspect for the presence of 2 arteries a rteries & 1 vein ○ Absence of 1 artery may indicate kidney problem ○ Absence of umbilical blood vessels may indicate heart and kidney problem •
Assess for possible bleeding Dress the cord with alcohol to hasten drying Keep the cord clean and dry
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5. Admi Admini nist ster er eye eye car care e Crede’s prophylaxis to protect newborn against gonorrheal conjunctivitis acquired from the mother as the infant passes thru the birth canal Dry newborn’s face Open one eye at a time by putting pressure on upper and lower lids Instill 2 drops of 1% silver nitrate into the lower conjunctival sac If erythromycin ointment is used, squeeze a line of ointment along the • lower conjunctival sac from the inner canthus outward. Close eye to allow ointment to spread across conjunctiva. •
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5. Admi Admini nist ster er Vit Vitam amin in K Vitamin K is normally synthesized in the presence of bacterial flora in the inte intest stin ines es.. Sinc Since e newb newbor orn’ n’s s inte intest stin ines es are are stil stilll ster steril ile, e, Vita Vitami min n K is administered administered to facilitate facilitate production production of clotting clotting factor factor thus, thus, preventin preventing g hemorrhage. Vitamin K (1 mg) is injected into the vastus lateralis (IM). This site is • preferred because gluteal muscles of children below 12 months who have not yet learned how to walk are still not fully developed. •
5. Place Place proper proper ident identifi ificat cation ion of newbor newborn n Pediatric Nursing Page 2 of 46
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Coarse & silky Stiffened by thick cartilage Test pendulous, full scro scrotu tum, m, exte extens nsiv ive e rugae
6. Cleanse Cleanse baby with with oil to remove remove blood, blood, mucus mucus,, vernix vernix
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2 >100 Good, strong cry
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1 <100 Slow, irregular Weak cry Some flexion of extremities Grimace Extremities bl blue, body is pink (acrocyanosis)
This should be done before they are removed from the delivery room Take newborn’s footprints
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5. Init Initia iall fee feedi ding ng If to be formula formula fed: give 1 oz sterile sterile water at 4-6 hours. This is a test • feedin feeding g to be certai certain n that that the infant infant can swallo swallow w withou withoutt aspira aspiratio tion. n. Formula milk is given on the 4 th feedin feeding g (rati (rationa onale: le: if formul formula a milk milk is aspirated, this may cause bacterial pneumonia). If to be breast fed: usually 30 minutes after normal delivery, 4 hours after • CS (ratio (rational nale: e: abilit ability y to suck suck and swallow swallow in breas breastt fed infants infants is not signif sig nifica icant nt becaus bec ause e if colost col ostrum rums s is aspira asp irated ted, , it has no effect effect on the S lungs). T J U D E
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5. Circ Circum umci cisi sion on Surgical removal of penis foreskin usually done on the 1 st or 2nd day of life life afte afterr the the baby baby has has synt synthe hesi sized zed enou enough gh Vita Vitami min n K to prev preven entt hemorrhage. Contraindications: hypospadias, epispadias Procedure: ○ Place infant in supine position ○ Restrain the infant ○ Prepare & drape the area around the penis ○ Clamp is fitted over the end of penis, stretching the foreskin taut Prepuc Prepuce e is separated separated from the glans glans & a circle circle of prepu prepuce ce is ○ existed Complications: hemorrhage, infection, urethral fistula formation Nursing responsibilities: ○ Observe closely & check for bleeding ○ Wrap penis with a strip of petroleum gauze to prevent the diaper from adhering from the circumcised area ○ Don’t want away a film of yellowish mucous which often covers the glans.
A.CARE OF THE NEWBORN IN THE NURSERY 5. Check Check ID band band (wris (wristt or ankle) ankle) 6. Take vital statis statistics tics (anthr (anthropome opometric tric measur measuremen ement) t) a. Weight Average birth weight is 6.5 – 7.5 lbs. or 3.0 – 3.4 kg or 3000 – 3400 gm Arbitary lower limit is 2.5 kg or 55 lb or 2500 gm. Below this weight, the newborn is considered low birth weight infant Newborns lose 5-10% of birth weight (6-10 oz) during the first • few days of life (physiologic wt loss) due to: ○ Newb Newbor orn n is no long longer er in the the infl influe uenc nce e of mate matern rnal al hormones ○ Newborn voids & passes stools If breast breast fed, they have limited intake because because colostrum colostrum ○ has low caloric content ○ If bottle fed, sucking is not yet effective Birth weight is doubled by 6 mos, tripled by 1 year, quadrupled by 2 ½ years. •
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a. Length Average length is 19-21.5 inches or 47-53 cm •
a. Head Head circ circum umfe fere renc nce e Normal: 33-35 cm • <32—microcephaly >37—macrocephaly measured with a tape measure drawn across the center of the forehead and the most prominent portion of the posterior head •
a. Ches Chestt cir circu cumf mfer eren ence ce Normal: 31-33 cm • Pediatric Nursing Page 3 of 46
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Measured at the level of the nipples Head circumference >chest circumference till 2 years of age
a. Abdomi Abdominal nal circum circumfer ferenc ence e Normal: 31-33 cm • 5. Take Take vita vitall sign signs s a. Tem Temper peratur ature e At birth, it is 37.2 C & must be maintained at 35.5– 36.5 C Immediately after birth take rectal temp to check patency of anus S T a. Pulse ra rate Immediately after birth, PR is 100-180 J beat beats s per per min minute as the neon neonat ate e U struggles for respiration D Normal PR is 120-140 beats/min E Palpate femoral pulses because absence may suggest possible C coarctation of aorta O Radial pulses are not ordinarily L palpable L E a. Resp Respir irat ator ory y rate rate G Immediately after birth, it may be as E high as 80/min Normal RR is 30-60/min S Observe movement of abdomen T a. Bloo Blood d pre press ssur ure e J Not Not rout routin inel ely y take taken n unle unless ss card cardia iac c U anomaly is suspected D At birth, BP is 80/46 mm Hg E After 10 days, Bp is 100/50 The cuff to be used must not be more C than 2/3 of the length of the upper arm O or thigh L FLUSH METHOD may be used L ○ Apply cuff to an extremity E ○ Elevate extremity & apply elastic bandage on the distal G part of the extremity E ○ Inflate cuff to 200 mmHg ( extremity is pale) ○ Slowly deflate cuff as you observe extremity S ○ As soon as the extremity turns pink, read the manometer T ○ Only 1 reading is obtained which is the average between the diastolic & systolic pressures J ○ Normal: 60 at birth U 75 after 10 days D • •
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Physical exam a. Skin ColorColor- most newbor newborns ns have have a ruddy ruddy complexion due to increased concen concentra tratio tion n of rbc in blood blood vessel vessels s and decrease decrease subcutaneous subcutaneous fats. This fades slightly over the first month Acrocyanosis- extremities are blue and the body is pink. This is normal during the first 2 days of life Pallor- may be due to anemia due to blood loss when cord was cut; few iron stores due to poor maternal nutrition; blood incompatibility; fetal-maternal transfusion. Gray- may indicate infection Jaun Jaundic dicee- yell yellow owin ing g of the the skin skin & scle sclera rae e due due to the the inabil inability ity of the newbor newborn n to conju conjugat gate e biliru bilirubin bin due to immature liver function. •
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Globin (reused by body) Destruction of RBCs Iron (reused by body) Heme Protopporphyrin
Indirect bilirubin (Fat soluble)
S T glucoronyl transferase
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Physiologic jaundice (Icterus Neonatorum) Onset- 2nd or 3rd day Duration- 5-7 days Babi Ba bies es bein being g brea breast st fed have ave lon longer ger dura durati tion on of ○ phys physio iolo logi gic c jaun jaundi dice ce beca becaus use e brea breast st milk milk cont contai ain n preg pregna nand ndio ioll whic which h depr depres esse ses s acti action on of gluc glucor oron onyl yl transferase ○ Management of physiologic jaundice: ○ Morning sunlight will stimulate liver to produce glucoronyl transferase & convert indirect bilirubin to direct bilirubin. Harlequin sign- due to immature circulation ○ Neon Neonat ate e lyin lying g on his side ide will ill appe appear ar red on the the dependent side of the body & pale on the upper side ○ Change position of infant Birthmarks ○ Hemangiomas- vascular tumor of the skin Nevus flammeus (port-wine stain) Macular purple or dark red lesion, usually on the face Strawberry hemangioma Elevated, thick, hard Associated with high estrogen level Cavernous hemangiomas Dilated vascular spaces, elevated ○
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Mongol Mongolian ian spotsspots- slate slate gray gray patche patches s found found across across the sacrum or buttocks, usually disappears by school age.
Vernix caseosa- white cream cheese-like substance noticeable on newborn’s skin at birth Lanugo- fine downy hair covering newborn’s shoulders, back & upper arms ○ Immature newborns has more lanugo than mature infant ○ Disappear by 2 weeks Desquamation- drying of newborn’s skin within 24 hours of birth which results in areas of peeling Pediatric Nursing Page 5 of 46
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MiliaMilia- pinpoi pinpoint nt white white papule papule (plugg (plugged ed or unopen unopened ed sebace sebaceous ous gland) on cheek or across the bridge of the nose ○ Disappear by 2-4 weeks Skin turgor- should be resilient & elastic
a. Head- 1/4 of the total total length; length; dispr disproport oportionate ionately ly large large Large and prominent forehead Receding chin which quivers if the infant is started or is crying Well-nourished newborns have full-bodied hair while those poorly nourished or immature newborns have stringy, lifeless hair Fontanelles should not be sunken (may indicate dehydration) nor bulding (may indicate increase ICP) Anterior Anterior fontanelle fontanelle (diamond (diamond shape) shape) normally normally closes closes at 12-18 12-18 mos Posterior Posterior fontanelle fontanelle (triangula (triangularr in shape) shape) normally normally closes closes by the • nd end of the 2 month Overriding Overriding of suture suture linens linens is normal normal S due to extrem extreme e press pressure ure exerte exerted d by T passage thru the birth canal. Sutures should never be separated (increased J ICP) U Infant’s head may appear prominent & D asymmetric due to molding so that it E can can fit fit the the cerv cervix ix cont contou ours rs.. This This is normal and the head will be restored C to its normal shape within a few days O Crani raniot otab abes es whic which h are are local ocaliz ized ed L softening softening of the cranial bones are due L to press pressure ure of fetal fetal skull skull agains againstt the E moth mother er’s ’s pelv pelvic ic bone bone in uter utero. o. It is G more common in first born infants E Caput Succedaneum is edema of the • scal scalp p at the the pres presen enti ting ng part part of the the S head. It may involve both T hemi hemisp sphe here res. s. Edem Edema a will will slow slowly ly be absorbed about the 3rd day of life. It J needs no treatment U Ceph Cephal alhe hema mato toma ma is a coll collec ecti tion on of D bloo blood d betw between een peri perios oste teum um of skul skulll E bone and the bone itself. Unlike caput Succ Succed edan aneu eum, m, caph caphal alhe hema mato toma ma is C conf confin ined ed to an indi indivi vidu dual al bone bone and and O does not cross suture lines. It usually L takes takes weeks weeks ofre ofre a cephal cephalhem hemato atoma ma L to be absorbed. E G a. Eyes E Newborns cry tear earless essly due to • • •
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immature lacrimal ducts Iris of newborns are gray or blue till the 3rd month of life Edema is usually usually present around the orbi orbitt or on the the eyel eyelid ids s whic which h will will remain for 2-3 days Corn Cornea ea shou should ld be roun round d and and adul adulttsized Larger cornea may indicate congenital glaucoma Pupils are round, dark and regular in shape Key holed pupils- coloboma White pupil- congenital cataract •
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There There is physio physiolog logic ic strabi strabismu smus s due to underd underdeve evelop loped ed eye muscles till 4 mos.
