Escolar Documentos
Profissional Documentos
Cultura Documentos
Jude College
Dimasalang cor. Don Quijote St.
Sampaloc, Manila
PEDIATRIC NURSING
a. Suction newborn
• Suction the mouth first before the nose to prevent aspiration
• Sunctioning should be gentle to prevent laryngospasm
• It should not be more than 1 minute otherwise, it will stimulate vagus
nerve causing bradycardia.
a. Occlude one nostril at a time to test for patency since newborns are nasal
breathers
b. Observe characteristics of respirations
Sign Score
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Page 1 of 46
0 1 2
Heart rate Absent <100 >100
Respiratory effort Absent Slow, irregular Good, strong cry
Weak cry
Muscle tone Limp flaccid Some flexion of extremities Well flexed extremities
Reflex irritability No response Grimace Cry, withdrawal of foot
Color Blue, pale Extremities blue, body is Completely pink
pink (acrocyanosis)
S INTERPRETATION:
T
• 0-3 = This may indicate severe respiratory & CNS depression. The baby is in
J serious danger needing immediate resuscitation
U • 4-6 = Condition is guarded & may need more suctioning & oxygenation
D • 7-10 = Routine care only, no special care needed
E
5. Assess gestational age
C
O Clinical criteria for gestational age assessment
L
L GESTATIONAL AGE
E Finding
0-36 WKS 37-38 WKS 39 WKS
G
Sole creases Anterior transverse crease Occasional creases in Sole covered with
E
only anterior 2/3 creases
Breast nodule 2 mm 4 mm 7 mm
S
diameter
T
Scalp hair Fine & fuzzy Fine & fuzzy Coarse & silky
J Ear lobe Pliable, no cartilage Some cartilage Stiffened by thick
U cartilage
D Testes and Testes in lower canal, small Intermediate Test pendulous, full
E scrotum scrotum, few rugae scrotum, extensive
rugae
C
O 6. Cleanse baby with oil to remove blood, mucus, vernix
L
L 7. Cord care
E • Inspect for the presence of 2 arteries & 1 vein
G ○ Absence of 1 artery may indicate kidney problem
E ○ Absence of umbilical blood vessels may indicate heart and kidney
problem
S
T • Assess for possible bleeding
• Dress the cord with alcohol to hasten drying
J • Keep the cord clean and dry
U
D 5. Administer eye care
E • Crede’s prophylaxis to protect newborn against gonorrheal conjunctivitis
acquired from the mother as the infant passes thru the birth canal
C • Dry newborn’s face
O • Open one eye at a time by putting pressure on upper and lower lids
L • Instill 2 drops of 1% silver nitrate into the lower conjunctival sac
L • If erythromycin ointment is used, squeeze a line of ointment along the
E lower conjunctival sac from the inner canthus outward. Close eye to allow
G ointment to spread across conjunctiva.
E
5. Administer Vitamin K
• Vitamin K is normally synthesized in the presence of bacterial flora in the
intestines. Since newborn’s intestines are still sterile, Vitamin K is
administered to facilitate production of clotting factor thus, preventing
hemorrhage.
• Vitamin K (1 mg) is injected into the vastus lateralis (IM). This site is
preferred because gluteal muscles of children below 12 months who have
not yet learned how to walk are still not fully developed.
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• This should be done before they are removed from the delivery room
• Take newborn’s footprints
5. Initial feeding
• If to be formula fed: give 1 oz sterile water at 4-6 hours. This is a test
feeding to be certain that the infant can swallow without aspiration.
Formula milk is given on the 4th feeding (rationale: if formula milk is
aspirated, this may cause bacterial pneumonia).
• If to be breast fed: usually 30 minutes after normal delivery, 4 hours after
CS (rationale: ability to suck and swallow in breast fed infants is not
S significant because if colostrums is aspirated, it has no effect on the
T lungs).
