Pediatric Nursing Pentagon

PEDIATRIC NURSING I. Growth & Development *Growth - Increase in physical size of a structure or whole. - Quantitative change.

Two parameters of Growth 1.

Weight- Most sensitive measure of growth, especially low birth rate. 6 months-----BW doubles 12 months----BW triples 2-2 ½ yrs-----BW yrs-----BW quadrupled

2. Height - Increase by 1”/mo during 1st 6 months, 7-12 months by 1 ½ inch. - Average Average increase in height height - 1st year = 50% Stoppage of ht coincide with eruption of wisdom tooth. *Development - Increase skills or capability to function Qualitative

How to measure development: 1. Observ Observee chil child d doin doing g spec specifi ificc task task.. 2. Role Role desc descrip riptio tion n of of child child’s ’s progre progress ss 3. DDST- Denver development screening test except mental, its I.Q. Test MMDST (Phil) Metro Manila Developmental Screening Test.

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

*Maturation- same with development “readiness” *Cognitive Development –ability to learn and understand from from experience, to acquire acquire and retain knowledge, knowledge, to respond to a new situation and to solve problems. *Learning---change *Learning---change of behavior IQ Test- test to determine cognitive development Formula: Mental age x 100 = IQ Chronological age

* Average IQ – 90-100 * Gifted child- > 130 IQ

II. Basic Divisions of Life 1.

Prena Prenatal tal stage stage fro from m conce concepti ptionon- birth birth

2.

Perio eriod d of of Inf Infaancy ncy a. Neonate- 1st 28 days day s or 1st 4 weeks of life b. Formal infancyinfancy- 29 day – 1 year

3.

Early arly Chil Childh dhoo ood d a. Toddl oddleer – 1-3 1-3 yrs yrs b. Pre school 4-6 years years

4.

Middl iddlee Ch Childh ildhoo ood d a. School age- 7 – 12 yrs

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Late Ch Childhood a. Pre Pre ado adole lesc scen entt 11 – 13 13 yrs yrs b. Adolescent 12 - 18 – 21

Created by Niňa E. Tubio

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

a. b.

Renal, Renal, GIT, GIT, musculoske musculoskeletal letal,, circulato circulatory--ry----gr -grows ows rapidly rapidly during during childho childhood od Neuromuscular Neuromuscular tissue (CNS, brain, brain, S. cord)---grow cord)---grow rapidly 1-2 years years of life Brain achieved its adult proportion by 5 years. 1-2 y/o- very important yrs---if with severe malnutrition--mild malnutrition--mild mental retardation • •

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

Rates of G&D: a. Fetal and Infancy – period of most rapid G&D -----*prone to develop anemia b. Adolescent- period of rapid G&D G&D Toddler- slow growth period c. Toddle Toddlerr and presc preschoo hooll- alter alternat nating ing rapid rapid and and slow slow d. Scho School ol ageage- slow slower er grow growth th

3. Each child is unique A. Heredity:

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

B. Environment: Q – quality of nutrition S – socio eco. status H – health O – ordinal position in family P – par pareent chi child ld rela elation tionsh ship ip

Eldest- ability in comm. & social skills youn younge gesst- more ore toi toile lett trai traine ned d

4. G&D occurs in a regular direction direction reflecting a definitive & predictable patterns or trends. A. Directional Trends- occur in a regular direction reflecting the development of neuromuscular function. These apply to physical, mental, social and emotional development and i ncludes. 1. Cephalo-caudal--- “head to toe” • Occurs along body’s long axis in w/c control over head, mouth & eye movements & precedes control over upper body torso and legs. 2. Proximo- distal---- “Centro distal” • From center of body to extremities. 3. Symmetrical----side of body develop on same direction at same time at same rate. 4. Mass Specific “Differentiation” - Learns simple operations before complex function, from broad general pattern of behavior to a refined pattern.

B. Sequential- involves a predictable sequence of G&D to w/c w/c the child normally passes. 1. Locomotion- creep, crawls, sit then stand. 2. Socio & Language skills- solitary games, parallel games C. Secular- worldwide trend of maturing earlier & growing larger as compared to succeeding generations. 5.Behavior--most 5.Behavior--most compressive indicator of developmental status. 6. Universal language of child- play 7. Great Great deal deal of skill skill and behavior behavior is is learned learned by practic practice. e. Practice Practice makes makes perfe perfect. ct. st 9. Neonatal reflexes must be lost 1 before dev’t can proceed. -Plantar reflex shld. disappear before baby can walk


*1st cry--oha 2nd sound-cooing 3rd sound-ahh(bowel) *1st play-solitary

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-Moro reflex shld. disappear before baby can roll *Persistent primitive infantile reflexes- case of cerebral palsy

IV. Theories of G&D Developmental Tasks- different from chronological age  skill or growth responsibility arising at a particular time in t he individual’s life.  The successful achievement of w/c will provide a foundation for the accomplishments of future tasks. Theorists 1. SIGMUND FREUD: (1856-1939) Austrian neurologists----neurologists----- Founder of Psychoanalysis - offered offered personality development, Psychosexual theory theory *Phases of Psychosexual Theory* a.) Oral Phase------------- 0-18 months - Mouth: site of gratification -Activity of infant- biting, sucking crying. -Why do babies suck?- enjoyment & release of tension. -Provide oral stimulation even if baby on NPO. -Pacifier. -Never discourage thumb sucking.

b.) Anal Phase------------- 18 months-3 years -Anus: site of gratification -Activity- elimination, retention or defecation of feces must take place - Principle of holding on or letting go. -Mother wins or child wins -Child wins- stubborn, hardheaded anti social. (anak pupu na, child holds pupu, child wins) -Mother wins- obedient, kind, perfectionist, meticulous---------OC-anal phase -Help child achieve bowel & bladder control even if child is hospitalized. c.) Phallic Phase----------- 3-6 years - Genitals: site of gratification - Activity- may show exhibitionism - Increase knowledge of a sexes - Accept child fondling his/her own genitalia as normal exploration - Answer Childs question directly. - Right age to introduce sexuality – preschool d.) Latent Phase---------- 7-12 years -Period of suppression- no obvious development. -Childs libido or energy is diverted to more concrete type of thinking -Helps child achieve (+) experience, experience, ready to face conflict of adolescence e.) Genital Phase--------- 12-18 years -Genitals: site of gratification -Achieve sexual maturity -Learns to establish relationships with opposite sex. -Give an opportunity to relate to opposite sex. 2. ERIC ERICKSON - Psychoanalysis theory -stresses important of culture & society to the development of ones personality -environment , culture *Stages of Psychosocial Theory*

a.) Trust vs. Mistrust – 0-18 months . -foundations of all psychosocial task -to give & receive is the psychosocial theme -know to develop trust baby 1. Satisfy needs on time - breastfeed 2. Care must be consistent & adequate


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-both parents- 1st 1 year of life 3. Give an experience that will add to security- touch, eye to eye contact, soft music. b.) Autonomy vs. Shame & Doubt---- 18-3 years - Independence /self gov’t - Develop autonomy on toddler ---1. Give an opportunity of decision making, offer offer choices. 2. Encourage to make decision rather than judge. 3. Set limits c. Initiative vs. Guilt------------------------ 4-6 years -Learns how to do basic things -Let explore new places & events -activity recommended- modeling clay, finger painting--enhance imagination & creativity & facilitate fine motor dev’t d. Industry vs. Inferiority------------------- 7-12 yrs -Child learns how to do things well -Give short assignments & projects e. Identity vs. Role Confusion or Diffusion 12-18 yrs -Learns who he/she is, what kind of person he/ she will become by adjusting to new body image and seeking emancipation from parents -Freedom from parents. f. Intimacy vs. Isolation-----------------------18-25 yrs. Up to 30 y/o -looking for a lifetime partner and career focus g. Generatively vs. Stagnation------------ 30-45 y/o h. Ego Integrity vs. Despair---------------45-65 & above 3. JEAN PIAGET - Swiss psychologists , pioneer work on dev.t of intelligence in children -develop reasoning power *Stages Of Cognitive Development*

A. Sensory Motor------ 0-2 y/o -“Practical Intelligence”- words & symbols not yet available baby communicates thru senses & reflexes. Schema (Subdivision) 1. Neonate Reflex 2. Primary Circular Reaction

Age 1 month 1-4 months

3. Second Secondar ary y Circul Circular ar Reacti Reaction on

4-8 months months

4. Coordination of Secondary Reaction

8-12 months

5. Tertiary Circular Reaction

12-18 months (1-1 1/2yrs.)

6. Invention of new means thu mental combination---“Symbolic combination---“Symbolic Representation”

18-24 months

Behavior

All reflexes -Activity related to body -Repetition of behavior (ex. thumb sucking) sucking) -Acti -Activit vity y not relat related ed to body body -Discover object & person’s permanence -Memory traces present -Anticipate familiar events. -Exhibit goal directed behavior of permanence & separateness (search of lost toy, knows mom, throw & retrieve) -Use trial & error to discover places & events -“ invention of new means” -capable of space & time perception (hits fork, spoon on table or drops fork) -Transitional phase to the pre operational thought process.

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

Schema 1. Preconceptual

Age 2-4 yrs

2. Initiative

4-7 yrs


Behavior -Think -Thinking ing basica basically lly com comple plete te lite litera rall & stati staticc -Egocentric- unable to view others viewpoint -Concept of dying is only now -Concept of distance is only as far as they can see. -Concept of Animism: inanimate object is alive (-) reversibility concept- in every action there’s an opposite reaction or cause & effect Beginning of Causation

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C. Concrete Operational Thought------ 7-12 years 1. Can find find solution solution to everyda everyday y problems problems with with system systematic atic reason reasoning. ing. 2. *Aware *Aware concept concept of reversibi reversibilitylity- cause cause & effect effect 3. Concept Concept of Conserva Conservation tion – consta constancy ncy despite despite of transform transformation. ation. 4. Activity Activity recomme recommendednded- collecti collecting ng & classifying classifying:: stamps, stamps, stationeri stationeries, es, dolls, dolls, rubber band band markers. D. Formal Operational Thought--------- 12 and up. 1. Cognit Cognition ion achiev achieved ed its final final form form 2. Can deal deal with with past past prese present nt & future future 3. Have abstract abstract & mature mature thoughts thoughts & forma formall reason reasoning. ing. 4. Can find find solution solutionss to hypothe hypothetical tical proble problems ms with with scientif scientific ic reason reasoning. ing. 5. Activity: Activity: talk time:-time:-- will sort out opinions opinions & curre current nt events. events. 4. KOHLBERG (1984) - recognized the theory of moral dev’t as considered to closely approximate cognitive stages of dev’t *Stages of Moral Development* A. Infancy – “Amoral, Pre-religious or pre-moral stage

Age 1. Pre-conventional 2-3 yrs 4-7

Stage Level 1 1 2

2. Conventional 7-10

Level 3

10-12

-*Punishment/ obedience oriented (heteronymous morality) child does right cause a parent tells him or her to & to avoid punishment -Individualism. Instrumental purpose & exchange. Carries out action to satisfy own needs rather than society. -Will do something for another if that person does something for the child. -Orientation to interpersonal relations of mutuality. Child follows rules cause of a need need to be a “good” person in own eyes & eyes of others. -Maintenance of social order fixed rules & authority. Child finds ff. rules satisfying. Follows rules of authority figures.

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3. Pos Postt-co conv nven enti tion onal al Above 12 yrs

Description

Leve Levell III III 5 6

-Social contract, utilitarian level making perspectives. Fo Follows standards of society fro the good of the people. Unive niverrsal ethi ethiccal prin princciple iple orie orien ntati tation on.. Follo ollow ws inte interrnali nalizzed sta standa ndards of conduct.

V. DEVELOPMENTAL MILESTONES -Major markers of growth and dev’t 1. Period of Infancy: *Universal language of child----- Play a. Play- Solitary plays (non-interactive) Priority Priority : Safety Safety (toys: (toys: age age appro appropriat priate) e) Main goal: Facilitate motor & sensory dev’t Ex. mobile, teeter, teeter, music box, box, rattle b. Fear- Stranger Stranger anxiety begin 7-8 months: months: peak 8 months diminishes diminishes 9 months c. Milestones:


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Neonate:

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

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1 month:

> Dance reflex disappears looks at mobile

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

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2 months:

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3 months:

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

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4 months:

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

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5 months:

> Turn both ways “roll over” >Teething rings, handles rattle well >Moro reflex disappears ( 4-5 months) > Enjoys looking around environment

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6 months:

>Reaches out in anticipatory of being picked up *>Sits with support >Uses palmar grasp, handles bottle well ruptio tion n of 1st temporary teeth: 6-8 months: 2 lower incisors >Erup >Say vowel sounds “ah”, “oh” > Sucking reflex disappears >Recognizes strangers (6-7 months) peak 8 months, diminishes 9 months

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7 months:

>Transfer object from hand to hand >Likes object that are good size for for transferring transferring

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8 mon month ths: s:

>Sits >Sits witho without ut supp suppor ortt >Peak of stranger anxiety >Planters reflex disappears 8-9 months in prep. for walking

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9 months:

> Creeps or crawls, needs space for creeping >Neat finger grasp reflex, probes with forefinger (finger feeds) >Combine 2 syllables “mama” & “dada”

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10 months: >Pull self to stand >Understands “no” >Responds to own name >Activity: peak a boo, pat a cake, can clap

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

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12 months: >Stands alone, take 1st step >Walk with assistance >Drink from cup, cooperate in dressing >Says 2 words mama & dada >Pots & pans, pull toys, nursery rhymes >Imitates action, comes when called >Uses mature pincer grasp, throws object

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> Follows one-step with gesture 2. Toddler:

a. Play: Parallel play- 2 toddlers playing separately -Provide with similar toys Ex. squeaky frog to squeeze, waddling duck to pull, trucks to push-push pull toy, building blocks, pounding peg, toys to ride on b. Fear: Separation Anxiety: begin 9 months, months, peak 18 months months 3 Phases Of Separation Anxiety (in order) P- protect D- despair D- denial -don’t prolong goodbye -say goodbye firmly to develop trust- say when you will be back c. Milestones 

15 months: >Plateau stage >Walk >W alkss alone alone *Laten *Latenes esss in walkin walkingg---m --mild ild menta mentall retar retardati dation on >Puts small pellets into small bowl >Holds spoon well >Seats self on chair, creeps up stairs >Scribbles voluntarily, say 4 - 6 words

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

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

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

*Posterior Molar- last temporary teeth to appear >Beginning of toothbrush – 2-2 ½ yrs >Tooth brushing with little assistance 3 yrs , brushing alone – 6 yrs > The right time to bring to dentist- when temp teeth complete 