a. Ears Pinna, tends to bend easily Level of top part of the ear should be in line with the upper canthus of the eye ○ Ears set lower may indicate chromosomal abnormalities • •
a. NoseNose- may may appea appearr large large for for the the face face b. Mouth Shoul Should d open open evenly evenly when when newbo newborn rn cries, cries, otherw otherwise ise it may indicate cranial nerve injury Tongue appears large and prominent Palate should be intact Epstein’s pearls maybe mistaken for oral thrust which are white or gray gray patc patche hes s on the the tong tongue ue and and side sides s of cheek cheeks s due due to candida infection It is unusual for a newborn to have teeth but if 1 or 2 are found (natal teeth), it should be evaluated for stability. Loose teeth should be extracted to prevent aspiration. •
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a. Neck Short Short and chubby chubby,, creas creased ed with with skin skin folds Rigid neck- cogenital torticollis Strong enough to support the weight of the head Trachea may be prominent in front of the neck Thyroid gland is not palpable If palpable, suspect congenital goiter •
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a. Chest Breast ast may be engorged due to influence of maternal hormones Occa Occasi sion onal ally ly,, brea breast sts s of newb newbor orns ns secrete thin, watery fluid (witch’s milk) due to maternal hormones Should be symmetric in appearance Retractions should not be present •
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a. Abdomen con contou tour is sligh lightl tly y prot protub uber eran ant, t, globular scaphiod or sunken abdomen – missing abdominal contents bowel sounds should be heard with in an hour after birth edge of the liver is palpable at 1-2 cm below the right costal margin if >3cm – developing CHF edge of the spleen is palpable 1-2 cm below the coastal margin for the 1st hr of birth, umbilical cord is • white, gelatinous marked with red and blue blue stre streak aks s of umbi umbili lica call vein vein and and arteries. arteries. After 1 hour, hour, cord begins begins to shrink, dry and be discolored. 2nd or 3rd day – black • 6th – 10th day – breaks free, leaving a • granulating granulating area a few cm across across that heals during the following week right kidney can usually be palpated •
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a. Anog Anogen enit ital al Area Area Check for the patency of the anus • Note Note the the time time that that the the infan infantt passed passed out meconi meconium. um. If the the • st newbor newborn n does does not pass meconi meconium um in the 1 24 hrs, hrs, suspec suspectt imporforate anus or meconium ileus Male genitalia • scrotum is edematous due to maternal hormones ○ ○ testes should be present in the scrotum ○ Cryptorchidism- undescended testes, may be due to short vas deferens, closed scrotal sac, ectopic testes, agenesis, deficient testosterone ○ Penis appears small. Inspect if urethral opening is at the tip of the glans. ○ If found on the dorsal surface- epispadias ○ If found on the ventral surface- hypospadias ○ Prepuce (foreskin) of the penis should be examined to test for phimosis (tight foreskin) Female genetalia ○ Vulv Vulva a mayb maybe e swol swolle len n due due to infl influe uenc nce e of mate matern rnal al hormones ○ May have mucous vaginal secretion which is sometimes blood-tinged, also due to maternal hormones a.Back Supine appears flat in the lumbar & S sacral areas T Curve Curve starts starts to form when the child is able to sit & walk J U a.Extremities D Arms & legs appear short E Hand Hands s are are plum plump p & clen clench ched ed into into fists C Fingernails are soft and smooth & O are long to extend over the L fingertips L Arms and legs should move E symmetrically G Chec Check k the the digit igits s for for webbi ebbin ng E (syndacty (syndactyly), ly), extra toes or fingers fingers (pol (polyd ydac acty tyly ly), ), lack lackin ing g toes toes or S fingers (oligodactyly) T Observ Observe e for thalid thalidomi omide de effect effects: s: • comple complete te absenc absence e of extrem extremiti ities es J (Amelia), absence of distal U extremitie extremities s (pocomeli (pocomelia), a), absence absence D of either upper or lower extremity E (hemmelia). Check pulses C Radi Radial al puls pulses es are are norm normal ally ly O st nonp no npap apab able le in the th e 1 3 months mon ths L due to decrease peripheral L resistance from upper extremities. E If palpable, suspect coarctation of G aorta. E Femoral Femoral pulses pulses are normally normally palp palpab able le due due to high high peri periph pher eral al S resistance from lower extremities. T If non non palp palpab able le,, conc conclu lusi sive ve of coarctation of aorta. J U Abnorm Abnormal al rotat rotation ion & exten extensio sion n of D foot suggests talipes/club foot E Types: Talipes equinovarusinward rotation of foot, most C common. O L Pediatric Nursing L Page 8 of 46 E G E •
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Talipes equinovalgus- outward rotation of foot Talipes calcaneous- upward rotation of foot Talipes equinas- downward rotation of foot •
Abduct hip to 90 Limited abduction to 60- congenital hip dislocation
a. Revi Review ew of s sys yste tems ms a. Card Cardio iova vasc scul ular ar syst system em In utero, oxygenation takes place in the placenta not in the fetal lungs. So, pressure in the left side is less than the pressure in the right side of the heart. Fetal accessory structures: ○ Foramen ovale- opening between the right and left atria ○ Ductus arteriosus- connects pulmonary artery & aorta ○ Ducturs venosus- bypasses the liver ○ Umbilical vein- carries oxygenated blood 2 umbilical arteries- carry deoxygenated blood ○ As soon as the cord is clamped, the newborn is forced to take in O2 • thru the lungs. This expansion of the lungs will cause the pressure of the left side of the heart to be higher than the pressure of the right heart. This in turn will cause: ○ Foramen ovale will close and turn into a ligament (fossa ovalis) ○ Duct Ductus us arte arteri rios osus us chan change ges s into into a liga ligame ment nt (lig (ligam amen entu tum m arteriosum) ○ Duct Ductus us veno venosu sus s chan change ges s into into a liga ligame ment nt (lig (ligem emen entu tum m venosum) ○ Umbilical vein & arteries will atrophy & degenerate since no more blood goes thru it A newborn’s blood volume is around 300 ml ○ RBC- 6 million/cubic mm ○ Hgb- 17-18 gg/100ml blood Hct- 45% - 50% ○ ○ Platelets- 100,000- 200,000 ○ WBC- 15,000-45,000/cubic mm •
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a. Respi Respira rato tory ry syst system em Newborn’s first breath requires tremendous amount of energy to • pull pull in. Once Once the alveol alveolii have have initial initially ly been been inflat inflated, ed, breath breathing ing becomes much easier for the baby Heart of the newborn takes more space than in an adult so the amount of lung expansion is limited •
a. Gastr Gastroi oint ntes esti tina nall syst system em Usually sterile at birth Stomach can hold about 60-90 ml Has limited limited ability ability to digest digest fat and starch starch because because pancre pancreati atic c • enzymes are deficient during t he 1st few months of life Regurgitates easily due to immature cardiac sphincter Usually has low glucose & protein serum level due to immature liver function Stools: • Meconium- 1st stool that is usually passed 24 hours after ○ birth. birth. Sticky Sticky,, tar-li tar-like ke black blackish ish green, green, odorle odorless ss that that was form formed ed from from mucu mucus, s, vern vernix ix,, lanu lanugo go,, horm hormon ones es that that accumulated in utero Transitional stool- 2nd or 3 rd day of life which may resemble resemble ○ diarrhea (bright, green, loose) Stool of breast fed infants—4 th day of life; golden yellow, ○ sweet smelling, mushy stools passed 3-4x a day • •
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Stoo Stooll of form formul ula a fed fed infa infant ntss- pale pale yell yellow ow,, firm, has a slightly tly more more notice noticeabl able e odor, odor, passed 2-3x a day Brig Bright ht gree green n stoo stools ls— — those placed under phototherapy Stool with mucus—milk allergy or other irritant should be suspected Gray/clay colored stoolbile duct obstruction Black/tarry stoolintestinal bleeding
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a. Urin Urinar ary y syst system em •
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Newborns void within 24 hours after birth Single voiding is only about 15 ml Daily urine output is 30-60 ml/day Specific gravity- 1.0008-1.010 Proteinuria is normal in the 1 st 3 mos. Light in color & odorless because their kidneys do not concentrate urine well Fema Female le newb newbor orns ns prod produc uce e a stea steady dy stre stream am when when voiding Male newborns void with enough force to produce a small projected arc syst system em Maternal Ab (IgG) cross placenta to the fetus during the the last last 2 week weeks s of preg pregna nanc ncy y (pas (passi sive ve natu natura rall immunity) and serve as protection against 6 childhood diseases: poliomyelitis, measles, diphtheria, pertussis, rube rubell lla, a, teta tetanu nus. s. Ther There e is litt little le immu immuni nity ty agai agains nstt varicella (Chicken pox) or herpes simplex. Neon Neonat ate e has has diff diffic icul ulty ty form formin ing g anti antibo bodi dies es agai agains nstt antigens until 2 mos. Of age. That is why immunizations are started at 2 mos. syst system em Limpne Limpness ss or total total absenc absence e of muscul muscular ar respon response se to manipulation may indicate narcosis, shock or cerebral injury. Reflexes: Blink reflexreflex- protects protects ○ the eye from any obje object ct comi coming ng near near it; rapid eyelid closure; does not disappear. Rooting Rooting reflexreflex- the neonate turns head in the direction direction where the cheek is brushed or stroked near the corner of the mouth; mouth; helps the baby baby to fin food; food; disapp disappear ear at 6 weeks of life. Sucking reflex- the neonate makes a sucking motion when the lips are touched; begins to diminish at 6 mos. of age; disappears if not stimulated, thus an infant on NPO should be given pacifier to stimulate sucking Swallowing reflex- food placed at the posterior portion of the the tong tongue ue is auto automa mati tica call lly y swal swallo lowe wed; d; it does does not not disappear. Extrus Extrusion ion reflex reflex-- any substa substanc nce e placed placed at the anteri anterior or tongue will be spit out; it disappears at about 4 mos. of age when the infant is ready to eat semi solid foods Pediatric Nursing Page 10 of 46
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S T J U D E C O L L E G E S T J U D E C O L L E G E S T J U D E
a. Senses •
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Palmar grasp reflex- newborns grasp an object placed in their palm by closing their fingers on it; disappears at 6 weeks to 3 mos. Plantar grasp reflex- when an object touches the sole of newborn’s foot at the base of the toes, the toes grasp in the same manner as the fingers do Tonic neck reflex- when lying on his back, the newborn’s newborn’s arm and leg are extended on the side where the head is turned. The arm and leg on the opposite side are flexed; disappears disappears between between the nd rd 2 and 3 mos. Of life Moro Mo ro (sta (start rtle le)) refl reflex ex-○ most most impo import rtan antt refl reflex ex indicative of neurological status, this is elicited by star startl tlin ing g the the newb newbor orn n with loud noise, noise, jarring jarring the bassinet or the head is allowed to drop back backwa ward rd in a supi supine ne posi positi tion on.. The The newb newbor orn n will will abduc abductt and adduc adductt in his his arms arms and and legs legs.. Their Their finger fingers s ass assume ume a typical “C” position. This fades by the end of the 4th and 5th month. Babinski reflexthe ○ infant infant will fan the toes toes when the side ide of the the foot is stro troked in an inverted inverted “J” curve curve from the heel upward. This is in contrast to the adult who flexes flexes the toes. It begins to disappear by 3 mos. of age ○ Landau reflexa newbor newborn n help help in prone prone position should dem demons onstrat trate e muscl uscle e tone. ○ Deep tendon reflex A pate patell llar ar refl reflex ex can can be elic elicit ited ed by tapp tapping ing the the patellar tendon with the tip of the finger. The lower leg will move perceptibly if the infant has a mature reflex. This is a test for spinal nerves L2-L4 A biceps reflex is elicited by placing the thumb of your left hand on the tendon of the biceps muscles. Tap the thumb as it rests on the tendon. You will feel the tendon contract. This is a test for spinal nerves C5-C6.