J 5. Circumcision
U • Surgical removal of penis foreskin usually done on the 1st or 2nd day of
D life after the baby has synthesized enough Vitamin K to prevent
E hemorrhage.
• Contraindications: hypospadias, epispadias
C • Procedure:
O ○ Place infant in supine position
L ○ Restrain the infant
L ○ Prepare & drape the area around the penis
E ○ Clamp is fitted over the end of penis, stretching the foreskin taut
G ○ Prepuce is separated from the glans & a circle of prepuce is
E existed
• Complications: hemorrhage, infection, urethral fistula formation
S • Nursing responsibilities:
T ○ Observe closely & check for bleeding
○ Wrap penis with a strip of petroleum gauze to prevent the diaper
J
from adhering from the circumcised area
U
○ Don’t want away a film of yellowish mucous which often covers
D
the glans.
E
A.CARE OF THE NEWBORN IN THE NURSERY
C
5. Check ID band (wrist or ankle)
O
L
6. Take vital statistics (anthropometric measurement)
L
a. Weight
E
• Average birth weight is 6.5 – 7.5 lbs. or 3.0 – 3.4 kg or 3000 –
G
3400 gm
E
• Arbitary lower limit is 2.5 kg or 55 lb or 2500 gm. Below this
weight, the newborn is considered low birth weight infant
S
T
• Newborns lose 5-10% of birth weight (6-10 oz) during the first
few days of life (physiologic wt loss) due to:
○ Newborn is no longer in the influence of maternal
J
U hormones
D ○ Newborn voids & passes stools
E ○ If breast fed, they have limited intake because colostrum
has low caloric content
C ○ If bottle fed, sucking is not yet effective
O • Birth weight is doubled by 6 mos, tripled by 1 year, quadrupled
L by 2 ½ years.
L
E a. Length
G • Average length is 19-21.5 inches or 47-53 cm
E
a. Head circumference
• Normal: 33-35 cm
<32—microcephaly
>37—macrocephaly
• measured with a tape measure drawn across the center of the
forehead and the most prominent portion of the posterior head
a. Chest circumference
• Normal: 31-33 cm
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• Measured at the level of the nipples
• Head circumference >chest circumference till 2 years of age
a. Abdominal circumference
• Normal: 31-33 cm
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Globin (reused by body)
Destruction
of RBCs
Heme
Protopporphyrin Indirect bilirubin
(Fat soluble)
S
T
glucoronyl transferase
J
U
D
Direct bilirubin
E
• Physiologic jaundice (Icterus Neonatorum)
C
• Onset- 2nd or 3rd day
O
• Duration- 5-7 days
L
○ Babies being breast fed have longer duration of
L
E physiologic jaundice because breast milk contain
G pregnandiol which depresses action of glucoronyl
E transferase
○ Management of physiologic jaundice:
S ○ Morning sunlight will stimulate liver to produce glucoronyl
T transferase & convert indirect bilirubin to direct bilirubin.
C • Birthmarks
O ○ Hemangiomas- vascular tumor of the skin
L Nevus flammeus (port-wine stain)
L Macular purple or dark red lesion, usually on the
E face
G Strawberry hemangioma
E Elevated, thick, hard
Associated with high estrogen level
S Cavernous hemangiomas
T Dilated vascular spaces, elevated
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• Milia- pinpoint white papule (plugged or unopened sebaceous
gland) on cheek or across the bridge of the nose
○ Disappear by 2-4 weeks
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• There is physiologic strabismus due to underdeveloped eye
muscles till 4 mos.
a. Ears
• Pinna, tends to bend easily
• Level of top part of the ear should be in line with the upper
canthus of the eye
○ Ears set lower may indicate chromosomal abnormalities
b. Mouth
• Should open evenly when newborn cries, otherwise it may
indicate cranial nerve injury
• Tongue appears large and prominent
• Palate should be intact
• Epstein’s pearls maybe mistaken for oral thrust which are white
or gray patches on the tongue and sides of cheeks due to
candida infection
• It is unusual for a newborn to have teeth but if 1 or 2 are found
(natal teeth), it should be evaluated for stability. Loose teeth
should be extracted to prevent aspiration.