36 month monthss or or 3 yrs: yrs: >Trusting 3 >Unbutton buttons (unbutton before learn to button) >Draw a +, learns how to share >Knows full name & sex (gender identity)

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>Speaks fluently, 300-900 words >Nighttime bladder control achieved >Ride a tricycle d. Characteristic Traits of Toddler 1. Negativistic- “NO!” -way to search search for independence independence >Limit questions >Modify questions to a statement 2. Rigid, ritualistic & stereotype >Ritualism- to gain mastery 3. Temper Tantrums (most common) >Head banging, screaming, stamping feet, holds breath >Ignore behavior *Protruding abdomen-d/t underdeveloped abdominal muscles *Physiologic anorexia- d/t preoccupation with environment- food fads, short period of time >Loves rough & tumbling play >Loves toilet training >Failure of toilet t raining- unreadiness *Clues For Toilet Readiness: 1.) can stand, stand, squa squatt walk walk alone alone 2.) can comm communi unicat catee toilet toilet needs needs 3.) can main maintai tain n drynes drynesss for 2 hours hours 3. Pre-Schoolers:

a. Play : Associative or Cooperative Play >bahay-bahayan – play house

>Role playing

b. Fear : Body Mutilation or Castration >Fear of dark places, witches >Fear of thunder & lightning >Fear of ghosts

Draws by age: 2 1/2 3 4 5

c. Milestones 

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

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5 years years old: > Frustrating 5 > Copy a triangle > Draw a 6 part man > Imaginary playmates > 2,1 2,100 00 word wordss > Jum Jumps ps over over low low obje object ctss

d. Character Traits of Pre-Schooler: 1. Curious, creative imaginative, imitative 2. Favorite words- “why & how” 3. Complexes- identification to parent of same sex & attachment to parent of opposite sex Ex. Oedipal complex- girl to dad/boy to mom Electra complex- identification to mother (daughter-mother), attachment to father >Cause of incest marital discord e. Behavior Problems 1. Telling tall tales d/t over imagination 2. Imaginary friend- to release tension & anxieties 3. Sibling rivalry- jealousy to newly delivered baby. 4. Regression- going back to early stage Sx: >thumb sucking (should be oral stage only)


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>baby talk, bed wetting, fetal position 5. Masturbation- sign of boredom -divert attention, offer a toy 4. School Age:

a. Play: Competitive play Ex. Tug of war, track and field, basket ball b. Fear. 1. School Phobia -orient to new environment 2. Displacement from school -teacher and peer of same sex 3. Loss of Privacy -wants bra 4. Fear of Death: thinks death is reversible as sleep

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

c. Significant Person: Person: Teacher, peer of same same sex d. Significant Development -boys prone to bone fracture - mature vision 20/20 e. Milestones


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6 years old: >Temporary teeth begin to fall >Perm teeth appear- 1 st molar 1st temp teeth- 5 months 1st perm teeth- 6 yrs >Year of constant motion > Common: green-stick fracture >Recognize all shapes >1st grade teacher becomes authority figure >Nail biting >Begin interest in God.

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7 years old; Age of Assimilation >Copy a diamond >Enjoys teasing and playing alone >Quieting down period

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8 years years old: Expans Expansive ive age age >Smoother movement >Loves to collect objects >Count backwards > Normal homosexual

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

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10 years old: >Age of Special Talent >Writes legibly >Ready for competitive games >More considerate & cooperative >Joins orgs. >Well mannered with adult >Critical of adults

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11-1 11-12 2 y/o: y/o:

>Pre >Pre-a -ado dole lesc scen ents ts >Full of energy & constantly active

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>Secret language are common >Share with friends secrets >Sense of humor present >Social & cooperative f. Character Traits of School Age: 1. Industrious 2. Modest 3. Can’t bear to lose- will cheat 4. Love collections- stamps *SIGNS OF SEXUAL MATURITY*

Girls

Boys

I-inc size breast breast & genitalia genitalia (thelarche- 1st sign sexual at.

A-appearance axillary & Pubic hair

W- widening of hips

D-deepening of voice

A- appearance axillary & pubic hair ( adrenarche)

D- development of muscles

M- menarche- last sign sexual mat. Girls

I— increase increase in testes and penis penis size ( 1st sign sexual mat) P- production of viable sperm ( last sign sexual maturity)

5. Adolescent :

a. Fear : 1. Obesity 2. Acne 3. Homosexuality 4. Death 5. Replacement from friends b. Significant Person: Person: Peer of Opposite Sex c. Significant Development 1. experiences conflict bet. his needs for sexual satisfaction & societies expectation *Core Concern : Change of body image & acceptance of opposite sex sex Emission (wet dreams) dreams) * Hallmark of Adolescence: Nocturnal Emission 2. Distinctive odor d/t stimulation of apocrine glands 3. Sperm is viable by 17 y/o 4. Testes & scrotum increase until age 17 5. Breast & female genitalia increase until age 18 d. Personality Traits Adolescents: 1. Idealistic 2. Very conscious with body image 3. Rebellious 4. Reformers, adventuresome e. Problems: 1. 2.


Vehic ehicul ular ar acci accide dent nt Smoking

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3. 4. 5.

Alcoholism Drug add addiction Pre-m e-marit aritaal se sex

II. IMMEDIATE CARE OF NEWBORN 1st days of life: 1. 2. 3. 4. 5. 6. 7. 8.

Initia Initiatio tion n and main mainten tenanc ancee of resp respira iratio tion n Establ Establish ishmen mentt of extra extra uter uterine ine circ circula ulatio tion n Cont Contro roll of body body temp temp Establ Establish ishmen mentt of of wast wastee elim elimina ination tion Inta Intake ke of ade adequ quat atee nouri nourish shme ment nt Prev Preven entio tion n of infe infect ctio ion n Establ Establish ishmen mentt of an infantinfant-par parent ent relat relation ionshi ship p Dev’t Dev’t care care that that balances balances rest & stimula stimulation tion or or mental mental dev’t dev’t

1.) Initiation Initiation and Maintenance Maintenance of Respirat Respiration ion

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

a. Remove secretions bulb syringe b. Catheter Suctioning 1.) Place head to side to facilitate drainage of secretions 2.) Suction mouth 1st before nose -neonates are nasal breathers 3.) Period of time 5-10 sec suctioning, suctioning, gentle and quick Prolo Prolonge nged d & deep deep suctio suctionin ning g can can lead lead to to : Hypoxi Hypoxiaa Laryngospasm, Bradycardia d/t stimulation of vagal nerve--near esophagus & anus 4.) Evaluate for patency -cover nostril & baby struggles there’s a need for additional suctioning c. If not effective, requires effective laryngoscopy to open a/w. After deep suctioning an endotracheal tube can be inserted and oxygen can be administered by (+) pressure bag and mask with 100% oxygen at 40-60b/m. Nsg alert In O2 O2 Administration: 1. No smoking to prevent combustion 2. Always humidify to prevent drying of mucosa 3. Over dosage of oxygen can lead to scarring of retina leading to blindness (Retro Lentalfibrolasia or Retinopathy of Prematurity) ROP --- prone prone to:SGA,LBW,Preter to:SGA,LBW,Preterm m 4. When meconium stained (greenish) never administer oxygen with pressure (O2 pressure will push mecomium inside)------Atelectasis 2.) Establishing Extra-Uterine Circulation

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

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


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

*3 SHUNTS* SHUNTS-shortcuts 1. Ductus Venosus- -shunts from from liver to IVF (umbilical vein to inferior vena vena cava) 2. Foramen Ovale- shunts bet 2 atrias 3. Ductus Arteriosus- from pulmonary artery to aorta Decrease PO2, increase PCO2 acidosis

Will cause 1st breath /cry of baby

Decrease Pulmo Artery Pressure

Increase PO2

1. Closure of Ductus Arteriosus

Decrease blood flow

2. Closure of Ductus Venosus & AVA

Increase pressure to Left side of heart

3. Closure of Foramen Ovale

What will sustain 1st breath- decreased artery pressure What will initiate lung circulation-lung expansion What will complete circulation- cutting of cord 4.) 2 Ways to facilitate closure of Foramen Ovale a.) Tangential Footstep- slap foot of baby----slap---cry---lung baby----slap---cry---lung expansion -never stimulate baby to cry if secretions not fully drained to prevent aspiration -check characteristic of cry *Normal cry- strong, vigorous and lusty cry *Normal cry of baby boy: lower cri-du-chat syndrome-chromosomal syndrome-chromosomal obliteration obliteration cat like cry (meow) b.) Proper position : Right side lying pos . -will increase pressure on left and foramen ovale will close *Foramen Ovale and Ductus arteriosus will begin to close within 24h *Universal Cry Cry of a Baby: Baby: “O-ha” Obliteration-complete Obliteration-complete closure Structure Appropriate Time of Structure Remaining Obliteration Foramen Ovale Begins 24 hrs, 1yr Fossa Ovalis Ductus Begins 24 hrs., 1 month Ligamentum Ar Arteriosum Arteriosus Ductus Venosus 2 months Ligamentum venosum 1.) Lateral umbilical Ligament Umbi Umbili lica call arte artery ry 2-3 2-3 mont months hs 2.) Interior iliac artery Umbilical vein 2-3 months Ligamentum Teres ( round ligament of liver)


Failure to Close

Atrial Septal Defect Patent Ductus Arteriosus

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*Position of infant immediately after birth: NSD-Trendelenberg/ NSD-Trendelenberg/ T position for drainage drainage contraindication of Trendelenberg position - increase ICP CS- Supine or crib level position

Signs of Increased ICP 1. Abnormally large head Hypertension 2. Bulging and tense fontanel Bradycardia Cushing’s Triad of ICP 3. BP and widening pulse pressure Tachypnea 4. RR & PR 5. Projective Vomiting- sure sign of cerebral irritation 6. High deviation – Diplopia – sign of ICP older child 4-6 months- normal eye deviation if >6 months- lazy eyes 7.) High pitch shrill cry- late sign of ICP 3. Control of Body Temperature : Temp Regulation

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*Goal *Goal in tem temp p regula regulatio tion n is to main maintai tain n it not not less less than than 97.7% 97.7% F (36. (36.5 5 C) Maintenan Maintenance ce of temp temp is crucial crucial on prete preterm rm and and SGA (small (small for gestational gestational age) - babies babies prone prone to hypothermia or cold stress

A. Factors Factors Leadin Leading g to Dev’t Dev’t of HYPO HYPOTHE THERMIA RMIA 1. Prete Preterm rmss are born born PoiKilo PoiKilothe therm rmicic- cold cold bloode blooded d Babies easily adapt to temp of environment d/t immaturity of thermo regulating system of body. >Hypothalamus 2. Inad Inadeq equa uate te SQ SQ tis tissu suee fat fatss 3. Baby is not capable of shivering *Earliest sign of hypothermia- increase in RR 4. Babies are born wet PROCESS OF HEAT LOSS 1. Ev Evaporation------body to to ai air (T (TSB) 2. Con Condu duct ctio ionn---------body body to to col cold d sol solid id obj objec ectt (col (cold d com compr pres ess) s) 3. Conv Convec ecti tion on----------body body to cool cooler er surr surrou ound ndin ing g air air (air (airco con) n) 4. Radi Radiat atio ionn------------- body body to cold cold obje object ct not not in cont contac actt wit with h bod body y •

Effects of Hypothermia ( Cold stress) 1.) Hypoglycemia- 45-55 mg/dl normal ( 50- borderline) d/t utilization of glucose 2.) Metabolic acidosis- catabolism of brown fats (best insulator of newborns body) will form ketones ( found in chest/back) chest/back) 3.) High risk for kernicterus- bilirubin in brain leading to cerebral palsy 4.) Additional fatigue to allergy stressful heart To Prevent Hypothermia: 1. Dry and wrap wrap baby 2. Mechanical pressure – radiant radiant warmer warmer (incubator) *Pre-heat first isolette (or square acrylic sided incubator) 3. Prevent an necessary necessary exposure – cover baby 4. Cover baby with tin foil foil or plastic 5. Embrace the baby- kangaroo care care (skin to skin contact) 4. Establish Adequate Nutritional Intake Physiology Breast Milk Production: As you deliver baby, E &

Physiology of Breast Milk Release: Sucking of the Breast

P

APG releases: Prolactin

Posterior P. G. releases Oxytocin

w/c acts on Acinar Cells/Alveoli To Produced foremilk


Contraction of smooth muscles of the Lactiferous tubules

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Stored in lactiferous Tubules (or Collecting Tubules)

Milk Ejection Reflex

Let-Down Reflex

*CS- breastfeeding after 4 hours *NSD- breastfeeding asap *Advantages of Breastfeeding *Store milk- plastic storage container 1. Economical >good for 6 mon. from freezer/ at rm. temp. don’t heat 2. Alwa lways ava avail ilab able le 3. Promot omotees Bon Bonding ding 4. Breastfe Breastfed d babies babies have have higher higher IQ than bottle fed babies. babies. 5. It fac facil ilit itat ates es rap rapid id invo involu lutio tion n 6. Decre Decrease ase incide incidence nce of brea breast st canc cancer. er. 7. Contents of BREAST MILK: a. Antibodies- IgA b. Lactobacillius bifidus- interferes interferes w/ attack attack of pathogenic bacteria bacteria in GIT c. Has macrophages d. Lactoferrin e. Lyzozymes f. Interferons Interferons Disadvantages: 1. Possibilit Possibility y of transfe transferr HEP B, B, HIV ( 30%-39%) 30%-39%),, cytomegalo cytomegalovirus virus virus. virus. 2. No iron iron-------p -pro rone ne to IDA IDA 3. Fath Father er can can’t ’t fee feed d & bon bond d as well well 3 Stages of Breastmilk: 1. Colostrum- 2-4 days post-delivery content: fats, IgA, CHO, CHON, minerals, fat soluble minerals 2. Transitional milk- 4 – 14 days content: lactose, water soluble vit., minerals 3. Mature Mature milk- 14 & up (3 L) L) content: fats (linoleic acid) – resp for devt of brain & integrity of skin CHO- lactose – easily digested, baby not constipated. - responsible of sour milk smelling odor of stool & astringent property of milk