Hearing A fetus is able to hear in utero They appear to have difficulty locating sound, not turning toward it consistently They respond with generalized activity to a sound They calm in response to a soothing voice & startle at loud noises They recognize their mother’s voice as if they have heard it in utero Vision Newborns see as soon as they are a re born Pediatric Nursing Page 11 of 46
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They cannot follow objects past the midline of vision (9-12”) They focus best in black & white objects Touch- most developed & most sensitive of all the senses
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Taste Taste buds are developed & functioning before birth Newborns Newborns turn away from bitter taste & readily readily accepts accepts the sweet sweet taste of milk or glucose water Smell Present as soon as the nose is clear of mucus & amniotic fluid Sensitive to breast milk
a. Disc Discha harg rge e plan planni ning ng Daily care ○ Bathing Shou Should ld be done done prio priorr to, to, not not afte afterr a feed feedin ing g to prevent regurgitation, spitting up or vomiting Bath water should be around 98-100 F (37-38 C) Soap should be mild ○ Diaper area care When changing diapers, the area should be washed with clean water & be dried well so that ammonia in urine will not irritate the infant’s skin An ointment such as petroleum jelly may be applied •
S T J U D E C O L L E G E S T J U D E
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Sleep patterns ○ A newborn sleeps an average of 16 hrs/day in the first week at home & an average of 4 hours at a time ○ At 4 mos., the baby sleeps 15 hrs/day & 8 hrs at a time ○ Most typical time for wakefulness- 6:00-11:00 PM Nutrition ○ Recommended daily allowance for the newborn Calories- 120 cal/kg body wt (birth-2 mos.) ○ ○ 100 kcal/kg body wt (1 year) Protein- 2.2/kg body wt (birth- 2 mos.) ○ ○
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Minerals- calcium is important because of its contribution to bone growth. The infant born from a mother with adequate intake of iron during pregnancy has Fe stores that will last for the 1st 3 mos. of life Vitamins- Vitamin A,C,D are recommended for the entire 1 st year of life Breastfeeding advantages For the mother Release oxytocin aids uterine involution May serve as protective function in preventing breast cancer Promotes maternal-infant bonding • •
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For the infant Contain secretory IgA Con Contain tains s the the ideal deal elec electr trol oly yte & • composition for human infant growth
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miner ineral al
Difference between human milk & cow’s milk Carbohydrates Human milk has more carbohydrates •
Fats • •
Human & cow’s milk has same fat content Lino Linole leic ic acid acid neede eeded d for for gro growth wth & skin kin integrity is 3x higher in human milk proteins
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Protein • •
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Human milk has less proteins than cow’s milk Casein is the main protein in cow’s milk which is more difficult to digest Lactalbumin is the main protein in human milk and is easier to digest
Minerals Cow Cow’s milk ilk has has mor more miner ineral als s but but the the • newborn’s kidneys are not yet mature enough and might be overwhelmed by high mineral content of cow’s milk
Similarities Both are deficient in Iron Both contain 20 cal/oz Both should be given by demand feeding • • •
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A. Newb Newbor orn n at at Risk Risk 2. Premature Premature Babies Babies (low (low birth birth weight weight infants infants)) b. Anem Anemia ia of of prem premat atur urit ity y Normochromic, normocytic anemia Develops during the first 3 to 4 mos. of life due to immaturity of • the hematopoietic system Bloo Blood d trans ransfu fusi sion ons s may may be done one to supply pply neede eeded d blood lood components until maturity of the hematopoietic system is achieved Is diff differ eren entt from from Iron Iron-d -def efic icie ienc ncy y anem anemia ia also also occu occurr rrin ing g in premature infants because transfer of Fe stores from the mother to the baby occurs during the last 2 weeks of pregnancy. In this type of anemia, Fe supplements may be given to the baby
J U D E
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b.Kernictrus Destru Destructi ction on of the brain brain cells cells by indire indirect ct biliru bilirubin bin due to excess excessive ive breakdown of RBC & immaturity of the liver Monitor indirect bilirubin level Photot Pho tother herapy apy—do —done ne with with the use use of artifi artificia ciall blue blue light light to conve convert rt indirect bilirubin to its excretable form ○ Undress the baby to expose all areas of the body ○ Cover genitals & eyes ○ Turn the baby every 2 hours ○ Assess skin turgor because the infant may lose considerable fluid thru insensible water water loss due to to the temperature of the light ○ Increase fluid intake to prevent dehydration ○ Check Check stools stools & urine. urine. Their stools stools usually usually are frequently frequently loose & bright green due to excessive bilirubin excreted. Urine may be dark-colored from urobilinogen formation
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b. Infection This is due to immature immune defenses in premature infants In addition, they have a deficiency in IgG (antibodies) which is usually transferred from the mother to the baby during the last 2 weeks of pregnancy
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Similarities Both are deficient in Iron Both contain 20 cal/oz Both should be given by demand feeding
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2. Post Post Ma Matu ture re Ba Babi bies es Born after the 42nd week of pregnancy They are at risk because the placenta is timed to be effectively functioning for 40 weeks, after that, it seems to lose its ability to function Characteristics: Dry, cracked, leather-like skin due to lack of fluid & absence of vernix •
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Fingernails have grown beyond fingertips They may be meconium-stained May be alert as a 2-week old baby
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Management: Protect baby from chilling Monitor vital signs Provide emotional support to the mother • • •
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Hemolytic disease of the newborn Moth Mo ther er deve develo lops ps anti antibo bodi dies es agai agains nstt feta fetall RBC RBC lead leadin ing g to its its destru destructi ction on of hemoly hemolysis sis.. This This in turn turn causes causes severe severe anemia anemia and hyperbilirubinemia. b. RH inco incomp mpati atibi bilit lity y If mother is Rh (D) negative and fetus is Rh positive (has D • antigen), the mother will begin to form antibodies against the D antigen. However, most AB are formed 72 hours after the delivery of the baby. So during the 2 nd pregnancy, there will be a high level of AB D to S destroy fetal RBC. By the end T of the 2nd pregnancy, the fetus may be severely compromised. J U b. AB ABO O inco incomp mpat atibi ibili lity ty D Mate Ma tern rnal al bloo blood d type type is O and and E fetal blood type is A, B, or AB. Hemolysis of blood begins with C birth O L Characteristics L ○ Doesn’t appear jaundiced E ○ Enlarged spleen and liver G ○ Edema E ○ Progressive jaundice within the first 24 hours of life— hemolytic process S T Management: •
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Initiative early feeding to stimulate bowel peristalsis Susp Suspen end d brea breast st feed feedin ing g for for 24 hour hours s to redu reduce ce accumulating indirect bilirubin Initiate phototherapy Exchange transfusion Withdrawing few amounts (2-4 ml) of infant’s bloo blood d and and then hen repla eplac cing ing it with ith equa equall amounts of donor blood Monitor vital signs Keep infant warm 2. Infant Infant of a diab diabetic etic mother mother
Characteristics •
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Typi Typica call lly y long longer er and and weig weighs hs more than other babies (macro acros somic omic)) due due to over over stimulatio stimulation n of pituitary pituitary growth growth hormone and extra fat deposits due due to high high leve levell of gluc glucos ose e during pregnancy Caud Caudal al:: regr regres essi sion on synd syndro rome me (hypoplasia of lower extremities) Cushingoid appearance (fat and puffy) Lethar Lethargic gic or limp limp on the first days of life
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They are usually born by cesarean birth Severe hypoglycemia during the 1 st 24 hours (blood sugar <40mg/dl in newborns)
2. Infant Infant of a drug-d drug-depen ependen dentt mother mother Characteristics: Tends to be small for gestational age Has withdrawal symptoms shortly after birth ○ Irritable ○ Disturbed sleep pattern ○ May have tremors ○ May sneeze frequently ○ High-pitched cry ○ Hyperreflexia & clonus (neuromuscular irritability) ○ Tachypnea Vomiting & diarrhea which may lead to dehydration ○
Management Keep infant in an a n environment free from excessive stimuli Maintain fluid & electrolyte balance • •
2. Infant Infant with with feta fetall alcoho alcoholl syndr syndrome ome Alcohol crosses the placenta Characteristics: Tremulous, fidgety, irritable Weak sucking reflex Sleep disturbance Mental retardation—most serious, long term effect •
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7.Inborn errors of metabolism •
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a.Phenylketonuria Phenylalanine Phenylalanine
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There is absence of phenylalanine hydroxylase which causes the accumulation of phenylalanine in the blood stream & tiss tissue ues s caus causin ing g perma ermane nent nt brai brain n dama damage ge & ment mental al retardation Pheny Phenylpr lpruvi uvic c acid acid spills spills into into the urine urine which which causes causes it to • have a typically musty or “mousey” odor Characteristics: • Child becomes fair-skinned, blonde & blue eyed because tyrosine is needed for building body pigment and thyroxine Fails to meet average growth standard
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Management Put the infant in an extremely low phenylalanine formula
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a.Galactosemia Disorder Disorder of carbohydra carbohydrate te metabolism metabolism characteri characterized zed by an • abnormal amount of galactose in the blood and in the urine Defici Deficienc ency y in galact galactose ose 1- phosph phosphate ate uridyl uridyl trans transfer ferase ase • which converts galactose into glucose Characteristics Lethargy Hypotonia Diarrhea and vomiting Hepatomegaly, cirrhosis •
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Tyrosine
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A grou group p of here heredi dita tary ry bioc bioche hemi mica call diso disord rder ers s affe affect ctin ing g metabolism May be due to deficiency in a particular enzyme Affect amino acid, protein, carbohydrate & lipid metabolism
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Jaundice
Management: ○ Place infant infant in a galactose-free diet
Congenital anomalies a. Clef Cleftt lip lip & cle cleft ft pal palat ate e Cleft lip ○ More common among males than females ○ Occurs at approximately 1:1000 live births ○ Has a familial tendency ○ Presence of teratogens during wks 5-8 of intrauterine life ○ Characteristics: The defect can be just a small notch in the upper lip or a total separation of the lip & facial structure structure up into the floor of the nose Nose is generally flattened Gingiva and upper teeth may be absent May be unilateral or bilateral •
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Management Cleft Cleft lip surger surgery y (cheil (cheilopl oplast asty) y) may be done done shortl shortly y after after birth birth ○ beca becaus use e earl early y repa repair ir will will help help the the infa infant nt experience pleasure of sucking as soon as S possible T J U D E C O L L E G E
Cleft palate ○ More common among females than males ○ Occurs at approximately 1:2500 live births ○ Cleft lip with cleft palate occurs at approximately 1:1000 live births ○ Genetic, familial, presence of teratogens Characteristics: ○ Opening on the palate which may involve the anterior hard palate, posterior soft palate or both Usually in the midline •
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Management ○ Cleft Cleft palate palate surge surgery ry is not done until until the chil child d is arou around nd 4-6 4-6 mos. mos. Beca Becaus use e it can can damage the tooth buds Associated problems: ○ Altered nutrition
Pre-op nursing care: Suppo Support rt the baby in an uprigh uprightt positi position on (sitti (sitting ng or semi semi sitting) while feeding Use a commercial cleft lip nipple Be careful when feeding because this may cause aspiration Burp frequently because they have the tendency to swallow air due to their inability to maintain a closed seal around the nipple
Post-op nursing care Keep on NPO for at least 4 hours Avoid placing tension on the suture line Breast feeding or bottle feeding is contraindicated during • the immediate post op period. Use a breck feeder Do not use straw to drink After repair of the cleft palate, liquid diet is continued for the first 3-4 days followed by a soft diet until healing is complete Never use spoon or fork when feeding Offer water after feeding to rinse suture line • •
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Ineffective airway clearance Observe for respiratory distress due to local edema in the immediate post op period If suction is really needed, be gentle and don’t touch suture line Post-cheiloplasty, put on side-lying position to drain saliva Use of mist tent to liquefy secretions Impaired tissue integrity at incision site Avoid tension on the suture line A loga logan n bar bar or an adhe adhesi sive ve band bandag age e is used used to prot protec ectt suture line Anticipate infant’s need because crying increases tension on the suture Avoid placing anything hard or sharp (toys) on the suture line Keep elbow restraints in place
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Infection Clean Clean suture suture line line with with steril sterile e sol soluti ution on and steril sterile e cot cotton ton- tipped applicators after every feeding They are high risk for ear infection so routine screening for hearing loss is needed Teac each the pare paren nts sig signs of infe infec ction tion:: pain, ain, fev fever, er, ear ear S discharge T J U D E C O L L E G E S T
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Hydrocephalus Excess of cerebrospinal fluid in the ventricles and subarachnoid spaces of the brain Causes:
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Communicating or extraventricular hydrocephalus- there is passage of fluid between ventricles and spinal cord Non communicating or intr intrav aven entr tric icul ular ar hydr hydroc ocep epha halu lussthere is block to passage of fluid
Assessment: Incr Increa ease se head head size size with with bulg bulgin ing g fontanelles (first sign) Papilledema Edema of optic disk Scalp becomes shiny, scalp veins prominent Sunset eyes Head lag even after 4 mos. Shrill, high-pitched cry Irritable and lethargic
S T J U D E