a. Neck
S • Short and chubby, creased with skin
T folds
Rigid neck- cogenital torticollis
J • Strong enough to support the weight
U of the head
D • Trachea may be prominent in front of
E the neck
• Thyroid gland is not palpable
C If palpable, suspect congenital goiter
O
L a. Chest
L • Breast may be engorged due to
E influence of maternal hormones
G • Occasionally, breasts of newborns
E secrete thin, watery fluid (witch’s milk)
due to maternal hormones
S • Should be symmetric in appearance
T • Retractions should not be present
J a. Abdomen
U • contour is slightly protuberant,
D globular
E • scaphiod or sunken abdomen –
missing abdominal contents
C • bowel sounds should be heard with in
O an hour after birth
L • edge of the liver is palpable at 1-2 cm
L below the right costal margin
E • if >3cm – developing CHF
G • edge of the spleen is palpable 1-2 cm
E below the coastal margin
• for the 1st hr of birth, umbilical cord is
S white, gelatinous marked with red and
T blue streaks of umbilical vein and
arteries. After 1 hour, cord begins to
J shrink, dry and be discolored.
U • 2nd or 3rd day – black
D • 6th – 10th day – breaks free, leaving a
E granulating area a few cm across that
heals during the following week
C • right kidney can usually be palpated
O
L
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G
E
a. Anogenital Area
• Check for the patency of the anus
• Note the time that the infant passed out meconium. If the
newborn does not pass meconium in the 1st 24 hrs, suspect
imporforate anus or meconium ileus
• Male genitalia
○ scrotum is edematous due to maternal hormones
○ testes should be present in the scrotum
○ Cryptorchidism- undescended testes, may be due to short
vas deferens, closed scrotal sac, ectopic testes, agenesis,
deficient testosterone
○ Penis appears small. Inspect if urethral opening is at the
tip of the glans.
○ If found on the dorsal surface- epispadias
○ If found on the ventral surface- hypospadias
○ Prepuce (foreskin) of the penis should be examined to test
for phimosis (tight foreskin)
• Female genetalia
○ Vulva maybe swollen due to influence of maternal
hormones
○ May have mucous vaginal secretion which is sometimes
blood-tinged, also due to maternal hormones
a.Back
S • Supine appears flat in the lumbar &
T sacral areas
• Curve starts to form when the child
J is able to sit & walk
U
D a.Extremities
E • Arms & legs appear short
• Hands are plump & clenched into
C fists
O • Fingernails are soft and smooth &
L are long to extend over the
L fingertips
E • Arms and legs should move
G symmetrically
E • Check the digits for webbing
(syndactyly), extra toes or fingers
S (polydactyly), lacking toes or
T fingers (oligodactyly)
• Observe for thalidomide effects:
J complete absence of extremities
U (Amelia), absence of distal
D extremities (pocomelia), absence
E of either upper or lower extremity
(hemmelia).
C • Check pulses
O Radial pulses are normally
L nonpapable in the 1st 3 months
L due to decrease peripheral
E resistance from upper extremities.
G If palpable, suspect coarctation of
E aorta.
Femoral pulses are normally
S palpable due to high peripheral
T resistance from lower extremities.
If non palpable, conclusive of
J coarctation of aorta.
U
D • Abnormal rotation & extension of
E foot suggests talipes/club foot
Types: Talipes equinovarus-
C inward rotation of foot, most
O common.