*Lactose IntoleranceIntolerance- deficiency of enzyme LACTASE LACTASE that digests LACTOSE LACTOSE —manifestation = Excessive Excessive Crying ------substitute-----soy ------substitute-----soy milk milk *Decrease CHON- lactalbumin Contents of Cows milk : fats CHON – casein- has curd that’s hard to digest Minerals–traumatic Minerals–traumatic effect on kidneys of babies. Can trigger stone formation. Phosphorus CHO 5. Prevention of Infection: Health Teachings: 1. Proper hygiene- proper hand washing Care of breast - cotton balls with lukewarm water (inner to outer) Caked colostrums- dry milk on breast 2. Best position in breastfeeding – upright sitting -avoid tension!—if w/ tension breast will not properly empty 3. Stimulate & evaluate feeding reflexes a.) Rooting reflex- by touching the side of lips/cheeks then baby will turn to stimulus. Disappear by 6 weeks- by 6 weeks baby can focus. Reflex will be gone - Purpose rooting- to look for food. b.) Sucking – when you touch touch middle of lips then baby will will suck - Disappears by 6 months - When not stimulated sucking will stop. c.) Swallowing- when food touches posterior of tongue then it will be automatically swallowed swallowed

d.) Extrusion/ Protrusion reflex -when food touches anterior portion of tongue then food will be extruded. Purpose: to prevent from poisoning


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Disappear by 4 months & baby can already spit out by 4 months. Criteria Effective Sucking:

a.) Baby’s Baby’s mout mouth h is hiked hiked up up to areol areolaa b.) Mom experiences after after pain. c.) Other Other nipple nipple is also also flowi flowing ng with with milk. milk. To prevent from crack nipples & initiate proper production of oxytocin. - begin 2-3 min at per breast ( 5 – 7 min other authors) to initiate production of oxytocin - increase 1 min/ day – until reaching 10 mins per breast or 20 mins/ feeding. For proper emptying & continuous milk production / feeding -feed baby on last breast that you feed her with, alternately ( if not emptied - mastitis) Problems Experienced in Breastfeeding : 1st day post-partum: post-partum: Breast soft & tender RD 3 day changes in breast post partum: a.)Engorged- feeling of fullness & tension in breast. - sometimes accompanied accompanied by fever known as MILK FEVER-continue FEVER-continue BF Mgt: Warm compress- for breastfeeding mom Cold compress – for bottle feeding & wear supportive bra. *When is involution involution of breast? breast? - 4 weeks b.) Sore nipple – cracked cracked with painful nipple Mgt: Exposure to air air – remove remove bra & wear dress, if not, expose expose to 20 20 Watt Watt bulb (12-18 inches away) avoid wearing plastic liner bra will will cre create ate moistu moisture, re, cotton cotton only-only-----con contin tinue ue BF c.) Mastitis- inflammation of breast : staphylococcus aureus (common) Factors: 1. Improper breast emptying 2. Unhealthy sexual practices -contraindicated for breast feeding - manually express inflamed inflamed breast----- feed on unaffected breast - give antibiotics – can still feed on unaffected breast Contra Indications in Breast Feeding: a. Maternal Conditions: >HIV >CMV >Hep. B > Coumadin

b. Newborn Condition: Inborn errors of metabolism Erythroblastosis Fetalis – Rh incompatibility Hydrops Fetalis, Tay Sachs disease Phenylketonuria, Galactosemia

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


Jaundice baby – light stool Under phototherapy – bright green Mucus mixed mixed with with stool - milk allergy *Clay colored stool – obstruction to bile duct Chalk clay stool – after barium enema Black stool – GIT bleeding (melena) Blood flecked stool anal fissure.

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*Currant jelly stool – *Ribbon like stool – Cult blood – *Steatorrhea stool –

intussuseption hirschsprung disease stool exam fatty, bulky foul smelling odor stool  malabasorption syndrome (Celiac disease or Cystic fibrosis)

III. ASSESSMENT FOR WELL-BEING A. APGAR SCORE – Dr. Virginia Apgar

Spec Specia iall Cons Consid ider erat atio ions ns::

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

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

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

HR (most important) Respiratory Effort Muscle Tone

APGAR Scoring Chart: 0 1 Absent <100 Absent Slow, irregular, weak Flaccid extremities Some flexion

Reflex Irritability Catheter Tangential Footslap

No Response No Response

Color

Blue/pale

Grimace Grimace Acrocyanosis (body- pink extremities-blue)

2 >100 Good strong cry Well flexed

Cough, sneeze Cry Pinkish

APGAR Result:

0 – 3 = severely depressed, need CPR, admission NICU 4 – 6 = moderately depressed, needs add’l suctioning & O2 administration 7 - 10 =good/ healthy CPR – cardio pulmonary resuscitation or CPR New: Cardio pulmonary pulmonary cerebral cerebral resuscitation (CPCR) 5 min no O2 – irreversible brain damage a/w 1. sh shake, no no re resp, ca call fo for he help 2. flat on head, use cardiac board 3. head tilt chin lift maneuver except spinal cord injury over extension may occlude airway Breathing ( ventilating the lungs) 1. check for breathlessness if breathless, give 2 breaths- ambu bag > 1 yr old- mouth to mouth, pinch nose to create a seal < 1 yr – mouth to nose Force – different between baby & child infant – puff Cir Circula ulation tion :

Chec heck for for puls pulseeles lessnes snesss : car carotid otid-- adu adult lt Brachial – infants


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

Infant 1:5 Adults 2:15

B. Respiration Evaluation

1. Assessment tool that determines respiration of baby : Silvermann Anderson Scale Criteria Chest movement Intercostal retraction Xiphoid retraction Nares dilatation Expiratory grunt

0 synchronized No re retraction None None None

1 Lag on on respiration Just visible Just visible Minimal Heard on stet only

2 See - saw Marked Marked Marked Heard on naked ear

Lowest score – best Interpretation result: 0 -3 – normal, no RDS 4 – 6 – moderate RDS 7 – 10 – severe RDS C. Assessment of Gestational Age 1. Clinical Criteria: Ballards & Dobowitz Findings Less 36 weeks (Preterm) 37 - 38 Sole cr creases Anterior tr transverse cr crease Occasional creases 2/3 only in Breast nodules 2mm 4mm or 3.5 mm Scalp hair Fine & fuzzy Fine & fuzzy Ear lobe Pliable Some cartilage Testes Testes and Scrotu Scrotum m testes testes in low lower er cana canall Some intermediate Scrotum – small few rugae

39 and up Covered with creases

> 5 or 7mm Coarse & silky Thick cartilage Testes pendulus Scrotum fully covered w/ rugae

*2. Signs of Preterm Babies > Born after 20 weeks weeks & before 37 weeks weeks >Frog leg or lax position >Hypotonic muscle tone- prone resp problem >Scarf sign – elbow passes midline pos. >Square window wrist – 90 degree angle of wrist Complications: RDS, Hypothermia, ROP >Heel to ear sign >Abundant lanugo *Type of Feeding Pre-Term: Pre-Term: Gavage Feeding –to prevent aspiration –d/t absence absence of gag & swallowing reflex *3. Signs of Post term babies: > 42 weeks >Classic sign – old man’s face >Desquamation >Desquamation – peeling of skin *Long brittle finger nails >Wide & alert eyes

IV. Neonates in Nursery 1. Special & Immediate Interventions: a. Nsg responsibility upon receiving baby- proper identification


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- Foot printing, affixing mother thumb print b. Take anthropometric measurement normal length- 19.5 – 21 inch or 47.5 – 53.75cm, average 50 cm head circumference 33- 35 cm or 13 – 14 “ Hydrocephalus - >14” Chest 31 – 33 cm or 12 – 13” (Average 32 cm) cm) Abdomen 31 – 33 cm or 12 – 13” c. Bathing >Oil bath – initial : To cleanse baby & spread vernix caseosa Fx of verni ernix x case caseos osaa : 1. Insul nsulat ator or 2. Bacterio- static * Babies of HIV + mom – immediately give full bath to lessen transmission of HIV (13 – 39% possibly possibly of transmission of HIV *Full bath – safely given when cord fall *Dressing the Umbilical Cord: strict asepsis to prevent tetanus d. Dressing the Umbilical Cord 1. * 3 Cleans in community

1. Clean hand 2. Clean cord 3. Clean surface Betadine or Povidone Iodine – to clean cord 2. Check AVA, then draw 3 vessel cord--- if 2 vessel cord—suspect cord—suspect absence of kidneys

- leave about about 1 inch” of cord - if BT or IV infusion – leave 8” of cord *Best site of blood nerve access: umbilical cord 3. Check cord every 15 min for 1st 6 hrs – bleeding .> 30 cc of blood----hemorrhage blood----hemorrhage

*Excessive bleeding of cord – Omphalagia – suspect hemophilia or blood dyscrasias *Cord turns black on 3rd day & fall 7 – 10 days *Failure to fall after 2 weeks- Umbilical granulation (w/o foul smelling odor, pinkish) Mgt: silver nitrate or cautery clea clean n with with nor norma mall sali saline ne sol solut utio ion n not not alco alcoho holl don’t us use bi bigkis – ai air persisten persistentt moistu moisture-u re-urine rine,, suspect suspect patent patent uracus uracus – fistula fistula bet bladder & normal normal umbilicus

Dx:

Nitra Nitrazin zinee pape paperr test test – if if yell yellow ow – urin urinee -----if if blue blue – amnio amniotic tic fluid fluid - if reddish -- Omphalitis Mgt: Surgery e. Credes Prophylaxis – Dr. Crede

Purpose: prevent opthalmia neonatorum or gonorrheal conjunctivitis * how transmitted – mom with gonorrhea or chlamydia Drug: erythromycin ophthalmic ointment- inner to outer Silver nitrate (used before) – 2 drops lower conjunctiva (not used now) -causes staining of skin, chemical conjunctivitis - does not give protection against STDs f. Administer Vit-K – to prevent hemorrhage hemorrhage R/T physiologic hypoprothrombinemia hypoprothrombinemia - Aquamephyton, phytomenadione or konakion - .5 – 1.5 mg IM, vastus lateral or lateral ant thigh - 5 mg preterm baby *Vit K – synthesized by normal flora of intestine Vit K – meds is synthetic d/t intestine is sterile


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g. Weight-taking > Normal wt 3.000 – 3400 gms/ 3 – 3.4 kg / 6.5 - 7.5 lbs > Arbitrary lower limit 2500 gm > Low birth wt baby delivered < 2500g > Small for gestational age (SGA) < 10th % rank or born small > Large for gestational age > 90th % rank or macrosomia macrosomia >4000 g > Appropriate for GA – within 2 standard deviation of mean (AGA) > Physiologic wt loss – 5 – 10% wt loss few days after birth

Small GA < (less) 10 Large GA > (more) 90 V. PHYSICAL EXAM & DEVIATIONS FROM NORMAL

A. Important Considerations: 1. if client is new born born, cover areas not being examined to prevent hypothermia 2. if clie client nt is infa infant nt – the the 1st yr of life - get VS – take RR 1st - begin from least intrusive to the most intrusive area 3. if client is a toddler and preschool, let them handle an instrument instrument like: - play syringe or stet, security blanket – favorite favorite article. Let baby hold it, allow bedtime rituals 4. Explain procedure & respect their modesty - school age & adolescent - by wearing your complete uniform *Security Blanket--- a transitional object as representation of the parents B. Components: 1. V/S: Temp: rectal- newborn – to rule out imperforate anus/assess patency of anus take take it once once only only,, 1 inc inch h ins inser erti tion on Imperforate anus 1. Atreti Atreticc – no anal anal openin opening g more more danger dangerous ous 2. Agen Agenet etic ic – no no ana anall ope openi ning ng 3. Stenos – has opening but narrow opening 4. Memb Membra rano nous us – has has open openin ing g Earliest sign: 1. No mecomium 2. Abdominal destention 3. Foul odor breath 4. Vomitous of fecal matter 5. Can aspirate – resp problem may arise d/t aspiration of intestinal contents----atelectasis Mgt: Mgt: Surg Surger ery y with with tem tempo pora rary ry col colos osto tomy my Cardiac rate: 120 – 160 bpm newborn Apical pulse – left lower nipple Radial pulse – normally absent. absent. If present present PDA (+) radial pulse pulse Femoral pulse pulse – normal present. If absent- COA - coartation of aorta aorta

Congenital Heart Diseases: *Common in girls – PDA, ASD , Atrial Septal (Acyanotic HD) *Common in boys – TOGA ( Transposition of great arteries) TA – Tronchus arteriosus TOF – Tetralogy of Fallot *Causes: 1. Familial 2. Expo Exposu sure re to rube rubell llaa – 1st month of pregnancy 3. Failur Failuree of of heart heart struct structure ure to progre progress ss

Cyanotic HD

2 Major Types: “AL CR” 1. Acyanotic L to R : Left to Right shunting 2. Cyanotic R to L : Right to Left Left shunting


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

S&Sx: a. Systolic murmurs at lower border of sternum and no other significant sign b. Cardiac catheterization catheterization reveals increased increased o2 saturation @ R side of heart c. ECG reveals hypertrophy of R side of heart Nsg Care: Cardiac catheterization: site – Right femoral vein 1. NPO NPO 6 hrs before before proce procedur duree 2. Protect Protect site site of cathete catheteriza rization. tion. Avoid Avoid flexion flexion of joints proximal proximal to site. site. 3. Assess Assess for for complicati complication on – infection, infection, throm thrombus bus forma formation tion – check check pedal pedal pulses pulses Mgt. 1.) *Long *Long ter term m anti antibio biotic tic – to prevent subacute bacterial endocarditis 2.) 2.) Open Open hea heart rt sur surge gery ry 2.) Atrial Septal Defect (ASD) – Failure of foramen ovale to close S & Sx: 1. Systoli Systolicc murmu murmurr @ uppe upperr borde borderr of sternum sternum 2. Result Result of cardiac cardiac cathet catheteriz erization ation & ECG ECG same with VSD-VSD-- O2 sat & hypertrophy Mgt: Open heart surgery 3.) Endocardial Cushion Defects (ECD) - atrium ventricular ventricular - affects both tricuspid tricuspid & mitral valve

Dx Mgt:

: Con Conffirm irmed by cardi ardiac ac cathe athete terriza ization tion : Open heart surgery Antibiotics to prevent subacute bacterial endocarditis

4.) Patent Ductus Arteriosus - Failure of ductus arteriosus to close - should close within 24 h -complete close – 1 month S & Sx : 1. Contin Continuou uouss mach machine inery ry like like murmur murmurss > outstanding sign of acyanotic HD 2. Prom Promin inen entt radi radial al puls pulsee 3. ECGECG- hyper hypertro trophy phy Left Left ventri ventricle cle Drug: 1. Endomethac Endomethacine ine – prostag prostaglandi landin n inhibitor inhibitor - facilitate facilitate closing closing of PDA PDA 2. Ligation Ligation of of PDA PDA by 3-4 3-4 y/o via thora thoracotom cotomy y procedu procedurere- nakadapa nakadapa child