Over Overpr prod oduc ucti tion on of flui fluid d by the the choroids plexus Obstruction of the passage of fluid Interference with the absorption of fluid from subarachnoid space
Types
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Altered communication pattern
Diagnostic studies:
Sonogram, CT scan, MRI, skull x-ray
Depends on its cause & extent
Surgical management
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If caused by obstruction, treatment usually involves bypassing the point point of obstru obstructi ction on by shunti shunting ng the fluid to normal normal or artifi artificia ciall points of absorption
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Management: Elevate head of bed Put them in a non stimulating environment Monitor vital signs Watch out for signs of increase ICP: bulging fontanelles, increasing head circumfer circumference, ence, irritabilit irritability, y, lethargy, lethargy, poor sucking, sucking, increase increase temperature, decrease PR, decrease RR. Reposition head every 2 hrs to prevent scalp breakdown Monitor head circumference daily
a. Neura Neurall tub tube e diso disord rder ers s Anencephaly ○ Absence of the cerebral hemisphere ○ Children cannot survive with this disorder because of absence of cerebral function •
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Microcephaly ○ Slow Slow brai brain n S T
grow growth th
due due
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Occurs when the posterior laminae or vertebrae fail to fuse More common at the 5 th lumbar or 1st sacral level May Ma y appe appear ar as a dimp dimple le at the the poin pointt of poor poor fusi fusion on;; abno abnorm rmal al tuffs of hair may be present
Meningocele ○
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Occurs when the meninges cove coveri ring ng spin spinal al hern hernia iate tes s thru thru unformed vertebrae Appear Appears s as a protru protrudin ding g mass mass at the center of the back Usually in lumbar region
Myelomeningocele
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Spina bifida oculta
J U D E C O L L E G E
to mate matern rnal al phen phenyl ylke keto tonu nuri ria a intr intrau autterin erine e inf infecti ection on suc such rubella or cytomegalovirus Results in mental retardation
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Management: Preve event infect ection/ruptu pture of protruding mass Put child on prone position Do not put diaper Cover sac with sterile gauze with NSS or antibiotic ○ Monitor for signs of increase ICP: bulging fontanelles, vomiting, highpitched cry, increasing head circumference, irritability, increase BP, decrease PR, decrease RR ○ Watch out for complications: Hydrocephalus Meningitis ○
J U D E C O L L E G E
The The spin spinal al cord cord,, spin spinal al flui fluid d and and meninges protrude thru the vertebral defect Resu Result lts s in lowe lowerr moto motorr neur neuron on damage Flaccid, lack of sensation in lower extremities Loss of bladder and bowel control
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Nuchal rigidity Photophobia Opisthotonus position (arching of the spine) Sign Signs s of meni mening ngea eall irri irrita tati tion on:: vomi vomiti ting ng,, kernigs, (+) brudzinski
(+) (+)
UTI Bowel incontinence Club feet Hip dislocation
D. BIRTH BIRTH RELA RELATED TED STRES STRESSOR SORS S 1. Respirator Respiratory y distress distress Syndrome Syndrome of the newborn (RDS)/H (RDS)/Hyaline yaline membrane membrane disease disease Caus Caused ed by low low leve levell of phos phosph phot otid idyl yl glyc glycer erol ol & leci lecith thin in comp compon onen entt of • surfactant which maintains expansion of alveoli Decrease surfactant alveoli •
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increase surface tension
When When this this happen happens, s, there there is less less exchan exchange ge of oxygen oxygen and carbon carbon dioxid dioxide e leading to: HYPOXIA Tissue hypoxia causes the release of lactic acid The pathologic feature of RDS is a hyaline-like membrane which prevents exch exchan ange ge of O2 & CO2 CO2 at the the alve alveol olar ar-b -blo lood od inte interr spac space e lead leadin ing g to ATELECTASIS Assessment: Expiratory grunting--a compensatory mechanism ○ ○ Cyanosis in room air ○ Nasal flaring ○ Sternal & subcostal retractions ○ Tachypnea (> 70 breaths/min) ○ Rales and diminished breath sounds Management ○ Avoid Avoid extrem extreme e body body temper temperatu ature re becaus because e increa increase se in BMR will will demand for O2 ○ Give sodium bicarbonate to correct acidosis ○ Monitor VS especially RR every 1-2 hours IV fluid may be needed or gavage feeding for hydration because ○ the respiratory effort makes the infant too exhausted to suck ○ Administer O2 to maintain normal PO2 and pH levels
1. Meconium An infant who experienced hypoxia in utero has a vagal reflex relaxation of • the rectal sphincter releasing meconium into the amniotic fluid. During the first breath, the baby inhales the amniotic fluid & aspirates meconium. This can can brin bring g abou aboutt infl inflam amma mati tion on of bron bronch chio iole les s or bloc block k bron bronch chio iole les s by mech mechan anic ical al plug pluggi ging ng.. Any Any of thes these e 2 mech mechan anis isms ms will will caus cause e seve severe re respiratory distress. Characteristics: Has difficulty establishing respirations at birth Tachypnea, retractions, cyanosis Management: The infant should be intubated Suction meconium from trachea & bronchi Antibiotic treatment may be given to prevent development of pneumonia • •
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S T J U D E C O L L E G E
lack of expansion of
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VII. PEDIATRIC NURSING D. GENERAL GENERAL PRINCIPL PRINCIPLES ES OF GROWTH AND DEVELO DEVELOPMENT PMENT Growth- increase in physical size quantitative change •
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2 aspects ○ weight- most sensitive measure of growth ○ birthweight- 2x at 6 mos 3x at 1 year 4x at 2 ½ years ○
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height Increase in ht. is 1”/mo from 1 mo- 6 mos. 1/2”/mo from 7 mos. - 12 mos. rate of growth is rapid during infancy and adolescence, slow during toddler, pre-school, and school age period rapid growth of limb occurs at school age period
Development- increase in skill or ability to function - Qualitative change Principles of growth and development ○ Growth and development are continuous process from conception till death Growth and development proceed in an orderly sequence ○ ○ Different children pass thru the predictable stages at different rates ○ All body systems do not develop at the same rate ○ Development is cephalo-caudal ○ Development proceeds from gross to refined skills ○ Development proceeds from proximal to distal body parts ○ There is an optimum time for initiation of experience or learning ○ Neonatal reflexes must be lost before development can proceed ○ A great deal of skill & behavior is learned by practice
D. THEORI THEORIES ES IN HUMAN HUMAN DEVELO DEVELOPME PMENT NT 1. Psychoana Psychoanalytic lytic theory theory (Sigmund (Sigmund Freud) Freud) STAGES Oral
AGE 0-1 year
Anal
2-3 years
Phallic
4-5 years
Late Laten ncy
6-1 6-12 years ears
Genital
13 & above
CHARACTERISTICS Infant su sucks fo for en enjoyment or or re relief of of te tension as as we well as as for nourishment Children fi find pl pleasure in in bo both th the re retention & defecation o off feces (toilet training Pleasure zone is genital area, masturbation, children’s energy is diverted to physical and intellectual activities Chil Childr dren en’s ’s en energy ergy is is div diverte erted d to phys physic ical al and and inte intell llec ectu tual al activities Energy is directed to attain mature heterosexual relationships
2. Psychosoc Psychosocial ial develo development pment theory theory (Erikson) (Erikson) STAGE Trust vs. Mistrust
vs.
6-12 6-12 years ears
IMPLICATIONS Prov Provid ide e expe experi rien ence ces s that that add add to secu securi rity ty.. Children learn to love and be loved Child learns to be independent & make decisions for self. Provide opportunity for decision making Child learns how to do things. Provide oppo opport rtun uniti ities es for for expl explor orin ing g new new plac places es and and activities Child hild lea learns rns how to do thin hings well well..
vs.
20-25 years
Offer support
Autonomy vs. Shame and Doubt Initiative vs. Guilt
Industry Inferiority Intimacy Isolation
AGE Birth18 mos. 18 mos. Vs. 3 years 3-5 years
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Gene Genera rati tivi vity ty Stagnation Integrity Despair
vs. vs.
25-65 years
vs.
65-death
3. Cognitive Cognitive developmen developmentt theory theory (Piaget) (Piaget) STAGES Sensorimotor Preop Preopera eratio tional nal Concrete Operational thought Formal operational thought
AGE Birth2 years 2-7 years years 7-12 7-12 years years
CHARACTERISTICS Uses reflex behavior; at the end of this stage, infants begin to demonstrate goal-directed behavior Thoug Thought ht become becomes s more more symb symboli olic. c. Child Child is egocen egocentri tric. c. Language development Syste Systemat matic ic reason reasoning ing.. Unders Understan tands ds relat relation ionshi ships ps
12 years and above
Can Can solv solve e reasoning
hypo hypoth thet etic ical al
prob proble lems ms
with with
scie scient ntif ific ic
4. Moral Moral develop developmen mentt theory theory (Kohlbe (Kohlberg) rg) STAGES S T
AGE
CHARACTERISTICS Preconventional 2-3 years Punishment & obedience orientation. 4-7 years Indi Indivi vidu duali alism sm.. Inst Instru rume ment ntalal-re relet letiv ivis istt orientation
Level 1 Level 2
JConventional U Level 3 D E Level 4
D. 1.
C O L L E G E
7-10 years 10-12 years
Orientation Orientation to interpers interpersonal onal relations relations of mutuality (good boy, nice girl) Law and order situation
Post conventional 12 & above Social contract. Follows standards of socie ocietty. Univ Univer ersa sall eth ethical ical pri princip nciple le orientation
Level 5 Level 6
BEHAVIOR TRAITS/CHARACTERISTICS INFANTS (0-12 mos.) Significant person- mother/caregiver Fear- stranger anxiety Physical growth Developmental milestones ○ 0-1 month largely reflex keeps hands fisted, able to follow object to midline momentary visual fixation on faces •
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3 months holds head and chest up when prone follows objects past midline laughs aloud ○
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2 months holds head up when prone social smile makes cooling sounds differentiates his cry ○
4 months no longer has head lag when pulled upright bears partial weight on feet when held upright grasps objects & brings to mouth
5 months raking grasp
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turns both ways
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6 months reaches out in anticipation of being picked up sits unsteadily (with minimal support) eruption of first tooth palmar grasp 7 months transfer objects hand to hand beginning fears of strangers 8 months sits securely without support fear of strangers (peak) 9 months creeps or crawls says first word (dada) 10 months puts self to stand uses pincer grasp (thumb to finger) 11 months walks with support 12 months stands alone walks with help holds cup & spoon well • •
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Play: solitary Appropriate toys: mobiles, rattles, music box, squeeze toys, plastic rings, rubber ducks, teething ring, textured toys
1. TODD TODDLE LER R (1(1-3 3 yea years rs)) Significant person: parents Fear: separation anxiety Physical growth: ○ Decrease appetite because of slower growth rate ○ Prominent abdomen because abdominal muscles are not yet strong enough to support abdominal contents ○ All deciduous teeth are generally present by 2 1/2 – 3 years ○ Should start regular dental care by 2 years Developmental milestones ○ Critical for language development ○ Favori Favorite te word word is “NO” (a manife manifesta statio tion n of develo developin ping g autonomy) ○ Negativistic, obstinate, difficult to manage ○ Acti Active ve,, curi curiou ous, s, moto motorr abil abilit ity y jump jumps s far far ahead ahead of his his judgment ○ By 18 mos., he imitates the things he sees a parent is doing ○ They have ritualistic behaviors They They go into into temper temper tantrum tantrum at one one time time or anothe another. r. ○ Temp Temper er tant tantru rums ms are are a natu natura rall cons conseq eque uenc nce e of thei theirr development. They occur as a response to an unrealistic reques requestt by parent parent,, conseq consequen uence ce of their their develo developme pment. nt. They They occur occur as a respon response se to an unreali unrealisti stic c reques requestt by parent, parent, or if the parents are saying, saying, “NO” too frequently frequently,,
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or maybe a response to difficulty making choices, or too much pressure from activities like toilet training ○ Know the cause of the tantrum ○ Tell the child that they disapprove of the tantrum then ignore the behavior ○ Keep child away from onlookers ○ Don’t accede to the wish of the child nor punish the child ○ Direct the child to more productive activities Toil Toilet et trai traini ning ng-- one one of the the bigg bigges estt task task duri during ng this this peri period od;; it is an individualized task for each child ○ 2 important developmental levels before a child can begin toilet training ○ control of rectal & urethral sphincters—if the child is able to walk well independently they must understand what it means to hold urine & stools until ○ they they can release release them them at a certai certain n place place and time—whe time—when n they they begin to be uncomfortable with their wet diapers ○ at 18 mos. Of age, the toddler has bowel control ○ at 2 1/2 years, he has day time bowel control ○ at 3-4 years, he has night time bladder control •
Play: parallel (side by side) This This is not unfrie unfriendl ndly y but is a normal normal develo developme pmenta ntall sequen sequence ce
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toddler period Appropriate Appropriate toys: push-pull push-pull toys, trucks, trucks, toy telephone, telephone, building blocks, balls, toy hammer with nail, drums, toys to ride on, pots, pan, swing, slide
1. PRESCHOOLER (3-6 years) Significant person: basic family (extended) Fear: fear of castration/body mutilation; fear of the dark, ghosts. Witches, thunder, lightning Physical growth Definite change in body contour: slimmer, taller Slight weight gain (4.5 lb/year) Minimal height gain (2-3.5”/year) Rarely do new teeth erupt because all 20 deciduous teeth area present by 3 years of age
Behaviors 3 years old undresses self runs climbs steps one at a time walks backwards stands on 1 foot vocabulary of 300- 900 words
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4 years old ○ can do simple buttons ○ jumps, skips ○ uses alternate steps when climbing stairs ○ vocabulary of 1500 words
5 years old ○ draws a 6-part man ○ throws over hand ○ runs well ○ vocabulary of 2100 words
Developmental milestones ○ They ask questions constantly Favorite word is “WHY” Pediatric Nursing Page 23 of 46
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hone honest stly ly at the the leve levell of thei theirr unde unders rsta tand ndin ing g so that that their heir curiosity curiosity,, vocabulary vocabulary building building & questioning are encouraged.