L
L Pediatric Nursing
E Page 8 of 46
G
E
Talipes equinovalgus- outward rotation of foot
Talipes calcaneous- upward rotation of foot
Talipes equinas- downward rotation of foot
• Abduct hip to 90
Limited abduction to 60- congenital hip dislocation
a. Review of systems
a. Cardiovascular system
• In utero, oxygenation takes place in the placenta not in the fetal
lungs. So, pressure in the left side is less than the pressure in the
right side of the heart.
• Fetal accessory structures:
○ Foramen ovale- opening between the right and left atria
○ Ductus arteriosus- connects pulmonary artery & aorta
○ Ducturs venosus- bypasses the liver
○ Umbilical vein- carries oxygenated blood
○ 2 umbilical arteries- carry deoxygenated blood
• As soon as the cord is clamped, the newborn is forced to take in O2
thru the lungs. This expansion of the lungs will cause the pressure
of the left side of the heart to be higher than the pressure of the
right heart. This in turn will cause:
○ Foramen ovale will close and turn into a ligament (fossa ovalis)
○ Ductus arteriosus changes into a ligament (ligamentum
arteriosum)
○ Ductus venosus changes into a ligament (ligementum
venosum)
○ Umbilical vein & arteries will atrophy & degenerate since no
more blood goes thru it
• A newborn’s blood volume is around 300 ml
○ RBC- 6 million/cubic mm
○ Hgb- 17-18 gg/100ml blood
○ Hct- 45% - 50%
○ Platelets- 100,000- 200,000
○ WBC- 15,000-45,000/cubic mm
a. Respiratory system
• Newborn’s first breath requires tremendous amount of energy to
pull in. Once the alveoli have initially been inflated, breathing
becomes much easier for the baby
• Heart of the newborn takes more space than in an adult so the
amount of lung expansion is limited
a. Gastrointestinal system
• Usually sterile at birth
• Stomach can hold about 60-90 ml
• Has limited ability to digest fat and starch because pancreatic
enzymes are deficient during t he 1st few months of life
• Regurgitates easily due to immature cardiac sphincter
• Usually has low glucose & protein serum level due to immature
liver function
• Stools:
○ Meconium- 1st stool that is usually passed 24 hours after
birth. Sticky, tar-like blackish green, odorless that was
formed from mucus, vernix, lanugo, hormones that
accumulated in utero
○ Transitional stool- 2nd or 3rd day of life which may resemble
diarrhea (bright, green, loose)
○ Stool of breast fed infants—4th day of life; golden yellow,
sweet smelling, mushy stools passed 3-4x a day
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○ Stool of formula fed
infants- pale yellow,
S
firm, has a slightly
T
more noticeable odor,
passed 2-3x a day
J
○ Bright green stools—
U
those placed under
D
phototherapy
E
○ Stool with mucus—milk
C allergy or other irritant
O should be suspected
L ○ Gray/clay colored
L stool- bile duct
E obstruction
G ○ Black/tarry stool-
E intestinal bleeding
S
a. Urinary system T
• Newborns void within 24 hours after birth
• J Single voiding is only about 15 ml
• U Daily urine output is 30-60 ml/day
• D Specific gravity- 1.0008-1.010
• E Proteinuria is normal in the 1st 3 mos.
• Light in color & odorless because their kidneys do not
C concentrate urine well
• O Female newborns produce a steady stream when
L voiding
• L Male newborns void with enough force to produce a
E small projected arc
G
a. Autoimmune E system
• Maternal Ab (IgG) cross placenta to the fetus during
S the last 2 weeks of pregnancy (passive natural
T immunity) and serve as protection against 6 childhood
diseases: poliomyelitis, measles, diphtheria, pertussis,
J rubella, tetanus. There is little immunity against
U varicella (Chicken pox) or herpes simplex.
• D Neonate has difficulty forming antibodies against
E antigens until 2 mos. Of age. That is why
immunizations are started at 2 mos.
C
a. Neuromuscular O system
• L Limpness or total absence of muscular response to
L manipulation may indicate narcosis, shock or cerebral
E injury.