*With decrease Pulmonary Blood Flow 5.) Pulmonary Stenosis- narrowing of valve of pulmonary pulmonary artery S &Sx: 1. Typical systolic ejection murmur---d/t congestion at the right side of heart 2. S2 sound widely split split 3. ECG- R. R. ventricular hypertrophy *Normal: Pulmonary Pulmonary Artery = size with aorta* 6.) Aortic Stenosis – narrowing of valve of aorta S & Sx: 1. If inactive, sx same with angina-like symptoms 2. Typical murmur 3. Rough systolic sound and thrill 4. ECG- Left ventricular hypertrophy Cardiac catheterizationMgt. For Pulmonary Stenosis & Aortic Stenosis---ECMO>E Stenosis---ECMO>Extra xtra Corporeal Membrane Oxygenation -a lung & heart machine - return to activity: 3 wks. 1.) 1.) Ball Balloo oon n Sten Stenot otom omy y 2.) Surgery


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

2.) Total Anomalous Pulmonary Venous Return – pulmo vein instead of entering Lt atrium, enters Rt atrium or SVC Increased pressure on Rt so blood goes to Left Outstanding Sx: Open Foramen Ovale -------so -------so blood L to R >Mild to moderate cyanosis >Polycythemia = thrombus = embolus = stroke >Asplenia- absent spleen Mgt: Restructuring of heart 3.) Truncus Arteriousus - aorta & pulmo artery is arising from 1 single vessel or common trunk with VSD S & Sx 1. Cyanosis 2. Polycythemia – thrombus = embolus = stroke Mgt: Heart transplant

4.) Hypoplastic Left Heart Syndrome – a non- functioning Left ventricle S & Sx: 1. Cyanosis 2. Polycythemia – t hrombosis, embolus, stroke Mgt: Heart Transplant *With decrease Pulmonary Blood Flow 5.) Tricuspid Atresia – Failure of tricuspid valve to open S&SX: 1. Open Foramen Ovale-----pressure Ovale-----pressure increase in right so open FO (R to L shunting – goes to Lt atrium) 2. Cyanosis, Polycythemia Mgt: Fontan procedure – to open tricuspid valve 6.) Tetralogy Of Fallot (TOF) P – pulmonary stenosis V – ventricular SD O – overriding or dextroposition of aorta R – Rt ventricular hypertrophy

S &Sx: 1. Rt ven ventr tric icul ular ar hype hypert rtro roph phy y 2. High High degr degree ee of cyan cyanos osis is 3. Polycythemia


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4. 5. 6. 7. 8. 9.

Severe Severe dyspnea dyspnea – squattin squatting g position position – relief relief , inhibit inhibit venous venous return return,, facilitate facilitate lung lung expansion. Growth Growth retardat retardation ion – due no O2----O2------- Mental Mental retardat retardation ion –d/t O2 in brain brain Tet spell or blue spells- short episodes of hypoxia—blue baby esp. when crying Syncope Clubbing Clubbing of of finger fingernails nails – due to chroni chronicc tissue tissue hypoxia hypoxia Boot Boot shap shaped ed heart heart – revea revealed led by x-r x-ray ay

Mgt: 1. 2. 3. 4.

O2 administr administration ation after after 1 month month old—to old—to wait for for the complete complete closur closuree of the ductus ductus arterios arteriosus us No vals valsalv alvaa maneu maneuver ver , fiber fiber diet diet laxa laxative tive Morphine Morphine – hypoxia hypoxia , Propanolo Propanololl – decrease decrease heart heart spasms spasms Palliative Palliative repair repair – BLT >Blalock >Blalock taussig taussig procedure procedure Brock procedure – complete procedure

ACQUIRED HEART DISEASES Heart Disease Disease (RHD) 1. Rheumatic Heart - inflammation disease ff an infection acquired by group A Beta hemolytic streptococcus (GABHS) a. Affected body – cardiac muscles and valves , musculoskeletal , CNS, Integumentary

b. Suspect : Sorethroat Sorethroat before RHD -----candidate -----candidate babies---eating lots of sweets c. Aschoff – rounded nodules with nucleated cells & fibroblasts – stays that occludes mitral valve. d. To Diagnose RHD uses the Jones Criteria

*Jones Criteria* Major 1. Polyarthritis – multi joint pain 2. Chorea – Sydenhamms Chores or St. Vitous Dance -purposeless involuntary hand and shoulder with grimace 3. Carditis – characterized by tachycardia

4. Erythema marginatum - macular rashes 5. SQ nodules

Minor 1. Arthralgia – joint pain 2. Low grade fever

3. All Dx Test & Lab results antibody C reactive protein Erythrocyte sedimentation rate Anti streptolysin O titer (ASO)

*Criteria: Presence of 2 major, or 1 major & 2 minor + history of sore throat will confirm the dx. Mngt: Supportive only Nsg Care: 1. CBR CBR , avoi avoid d con conta tact ct spor sports ts 2. Throat Throat swab swab – culture culture & sensit sensitivity ivity for for antibio antibiotic tic thera therapy py 3. *Anti *Antibio biotic tic mgt mgt – to preven preventt recur recurren rence ce 4. Aspirin Aspirin ( ASA ASA therapy) therapy)– – anti-inflam anti-inflammator matory. y. Low grade grade fever fever – don’t don’t give aspirin. aspirin. S/E of aspirin: if given to children continuously w/ bacterial infection: *Reyes syndrome – encephalopathy- fatty infiltration of organs such as liver & brain 2. Respiration Newborn resp resp – 30-60 cpm, irregular irregular abd or diaphramatic diaphramatic with short period of apnea apnea w/o cyanosis. If < 15 secs – normal apnea –newborn , if >15 secs. ---dead already Resp Check: Newborn – 40 – 90 bpm 1 yr - 20 – 40 2-3yr 20 – 30 5 yrs 20 – 25 10 yrs 17 – 22 15 & above 12- 20 BREATH SOUNDS HEARD DURING ASCULTATION: Sound 1. VESI VESICU CULA LAR R:


Characteristics Soft Soft,, low low pitc pitche hed, d, hear heard d ove overr per perip iphe hery ry of lung lungs, s, insp inspir irat ation ion long longer er then then expi expira rati tion on -Nor -Norma mall

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2. BRONCHOVESICULAR: BRONCHOVESICULAR:

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

3. BRONCHIAL SOU SOUNDS: NDS: Loud high pitched, heard over trachea, expiration longer than inspiration. Normal 4. RHONCHI : 5. RALES: 6. WHEEZING: 7. STRIDOR: 8. RESONANCE: 9. HYP HYPER ERRE RESO SONA NANC NCE: E:

Snoring sound made by air moving through mucus in bronchi. Normal or crackles – like cellophane – made by air moving through fluid in alveoli. Abnormal- pneumonia, pulmonary edema edema Whistling on expiration made by air being pushed through narrowed bronchi Abnormal – asthma, foreign body obstruction obstruction Crowing or rooster life sound – air being pulled through a constricted larynx. Abnormal – resp obstruction, inspiratory stridor Loud, low tone, percussion sound over normal lung tissue Loud Louder er,, lowe lowerr sou sound nd tha than n res reson onan ance ce,, a per percu cuss ssio ion n sou sound nd ove overr hype hyperi rinf nfla late ted d lung lung tissue

1. Asthma

Pathognomonic Sign: Expiratory wheezing Pet – fish. fish. Sport – swimming Drugs – Aminophylline – monitor BP, may lead to hypotension Allergens: dust Food Food allerg allergens ens:: seafoo seafood, d, chocol chocolate ate,, Climate Changes 2. Respiratory Distress Syndrome (RDS) or Hyaline Membrane Cause- lack of surfactant – for lung expansion ----------------end ----------------end stage: Atelectasis Hypotonia, Post surgery, Common to preterm Fibrine Hyaline : Sx----definite with in 1st 4 hrs. of life ---d/t ---d/t lack of surfactant surfactant Tachypnea with retraction -------ear -------earliest liest sign *Inspiratory Grunting – Pathognomonic Sx > 7 – 10 severe RDS (Silverman Anderson Index), respiratory acidosis end stage: Cyanosis d/t atelectasis *Chromolin Sodium---prevents Sodium---prevents asthmatic attack before attack administer administer > if with asthma attack ----bronchodilator---Aminophylline ----bronchodilator---Aminophylline—monitor —monitor BP Mgt: 1. Surfa Surfacta ctant nt repl replace aceme ment nt and and rescue rescue 2. PosPos- head head elev elevat ated ed 3. Prop Proper er suct suctio ioni ning ng 4. O2 with increase increase humidityhumidity- to prevent prevent drying drying of mucosa mucosa 5. Monito Monitorr V/S V/S skin skin colo colorr , ABG ABG----------R.A R.A..

6. 7.

*CPAP *CPAP-- cont continu inuous ous (+) (+) a/w a/w pressu pressure re PEEP PEEP - + end expira expirator tory y pre pressu ssure re Purpose of #6-7- to maintain alveoli partially open & alveoli collapse

3. LaryngoTracheo Bronchitis (LTB) Pathognomonic Sign: Inspiratory Stridor LTB – most common Creup -viral infection of larynx, trachea & bronchi Outstanding Sx : Croupy cough or barking barking Labored re respiration Respirator tory aci acidosis End stage – death Lab: 1. ABG 2. Neck Neck and and thr throa oatt cult cultur uree 3. Dx- neck neck x-ra x-ray y to rule rule out out epig epiglot lotitis itis 4. CBCCBC- to to dete determ rmin inee leuk leukoc ocyt ytos osis is Nsg Mgt: 1. Bronchodilators 2. Humidified oxygen 3. Prepare tracheostomy set 4. Corticosteroids 4. Broncholitis Inflammation Inflammation of bronchioles characterized by production of thick, tenacious mucus mucus *Causative agent – RSV - Resp sincytial virus


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Sx:

Flu-like sx Increased RR---Monitor: RR---Monitor: Tachypnea of >90 bpm =RDS Drug: rug: Anti Antivi vira rall – Rib Ribav avir irin in End stage – epiglotitis 5. Epiglotitis

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

*Acrocyanosis Birthmarks:

1. Mongolian Spots: stale gray or bluish discoloration discoloration patches commonly seen seen across the sacrum or buttocks d/t accumulation of melanocytes. Disappear by 1 yr old or 5 y/o pre-schooler pre-schooler 2. Milia – plugged or unopened sebaceous sebaceous gland, white pin point patches on nose, chin or cheek. 3. Lanugo – fine, downy hair – common preterm 4. Desquamation – peeling of newborn, newborn, extreme dryness that that begin sole and palm. 5. Stork bites (Telangiectasis nevi) – pink patches nape of neck  hair will grow as child grows old st 6. Erythema Toxicum – (flea bite rash)- 1 self limiting rash appear sporadically & unpredictably as to time & place. 7. Harlequin Sign – dependent part is pink, independent part is blue (side lying – bottom part is dependent pink) 8. Cutis Marmorato – transitory mottling of neonates skin when exposed to cold. 9. Hemangiomas – vascular tumors of the skin 3 Types Types of Hemangiomas a.) Nevus Flammeus – port wine stain – macular purple or dark red lesions seen on face or thigh. NEVER disappear. disappear. Can be removed removed surgically b.) Strawberry Strawberry hemangiomas – nevus nevus vasculosus – dilated capillaries capillaries in the entire dermal dermal or subdermal area. Enlarges, disappears at 10 y/o. c.) Cavernous hemangiomas – comm. network of venules in SQ tissue that never disappear with age. MOST DANGERIOUS – intestinal hemorrhage 10. Vernix Caseosa – white cheese like for lubrication, insulator

Skin Color & its significance: Blue – cyanosis or hypoxia Ringworm Infestation: White – edema Tinea Pedia : foot (athelte’s foot) Grey – infection Tinea Capites: head Yellow – jaundice , carotinemia Tinea Cruris: singit Pale – anemia Tinea Corporalis – body Representative Problems of the Skin: 1. Burn Trauma – injury to body t issue caused by excessive heat. INFANT 5-9 y/o ANTERIOR POSTERIOR Ant Post


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Head Neck Upper arm Lower arm Hand Trunk Back Genital @ buttocks Thigh Leg foot DEPTH: 1st degree –

2nd degree – 3rd degree –

9 .5 1 2 1 .5 13 13 13 1 2.5@ 2.75 2 .5 1.75

9 .5 1 2 1 .5 1.25

2.75 2 .5 1.75

6 .5 1 2 1 .5 1.25 13 13 1 2.5 @ 4 3 1.75

6 .5 1 2 1 .5 1.25

4 3 1.75

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

Mgt: Emergency: Prioritization depend on area of burn *1.) 1st aid

a.) a.) Put Put out out flam lames by roll olling ing chil child d on blan blanke kett b.) Immerse burned part on cold H2o *c.) Remove burned clothing of with sterile material, if none in the hosp. only d.) Cover burn with sterile dressing

2.) A/W a.) Suction PRN, o2 with increased humidity b.) Endotracheal Endotracheal intubation c.) Tracheostomy Tracheostomy 3.) Prevention of shock & F&E imbalance imbalance : Burns: Hyperkalemia—MD Hyperkalemia—MD will give insulin— for K to go back to cells a. colloids to expand blood volume b. isotonic saline to replace replace electrolytes c. dextrose & H2o to provide calories 4.) Tetanus Toxoid Booster 5.) Relief of pain – IV analgesic MORPHINE SO4 – needed for 2nd degree – very painful 6.) 1st defense of body – intact skin Prevention of Wound infection i. Cleani Cleaning ng & debr debridi iding ng of wound wound ii. Open Open or clos closee metho method d of wound wound car caree iii. iii. Whirl Whirlpoo pooll therapy therapy – drum drum with with solut solution ion rd 7.) Skin grafting – 3 degree – thigh or buttocks (autograft), (autograft), pigs/ animals – xenograft frozen cadaver – hallow graft 8.) Diet – increase CHON, increase calories. 2. ATOPIC DERMATITIS - Infantile eczema (hika ng balat) (asthma of the skin) Papillovesicular erythematus lesions with weeping & crusting Usual Cause : Food allergies: milk, citrus juice, eggs, tomatoes, wheat Sx: > Extreme pruritus---linear excoriation----wee excoriation----weeping ping crusting----- scaly shiny & white to ------------Lichenification Goal of Care:

1. Dec Decre reas asee prur prurit itus us – avoi avoid d foo food d alle allerg rgen en 2. Diet: Diet: Prosobi or Isomil Isomil 3. Hydrate skin w/ burrow solution 4. Topical Steroids ---1% hydrocortisone cream 5. Prevent infection – proper hand washing, trim nails/cut short