They are self-centered They have active imaginations, fantasies Imitative Age of OEDIPUS COMPLEX (strong emotional attachment of a pres presc chool hool boy boy for his mot mother) her) and and ELECT LECTRA RA COMP COMPLE LEX X (att (attac achm hmen entt of a pres presch choo ooll girl girl to her her father). ○ Each Each chil child d comp compet etes es with with the the same sex parent for the love & attention of the other parent. They typically typically have some speech difficulty. difficulty. They may begin to repeat words or syllables (broken fluency) Sibling rivalry Spend separate time with each other Involve the child in caring for the second child Preschoolers may engage in masturbation not punish the child Divert their attention (give toys to play with) ○ They may question question about genital genital orga organs ns or sex, ex, ans answer wer them them hone honest stly ly at the the leve levell of thei theirr understanding Play: associative, cooperative, dramatic, imaginary playmates Appropriate toys: dolls, housek housekeep eeping ing toys, toys, water water col colors ors,, clay clays, s, colo colori ring ng book book,, dres dresss-up up clothes, simple puzzles. 1. SCHOOL SCHOOL AGED AGED CHIL CHILD D (6-12 (6-12 years years old) old) Significant person: peers of the same sex, tea cher Physical growth: Mature slowly but steadily Weight gain of 3-5 lbs/years Increase in height of 1-2”/year By age 10, brain growth is complete Hypothalamus transmits enzy enzyme me to ante anteri rior or pitu pituita itary ry gland to produce gonadotropic hormones that activate change changes s in testes testes and ovarie ovaries s (10-14 years of age) Deciduous teeth are lost and permanent teeth erupt
Developmental milestones They are modest, industrious They enjoy collecting items They are competitive Stealing is a common problem 6 years old jumps, skips, stumbles, hops talk in full sentence play in groups first molars may erupt • • • •
7 years old central incisors erupt difference between sexes become apparent in play spends time in quiet play can tell time in hours
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8 years old improved coordination loves collecting clothes prefers playmates of own sex best friends develop •
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10 years old coordination improves interest in the opposite sex is apparent interested in rules and fairness enjoy privacy 11 years old more active become increasingly interested in the opposite sex •
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9 years old Always on the go They play hard Gang age
Play: competitive Age-ap Age-appro propri priate ate toys: toys: dolls, dolls, table table games, games, comic comic books, books, watching TV, remote control games, collecting items. 1. ADOLES ADOLESCEN CENT T (12-1 (12-18 8 years years old) old) Significant person: peers of opposite sex Fear: Fear: fear fear of acne, acne, homose homosexua xualit lity, y, obesit obesity, y, displa displacem cement ent from from friends, death Physical growth: Onset of puberty and cessation of body growth Physiologic growth is rapid Pubertal changes Male (testes testosterone) sudden growth spurt deepening of voice increase size of genitals pubic & axillary hair production of viable sperm • •
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Female (ovary estrogen & progesterone) Sudden growth spurt The larche (increase size of breath). Starts at 10 years old and ends at 18 years of age Sign to sexual maturation Appearance of pubic & axillary hair Widening of hips Menarche Happens between the time the girl develops pubic and axillary hair Ovulation starts 1-2 years before menarche •
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Behaviors Rebellious, reformers, idealistic, futuristic Use of status symbol Conscious of body image Emancipation from parents becomes an issue Hero worship (film star, athlete, writer, etc.)
D. IMMU IMMUNI NIZA ZATI TIONS ONS Immunity- ability to destroy a particular antigen IMMUNITY
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NATURAL
ACTI ACTIVE VE
ARTIFICIAL
PASS PASSIV IVE E
Suffered the disease. Exposed to the disease carrier
ACTI ACTIVE VE
Placental transfer. Breast feeding
IMMUNIZATION BCG DPT (3 doses at 1 mo. Interval) OPV (3 doses at 1 mo. Interval) Measles Hepa B (3 doses)
AGE 1.1 year School entrants 2 ½ mos. 3 ½ mos. 4 ½ mos. 1 ½ mos. 2 ½ mos. 3 ½ mos. 9 mos. 6 wks. – 11 mos
PASS PASSIV IVE E
Receiving vaccines for immunizable diseases
SITE Right deltoid Left deltoid ID Vastus lateralis
Receiving toxoid (IgG serum (Hepa)
ROUTE DOSE ID .05 ml ID 0.1 ml IM 0.5 ml
Oral
Oral
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Deltoid Vastus lateralis
SQ IM
0.5 ml 0.5- 1 mo. interval
VIII. CHILDREN AT RISK d. Respir Respirato atory ry Dysfun Dysfuncti ction on 1. Disorders Disorders of the the upper upper respirator respiratory y tract tract a.
Acute Acute nasoph nasophary aryngi ngitis tis cold) Most frequent infectious disease in children • Viral in origin Assessment Begins with nasal congestion Watery rhinitis Low grade fever Edematous & erythematous nasal mucous membrane May have thick purulent nasal discharge
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b. Ton Tonsili siliti tis s Infection and inflammation of palatine tonsils Assessment: Drooling because the throat is too sore for them to swallow saliva ○ ○ High fever ○ Lethargy Management: ○ Antipyretic for fever ○ Analgesic for pain ○ Antibiotics ○ Tonsillectomy—removal Tonsillectomy—remov al of palatine tonsils ○ Adenoidectomy—removal Adenoidectomy—remov al of pharyngeal tonsils Both are never done while the organs are infected because operation might spread the pathogens into the blood which may lead to septicemia Pre-op nursing care: complete PE, record bleeding & clotting time, CBC & urinalysis Post-op nursing care: ○ Monitor VS • •
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Place child on abdomen so that head is lower than the chest to drain blood & unswallowed saliva Asses Assess s for subtl subtle e signs signs of hemorr hemorrhag hage: e: increa increase se PR, increa increase se RR, frequent swallowing, throat clearing If bleeding occurs, elevate head & turn to side Frequent sips of clear liquid or ice chips may be given if the patient is awak awake e beca becaus use e this this will will incr increa ease se bloo blood d supp supply ly to the the area area thus thus reducing edema and pain
b. Epis Epista taxi xis s (nos (nose e bleed bleed)) May be due to trauma, hot dry environment, after a strenuous exercise, or during a respiratory illness Management: Keep Keep in an upri uprigh ghtt posi positi tion on with with head head tilte tilted d slig slight htly ly forw forwar ard d to ○ decrease pressure in the nasal vessels ○ Appl Apply y pres pressu sure re to the the side sides s of the the nose nose with with S fingers T ○ Calm Calm the the chil child d beca becaus use e cryi crying ng will will incr increas ease e pressure in the blood vessels of the head J U b.Croup (Laryngotracheobron (Laryngotracheobronchitis) chitis) D Inflammation of larynx, trachea & major bronchi E Cause is usually viral infection Assessment: C ○ Barking (croupy) cough mostly during the O night L Insp Inspir irat ator ory y stri strido dor— r—sh shar arp, p, high high-p -pit itch ched ed ○ L sound E ○ Marked retractions G ○ May have a low-grade fever E ○ Signs of respiratory distress (restlessness, increase PR and RR) S T Management: ○ Supp Supply ly cool cool mois moistt air air thru thru a mist mist tent tent J (plastic canopy that stretches over a child’s U bed) D ○Note: bedding may become wet & cold easily so keep linens dry E ○Monitor VS every 15 minutes C ○Comfort the child to prevent crying O ○Dexamethasone is given to reduce edema L ○Racemic epinephrine for bronchodilation L E b.Aspiration G Inhalation of foreign object into the airway E When When a chil child d aspi aspira rate tes s an obje object ct,, the the init initia iall •
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reac reacti tion on is chok chokin ing g & forc forcef eful ul coug coughi hing ng whic which h usually dislodges the object If the cough has no sound or there are signs of inc increas reasiing respi espira rattory ory dif diffic ficult ulty, Heim eimlic lich maneuver maneuver (children), (children), back blows & chest chest thrust thrust (infants) should be done. ○ Heimlich maneuver Stand behind behind the child (if lying on his back, stand at the head of the bed or table) Embrace the child & grip your fist with your other hand Pull back & up with a rapid thrust Back blows & chest thrusts ○Turn the infant prone over your arm ○ Using the heel of your hand, give 5 quick back blows between between the infant’s infant’s shoulder shoulder blades If the object is not expelled, place in a supine position •
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Provide 5 quick downward thrusts in the lower third of the sternum
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b. Bron Bronch chia iall obst obstru ruct ctio ion n Right Right main main bronch bronchus us is straig straighte hterr and has larger larger lumen than than the left • bronchus in children >2 years of age. That is why an aspirated foreign obje object ct may may lodg lodge e in the the righ rightt bron bronch chus us.. The The alve alveol olii dist distal al to the the obstruction will collapse (atelectasis) Assessment: ○ Cough ○ Dyspnea ○ Hemoptysis ○ Purulent sputum ○ Localized wheezing Monitor VS Keep on NPO for at least 1 hour Liquefy secretions •
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2. Disorders Disorders of the the lower lower respirator respiratory y tract tract a. Bron Bronch chio ioli liti tis s Inflammation of fine bronchioles & small bronchi Caused by virus Assessment: ○ 1 or 2 days of upper respiratory tract infection S ○ nasal flaring T intercostal & subcostal retractions ○ ○ increase RR J ○ wheezing U D E Management: ○ Provide adequate hydration to keep respiratory membranes moist C ○ Give moist oxygen O ○ IV therapy may be started L ○ Place in semi-fowler’s position for adequate chest expansion L ○ Some are more comfortable in prone position E G a. Pneum eumonia E Inflammation of the lung alveoli May be bacterial or viral in origin S Aspiration may also cause pneumonia T Classification: ○ Pneumococcal J High High fever, fever, nasal nasal flarin flaring, g, restra restracti ctions ons,, chills chills,, dyspne dyspnea, a, chest chest pain, pain, U tachypnea, tachycardia, rales D Antiobiotics: Penicillin G E Chlamydial ○ Often seen in newborns up to 12 weeks of age C ○ Nasal congestion, cough, tachypnea, wheezing, rales O Viral L Low-gr Low-grade ade fever, fever, non produ producti ctive ve cough, cough, tachy tachypne pnea, a, dimini diminish shed ed breath breath ○ L sounds, rales rest E Mycoplasmal G ○ More frequently seen in older children E ○ Fever, cough, enlarged cervical lymph odes, rhinitis ○ Antibiotic: erythromycin S Lipid T ○ Caused by aspiration of oily or lipid substance (peanuts) J ○ Cough, dyspnea, respiratory distress U Hydrocarbon D ○ Furniture polish, kerosene, gasoline, insect sprays, lighter fluid E ○ Nausea & vomiting, drowsy, dyspnea, increase RR ○ Don’t induce vomiting C ○ Stomach lavage O ○ Prevent secondary infection L Pediatric Nursing L Page 28 of 46 E G E • •
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d. Gastro Gastroint intest estina inall Disord Disorders ers 1. Diso Disord rder ers s of mot motil ilit ity y a. Diarrhea Diarrh Diarrhea ea in infant infants s is always always seriou serious s becaus because e they they have have little little extrac extracell ellula ularr fluid fluid reserv reserve. e. Sudden Sudden los losses ses of water water may lead to dehydration. May be bacterial or viral in origin Mild diarrhea ○ 2-10 loose watery stools/day ○ fever, fever, anorex anorexia, ia, irrita irritabili bility, ty, dry mucous mucous membra membrane, ne, increas increase e PR, warm skin, good skin turgor, normal urine output ○ Management: ○ Rest the gastrointestinal tract for 1 hour then start rehydration. Severe diarrhea: ○ Fever, Fever, weak weak & rapid rapid PR, coo cooll skin, skin, pale, pale, appreh apprehens ension ion,, listle listlessn ssness ess,, lethargy ○ With With obvi obviou ous s sign signs s of dehy dehydr drat atio ion: n: incr increa ease se PR, PR, depr depres esse sed d fontanelles, sunken eyes, poor skin turgor, weight loss ○ Bowel movement every few minutes ○ Stool is liquid green with mucus and blood ○ Scanty & concentrated urine ○ Management: ○ Maintain Maintain fluid and electrolyt electrolyte e balance balance by replacing replacing lost fluids fluids and electrolytes by starting IV infusion ○ Provide skin care because diarrheal stool is irritating ○ Wet lips with moisturizing to prevent crackling •
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Constipation Difficulty passing hardened stools Abdominal pain, pain on defecation As long as the stool is not hard and no discomfort is felt in passing the stool, it is not considered constipation Management: Enema may initially be needed Give stool softeners Advise high fiber, high fluid diet Encourage to develop regular bowel habits • •
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2. Infl Inflam amma mato tory ry disea disease ses s b. Appe Append ndic icit itis is Inflammation of the appendix Most common in school age children Cause is unknown Assessment: Anorexia (12-24 hours) • At first, the child will feel diffused abdominal abdominal pain which which gradually gradually localizes at the right lower quadrant. The point of sharpest pain is 1/3 of the way between anterior posterior iliac crest and umbilicus, referred to as Mc Burney’s point. Nausea and vomiting Fever Leukocytosis Rebound tenderness Reduced bowel sound • • • •