• G Reflexes:
E ○ Blink reflex- protects
the eye from any
object coming near
it; rapid eyelid closure; does not disappear.
○ Rooting reflex- the neonate turns head in the direction
where the cheek is brushed or stroked near the corner of
the mouth; helps the baby to fin food; disappear at 6
weeks of life.
○ Sucking reflex- the neonate makes a sucking motion when
the lips are touched; begins to diminish at 6 mos. of age;
disappears if not stimulated, thus an infant on NPO should
be given pacifier to stimulate sucking
○ Swallowing reflex- food placed at the posterior portion of
the tongue is automatically swallowed; it does not
disappear.
○ Extrusion reflex- any substance placed at the anterior
tongue will be spit out; it disappears at about 4 mos. of
age when the infant is ready to eat semi solid foods
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○ Palmar grasp reflex- newborns grasp an object placed in
their palm by closing their fingers on it; disappears at 6
weeks to 3 mos.
○ Plantar grasp reflex- when an object touches the sole of
newborn’s foot at the base of the toes, the toes grasp in
the same manner as the fingers do
○ Tonic neck reflex- when lying on his back, the newborn’s
arm and leg are extended on the side where the head is
turned. The arm and leg on the opposite side are flexed;
disappears between the
2nd and 3rd mos. Of life
S ○ Moro (startle) reflex-
T
most important reflex
indicative of neurological
J
status, this is elicited by
U
startling the newborn
D
with loud noise, jarring
E
the bassinet or the head
is allowed to drop
C
backward in a supine
O
position. The newborn
L
will abduct and adduct
L
in his arms and legs.
E
Their fingers assume a
G
typical “C” position. This
E
fades by the end of the
4th and 5th month.
S
○ Babinski reflex- the
T
infant will fan the toes
J when the side of the
U foot is stroked in an
D inverted “J” curve from
E the heel upward. This is
in contrast to the adult
C who flexes the toes. It
O begins to disappear by 3
L mos. of age
L ○ Landau reflex- a
E newborn help in prone
G position should
E demonstrate muscle
tone.
S ○ Deep tendon reflex
T A patellar reflex can be elicited by tapping the
patellar tendon with the tip of the finger. The lower
J leg will move perceptibly if the infant has a mature
U reflex. This is a test for spinal nerves L2-L4
D A biceps reflex is elicited by placing the thumb of
E your left hand on the tendon of the biceps muscles.
Tap the thumb as it rests on the tendon. You will
C feel the tendon contract. This is a test for spinal
O nerves C5-C6.
L
a. Senses L
• E Hearing
• G A fetus is able to hear in utero
• E They appear to have difficulty locating sound, not turning
toward it consistently
• They respond with generalized activity to a sound
• They calm in response to a soothing voice & startle at loud noises
• They recognize their mother’s voice as if they have heard it in
utero
• Vision
• Newborns see as soon as they are born
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• They cannot follow objects past the midline of vision (9-12”)
• They focus best in black & white objects
• Taste
• Taste buds are developed & functioning before birth
• Newborns turn away from bitter taste & readily accepts the sweet
taste of milk or glucose water
• Smell
• Present as soon as the nose is clear of mucus & amniotic fluid
• Sensitive to breast milk
a. Discharge planning
• Daily care
○ Bathing
Should be done prior to, not after a feeding to
prevent regurgitation, spitting up or vomiting
Bath water should be around 98-100 F (37-38 C)
Soap should be mild
○ Diaper area care
When changing diapers, the area should be washed
with clean water & be dried well so that ammonia in
S urine will not irritate the infant’s skin
T An ointment such as petroleum jelly may be applied
J • Sleep patterns
U ○ A newborn sleeps an average of 16 hrs/day in the first week
D at home & an average of 4 hours at a time
E ○ At 4 mos., the baby sleeps 15 hrs/day & 8 hrs at a time
○ Most typical time for wakefulness- 6:00-11:00 PM
C
O
• Nutrition
L
○ Recommended daily allowance for the newborn
L
E ○ Calories- 120 cal/kg body wt (birth-2 mos.)