3. IMPETIGO- skin disease.


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Causative agent – Grp. A beta Hemolytic streptococcus (GABHS), possibly staphylococcus > Papulovesicular surrounded by localized erythema becomes purulent & oozes oozes a honey colored crust 4. PEDICULOSISCAPITIS –“KUTO” Mgt: proper hygiene – wash soap and H2o, oral penicillin – bactroban ointment *Can lead to acute glomerulonephritis AGN ---common to children with this type 5. ACNE- adolescent problem >Self limiting inflammatory disease – sebaceous gland *Comedones – sebum causing white heads *Sebum- lipids of cholesterol causing acne bulgaris Mgt: Proper hygiene- mild soap or sulfur soap- antibacterial retin A or tretinoi Liver clearance before using Retin a: C/I to pregnant women 6. ANEMIA - pallor Causes: 1.) Early cutting of cord – preterm – cut umbilical cord ASAP Full term – cut umbilical cord when pulsation stops 2.) Bleeding disorders – blood dyscrasias Ex. a. Hemophilia – deficiency of clotting factor. Pattern of Inheritance : X linked recessive Usual carrier carrier : mother (with X chromosome chromosome carrying carrying the disease) disease) Usually affected affected children: children: Son If mom – carrier, son – affected If father carrier- transmitted to daughter 3 Types: Hemophilia A – Deficiency of coagulation coagulation component component factor 8 (classic/most common) Hemophilia B –or Christmas disease, deficiency of clotting factor 9 Hemophilia C – deficiency of clotting factor 11

Assessment: >Omphalagia – earliest earliest sign >30cc in newborn newborn >Newborn receive maternal clotting factor –reason why late Dx of hemophilia >Newborn growing – sudden bruising on bump area- marks earliest sign >Continuous bleeding – Hemarthrosis >damage or repeated bleeding of synovial membrane Dx test : PTT = Partial thromboplastin time – reveals deficiency in clotting factor *Long Term Goal- prevention of injury Nsg Dx: Increase risk of injury HT: avoid contact sport, swimming only, don’t stop immunization – change gauge of needle Falls –1st splint then immobilized , elevate affected part, apply pressure-not more then 10 min Of cold compress compress to prevent necrosis necrosis > Determine case before doing invasive procedure > No Aspirin > BT : Fresh frozen plasma or cryoprecipitate cryoprecipitate > Long-Term Goal: Prevention of Injury 7. LEUKEMIA - group of malignant malignant disease characterized characterized by > Rapid proliferation of immature WBCs Ratio: 500 RBC:1 WBC > WBC – protection from infection, soldiers of body > Immature WBC takes the nutrients from mature WBC Classification : 1. Lympho – affects lymphatic system 2. Myelo – affects bone marrow 3. Acute / blastic- affects immature cells 4. Chronic/ cystic- affects mature mature cells Most common cancer = (ALL) Acute Lymphocytic Leukemia *Main cause of Anemia: Failure of bone marrow to produce RBC S & Sx: TRIAD


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1. From invasion of bone marrow Signs igns of Infecti ection on:: a. Fev Feveer b. Poor wound healing c. Bone weakness & causes fracture Signs of Bleeding : a.) Petecchia Petecchiae-sma e-small, ll, round, round, flat, flat, dark dark red red spot spot b.) Epistaxis c.) Blood Blood in urine urine & emes emesis is Signs of Anemia : a.) Pallor , body malaise , constipation 2. From invasion of body organ: a. Hepatosplenomegaly Hepatosplenomegaly b. Abdominal pain c. CNS affectation affectation & increase increase ICP Dx Tests: 1. 2. 3. 4.

5. 6.

PBSPBS- periphe peripheral ral blood blood smear smear – determin determinee immatur immaturee WBC WBC CBC – determine determine anemi anemia, a, leukocyto leukocytosis, sis, throm thrombocyt bocytopeni openiaa neutrope neutropenia nia >done weekly during maintenance phase of therapy Lumbar Lumbar puncture puncture (LP) (LP) – determin determinee CNS involvem involvement. ent. Before Before LP, LP, Fetal positio position n Best: Avoid flexion of neck – will cause a/w obstruction.“C” position or shrimp. Bone marrow marrow aspira aspiration tion – determ determine ine blast blast cells cells or immature immature WBC > *Common site for BMA = Iliac Iliac crest > Post BMA s/effect – bleeding apply pressure. Put pt on affected side to prevent hemorrhage Bone Bone scan scan – determ determine ine bone bone invol involvem vement ent CT scan – determ determine ine organ organ involvemen involvement, t, CNS CNS affec affectation tation

Therapeutic Mgt: TRIAD FOR CANCER:

1. 2. 3.

Surgery Irradiation ion Chemothe therapy

Focus Nsg Care: Prevent infection 4 LEVELS OF CHEMOTHERAPHY---Goal of Tx: Achieve remission 1. Induction: every level is 1 session Meds: IV vincristine L- agpariginase Oral prednisone 2. Sanctuary- Treat leukemic cells that invaded testes & CNS *Give: Methotrixate- adm. intrathecally via CNS or spine cytocine, Arabinoside, steroids with irradiation

3. Maintenance- to continue remission Give: Oral Methotrisate – check WBC/ CBC order 1st before administering drug Adm. of methotrisate – do weekly WBC check 4. Reinduction – treat leukemic cells after relapse occurs. Meds – same as induction Give antigout agents: allopurinol or Zyloprim- treat or prevent hyperurecemic nephropathy. Nsg mgt:

Outstanding Nsg Dx:

1. High risk for infection 2. Alteration in nutrition less body requirement. requirement. 3. Alteration in Body image 4. Anticipatory grieving for family & parents Based on Maslow’s hierarchy

S/E of Chemotherapy 1. N/V – adm anti-emetic drugs 30 mins before before chemo until 1 day after chemo 2. Ulcerations / stomatitis / abscess of oral mucosa: Nsng. Dx: Altered oral mucus membrane > Oral care – alcohol free mouthwash , betadine mouthwash > Don’t brush – use cotton pledgets > Topical xylocaine before meals > Diet- soft, bland diet according to child’s preference


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

New Management: Management: Chemotherapy or Bone Marrow Transplant Transplant

8. Hemolytic Disorders:

a.

Hemolysis = destruction of RBC

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

Erythroblastosis Fetalis = hemolysis or destruction of RBC d/t

O2 carrying capacity

S & Sx: Intrauterine growth growth retardation w/ w/ pathologic jaundice w/in 24 hrs. b. ABO Incompatibility Most common incompatibility – ( mom) O – ( fetus) A Most severe incompatibility (Mom) O– (Fetus) B st Assessment: Can affect 1 pregnancy RBC - 20 days lifespan lifespan O = universal donor AB = universal recipient Dx: Coomb’s Test Indirect: mother ----- normal result is (-) Direct : from baby---normal result is initially (-) Drug Of Choice: Rhogam Vaccine Vaccine given to mothers mothers (-) w/in w/in 72 hrs. post-exposure post-exposure to fetal fetal RBC’s to destroy fetal RBC’s, then preventing Rh sensitization or antibody formation > given only w/in 72 hrs. once only 1 st pregnancy 9. Hydrops (h20) Fetalis – edematous on lethal state state with pathologic jaundice Within 24 h Mgt. for both: 1. Initi nitiaate fe feeding ding 2. Temporar Temporary y suspens suspension ion of breastfe breastfeeding eding to prevent prevent kernicter kernicterus us >content breast milk pregnanedioles – that delays action of glucoronyl transferase—a transferase—a liver enzymes that converts converts indirect bilirubin to become become direct bilirubin 3. Need Needss phot photot othe hera rapy py 4. Need Needss exch exchan ange ge ther therap apy y 10. Hyperbilirubinemia - > 12 mg/dL of indirect bilirubin among full term * Normal Value: 0-3 mg/dL bilir ilirub ubin in enc encep epha halo lopa path thy y 11. Kernicterus - > 20 mg/dL among full full term & >12 mg /dl of indirect for pre-term----lead pre-term----lead to cerebral cerebral palsy *Physiologic Jaundice –(Icterus Neonatorum) jaundice within 48 -72 h (2-3 days)------ NORMAL NORMAL -- just expose to morning sunlight *Pathologic Jaundice – (Icterus Gravis) jaundice w/n 24h or Jaundice during delivery d/t small Rh/edematous Rh/edematous ABO *Breastfeeding Jaundice —caused by pregnanediole pregnanediole (6-7th day)


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Pathophysi Pathophysiology ology:: ---------------------------------- Destroye Destroyed d RBCs releases Heme brokendown Iron (removed in the body) (not involved in jaundice)

Globin Protoporphyrin broken down Indirect Bilirubin (fat-soluble converted converted by kidney) Converted by Glucoronyl Transferase Transferase (liver enzyme)

Direct Bilirubin (water-soluble) (water-soluble) Assessment Assessment of Jaundice : *1. Blanching neonates forehead, nose or sternum sternum (use 2 thumbs to separate skin folds) - yellow skin & sclerae - color of stool – light stool - color of urine – dark urine Mgt: Phototherapy or photo oxygenation oxygenation (Normal HT: HT: 18-20 inch.) Nsg Resp: 1. Cover Cover eyes eyes – preven preventt reti retinal nal damage damage 2. Cove Coverr genit genital alss – prev preven entt Priapism – a painful continuous erection 3. Change Change posi positio tion n regula regularly rly – even even expos exposure ure to to light light 4. Increa Increase se fluid fluid inta intake ke – prone prone to to dehydr dehydrati ation on 5. Monito Monitorr I&O I&O – weigh weigh baby baby diaper diaper – 1 g= 1cc 6. Monitor Monitor V/S V/S – avoid avoid use use of oil oil or lotion lotion duedue- heat heat at photothe phototherapy rapy > Bronze baby syndrome------tr syndrome------transient ansient S/E of phototherapy phototherapy

4. Head

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

Craniostenosis or Craniosyntosis – premature closing of anterior fontanel

2. Microcephaly – small, small, slow growing brain d/t alcohol & HIV mom >5th percentile 3. Anencephaly – absence of cerebral hemisphere 4. Craniotabes – localized softening of cranial bone. Common – 1st born child (normal) -d/t early lightening (2 weeks weeks prior to EDD) EDD) Rickets’ d/t Vit. B deficiency – soft cranial bone in older children 5. Caput Succedaneum – edema of scalp d/t d/t prolonged pressure pressure at birth

Characteristics: 1. Prese esent at bir birth th 2. Cros Crosse sess sut sutur uree lin lines es 3. Disa Disapp ppea earr aft after er 2-3 2-3 day dayss 6. Cephalhematoma- collection of blood due to rapture of periosteal capillaries


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Characteristics : 1. Pres Presen entt afte afterr 24 hour hourss 2. Neve Neverr cro cross ss sutu suture re line line 3. Disa Disapp ppea earr aft after er 4-6 4-6 wee weeks ks 4. Moni Monito torr for for devel develop opin ing g jaund jaundic icee 7. Seborrheic Dermatitis – ‘Cradle Cap” Scaling, greasy appearing appearing salmon colored patches patches – seen on scalp behind ears ears and umbilicus Cause: - improper hygiene Mgt: 1. Proper oper hygi hygieene 2. Put oil oil night night before before shampoo shampoo (use (use baby baby oil or virgin virgin oil) 3. Use Use of of fine fine-t -too ooth thed ed comb comb 8. Hydrocephalus – excessive accumulation accumulation of CSF d/t anterior fontanel open after 18 months months

2 Types: 1. Communicating – extra ventricular hydrocephalus 2. Non-communicating a. Intr Intrav aven entr tric icul ular ar hydro hydroce ceph phal alus us b. Obstructive hydrocephalus hydrocephalus d/t tumor obstruction Nsg. Dx: High Risk For Injury Dx For Seizure Activity : EEG Sx: a. Abnormally large head, bulging fontanel –Earliest Sx of ICP b. Cushing’s Triad----Triad----- Hyper, Hyper, bradypnea,bradycardia bradypnea,bradycardia c. High pitched cry d. For older children & >6 months – Diplopia – eye deviation, projectile projectile vomiting---earliest vomiting---earliest sx e. Fontanel bossing – prominent forehead f. Prominent skull vein g. Sunset eyes Mgt: a. Position to lessen ICP – l ow semi-fowlers semi-fowlers 20-30 degree angle b. Administer- osmotic osmotic diuretic Mannitol/ Osmitrol Osmitrol , DiamexDiamex- Azetam c. Decrease CSF production ----drug: acetazolamide or Diamox d. Shunting – AV shunt or Vp shunt (ventriculoperitoneal shunt) Shave hair – in OR – to prevent growth of micro org. e. Hyperventilate child Nsg Care: 1.) Post VP shunt –position: immediately after---supine then after anesthesia --- side lying on non operated site - to prevent increase ICP Monitor for good drainage drainage in catheter: good sign is a sunken fontanel if bulging fontanel – blocked shunt Catheter change as child is growing

5. Senses A. Assessment of Eyes :

1. Chec Check k for for symm symmet etry ry 2. Sclera Sclera – norma normall color color – light light blue blue then then become become dirty dirty white 3. Pupil – round- adult size 4. Cornea – round & adult size


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* If large – Congenital Glaucoma NOTE FOR:

*Coloboma- part of iris is missing (notching) Sign: Key hole pupil *Brushfields Spots -----iris black with white spots *Congenital Cataract-----Whiteness -----Whiteness & Opacity of lens

COMMON TESTS Age

Common Tests *DOLL’S EYES TEST------ Test for blindness = Done on the 10th day = Pupil go to opposite direction when head is moved

1. Newborn

General Appearance:  Can only see 10-12 inches  Visual Acuity 20 /200 to 20/ 800 Reflex.

*GLOBELLAR’S TEST -------Test -------Test for Blink

= Points near nose & the baby should blink Infant & Children

* Test the ability to follow object past midline

2. 3 years old to School Age

*ALLEN CARDS -----------Test for Visual Acuity = Show common pictures 20 ft away *ISHIHARAS PLATES = Test for Color Blindness *E CHART ------ Test for Stereopsi of depth perception

3. Preschool

* COVER TESTING TEST ----- Test for Strabismus = Cover 1 eye for 10- 15 minutes. Then remove. Note For: ESOTROPIA = inward movement of eye ball EXOTROPIA = outward movement movement of eye * SNELLENS TEST ------- Test for normal vision * E CHART

4. School Age To Adult

DISEASES: 1. RETINOBLASTOMA

Outstanding Sign:

= Malignant tumor of the retina Cat’s Eye Reflex – the whitish glow of pupil - With red painful eye - Can lead to blindness

Mgt. a. Surgery: Surgery: Enucliation – the removal of the eyeball eyeball & replacement replacement of artificial artificial aye

B. Assessment of the NOSE 

1. 2.