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Management: surgical removal of appendix Pre-op nursing care: ○ Cathar Cathartic tics s & heat heat are contr contrain aindic dicate ated d becaus because e they they may cause cause rupture of appendix Shave and wash abdomen & perineum Urinalysis and CBC Start IV fluid for hydration Post- op nursing care: • •
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Chil Childr dren en will will retu return rn with with NGT NGT in plac place. e. Keep Keep on NPO NPO unti untill retu return rn of peristalsis Maintain IV fluid Monitor I and O If with ruptured appendix ○ Semi-fowle Semi-fowler’s r’s position so that infected drainage will drain onward rather than upward into the lungs ○ Start IV fluid ○ Begin antibiotics ○ Post-o Pos t-oper perati ativel vely, y, penros penrose e drain drain are mainta maintaine ined d in place place to drain drain infectious material ○ Examine wound carefully ○ Change dressings as ordered Complication: Peritonitis Sign Signs: s: rigi rigid d (boar (boardd-li like ke)) abdo abdome men, n, shal shallo low w resp respir irat atio ion, n, incr increa ease se temperature. •
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b. Necrot Necrotizi izing ng Entero Enterocol coliti itis s (NEC) (NEC) Bowel develops necrotic patches which interferes with digestion & may lead to paralytic ileus More common in immature infants Assessment: ○ Distended & tense abdomen S ○ Inability to empty stomach on next feeding T ○ (+) occult blood on stool ○ decrease BP J U Management: D ○ Temporary colostomy may be needed E ○ Provide colostomy care •
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Inflammatory bowel disease: Ulcerative colitis & Chron’s disease Ulceration in the mucosa & submucosa of the colon & rectum Wall Wall of the the colo colon n beco become mes s thic thicke kene ned d & infl inflam amed ed whic which h lead leads s to a “cobble-stone” appearance of the mucosa In Ulcerative colitis, entire lower bowel is affected Chron’ Chron’s s diseas disease, e, involv involved ed segmen segments ts are separ separate ated d by normal normal bowel bowel tissue & usually, areas affected are higher in the intestine Assessment: ○ Abdominal pain ○ Diarrhea & steatorrhea ○ Blood in the stool ○ Weight loss ○ Growth failure ○ Recurring fever Management: ○ Rest ○ TPN may be needed ○ Provide high protein, high carbohydrate, high vitamin diet ○ Anti-inflammatory drug (Prednisone) may be given ○ Provide emotional support Obstructive disorders a. Pyloric stenosis Difficulty of the stomach to empty its contents due to hyperthrophy or hyperplasia of the muscle surrounding the pylorus (valve between the stomach & beginning portion of the intestine) Assessment: ○ Projectile vomiting after 1 or 2 feedings Pediatric Nursing Page 30 of 46
Vomitus smells sour because it has been in contact with stomach enzymes Olive-shaped mass palpated on upper quadrant of abdomen ○ ○ Gastric peristaltic waves passing from left to right as the infant drinks ○ Sign Signs s of dehy dehydr drat atio ion: n: dry dry muco mucous us memb membra rane ne of mout mouth, h, depr depres esse sed d fontanelles, fever, decrease urine output, poor skin turgor, weight loss Management: ○ Pre-op nursing care: Administer IV fluids Determine baseline weight ○ Post op Frequent feedings of small amount of fluids Monitor daily weight Report if vomiting occurs ○
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Intussusception Invagination of the portion of the intestine into another Assessment: Severe abdominal pain which causes them to draw up their legs & cry They may be symptom-free after the pain In approximately 15 minutes, the abdominal pain may strike again Vomiting Blood in stool after 12 1 2 hours (“currant jelly” appearance) Distended abdomen Manage Managemen ment: t: surge surgery ry to remove remove invaga invagated ted portio portion n or reduce reduce the • intussusception Pre-op nursing care: Keep on NPO Begin IV infusion Post-op nursing care: Keep NGT & IV infusion in place • •
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c. Volvulus Twisting of the intestines leading to obstruction of the passage feces Assessment: ○ Intense crying and pain ○ Pulling up the legs ○ Abdominal distention ○ Vomiting ○ Abdominal mass • •
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Management: surgery to relieve vulvolus and reattach bowel
c. Inte Intest stin inal al obst obstru ruct ctio ion n Assessment ○ The infant does not pass meconium or may pass 1 stool, then stop ○ Distended abdomen Vomiting ○ ○ Increase bowel sounds ○ Character of infant’s cry: hard and forceful ○ Increase PR •
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Manage Mana geme ment nt:: this this is an emer emerge genc ncy y to prev preven entt dehy dehydr drat atio ion n & electrolyte imbalance. The area of stenosis is removed and the bowel is anastomosed
c. Hirschsp Hirschsprung rung disease disease (A (A ganglio ganglionic nic megacolon) megacolon) Absence of ganglionic innervation to the muscle of a section of the bowel so that there are no peristalsic waves to further the passage of the fecal material Assessment: Symptoms Symptoms are apparent after 6-12 mos. Of age. ○ History of chronic constipation of intermittent constipation and diarrhea ○ Ribbon-like stools ○ Abdominal pain •
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Nausea and vomiting Management: surgery (Swenson pull-through) usually done at 12-18 mos of age because it is difficult to perform the surgery in small abdomen so a temporary colostomy is done ○ Pre-op nursing care Dail Daily y enem enemas as to achi achiev eve e bowe bowell move moveme ment nts. s. Use Use norm normal al sali saline ne (isotonic) not tap water (hypotonic) because tap water moves rapidly to the interstitial and intravascular fluid compartments which may lead to cardiac congestion or cerebral edema Provide colostomy care Provide frequent feedings with low residue diet ○ Post-op nursing care Keep NGT and IV in place Watch out for abdominal distention Assess bowel sounds & observe for passage of flatus and stool When peristalsis returns, give small frequent feedings ○
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2. Stru Struct ctur ural al defe defect cts s a. Hernias Diaphragmatic hernia ○ Abdominal organ (usually stomach or intestine) protrudes through a defect in the diaphragm into the chest cavity. This usually occurs on the left side, displacing the heart to the right of the chest & the left lung collapses Assessment: ○ S ○ Respiratory difficulty from the time of birth T ○ Cyanosis ○ Intercostals & subcostal retractions J ○ Sunken abdomen U ○ Absent breath sound on affected lung D ○ Management: E ○ Elevate head to ease breathing C ○ Turn the infant so that affected lung is down so O that the unaffected lung will expand completely L ○ NGT or gastro gastrosto stomy my tube tube is insert inserted ed to preven preventt L distention E ○ Infa Infant nts s with with diap diaphr hrag agma mati tic c need needs s imme immedi diate ate G surgical repair E •
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A portio portion n of the intest intestine ine protru protrudes des throug through h an opening of the umbilical ring The The mass mass is gene genera rall lly y 1-2 1-2 cm in diam diamet eter er but but usually gets bigger when the child cries or strains If fascial ring is <2 cm, closure is spontaneous and needs no repair If fascial ring is >2 cm, it needs surgery which is done to school age
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Protrusion of a section of a bowel into the inguinal ring Assessment: Lumpin the groin usually on the right side Sometimes Sometimes,, hernia hernia is only apparent when crying due to increase abdominal pressure If pain pain is prese present, nt, the bowel bowel has become become incarcera erated in the sac (emergenc ency situation) Management: surgery
Imperforate anus Failure of the 2 sections of the bowel to meet or if the membrane betwee between n the 2 surfac surfaces es doesn doesn’t ’t dissol dissolve ve during during the 7 th week week of intrauterine life Pediatric Nursing Page 32 of 46
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Assessment: ○ No anal formation ○ Inability to insert rectal thermometer ○ A membrane filled with black meconium is seen protruding from the anus ○ No stool is passed leading to abdominal distention Management: ○ Post-op, NGT is inserted for decompression ○ Check bowel sound ○ Small oral feedings are resumed when bowel sounds are present ○ Maintain the suture line clean by irrigating it with normal saline ○ Take temperature thru axilla
a. Pepti eptic c ulc ulcer er Shallow excavation in the mucosal wall of stomach, pylorus or duodenum Due Due to the the over over secr secret etio ion n of gast gastri ric c juic juices es or fail failur ure e of the the muco mucosa sa to neutralize gastric secretions Causes: Causes: administrat administration ion of adrenocort adrenocorticotr icotropic opic hormone hormone or corticos corticosteroid teroids s in neonates: associated with stress (prolonged labor, sepsis: genetic factor Assessment: ○ Neonate: hematemesis (blood in vomitus) Melena (blood in stool) ○ Toddler: feeding problems Vomiting Pre-school: Pain on arising not relieved be eating, poorly localized ○ Older Older schoo schooll age/ad age/adole olesce scent: nt: gnawin gnawing g or aching aching pain pain in epigas epigastri tric c ○ befo before re meal meals s that that is reli reliev eved ed by eati eating ng,, vomi vomiti ting ng tend tender erne ness ss in epigastric region. Management: ○ Medications to decrease gastric acidity acidity (Cimetidine) taken with meals or at bedtime ○ In infants, give frequent small feedings ○ In children, avoid heavily spiced foods ○ Provide emotional support and relieve stress •
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2. Malabsorpti Malabsorption on syndrome syndrome (Celiac (Celiac disease) disease) Sensit Sensitivi ivity ty or immuno immunolog logic ic respon response se to protei protein, n, partic particula ularly rly the gluten gluten factor factor of • protein found in grains Upon Upon inge ingest stio ion n of thes these e food foods, s, chan change ges s occu occurr in the the inte intest stin inal al muco mucosa sa thus thus preventing the absorption of foods across the intestinal villi into the blood stream Assessment: ○ Anorexia ○ Irritability ○ Distended abdomen ○ Steatorrhea ○ Malnutrition Management: gluten-free diet for life Foods containing gluten: wheat, oats, barley products •
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2. Hepa Hepati tic c diso disord rder ers s a. Hepat epatiitis tis Inflammation & infection of the liver •
Causative agent Incubation period Period of communicability
Mode of transmission
Hepatitis A Hepa A virus 25 days 2 weeks eeks befo beforre ons onset jaundice
Hepatitis B Hepa B virus 120 days of Later part of the incubation period, acute stage
inge ingest stio ion n of cont contam amin inat ated ed water, water, sexual sexual trans transmis missio sion n from oral intercourse
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Contaminated blood, plasma or semen, placental transmiss transmission, ion, contamina contaminated ted syringe
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Assessment: ○ Headache, vomiting ○ Generalized aching ○ Right upper quadrant pain ○ Icteric sclera ○ Generalized jaundice ○ White or gray-colored stool ○ Low-grade fever, sore throat, nasal discharge ○ Dark-colored urine after 3-7 days Management: ○ Maintain a high-caloric diet ○ Strict hand washing & isolation technique ○ Cool bath to reduce discomfort from pruritus Complication: Hepatic coma
a. Obstru Obstructi ction on of of the the bile bile ducts ducts Bile cannot enter intestinal tract & accumulates in the liver, bile enters the blood stream so that infant appears a ppears jaundice Assessment: ○ Jaundice after 2 weeks ○ Rise in direct bilirubin ○ Elevated alkaline & phosphatase level ○ Poor absorption of fat-soluble vitamins ○ White stools due to lack of bile pigments Management: ○ If mucus plug is suspected, give MgSO4 or dehydrochloric acid ○ It atresia of bile duct is suspected, surgery is needed ○ Pre-op nursing care: Low-fat, high protein pre-op diet Give vitamins A, D, K ○ Post-op nursing care: Keep NGT in place until peristalsis returns Observe for abdominal distention Monitor stool •
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2. Nutrit Nutrition ional al defici deficienc encies ies a. Vita Vitami min n A defi defici cien ency cy Night blindness- earliest sign Xerophthalmia- conjuctive becomes dry and lusterless Kerato Keratomal malaci aciaa- necros necrosis is of the cornea cornea with with perfor perforati ation, on, los loss s of ocular ocular fluid, fluid, blindness Treatment: administration of supplementary Vitamin A Diet rich in Vitamin A • • •
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a. Thiami Thiamine ne (Vit (Vitami amin n B1) defici deficienc ency y Beriberi Earliest signs: ○ Tingling or numbness of extremities ○ Occasional heart palpation ○ Exhaustion Treatment: Administration of Thiamine • Thiamine rich diet • •
a. Niac Niacin in defi defici cien ency cy Pellagra Characteristics (4 Ds); ○ Dermatitis ○ Diarrhea ○ Dementia ○ Death • •
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Characteristics: ○ Muscle tenderness ○ Petechial hemorrhage of the skin Nose bleeding ○ ○ Swollen gums Treatment: Administration of supplementary Vitamin C diet rich in fresh fruits and vegetables.