G ○ 100 kcal/kg body wt (1 year)
E ○ Protein- 2.2/kg body wt (birth- 2 mos.)
Minerals
• Cow’s milk has more minerals but the
newborn’s kidneys are not yet mature enough
and might be overwhelmed by high mineral
content of cow’s milk
Similarities
• Both are deficient in Iron
• Both contain 20 cal/oz
• Both should be given by demand feeding
○ Similarities
Both are deficient in Iron
Both contain 20 cal/oz
Both should be given by demand feeding
S A. Newborn at Risk
T 2. Premature Babies (low birth weight infants)
b. Anemia of prematurity
J • Normochromic, normocytic anemia
U • Develops during the first 3 to 4 mos. of life due to immaturity of
D the hematopoietic system
E • Blood transfusions may be done to supply needed blood
components until maturity of the hematopoietic system is achieved
C • Is different from Iron-deficiency anemia also occurring in
O premature infants because transfer of Fe stores from the mother to
L the baby occurs during the last 2 weeks of pregnancy.
L • In this type of anemia, Fe supplements may be given to the baby
E
G b.Kernictrus
E • Destruction of the brain cells by indirect bilirubin due to excessive
breakdown of RBC & immaturity of the liver
S • Monitor indirect bilirubin level
T • Phototherapy—done with the use of artificial blue light to convert
indirect bilirubin to its excretable form
J ○ Undress the baby to expose all areas of the body
U ○ Cover genitals & eyes
D
○ Turn the baby every 2 hours
E
○ Assess skin turgor because the infant may lose considerable fluid
thru insensible water loss due to the temperature of the light
C
○ Increase fluid intake to prevent dehydration
O
L ○ Check stools & urine. Their stools usually are frequently loose &
L bright green due to excessive bilirubin excreted. Urine may be
E dark-colored from urobilinogen formation
G
E b. Infection
• This is due to immature immune defenses in premature infants
S • In addition, they have a deficiency in IgG (antibodies) which is usually
T transferred from the mother to the baby during the last 2 weeks of
pregnancy
J
U 2. Post Mature Babies
D • Born after the 42nd week of pregnancy
E • They are at risk because the placenta is timed to be effectively functioning
for 40 weeks, after that, it seems to lose its ability to function
C • Characteristics:
O • Dry, cracked, leather-like skin due to lack of fluid & absence of vernix
L
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G
E
• Fingernails have grown beyond fingertips
• They may be meconium-stained
• May be alert as a 2-week old baby
• Management:
• Protect baby from chilling
• Monitor vital signs
• Provide emotional support to the mother
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• They are usually born by cesarean birth
• Severe hypoglycemia during the 1st 24 hours (blood sugar
<40mg/dl in newborns)
Management
• Keep infant in an environment free from excessive stimuli
• Maintain fluid & electrolyte balance
• Management:
○ Place infant in a galactose-free diet
7. Congenital anomalies
a. Cleft lip & cleft palate
• Cleft lip
○ More common among males than females
○ Occurs at approximately 1:1000 live births
○ Has a familial tendency
○ Presence of teratogens during wks 5-8 of intrauterine life
○ Characteristics:
The defect can be just a small notch in the upper lip or a
total separation of the lip & facial structure up into the floor
of the nose
Nose is generally flattened
Gingiva and upper teeth may be absent
May be unilateral or bilateral
• Management
○ Cleft lip surgery (cheiloplasty) may be done shortly after birth
because early repair will help the infant
S experience pleasure of sucking as soon as
T possible
J • Cleft palate
U ○ More common among females than males
D ○ Occurs at approximately 1:2500 live births
E ○ Cleft lip with cleft palate occurs at
approximately 1:1000 live births