(Sense Of Smell)

Normal color of nasal membrane: membrane: Pinkish

Check Check for presence presence of of creases creases & pale color color of of nasal nasal membra membrane ne Chronic Rhinitis  Indicative of Chec Check k if inf infla lame med d & red redde dene ned d


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

3. 4.

Indicative of infection

Check fo for Flaring of Alenase  A case of RDS Check fo for Cyanosis at rest  Indicative of CHOANAL ATRESIA = The posterior nares obstructed obstructed with bone or membrane Sx:

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

Check Check for for pres presenc encee of hair hair in nose: nose: Cilia Cilia  Adolescent with no hair with ulceration of nasal mucosa: Cocaine user NOTE FOR: a. EPISTAXIS or Nosebleed N.I: Position: Sit upright, head slightly forward to facilitate drainage & prevent aspiration Put Cold compress & apply gentle pressure pressure Give Epinephrine *Most developed sense of newborn – SENSE OF TOUCH The way the baby can i dentify the mother

C. Assessment of the Ears: (Sense of hearing) HEARING *1st sense to develop develop & last to disappear – HEARING * Normal Color of the Tympanic Membrane : Pearly Gray

1. Check for for symmetry symmetry 

If ears not properly aligned with the outer cantus of eyes or low set ears: ears: Suspect A. KIDNEY MALFORMATION:

1.

RENAL AGINESIS = the absence of kidney

2 Types: a. Unilateral Unilateral = only 1 is present present b. Bilateral = absence of 2 kidneys Sign Sign in in uter uterus us : Olig Oligoh ohyd ydra ramn mnio ioss Sign in newborn: 2 vessel cord Sx: Failure to void within 24 hrs Mgt:

Kidney Transplant

BELLY SYNDROME SYNDROME 2. PRUNE BELLY The newborn has a wrinkled abdomen that looks like a prune d/t abdomen swelled with fluid in the womb, then lost that fluid after birth, leading to puckering of excess skin. B. CHROMOSOMAL ABERRATIONS:

Cause: Advance Advance maternal maternal age >35 y/o 1.NONDISJUNCTION = Uneven division of chromosome a. TRISOMY 21 or “DOWN SYNDROME” = Extra #21 chromosome


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= Related to advance advance paternal age: age: 47xx + 21 Sx: Low set ears Mongolian slant Broad, flat nose Epicanthal Fold = extra fold of eyelids Brushfield’s Spot = black black & white specks in the iris Pectum Excavatum = sunken sternum Puppy’s neck Hypotonic = muscle tone prone to URTI Simian crease = a single transverse transverse line on palm. Alert: Always check PR for tachycardia d/t hypotonia Check for respiration Check for mental retardation----educable b. T TRISOMY RISOMY 18 or “ENDVARD SYNDROME”

- Affecting more girls than three times as boys. - Caused by the presence of an extra number 18 chromosome Sx: Pecan Carinatum (protruding sternum) Small Jaw (micrognathia) Hypoplastic (underdeveloped) fingernails c. TRISOMY 13

“ PATAU SYNDROME”

- Associated w/ multiple abnormalities, including defects of the brain that lead to seizures, seizures , apnea, apnea, deafness, and eye abnormalities. Sx: Coloboma Cleft lip & cleft cleft palate Low set ears d. TURNER’S

Syndrome/Bonnevie-Ullrich Syndrome” Syndrome” “Monosomy X Syndrome/Bonnevie-Ullrich - Occurs only in females - The girl's cells are missing an X chromosome, or part of an X chromosome. Sx evident during puberty

Sx: Short height Lack of developing ovaries Sterile e. KLINEFELTER’S SYNDROME

- 47XXY or XXY syndrome is a condition caused by a chromosome nondisjunction in males; affected individuals have a pair of X of X sex chromosomes instead of just one - Has male genitalia - No deepening of voice - Small testes, penis -sterile *Klinefelter – Calvin Kl Kline – male

*Turner – Tina Tu Turner – female

2. DELETION ABNORMALITIES = deletion of the genes on chromosomes a. CRI-DU-CHAT SYNDROME or “Chromosome 5p deletion d eletion syndrome”

- Results from a missing piece of chromosome # 5. Sx: Severe mental retardation – outstanding sx Wide-set eyes (hypertelorism) (hypertelorism)


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Downward Downward slant of the eyes (palpebral fissures) All other sx of down syndrome b. FRAGILE X SYNDROME SYNDROME or “Marker X Syndrome”

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

Same Same with with othe otherr chr chrom omos osom omal al abno abnorm rmal alit itie iess

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

- When there is no loss or gain of chromosomal material & the individual is mentally & physically normal. However, there is an increased risk of having chromosomally abnormal offspring because individuals who carry balanced chromosome rearrangements rearrangements may produce chromosomally unbalanced gametes. b. UNBALANCED TRANSLOCATION SYNDROME

- Happens if following repair, there is a loss or gain of chromosomal chromosomal material . There are significant clinical consequences for this type. 4 . Others a. MOSAICISM – a situation where the nondisjunction of chromosomes chromosomes occurs during during the mitotic cell division after fertilization results to diff. cells contains different # of chromosomes. - Where an individual has two or more cell populations that differ in genetic makeup. This situation can affect any type of cell, including blood cells, gametes (egg and sperm cells) & skin.

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

NOTE FOR:

*OTITIS MEDIA

= Inflammation of middle ear Common to children d/t wider & shorter Eustachian tube Causes : 1. Bottle propping w/c may also lead to dental carries 2. Cleft lip/ cleft palate


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Sx:

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

Nsg Care: 1. 2.

Position: Position: Side-ly Side-lying ing on affected affected aside – to facili facilitate tate drainage drainage Suppor Supportive tive Car Caree- Bed Bed rest, rest, incre increase ase flui fluid d intake intake

Med Mgt: 1. Massive dosage antibiotic to prevent prevent complication of Bacterial Meningitis Meningitis 2. Apply ear ointment 3. Mucolytics How? School age : Pull pinna up & down < 3 y/o = down & back > 3 y/o = up & back Small child = down & back ( no age) 4. Surgery : Myringotomy w/ Tympanostomy Tube Insertion: Prevents permanent hearing loss Nsg. Care: Post surgery: Position Position on affected side for drainage When taking a bath put ear plugs on both ears If tympanous tube falls – healed already- usually 6 months D. Assessment of the Mouth & Tongue

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

Sx: 1.

Cont Contin inuo uous us dro drool olin ing g of sali saliva va *Drooling Indicates 2 disorder:

2. Mgt:

Bell’s Palsy & TEF/TEA

Inability Inability to open open the eye eye & close close the other other eye eye at the same same time-time---mon -monitor itor for for dryness dryness

Refer to PT

b. TRACHEOESOPHAGEAL FISTULA/ATRESIA ( TEF /TEA)

- TEF – there is a thin connection bet. the esophagus & stomach - TEA – there is no connection bet. the esophagus & stomach Outstanding Sx:

4 C’s

C Mgt:

Coughing Choking Continuous drooling Cyanosis

Emergency surgery

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


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d. NATAL TOOTH - Tooth at birth d/t Hypervitaminosis of mother during pregnancy - If movable remove with a clean gauze f. NEONATAL TOOTH - Appearance of temporary temporary teeth w/n the 28 days of life instead of 6 months

* ANODONTIA – No eruption of temporary teeth even at 5 y/o g. ORAL MONILIASIS or ORAL THRUSH “O ral Candidiasis”

- White cheese-like substances & curd like patches that coats tongue CA: Candida Albicans Nsg Care: Do not remove, wash mouth with cold boiled water Administer meds: meds: Nystatin / Mycostatin: Mycostatin: Antifungal g. *KAWASAKI DISEASE or “Mucocutaneous Lymphnode Syndrome” - A Strawberry tongue, originated in Korea - Dr. Kawasaki discovered it - Common in Japan Criteria For Diagnosis Of Kawasaki Disease

1. Fever lasting more than 5 days 2. Bilateral Conjunctivitis 3. Changes of lips & oral cavity - Dry, red fissure of lips - Strawberry tongue - Diffuse erythema of hands & feet 4. Changes of Peripheral Extremities - Erythema of the hands & soles - Indurative edema of the hands & feet - Membranous desquamation from fingertips 5. Polymorphous rash 6. Acute nonpurulent swelling of cervical lymph node to > 1.5 cm in diameter Complication: Myocardial Infarction in Children ( only MI in children) Mgt:

sp irin in Administer Dr Drug: Aspir Gamma Globulin

E. Assessment of the Lips

1. Check for symmetry NOTE FOR:

a. *CLEFT LIP - Failure of median maxillary nasal nasal processes to fuse by 5-8 wks of pregnancy - Common to boys - Unilateral b. *CLEFT PALATE - Failed palate to fuse by 9 – 12 wks of pregnancy - Common to girls - Unilateral or bilateral Sx: 1. Evid Evideent at bir birth 2. Milk Milk esca escapes pes to nost nostril ril during during feedin feeding g


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3.

Freque Frequent nt colic colic & otitis otitis media media or URTI URTI

Nsg Care: 1. Provide soft & large nipples---cross cut 2. Burp baby often

+

Mgt: 1. Surgery : Depends on the Rule of 10 10 wks. Old 10 grams HgB 10 lbs. weight a. Cleft Lip Repair Repair = Cheiloplasty - Done 1-3 months to save sucking reflex (lost in 6 months ) b. Cleft Palate Repair = Uranoplasty - Done 4-6 months to save speech Pre- Operative Care: 1. Provide emotional support especially to mom 2. Provide Proper Proper nutrition to prevent prevent colic Feeding : Upright seating position Burp frequently : 2x at middle & after feeding in a prone position& in a lower to upper tap 3. Orient parents to type of feeding Rubber tipped syringe = Post-cheiloplasty Paper cup/ soup spoon/ plastic plastic cup = Post-uranoplasty Post-uranoplasty 4. Apply restraints; Elbow restraints pre-opt so baby can adjust post op & decrease movement 5. 7-8 years after: Velopharyngeal Flap Operation: To fix nostril & pharynx ALL Operation for mouth (adenoidectomy, tonsillectomy): MOST IMPORTANT DIAGNOSTIC TEST TO CHECK: CLOTTING TIME

•

•

Condition that warrants suspension of operation: COLDS & PHARYNGITIS = can lead to generalized infection TO SEPTICEMIA

Post Operative Nsg Care:

1. Airway: Position post-cheilopasty : Side lying to facilitate drainage Post-uranoplasty (tonsillectomy): (tonsillectomy): Prone position to increase mucus secretion Avoid using straw,spoon,fork straw,spoon,fork 2. Assess for RDS & signs of bleeding 3. Assess for bleeding: Frequent Frequent swallowing 6-7 days after surgery surgery indicates bleeding 4. Proper nutrition Post-NPO: Children- offer first sterile water before clear liquid Clear liquids: Gelatin except red red or brown color it may may mask bleeding (Popsicle- not ice cream) Full liquid Soft diet Regular diet 5. Maintain integrity of suture line such as: Logan bar – wash ½ strength Hydrogen Peroxide & saline solution: Bubbling effect traps microorganism Prevent crusting & scarring by putting sterile gauze + NSS - Prevent baby form crying give analgesic for pain

6. Assessment of the Neck


37

1. Check for symmetry NOTE FOR: a. CONGENITAL TORTICOLIS or “ Wryneck ”

- Congenital shortening or Birth injury of sternocleidomastoid sternocleidomastoid muscle during delivery d/t excessive excessive traction traction at at cephalic cephalic delivery delivery Mgt: Daily passive stretching exercise Surgery Complication : Scoliosis 2. Check the thyroid gland – for basal metabolism b.

CONG CONGEN ENIT ITAL AL CRET CRETIN INIS ISM M

- Absence or non functioning thyroid glands or Hypothyroidism Reasons for Delayed Dx: 1. 2. 3.

Thyroid Thyroid glands glands covere covered d by sternocl sternocleidom eidomastoi astoid d muscles muscles in in newborn newborn Baby Baby recei received ved mater maternal nal thyrox thyroxin in Baby Baby slee sleeps ps 16 – 20 20 hrs hrs a day day Earliest Sign: 1. 2. 3. 4. 5. Late Sign: 1.

Chan Change ge in Suck Suckin ing g -1s -1stt Change Change in Cry Crying ing – 2nd 2nd –decr –decreas easee sound sound Slee Sleep p exce excess ssiv ivel ely y Consti Constipat pation ion d/t decrea decrease se peri perista stalsi lsiss Edem dema – moon oon fa face

Ment Mental al Reta Retard rdat atio ion n Prognosis: Mental retardation preventable when Dx is early New Born Screening: Screening: it is included in the 6 diseases diseases to be tested

Dx: 1. 2. 3.

PBIPBI- Prot Protei ein n Bou Bound nd Iodi Iodine ne RIA RIA - Radi Radioi oimm mmun unoa oass ssay ay Tes Testt Radi Radioa oact ctiv ivee Iod Iodin inee Upt Uptak akee

Mgt: Synthroid (Sodium Levothyrosin) Levothyrosin) = Synthetic thyroid given given lifetime Check PR before giving synthroid Tachycardia = Sx of Hyperthyroidism 7. Assessment of the Chest

1. Check for Symmetry NOTE FOR: a. WITCH MILK - Transparent fluid coming out from newborn r/t hormonal changes b. Respiratory Distress Syndrome (RDS) - Retroactive chest c. PECTUS EXCAVATUM - Sunken Sternum d. BRONCHCOLITIS - Distention of the alveoli - Viral in origin


38

Sx: - Respiratory Distress - Increase Increase RR > 60/minute - Wheezing: high-pitch on expiration 8. Assessment of the Abdomen

1. Assess in order: a. b. c. d.

Inspection Auscultation Percussion Palpation

I A P P =Last to perform because it will change bowel sounds

*Normal contour of the abdomen = Slightly protruding NOTE FOR: a. DIAPHRAGMATIC HERNIA - Sunken abdomen or the protrusion of stomach content thru a defective diaphragm d/t failure of pleuroperitoneal canal to close (located at the left postero-lateral side)

Sx: 1. 2. 3.

Sunk Sunken en abdo abdom men Signs of RDS R to to L shuntin ting

Mgt: 1. Emergency surgery within 24h Diaphragmatic Diaphragmatic Repair w/ the use of Teflon Patch while place on (ECMO) Extra Corporal Membrane Oxygenation 2. Cont Contin inuo uous us CPA CPAP P & CP CPPB b. OMPHALOCELE – Protrusion of stomach contents in bet. junction of abdominal wall & umbilicus.