a. Vita Vitami min n D defi defici cien ency cy Rickets Characteristics: ○ Poor muscle tone ○ Delayed motor development Delayed tooth eruption ○ ○ Gastrointestinal upset ○ Excessive perspiration of the head ○ Swelling of epiphysis of the long bones ○ Bowlegs, knock-knee deformities ○ Spinal deformities Treatment: Administration of Vitamin D Diet rich in Calcium & Vitamin D Expose children to sunlight • •
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a. Iodi Iodine ne defi defici cien ency cy Goiter (hyperplasia of the thyroid gland) Has difficulty breathing Treatment: supplemental iodine Synthetic thyroxine High-iodine diet • •
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a. Kwas Kwash hiork iorkor or Caused by protein deficiency More frequently seen in children ages 1-3 years Characteristics: ○ Growth failure ○ Muscle wasting ○ Irritability ○ Iron-deficiency anemia ○ Diarrhea Treatment: high protein diet • • •
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a. Nutr Nutrit itio iona nall Mara Marasm smus us Deficiency of all food groups ○ ○ Most commonly seen in children younger than 1 year ○ Characteristics: ○ Growth failure ○ Muscle wasting ○ Iron- deficiency anemia ○ Diarrhea ○ Treatment: diet rich in nutrients 2.Poisoning More common between the ages of 2-3 years Emergency management of poisoning at home: ○ Call for help ○ Identify the poison ○ Check the respiration If deep, rapid- ACID If slow, shallow- ALKALINE ○ Remove poison from the body including vomiting ○ Give Give syru syrup p of ipec ipecac ac:: 15 ml (ado (adoles lesce cent nt,, scho school ol-ag -age e chil child, d, preschooler) 10 ml (infant) followed by 200 ml of fluid • •
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If syrup of Ipecac is not available, induce gagging by placing finger in the back of the throat Do not induce vomiting if: The child is comatose The child has seizure The poison was caustic, corrosive or hydrocarbon Give antidote (opposite of the poison) Universal antidote (opposite of the poison) Burned toast Milk of magnesia Strong tea Gastric lavage administer saline cathartic (harsh laxatives) can cause dehydration & fluid electrolyte e lectrolyte imbalance
a. Salicy Salicylat late e poison poisoning ing (asp (aspiri irin) n) ○ Toxic dose: 150-200 mg/kg body weight ○ Indicative signs: ○ Hyperventilation leading to respiratory alkalosis ○ Metabolic acidosis ○ High fever ○ Dehydration ○ Tachycardia S ○ Vomiting T ○ Diarrhea ○ Restlessness J ○ Confusion U ○ Tinnitus D ○ Management E ○ Remove poison from the body Give syrup of ipecac C Gastric lavage O ○ Offer fluid orally to dilute poison and prevent dehydration L ○ Give sodium bicarbonate to create alkaline urine L ○ Tepid sponge bath, cooling blanket E ○ Start IV fluid G ○ Monitor VS, signs of hypoglycemia, metabolic acidosis E S T J U D E C O L L E G E S T J U D E C O L L E G E
a. Caus Causti tic c pois poison onin ing g ○Lye in washing powder, toilet bowl cleaners, hair care products ○S/Sx: ○ Pain in mouth & throat ○ Drooling ○ Mouth turns white due to burn and later turns brown due to edema & ulceration ○ Vomiting of blood & mucus ○ Tachycardia ○ Tachypnea ○ Pallor ○ Hypotension ○Management: NOTE: Vomiting should never be induced because the corrosive substance will burn as it moves along the GI tract ○Dilute poison with milk or water ○Start art ster steroi oid d thera herapy py to dec decreas ease chan hance of perma ermane nen nt esophageal scarring ○Monitor VS a. Lead Lead pois poison onin ing g ○Interferes with RBC function ○Effects: CNS: lethargy, impulsiveness, mental dysfunction Hematology: Hypochromic, microctic anemia Pediatric Nursing Page 36 of 46
GI: constipation, abdominal pain, vomiting Kidney: hematuria ○ Management: Chelation therapy to remove lead from soft tissue and bone & eliminate it in the urine EDTA (Edetate Calcium Disodium) BAL (Dimercaprol)
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A. CARDIO CARDIOVAS VASCUL CULAR AR DYSFUN DYSFUNCTI CTION ON Normal Blood Flow Different parts of the body
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Left Ventricle
Unoxygenated Unoxygenated blood
Inferior & Superior Vena Cava
Mitral valve
Right atrium
Left Atrium
Tricuspid valve
Pulmonary vein Oxygenated blood
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Pulmonary artery
lungs
1. Congen Congenita itall heart heart diseas disease e a. A Cyan Cyanot otic ic Hea Heart rt Dis Diseas ease e There is a presence of left to right shunt. There is a defect that allows the blood to flow from the left side of the heart (higher pressure) back to the right side (lower pressure). Thus, the right heart is subjected at a greater pressure. Also, there is less oxygenated blood being delivered to the different parts of the body which will cause the left heart to compensate by pumping harder. This condition might eventually lead to heart failure. ○
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Ventricular Septal Defect ○ Most common of all congenital cardiac defects ○ 2 in every 1,000 live births ○ There There is an openin opening g in the septum septum betwee between n the left and right ventricl ventricles. es. Because of this, the oxygenated blood which is supposed to b e delivered to the different parts of the body is shunted back to the to the right ventricle and into into the pulmon pulmonary ary circul circulati ation on for reoxyg reoxygena enatio tion. n. Thus, Thus, there there is less less oxygenated blood being delivered to the body. ○ Assessment: Loud, harsh systolic murmur along left sternal border at the 3 rd or 4 th ICS at ○ about 4-8 weeks of age ○ A thrill may be palpable ○ Diagnostics: x-ray, MRI, UTZ which will reveal right ventricular hypertrophy ○ Management: ○ Around 60% of small ventricular septal defects will spontaneously close while the remaining 40% requires open heart surgery Atrial Septal Defect ○ There is an abnormal communication between left and right atriums. Because of this, oxygenated blood from left atrium will go back to the right atrium, so that that oxygen oxygenate ated d blood blood which which is suppos supposed ed to be delive delivered red to the body is diminished. ○ Assessment: Harsh systolic murmur over 2 nd or 3rd ICS (pulmonic area) ○
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Split heart sound sound (fixed (fixed splitting) splitting) which is almost almost always always diagnostic diagnostic of Atrial Atrial Septal defect. Diagnostics: Echocardiography reveals enlarged right side of the heart and increase pulmonary circulation ○ Management: Open heart surgery ○
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Patent Ductus Arteriosus ○ The ductus arteriosus is an accessory fetal vessel that closes at birth or be completed at 3 mos. of age in some infants. It connects the pulmonary artery and aorta. If it fails to close, oxygenated blood from the aorta will go back to the pulmonary artery back into the lungs for reoxygenation. This puts additional strain on the left ventricle causing hypertrophy. ○ Assessment: Wide pulse pressure ○ Continuous “machinery” murmur on upper right sternal border or under the left clavicle in older children ○ Diagnostics: ECG or x-ray reveals ventricular hypertrophy ○ Management: Administration of oral or IV Indomethacin Ligate patient ductus arteriosus ○ If surgery is not done, there is increased increased risk of Congestiv Congestive e Heart Failure and infectious endocarditis. Pulmonary Stenosis ○ Narrowing of pulmonary valve or pulmonary artery distal to the vavle. vavle. Due to this, this, the right right ventri ventricle cle cannot cannot effect effective ively ly empty empty blood blood by the way of pulmonar pulmonary y artery artery which which will will lead lead to right right ventricular hypertrophy ○ Assessment: ○ Systolic ejection murmur at upper left sternal border ○ Thrill may be present in left upper sternal area or the suprasternal notch ○ Diagnostic Diagnostics: s: ECG reveals reveals right ventricula ventricularr hypertrop hypertrophy; hy; cardiac cardiac catheter will reveal degree of stenosis ○ Management: balloon stenotomy Aortic Stenosis ○ Narr Narrow owin ing g of aort aortic ic valv valve e whic which h prev preven ents ts left left vent ventri ricl cle e from from effect effective ively ly emptyi emptying ng blood blood to the aorta. aorta. This This causes causes increa increase se pressure in the left ventricle as it attempts to force blood to the stenosed valve. ○ Assessment: ○ May be asymptomatic Murmur loudest at the 2nd right ICS ○ ○ Thrill may be present at the suprasaternal notch ○ Diagnostic Diagnostics: s: ECG reveals reveals right ventricula ventricularr hypertrop hypertrophy; hy; cardiac cardiac catheter reveals degree of stenosis ○ Management: balloon stenotomy, surgical repair
Coarction of Aorta (COA) There is narrowing of the aorta so that oxygenated blood which is supposed to be delivered to the different parts of the body cannot pass thru. This will also cause the left ventricle to pump harder which will eventually lead to ventricular hypertrophy. Assessment: Absence of femoral pulse BP in upper extremities is higher than in lower extremities. Normally, there is higher BP in lower extremities because of peripheral resistance. Vertigo, headache Exceptional irritability in a child <3 years old Epistaxis ○
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Leg pain pain on exer exerti tion on beca becaus use e of decr decreas eased ed bloo blood d supp supply ly to the the lowe lowerr extremities Murmur may occasionally be present Diagnostics: x-ray, ECG reveals left side hypertrophy Management: surgery between 3-4 years of age
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Cyan Cyanot otic ic hea heart rt dis diseas ease e ○ There is presence of right to left shunt. There is a defect that allows an oxygenated blood to enter the general circulation. Transposition of great vessels The pulmonary artery arises from the left ventricle instead of the right while the aorta aorta arises arises from the right ventri ventricle cle instead instead of the left. Thus, Thus, blood blood entering the right atrium goes to the right ventricle, then the aorta, to the different parts of the body which is completely unoxygenated. On the left side of the heart, oxygenated blood from the lungs enter the pulmonary vein to the left atrium to the left ventricle and out to the pulmonary artery to the lungs for re-oxygenation. Assessment: ○ Cyanotic from birth ○ Murmur may be present or not Diagnostics: x-ray film reveals enlarged heart Management: Surgery
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Tetralogy of Fallot ○ 4 anomalies: Pulmonary stenosis- because of this, un-oxygenated blood cannot pass thru it thus increasing the pressure on the right ventricle Ventri Ventricul cular ar septal septal defect defect-- there there is an openin opening g betwee between n the left left and right right ventri ventricle cles. s. Becaus Because e of the increa increasin sing g pressu pressure re on the right right ventri ventricle cle,, unoxygenated blood will flow thru this opening to the heart to the left ventricle Overriding aorta- un- oxygenated septal defect to be delivered to the different parts of the body Right Right ventri ventricu cular lar hypert hypertrop rophyhy- becaus because e of pulmon pulmonary ary stenos stenosis, is, the right right ventricle will pump harder so as to force blood to the stenosed artery. ○ Assessment: ○ Cyanosis Poly Polycy cyth them emia ia (inc (incre reas ase e in numb number er of RBC) RBC) -- an atte attemp mptt of the the body body to provide adequate RBC to supply oxygen to the body. However, this causes the blood to become too thick, predisposing the child to thrombophlebitis, embolus, CVA Severe dyspnea relieved by squatting ○ ○ Clubbing of fingers & toes ○ Growth and mental retardation ○ A loud, harsh murmur may be present Diagnostics: x-ray reveals enlarged heart ○ ECG reveals right ventricular hypertrophy Cardiac catheter
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Management: surgery at 2-3 years of age
1. Conges Congestiv tive e Heart Heart Failu Failure re (CHF) (CHF) Occurs Occurs when the heart heart cannot cannot pump enough enough blood to supply supply oxygen oxygen & nutrients to body cells. There is pooling of blood in the pulmonary or venous systems Assessment: Right-sided heart failure: Tachycardia Hepatomegaly Irritable, restlessness due to abdominal pain Edema-late sign in children Weight gain Left-sided heart failure: Pediatric Nursing Page 39 of 46
Tachycardia Tachypnea, dsypnea Rales Bloody sputum Easy fatigability Feeding difficulty Cyanosis Diagnostics: chest x-ray, echocardiography & fluoroscopy reveals an enlarged heart. On PE, apical heart beat is displaced laterally & downward Management: ○ Reduce workload of heart: Provide rest, minimal handling Small frequent feedings ○ Evacuate accumulated fluids: S Diuretics T Low-Na diet ○ Improve cardiac contractility: J U Digitalis D E 1. Rheu Rheuma mati tic c feve feverr An autoimmun autoimmune e disease disease caused caused by group-A-b group-A-beta-h eta-hemoly emolytic tic streptococ streptococcal cal C infect infection ion.. This This often often follow follows s an attack attack of GroupGroup-A A beta-h beta-hemo emolyt lytic ic strep strep O infection like tonsillitis, phrayngitis, scarlet fever or impetigo L This disease is diagnosed if there are 2 major or 1 minor symptoms present L plus a previous history of streptoinfection (Jone’s criteria) E ○ Major manifestations: G Chorea: E most striking symptom loss of voluntary muscle control S dysfunctional speech T weak hand grasp Carditis- most serious; presence of systolic murmur J Erythema marginatum- macular rash over the trunk & extremities U Subcutaneous nodules painless lumps on joints D Polyarthritis- large joints becomes red, swollen, hot & tender E ○ Minor manifestations: Fever C Previous strep infection O Arthralgia L Elevated ESR (inflammation) L (+) C reactive protein E Leukocytosis G Prolonged P-R interval (ECG) E
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Bed Bed rest rest to redu reduce ce card cardia iac c work worklo load ad unti untill ESR, ESR, C reac reacti tive ve protein, PR return to normal ○ Take VS especially apical pulse ○ Provide diet high in protein and calorie ○ Drugs: Penicillin to eliminate group-A-beta-hemoly group-A-beta-hemolytic tic streptococcus Salicylates to reduce inflammation & pain Phenobarbital to reduce purposeful movements of chorea Corticosteroids to reduce inflammation ○
A.HEMATOLOGIC DYSFUNCTION 1. RBC RBC Diso Disord rder er:: Anem Anemia ia Decrease in the number or function of erythrocytes •
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Normochromic, normocytic anemias RBCs RBCs are norm normal al in both both colo colorr and and size size but too too few few in
number Acute blood-loss anemia May Ma y be caus caused ed by trau trauma ma such such as acci accide dent nt,, acut acute e neph nephri riti tis, s, ○ placenta previa; abruptio placenta Pediatric Nursing Page 40 of 46
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Assessment: Pallor Tachycardia Tachypnea Gasping respiration Sternal retractions Cyanosis Treatment: Control bleeding Place in a supine position to provide circulation to the brain cells Keep child warm with blanket Blood transfusion may be necessary
Aplastic Anemia ○ Results from depression of hematopoietic activity in bone marrow ○ Formation of WBC, RBC and platelets are affected ○ Maybe due to excessive exposure to radiation, drugs, chemicals which cause bone marrow damage (chloramphenicol, sulfonamides, arsenic, benzene, quinine) ○ Assessment: Pallor Easy fatigability Anorexia Petechiae Nose bleeding GI bleeding Prone to infection ○ Management: Supp Suppre ress ss abno abnorm rmal al bone bone marr marrow ow with with anti anti-t -thy hymo mocy cyte te globulin (ATG) or anti-lymphocyte globulin (ALG) Packed RBC & platelet transfusion may be necessary Corticosteroids & testosterone may be given Strict hand washing to prevent infection
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Hypochromic anemias RBCs are pale Iron deficiency anemia Most common anemia of infancy & childhood due to poor intake of dietary iron Causes: dietary deficiency, chronic blood loss, low birth weight infants, excessive demands Assessment: ○ Pale mucous membranes ○ Poor muscle tone ○ Reduced activity ○ Heart may be enlarged ○ Spleen may be slightly enlarged Management: ○ Treat underlying cause ○ Diet rich in Iron ○ Give Ferrous sulfate—should be taken after meal to reduce GI irritation. Vitamin C may be given together with Fe to increase absorption. Imferon (Iron-dextran injecton) given IM ○ ○ Stains skin ○ Irritating unless given by deep Z-track technique •
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Caused Caused by defici deficienc ency y or inabili inability ty to use use Vitamin B12 due to lack of intrinsic factor in the gastric mucosa
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Assessment: Pallor, anorexia Irritability Chronic diarrhea Ataxia, hyporeflexia, paresthesia Treatment: lifelong monthly injection of Vitamin B12 (IM)
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Neoplastic disorder: LEUKEMIA ○ Distorted & uncontrolled proliferation of WBC ○ Most common type of cancer in children Acute Myelogenous Leukemia (AML) Most common type in adulthood Over proliferation of granulocytes Acute Lymphocytic Leukemia (ALL) Most common type in children Highest incidence is in children between 3-5 years of age ○ Unknown cause: may be due to prenatal exposure to radiation, drugs and chemicals: family predisposition. Due to rapid proliferation of abnormal WBC: Decrease RBC- anemia - Pallor, lethargy Decrease platelets- thrombocytopenia - Petechiae, bleeding, bruise easily Decrease normal WBC- leukopenia - Prone to infection •
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Othe Otherr s/sx s/sx:: head headac ache he,, vomi vomiti ting ng,, atax ataxia ia,, abdo abdomi mina nall disten distentio tion, n, abdomi abdominal nal pain, pain, anorex anorexia, ia, hepato hepatomeg megaly aly,, sple spleno nom megal egaly, y, bon bone pain pain,, pain painle less ss gene generrali alized zed adenopathy
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A. RENA RENAL L DYS DYSFU FUNC NCTI TION ON 1. Urinar Urinary y Tract Tract Infect Infection ion (UTI) (UTI) Occurs from ascending spread from the urethra to the bladder Occur more often in girls because their urethra is shorter & is located closer to the anus Assessment: ○ Pain on urination ○ Frequency ○ Burning ○ Hematuria Cystitits: low-grade fever, abdominal pain, enuresis (bedwetting) Pylonephritis: fever, abdominal or flank pain, vomiting, malaise Management: ○ Antibiotics (Amoxicillin, ampicillin) ○ Drink large amount of fluids to “flush” infection out of the urinary tract •
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1. Acute Acute Glome Glomerul rulone onephr phriti itis s (AGN) (AGN) ○ Inflammation of the glomeruli of the kidney that usually occurs as a hypers hypersens ensiti itivit vity y reacti reaction on to groupgroup-A A beta-h beta-hemo emolyt lytic ic bacter bacterial ial infection Assessment: Pediatric Nursing Page 42 of 46
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Has a history of recent respiratory infection or impetigo Gross hematuria, proteinuria, oliguria Hypertension Abdominal pain Low-grade fever Periorbital edema Anorexia Vomiting, headache Diagnostics: ○ Hypoalbuminemia ○ Mild anemia ○ Increase ESR ○ Increase BUN and creatinine ○ Elevated antistreptolysin O Management: ○ Place in semi-fowler’s position ○ Oxygen administration may be necessary ○ Diet should be low in protein, low salt ○ Weigh daily ○ Medications: antihypertensive, digitalis, penicillin
3. Nephro Nephrotic tic Syndr Syndrome ome (Neprh (Neprhosi osis) s)]] Increased glomerular permeability which causes abnormal loss • of protein in the urine May be caused caused by hypers hypersens ensiti itivit vity y to Ag-Ab Ag-Ab reacti reaction on of an autoimmune process •
Increase glomerular permeability
Protein lost in urine
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HYPEREDEMA
A.NEUROLOGIC DSYFUNCTIONS 1. Cere Cerebr bral al Pals Palsy y ○ Group of disorders affecting the upper motor neuron resulting in motor dysfunctions ○ Frequently caused by brain anoxia leading to cell destruction May be caused before, during or shortly after birth (placenta, ○ prev previa ia,, abru abrupt ptio io plac placen enta ta,, mate matern rnal al infe infect ctio ion, n, nutr nutrit itio iona nall deficiency, prematurity, prolonged labor, forceps delivery, RDS, neonatal infections, traumatic head injury) ○ Types: ○ Spastic—hyperactive, hypertonic muscles, exaggeration of deep tendon reflexes, abnormal reflexes ○ Athetoid Athetoid type- abnormal involuntar involuntary y movement, movement, limp, flaccid early in life, worm-like movement, drooling Pediatric Nursing Page 43 of 46
Ataxic type—awkward, wide-based gait, primary incoordination ○ Mixed type Assessment: ○ Delayed motor development ○ Abnormal head circumference (may be smaller due to slow brain growth) ○ Abnormal postures ○ Abnormal reflexes ○ Abnormal motor performance May have sensory disturbances: strabismus, visual problems, speech problem ○ Irritable, impulsive, short attention span ○ May have mental retardation Management: ○ Maintain safe environment & prevent injuries ○ Facilitate passive & active ROM exercises ○ Prevent contractures ○ Assist in doing self-care (dressing) ○ Provide adequate nutrition ○ High roughage to prevent constipation ○ Soft diet to children who cannot chew or swallow well ○ Be patient because these children take longer time eating ○
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Meningitis Infection of the cerebral meninges Caused by H. Influenzae, Neisseria meningitides, group-B streptococcus Assessment: ○ May occur insidiously or suddenly ○ 2-3 days of upper respiratory tract infection ○ Irritability ○ Headache ○ Convulsion In newborns: ○ Poor sucking ○ Weak cry ○ Lethargy ○ Convulsion ○ Apnea ○ Bulging and tense fontanelles Signs of meningeal irritability: ○ Nuchal rigidity (+) Kernigh’s sign (pain on extending the knee when thigh is bent on the abdomen) ○ (+) Brudzinski’s sign ○ Opisthotonus (back is arched & neck hyperextended) Diagnostics: ○ Lumbar puncture reveals: ○ Increase WBC ○ Increase protein ○ Decrease glucose ○ Increase ICP Management: ○ Antibiotic therapy (Ampicillin, Chloramphenicol) given IV for rapid effect ○ Corticosteroid may be given to decrease ICP ○ Provide rest & quiet environment ○ Monitor VS, level of consciousness & motor activity ○ Weigh child daily ○ Avoid sudden change in position 3. Ence Enceph phal alit itis is Inflammation of brain tissues Caused by protozoa, bacteria, fungi, virus Assessment: ○ Headache Pediatric Nursing Page 44 of 46
Fever ○ Signs of meningeal irritation ○ Muscle weakness ○ Paralysis ○ Confusion ○ Irritability Management: ○ Antipyretic to control fever ○ Antibiotic treatment ○ Anticonvulsant ○ Provide rest ○ Monitor VS, LOC, motor activity & signs of increase ICP ○
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3. Seizures Involuntary contraction of muscle due to abnormal electrical brain discharges Causes: In newborns: ○ Trauma at birth ○ Metabolic disorder (hypoglycemia, hypocalcemia, lack of Vitamin B6) ○ Neonatal infection ○ Kernicterus In infants and toddlers: ○ Infantile spasms S ○ Poisoning or drugs T ○ Febrile convulsions (38.9-40 C) Activ Active e tonictonic-clo clonic nic patter pattern n lastin lasting g J 15-20 seconds U Types: Psychomotor seizure ○ D Sudd Sudden en chan change ge in post postur ure e (arm (arm E dropping) Child slumps to the ground C Unconscious O Regains consciousness in less than 5 L minutes L ○ Focal seizure E Originate from a specific brain area G Begins Begins in the fingers fingers & spread spreads s to • E the the wris wrist, t, arm arm & face face in a clon clonic ic contraction S May Ma y progr rogres ess s to a gener eneral aliz ized ed T seizure ○ Absence seizure (Petit Mal) J Staring spell last asting for a few U seconds D Rhythmic blinking E Twitching of mouth or extremity After seizure, child resumes activity C unaware of what happened O ○ Tonic-clonic seizure (Grand Mal) L 4 stages: L Prodromal period E ○ Drows Drowsine iness, ss, dizzin dizziness ess,, malais malaise, e, lack lack of coo coordi rdinat nation ion,, G tension E Aura Aura-- may may refl reflec ectt port portio ion n of the the brain affected S ○ Smelling unpleasant odors- medial portion of temporal T lobe ○ Seeing flash lights- occipital area J U ○ Repeated hallucinations- temporal lobe D ○ Numbness of extremities- parietal lobe E ○ “Cheshire cat grin” – frontal lobe Tonic-clonic convulsion C Tonic (20 seconds) O All muscles of the body contract L Pediatric Nursing L Page 45 of 46 E G E • •
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Falls to the ground Extremities stiffen Saliva collects in the mouth May bite his tongue Clonic (20 seconds) • Muscles rapidly contract & relax Quick jerky motions May blow bubbles or foamy saliva Post-ictal period Child falls into a sound sleep for 1-4 hours When When he awak awaken ens, s, he appe appear ars s drow drowsy sy,, has has seve severe re headache & has no memory of the seizure ○ Status epilepticus Occurs in rapid succession without pause A medical emergency because the child does not have the time to aera aerate te the the lung lungs s & may may lead lead to brai brain n dama damage ge due due to decrease O2 supply Management: ○ Protect the child from hurting himself (remove chairs and other objects that may harm the child) ○ Do not restrain the child ○ Remain calm ○ Loosen clothes ○ Keep Keep the the head head on 1 side side to prev preven entt tong tongue ue S from obstructing the airway T ○ Keto Ketoge geni nic c diet diet (hig (high h fat, fat, low low prot protei ein n and and carbohydrate) J ○ Medications: U Drug depend on the type of seizure D Psychomotor- Phenytoin, Carbamazepine, Primidone E Absence (Petit Mal)- Ethosuximide (Zarontin), Valproate Tonic-clonic (Grand Mal)- Phenytoin Sodium (Dilantin) C Do not no t disc discon onti tinu nue e drug drug abru abrupt ptly ly beca becaus use e it may may resu result lt in • O severe seizure L Periodic blood sampling to monitor blood levels of the medicine L E MISCELLANEOUS G Infantile Eczema (Atopic Dermatitis) E Skin allergic reaction mainly from food allergy (milk, eggs, wheat, citrus, juices, tomatoes) S Common in formula-fed infants T May begin in the 2nd month of lasting until 2-3 years of age • • • •
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J U D E C O L L E G E S T J U D E C O L L E G E
Pediatric Nursing Page 46 of 46