Mgt: Very small surgery – return the stomach contents If large: Suspension surgery - Let the baby grow more to accommodate the stomach content Nsg Mgt: 1. Protect the sac with sterile wet dressing 2. Apply silver sulfadiazine ointment to prevent infection c. GASTROCHISIS - Absence of the abdominal wall exposing all the stomach contents Nsg Mgt: 1. Provide sterile wet dressing 2. FUNCTION OF THE GIT

a. b. c.

Assis Assists ts in in main maintai tainin ning g F&E F&E & acid acid base base balanc balancee Processes & absorbs nutrients to maintain maintain metabolism & support G & D Excret Excretee wast wastee prod product uctss from from diges digestive tive proce process ss

Newborn:


Gastric Capacity – 1-2 oz Gastric Emptying – every 2-3 hrs. Normal Body Weight Weight – 3,000 to 3,500 grams

39

3. RECOMMENDED DAILY ALLOWANCE

Calories : 120 cal / Kbw/day Kbw/day or 360 – 380 cal/ day CHON = 2.2g /Kbw/day /Kbw/day Fluids = 16-20 cc/kg/day 4. PRINCIPLES IN SUPPLEMENTARY S UPPLEMENTARY FEEDING *Supplementary Feeding usually at 6 months months *Supplementary feeding can be given as early as 4 months *Weaning starts at 6-9 months or when shortening the nursing time *Never wean a child when in crisis a.) Solid food offered to baby in the ff. sequence! 1st - Cereals – rich rich in iron—Reserves iron—Reserves is catabolized already already by 6 months nd 2 - Fruits 3rd - Vegetables 4th - Meat b.) Begin with small quantities quantities c.) Finger foods – offered 6 months d.) Soft table food – “modified family menu” given by 1 year e.) Dilute fruit juices & offered by 6 months Ratio of fruits to water 1:4 (1 squeeze squeeze orange = 1 ounce) f.) Never give half cooked eggs – usually causes of Salmonellosis/Gastroenteritis Salmonellosis/Gastroenteritis g.) Don’t give honey may cause Infant Botulism h.) Offer new food one at a ti me – interval of 4 – 7days or 1 week To determine food allergens 5. MAJOR CONCEPTS OF FLUID & ELECTROLYTE BALANCE Total Body Fluids: C omprises 65 - 85% of body wt of infants & children Where fluids are greater in infants: ECF – reason why babies prone to develop dehydration

6. ACID BASE BALANCE

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

a. RESPIRATORY ACIDOSIS = Carbonic acid excess excess Causes: Hypoventilation RDS COPD


40

Laryngotracheobronchitis Laryngotracheobronchitis (LTB) b. RESPIRATORY ALKALOSIS = Carbonic acid deficit Causes: Hyperventilation Fever Encephalopathy c. METABOLIC ACIDOSIS = Base HCO3 deficit Causes: Diarrhea Severe dehydration Malnutrition Celiac crisis d. METABOLIC ALKALOSIS = Base HCO3 excess

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

Acidosis Down

a. VOMITING = F orceful expulsion of stomach content

Sx: 1. 2. 3. 4.

Nausea Dizziness Facia aciall flu flush shin ing g Abdom bdomin inal al cram crampi ping ng

Assessment:

Mgt:

Amount, Frequent & force Projectile Vomiting – Indicates Increase ICP or Pyloric Stenosis BRAT DIET B – banana R – rice A- apple sauce T- toast

b. DIARRHEA – Exaggerated excretion excretion of intestinal contents

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

CA:

Bacteria (salmonella, shigella) Virus (Rotavirus- most common) Prozoan (Entamoeba histolytica)

2. CHRONIC-NON Cause: a. b. c. d. e.

SPECIFIC DIARRHEA/NON-INFECTIOUS

Food Food into intole lerrance ance Excessive fluid intake CHO, CHO, CHON CHON mala malabso bsorpt rption ion (abn (abnor ormal mality ity)) Allergy Irrita itable ble colo olon

Assessment: Frequency, Consistency, Consistency, Appearance of green colored stool


41

*Best criteria to determine diarrhea : Consistency Complication: 1. DEHYDRATION Mild dehydration Moderate dehydration Severe dehydration

Early Signs

5% wt loss 10% wt loss 15 % wt loss

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

Weight loss -----Best criteria criteria to determine dehydration Sunken fontanel & eyeballs Scanty & dark urine Absence of tears Poor skin turgor Severe dehydration: Marked Oliguria & Prolonged capillary refill time > 3 sec.

Mgt: 1. Acute Diarrhea = NPO (to rest the bowel ) With fluid replacement – IV Oresol : 1 glass & 1 t sp. of sugar, 1 pinch of salt Prone to Hypokalemia : Give K chloride Before administering of K chloride : Check if baby can void If cannot void = Hyperkalemia Drug: Na HCO3 : Administer slowly to prevent cardiac overload 8. GASTRIC MOTILITY MOTILITY DISORDER: (Lower GIT Obstruction) Obstruction) a. HIRSCHPRUNGS DISEASE - Congenital aganglionic megacolon - Aganglionic: Absence of ganglion cells needed for peristalsis

Earliest Sign in Neonate: 1. Failur Failure/D e/Dela elayed yed pas passag sagee of mecom mecomium ium after after 24h 2. Abdo Abdomi mina nall dist disten ensi sion on 3. Vomitus Vomitus of fecal fecal material material ---lea ---lead d to aspira aspiration-tion----A --Atelec telectasis tasis 4. Foul Foul-s -sme mell llin ing g brea breath th Signs in Early Childhood: 1. Ribbon like stool 2. Foul smelling stool 3. Constipations 4. Diarrhea Dx: 1. 2. 3. 4.

Barium Barium Enem Enemaa – Reveals Reveals narr narrowe owed d portion portion of bowe bowell Rectal Rectal Biops Biopsy y – Reveals Reveals abse absence nce of of gangli ganglioni onicc cells cells Abdominal Abdominal X-ray X-ray – Reveals Reveals dilated dilated loops loops on intes intestine tine Rectal Rectal manomet manometry ry – Reveals Reveals failure failure of intestine intestine sphinc sphincter ter to relax relax

Therapeutic Mgt/Nsg care 1. NGT feeding ing: Measure tube from nose to ear to midline of xyphoid & umbilicus 2. Surgery a.) a.) Temp Tempor orar ary y colo colost stom omy y b. Anastomosis & pull through procedure Pre-opt: Provide Enema everyday


42

Use NSS: NSS: Isotonic ( 1 tsp. tsp. sugar + 500 cc cc of H20) H20) Not tap water: water: Hypotonic Can be absorbed by the cells----Circulatory cells----Circulatory Overload 3. Diet: Increase CHON Increase calories Decrease residue residue Ex. Offer pasta, spaghetti, chicken No corn, raisins ---may lead to aspiration

b. GASTROESOPHAGEAL REFLUX (GER) or CHALASIA

- Presence of stomach contents in the esophagus Assessment : 1. 2.

Chr Chronic onic vom vomitin iting g Fail Failur uree to to Thri Thrive ve Syn Syndr drom omee 2 Types: a. Organic Organic - d/t abnormality abnormality in the body/affected organ b. Non-organic – d/t abuse abuse Esophagea Esophageall bleeding bleeding manif manifeste ested d by Melena Melena or Hematem Hematemesis esis

3. Complication: 1. Aspiration pneumonia 2. Esophagitis 3. Inflammation 4. Esophageal cancer (Organic type) Dx Procedure: 1. Barium Barium Esopho Esophogr gram am – revea reveals ls ref reflux lux 2. Esophagea Esophageall Manometr Manometry y – reveals reveals lower lower esophage esophageal al sphincte sphincter r pressure 3. Intraeso Intraesophage phageal al pH content content – revea reveals ls pH of distal distal esophagus. esophagus. Medication For GERD 1. Anti-cholinergic

a.) Betanicole Betanicole (Urech (Urecholine oline)) – To increase increase esophagea esophageall tone & peristaltic peristaltic activity activity b.) Metachloporomide (Reglam) (Reglam) – To decrease decrease esophageal pressure pressure by relaxing pyloric & duodenal segments segments Increase peristalsis w/o stimulating secretions c.) H2 Histamin Histaminee Receptor Receptor Antagonis Antagonistt – To decrease decrease gastric acidity acidity & pepsin pepsin secretion Ex. Zimetidine, Ranitidine (Zantac) – take 30 min before meals d.) Antacid Antacid – To neutralize neutralizess gastric gastric acid betwe between en feedings feedings.. Ex. Maalox Maalox Surgery:

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

Nsg Care:

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

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


43

Assessment: 1 .) Outstanding Sx: Projectile vomiting d/t pressure from from narrowed narrowed pylorus Nursing Alerts: a. Vomiting is an Initial Sign of Upper GI obstruction b. Vomitus of upper GI GI can be blood tinged not bile streaked. streaked. (with blood) c. Vomitus of lower GI is bilous ( with pupu) d. Projectile vomiting – increase ICP or GI obstruction e. Abdominal distension – Major Sign of Lower GIT Obstruction 2.) Metabolic Alkalosis 3.) Failure to gain weight 4.) Olive shaped mass mass – On palpation (almond-shaped (almond-shaped mass) 5.) Peristaltic wave visible from L to R across epigastrum 6.) Always hungry, irritable Dx: 1. Ultrasound 2. X-ray of upper abdomen abdomen with barium swallow reveals reveals a “STRING SIGN” Mgt: 1. 2.

Pyloro Pyloromyo myotom tomy y - incis incision ion of the the pylo pyloric ric muscle muscle Fredret-R Fredret-Ramst amstedt edt Procedur Proceduree – separation separation of hypert hypertrophi rophied ed muscle muscle w/o incision incision

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

Thickened feeding ings (regular formula + Cereal) Monitor tor feedings (Clear liquid 24 hrs.) (Diluted Formula)

b. INSTUSSUSCEPTION

- Invagination or telescoping of position of bowel to another - Common Site: Ilio-Cecal junction (Junction bet. the small intestine) Cecum is bigger than the ileum - Not congenital Prone People:

Person who eats too fast Too much activities involving the movement of the stomach

Complication:

Invagination O2 supply Necrosis Swelling-----burst Swelling-----burst -------Peritonitis: -------Peritonitis: An emergency

Sx: 1.) 2.) 2.) 3.) 4.)

Persiste Persistent nt parox paroxysma ysmall abdomin abdominal al pain Vomit omitin ing g Currant Currant Jelly Jelly Stool: Stool: d/t bleeding bleeding & inflamma inflammation tion Palpa Palpable ble saus sausage age shap shaped ed mass mass

Dx: 1.) X-ray with Barium Enema – reveals “Staircase Sign” (coiled spring) Mgt: 1.) Hydrostat Hydrostatic ic Reductio Reduction n with with barium barium enema enema 2.) Anastomo Anastomosis sis & pull pull thru procedure procedure

10. INBORN ERRORS OF METABOLISM


44

- Due to deficient liver enzymes a. PHENYLKETONURIA (PKU)

- Genetic disorder that is characterized by an inability of the body to utilize the essential amino acid, phenylalanine d/t deficiency of liver enzymes (PHT) Phenylalaninehydroxylase Transferase : The liver enzyme that converts Phenylalanine to tyroxine or CHON to amino acid 9 Amino Acids: 1. Valine 2. Isolensine 3. Tryptophase 4. Lysine 5. Phenylalanine 6. Thyronine: Decrease melanin production Sx: a. Fair air compl omplex exio ion n b. Blond hair c. Blue eyes 7. Thyroxin: – decrease basal metabolism -Accumulation of Phenyl Pyruvic acid leads to: a. Atopic dermatitis b. Musty / mousy odor urine urine c. Seizure: Mental retardation Dx: 1. GUTHRIE TEST : Use blood as specimen Preparation: Increase CHON intake - Test if CHON will convert to amino acid 2. Specimen urine mixed with pheric chloride - Presence of green spots at diaper a sign of PKU Nsg Care: 1. DIET: Low phenylalanine diet: Food C/I : Meats, chicken, milk, milk, legumes, cheese, cheese, peanuts Give Lofenalac: Milk with synthetic protein b. GALACTOSEMIA - Deficiency of liver enzyme GUPT: Galactose Urovil Phosphatetranferase Phosphatetranferase Converts galactose to phosphate tranferase glucose Galactose will destroy brain cells if untreated – death within 3 days

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

c. CELIAC DISEASE - Gluten enteropathy

Assessment: Early Sx: a. Diarrhea Diarrhea:: Failure Failure to gain gain weight weight follow following ing diarr diarrheal heal episod episodes es b. Constipation c. Vomiting d. Abdominal Pain: Protuberant abdomen even if with muscle wasting e. Steatorrhea Late Sx: 1. Behavi Behaviora orall change changes: s: Irrit Irritabi ability lity & Apath Apathy y


45

2.

Muscle Muscle was wasting ting & loss loss of subc subcuta utaneo neous us fats fats

Celiac Crisis: Exaggerated vomiting with bowel inflammation

Dx: 1. Labor Laborato atory ry Studie Studiess : Stool Stool analys analysis is 2. Serum Serum Antigliadin Antigliadin & Antire Antireticuli ticulin n Antibodies Antibodies:: Confirmato Confirmatory ry Dx of the diseas diseasee 3. Sweat Te Test Nsg Care: 1. Gluten-free diet for lifetime 2. All brow food not allowed: Intolerance Common Gluten food: B- barley R- rye O- oat W- wheat 3. Allowed to eat rice & corn Mgt: 1. Vitam itamin in supp supple leme ment ntss 2. Mine Minera rall sup suppl plem emen ents ts 3. Steroids PATHOPHYSIOLOGY:

Gluten – Glutamine (Normal Absorption)

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

Malabsorption

Fats

CHON & CHO peripheral edema & malnutrition

Vit. D /Calcium

Vit. K

Iron folic acid

Inadequate blood coagulation

Steatorrhea

Osteomalasia

Bleeding

Anemia

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

Principles : 1. 2.

Deter Determin minee the subs substan tance ce taken taken & Asse Assess ss LOC LOC Unless Unless poison poison is corrosi corrosive, ve, caustic caustic (stro (strong ng alkali alkali such such as lye) lye) or or a hydroca hydrocarbon, rbon, INDUCE VOMITING is the most effective way to remove poison. 3. Give SYRUP OF PECAC : oral emetic to cause vomiting after drug overdose/poisoning 15 ml : Adolescent, school age & pre school 10 ml to infant


46

4. 5. 6. 7.

8.

UNIVERSAL UNIVERSAL ANTIDOTE: ANTIDOTE: Charcoa Charcoal, l, Milk Milk Of Of Magnesia Magnesia & Burned Burned Toast Never Never administer administer the charcoal charcoal before before syrup syrup of pecac pecac Antidote Antidote for Acetamin Acetaminophen ophen Poisoning: Poisoning: N – Acetylcyc Acetylcyctein tein (Mucomys (Mucomyst) t) For Causti Causticc poiso poisonin ning g like like Muria Muriatic tic Acid Acid:: Give vinegar to neutralize acid . Don’t vomit prepare tracheostomy set For For Gas Gas pois poison onin ing g: Give mineral oil to coat the intestine & prevent absorption of gas---go to stool

a. LEAD POSIONING

Accumulation Lead

Physiology:

Destroy RBC functioning Hypochronic Microcytic Anemia Destroy kidney functioning Accumulation of Ammonia Encephalopathy

Sx: 1. Beginn Beginning ing sympto symptoms ms of lethar lethargy gy 2. Impuls Impulsive ivenes nesss & Learnin Learning g difficu difficultie ltiess 3. As Lead increases increases,, severe encephalo encephalopathy pathy with with seizure seizure & permanent permanent mental retarda retardation tion Dx: 1. 2. 3.

Blood smear Abdom bdomin inal al X-ra -ray Long bones

1. 2.

Remo Remove ve chi child ld fro from m the the sou sourc rcee If lead lead is > 20 ug/dL ug/dL:: Need Need Chelation Chelation Therapy Therapy : Binds with lead & excret excreted ed by kidney kidney Ex. BAL (Dimercaprol) Ca EDTA ( Edetate Ca Disodium) A chelating agent must be administered in a large muscle group VIA DEEP IM Check urine specific gravity (Normal: 1.003-1.030) S/E: Nephrotoxic N.I: Warm compress compress post-chelation post-chelation to relieve pain

Mgt:

9. Assessment of the Reproductive Organ NOTE FOR: a. ANOGENITAL

1. Female: a. PSEUDOMENSTRUATION: - Slight bleeding on vagina R/T hormonal changes b. RAPE/CHILD ABUSE or BATTERED CHILD SYNDROME - Tearing of fourchette with blood Rape: Report within 48 h to brgy. Captain R.A. 7610 – CHILD ABUSE LAW - Non-accidental injury

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


47

2. Male: Assessment: 1. Assess scrotum with warm hands & warm room 2. Baby should pee w/in 24 hrs. NOTE FOR: a. UNDESCENDED TESTES or “CRYPTORCHIDISM” - Common to preterm (descend in 7 months) Orchidopexy Surgery: Com Complica licati tion on:: Ster terilit ility y

3. Check for the arch of urination urination b. EPISPADIAS

- Urinary meatus located dorsal or a bove glans penis c. HYPOSPADIAS - Urinary meauts located ventral or below glans penis Hypospadias w/ Chordee : Fibrous band causing penis to curb downward Mgt: Surgery d. PHIMOSIS = A tight foreskin Mgt: Circumcision e. PARAPHIMOSIS = loosened foreskin f. BALANITIS = Infection of glands penis d/t smegma g. TESTICULAR TORSION h. HYDROCEL

= Twisted testicle

= Fluid -filled scrotum Dx: Transillumination with use of flashlight - glowing sign

i. VARICOCELE = Enlarged vein of epididymis (Girls = Valvular varicosities)

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

Renal Disorder


Cause

Sx

Tx

NSG CARE

48

b. NEPHROTIC SYNDROME

Infectious

c.

AGN (Acute Glomerulonephritis) 3

Autoimmune Grp. A betahemolytic streptococcus Or GABHS

A’s:

AGN Autoimmune, Grp. A Betahemolytic St.

Before: Sore Throat *Impetigo

1. A na nasarca: General edema 2. Mass Massiv ive e proten protenur uria ia 3. Micros Microscop copic ic or no no hematu hematuria ria 4. Serum Serum CHON CHON decrea decreased sed 5. Serum Serum lipid lipid increa increased sed 6. Fatigue 7. Norm Normal al to low low BP

1. Prednisone 2. Diuretic (Furosemide)

1. (PPP) (PPP) Primar Primary y Peripheral Peripheral Periobital Edema 2. Modera Moderate te prote protenur nuria ia 3. Gross Gross Hematu Hematuria ria (Sign: Smokey urine) 4. Serum Serum K incr increas eased ed 5. Fati Fatigu gue e 6. *Increase *Increase BP BP – Outst Outstanding anding Sx

1. Anti-HPN drug (Hydralazine or Apresoline)

Focus of Care: 1. Monitor edema Weigh daily 2. Diet: Moderate CHON Increase K- OJ, beef broth, banana Low Na Diet

2. Iron supplements

1. Weigh daily 2. Monitor : BP V/S Neurologic status 3. Diet: Decrease K Decrease Na

Complication : 1. Hypertens Hypertensive ive encephalopa encephalopathy thy If HPN not treated 2. Anemia

11. Assessment of the BACK

1. Check for flatness & symmetry *Spina Bifida – From L5 to S1 NOTE FOR: a. OPEN NEURAL TUBE DEFECT - Decreased Folic Acid intake of mother & those during pregnancy undergoes steam bath/spa

2 Types: 1. SPINA BIFIDA OCCULTA - Failure of post laminae of vertebrae to fuse Sx: Dimpling of the back Abnormal tufts of hair 2. SPINA BIFIDA CYSTICA - Failure of post laminae of vertebrae to fuse with a sac Types:

1.* MENINGOCELE - Protrusion of CSF & Meninges - No alteration in function 2. MYELOMENINGOCEL MYELOMENINGOCELE E

- Protrusion of CSF & Meninges & Spinal Cord - Most dangerous type - On the back : under illumination shows a half glow 3. ENCEPHALOCELE


49

- CNS complication : Hydrocephalus--Cranial Hydrocephalus--Cranial meningocele or Myelomeningocele Most Common Problem : a. b. c.

Rupture of sac Prone position Ster Steril ilee wet wet dres dressi sing ng

Most Common Common Complication: Complication: Infection 1. For Myelomeningocele : Genitourinary & Fecal Incontinence 2. Orthopedic complication: Paralysis of lower extremities Sx: a. Weakness, paralysis of lower extremities b. Cold to touch c. Ulceration d. Absence of spontaneous movement e. Bladder – dribbling of urine g. Bowel – no control Dx: 1. During pregnancy thru MAFEP Mgt: Surgery just to prevent infection, will not cure Pre-opt – Protect the sac, use sterile doughnut ring Post op – prone position Nsg Care: Always check diaper b. SCOLIOSIS - Lateral curvature of the spine - Common to adolescence

2 Types: 1. Structural – d/t Wry neck 2. Postural – d/t improper posture or heavy bags Sx: 1. 2. 3.

Uneve neven n hem hemline line Bend Bend forw forwar ard d & 1 hip hip high higher er 1 should shoulder er blad bladee more more promin prominent ent than than the the other other

Nsg care: 1. Conservative – Avoid obesity, exercise 2. Preventive – Milwaukee brace : Worn 23 h a day 3. Corr Correc ecti tive ve surg surger ery y – Inse Insert rt Harr Harrin ingt gton on rod rod Post operative- How to move : Log Rolling- move client as 1 unit 12. Assessment of the EXTREMITIES:

1. Assess for the # of digits = 20 NOTE FOR: a. b. c.

SYNDACTYLY POLYDACTYLY OLIDACTYLY

- Webbing of digits (ginger-like foot) - Extra digits - Lack of digits

d. e.

AMELIA POCOMELIA

- Total absence of digits - Absence of distal part of extremities Both d/t use of anti-emetic in Pregnancy or Thalidomides

2. Assess for movement of extremities


50

a. ERB-DUCHENNES’ PARALYSIS - Paralysis of the brachial plexus injury or brachial palsy - Birth injury d/t breech delivery & excessive lateral traction Sx: 1. Unabl Unablee to abduct abduct arms arms from from should shoulder ers/ s/ Rotate arm externally or supinate forearm 2. Absen Absence ce or or asym asymme metri trical cal Moro Moro refle reflex x Mgt: 1. Rotate Rotate arm armss from from should shoulder erss with with elbow elbow flexe flexed d 2. Pass Passiv ivee ROM ROM exer exerci cise sess

b. CONGENITAL HIP DISLOCATION - Head of femur is outside the acetabulum Types:

1. 2.

Subluxated : Most common type Dislocated

1. 2. 3. 4. 5.

Shor Shorte teni ning ng of affe affect cted ed leg leg Asym Asymme metr tric ical al glut glutea eall fol fold d Limi Limite ted d move moveme ment nt – ear earli lies estt sx (+) Ortola Ortolanis nis sign sign – abnorm abnormal al clicking clicking sound sound during during abduct abduction ion (away) (away) When able to walk walk – child limps – Late Late Sx: Sx: Trendel Trendelenburg enburg Sign

Sx:

Goal of Mgt: Facilitate abduction Mgt. 1. 2. 3. 4. 5.

Tripl iple di diaper Carr Carry y baby baby astr astrid idee Frejka sp splint Pavl Pavlik ik har harnes ness Hip Sp Spica Ca Cast

c. TALIPES TALIPES or “Clubfoot” “Clubfoot”

Types: a.) EQUINOS b.) CALCANEUS c.) VARUS d.) VALGUS

= Plantar flexion (horsefoot) = Dorsiflexion: Heel lower that foot/ Anterior portion of foot flexed towards anterior leg = Foot turns in = Foot turns out

e.) EQUINOS VARUS = Most common (Combination) Assessment: 1.

Straig Straighte hten n legs legs & flexin flexing g them at midli midline ne posit position ion

Mgt: 1. Corrective Shoe- Dennis Dennis brown brown shoe, spica cast cast 2. Cast 13. OTHER TOPICS: A. CAST

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


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3. Plaster of Paris

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

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

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

1. 2.

Swing Th Through Swing to No weight bearing are are allowed into lower ext ext

3. Three point Gait - wt bearing is allowed in 1 ext 4. Four point gait 5. Two point Gait - Weight bearing allowed in 2 lower extremities Other Crutch-Maneuvering Techniques To sit down:

1. Grasp the crutches at the hand pieces for control 2. Bend forward slightly while assuming a sitting position 3. Place the affected leg forward to prevent weight-bearing and flexion To stand up:


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

1. Walk forward as far as possible on the step 2. Advance crutches to the lower step. The weaker leg is advanced first and then the stronger extremity shares the work of raising and lowering the body weight with the patient’s arms. To Go Up Stairs:

1. Advance the stronger leg first up to the next step. 2. Then advance the crutches and t he weaker extremity. (Strong leg goes up first and comes down last.) A memory device for the patients is “up with the good, down with the bad.”

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

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

I. Weight-bearing transfer from bed to chair. The patient stands up, pivots his back is opposite the new seat, and sits down. II. (Left) Non-weight-bearing Non-weight-bearing transfer from chair to bed. (Right) With legs braced. III. (Left) Non-weight-bearing transfer, combined method. (Right) Non-weight bearing transfer, transfer, pull-up method E. TRACTION - Used to reduce dislocation & immobilize fractures Principles of TRACTION:

1. 2. 3. 4.

The clie client nt shoul should d be in dors dorsal al or supine supine pos positio ition n For every every traction traction there is alway alwayss a counter counter trac traction tion Line Line of pull pull shoul should d be in in line line with with defor deformit mity y For tra tracti ction on to be eff effec ective tive,, it must must be contin continuou uouss

Types:

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

Nursing Responsibilities: Responsibilities: 1. 2. 3.


Assess Assess for circulati circulation on and and neurologic neurologic impairme impairment nt It can can lead lead to hype hypert rten ensi sion on Be carefu carefull in carryin carrying g out nursing nursing functio functions ns by not not moving moving the the weights weights

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F. AUTOIMMUNE SYSTEM Types of Immunity:

a.

IMMU IMMUNI NITY TY AGAI AGAINS NST: T: = Diphtheria, Pertussis, Tetanus, Polio & Measles l ast for 9-12 months in babies

b.

PASS PASSIIVE NAT NATURA URAL - Via placenta, placenta, breast milk

c.

ACTIVE NA NATURAL - Acquired disease & produces memory cells

d.

PASS PASSIV IVE E ARTI ARTIFI FICA CAL L - Receives anti-serum with anti-bodies from host - Hep. B

e.

ACTI ACTIV VE ARTI ARTIFI FIC CIAL IAL - Receives vaccine & produces memory cells - All EPI vaccines are active artificial EXCEPT HEP. B 12. NEUROMUSCULAR SYSTEM Reflexes A. BLIN LINK REF REFLE LEX X - Rapid eyelid closure when strong light is shown B. PALM PALMAR AR GRA GRASP SP REF REFLE LEX X - With solid object, baby will grasp object - Cling to mother for safety - 6 weeks to 3 months to disappear C. STEP STEP IN/ IN/WA WALK LK-I -IN N REFL REFLEX EX - Neonate placed on a vertical position with their feet touching a hard surface will take a few quick, alternating steps. * PACING REFLEX – Almost the same same with step in place reflex reflex only that you are touching the anterior surface of a newborn’s leg D. PLAN PLANTA TAR R GRA GRASP SP REFL REFLEX EX – When an object touches the sole of a newborn’s newborn’s foot at the base of the toes, the toes grasp in the same manner as the fingers do.

E. TO TONI NICC-CL CLON ONIC IC REFL REFLEX EX – When newborns newborns lie on their backs, their heads heads usually turn to one side or the other. The arm on the leg on the side to which the head turns extend, and the opposite arm and leg contract. F. MORO REFLEX – Letter “C” position - Disappears 4-5 months - Test for neuro integrity

G. MAGN MAGNET ET REFL REFLEX EX


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– when there is pressure pressure on the sole of the foot foot he pushes back against the pressure H. CROSSE CROSSED D EXT EXTENS ENSION ION REFLEX REFLEX – When the sole of the foot foot is stimulated by a sharp sharp object, it causes the foot to rise and the other foot extend I.

TRUN TRUNK K INCU INCURV RVAT ATIO ION N REFL REFLEX EX – While in prone position & the paravertical area area is stimulated, it causes flexion of the trunk and swing his pelvis towards the touch

J.

LANDAU RE REFLE FLEX – While in prone position and and the trunk is supported, the baby exhibit some muscle tone

K. PARA PARACH CHUT UTE E REA REACT CTIO ION N – While on ventral suspension, with the sudden change of equilibrium, it causes extension of the hand and legs L. BABI BABINS NSKI KI REFL REFLEX EX –When the sole of the foot foot is stimulated by an inverted inverted “J”, it causes fanning of the toes


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Pediatric Nursing Pentagon

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