C ○ Genetic, familial, presence of teratogens
O ○ Characteristics:
L Opening on the palate which may involve the anterior hard
L palate, posterior soft palate or both
E Usually in the midline
G
E • Management
○ Cleft palate surgery is not done until the
S child is around 4-6 mos. Because it can
T damage the tooth buds
J • Associated problems:
U ○ Altered nutrition
D
Pre-op nursing care:
E
• Support the baby in an upright position (sitting or semi
sitting) while feeding
C
• Use a commercial cleft lip nipple
O
• Be careful when feeding because this may cause aspiration
L
• Burp frequently because they have the tendency to swallow
L
air due to their inability to maintain a closed seal around the
E
nipple
G
E
Post-op nursing care
• Keep on NPO for at least 4 hours
S
• Avoid placing tension on the suture line
T
• Breast feeding or bottle feeding is contraindicated during
the immediate post op period. Use a breck feeder
J
• Do not use straw to drink
U
• After repair of the cleft palate, liquid diet is continued for
D
the first 3-4 days followed by a soft diet until healing is
E
complete
• Never use spoon or fork when feeding
C
• Offer water after feeding to rinse suture line
O
L
L Pediatric Nursing
E Page 16 of 46
G
E
○ Ineffective airway clearance
Observe for respiratory distress due to local edema in the
immediate post op period
If suction is really needed, be gentle and don’t touch suture
line
Post-cheiloplasty, put on side-lying position to drain saliva
Use of mist tent to liquefy secretions
○ Impaired tissue integrity at incision site
Avoid tension on the suture line
A logan bar or an adhesive bandage is used to protect
suture line
Anticipate infant’s need because crying increases tension on
the suture
Avoid placing anything hard or sharp (toys) on the suture
line
Keep elbow restraints in place
○ Infection
Clean suture line with sterile solution and sterile cotton-
tipped applicators after every feeding
They are high risk for ear infection so routine screening for
hearing loss is needed
Teach the parents signs of
infection: pain, fever, ear
S discharge
T
○ Altered communication pattern
J
U
a. Hydrocephalus
D
• Excess of cerebrospinal fluid in the ventricles and subarachnoid
E
spaces of the brain
C
• Causes:
O
Overproduction of fluid by the
L
choroids plexus
L
Obstruction of the passage of fluid
E
Interference with the absorption of
G
fluid from subarachnoid space
E
• Types
S
Communicating or extraventricular
T
hydrocephalus- there is passage of
fluid between ventricles and spinal
J
cord
U
Non communicating or
D
intraventricular hydrocephalus-
E
there is block to passage of fluid
C
• Assessment:
O
Increase head size with bulging
L
fontanelles (first sign)
L
Papilledema
E
Edema of optic disk
G
Scalp becomes shiny, scalp veins
E
prominent
Sunset eyes
S
Head lag even after 4 mos.
T
Shrill, high-pitched cry
Irritable and lethargic
J
U
• Diagnostic studies:
D
Sonogram, CT scan, MRI, skull x-ray
E
• Surgical management
C
Depends on its cause & extent
O
L
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E Page 17 of 46
G
E
If caused by obstruction, treatment usually involves bypassing the
point of obstruction by shunting the fluid to normal or artificial
points of absorption
• Management:
Elevate head of bed
Put them in a non stimulating environment
Monitor vital signs
Watch out for signs of increase ICP: bulging fontanelles, increasing
head circumference, irritability, lethargy, poor sucking, increase
temperature, decrease PR, decrease RR.
Reposition head every 2 hrs to prevent scalp breakdown
Monitor head circumference daily
• Microcephaly
○ Slow brain growth due to maternal phenylketonuria or
intrauterine infection such as
rubella or cytomegalovirus
S ○ Results in mental retardation
T
• Spina bifida oculta
○ Occurs when the posterior laminae
J
or vertebrae fail to fuse
U
○ More common at the 5th lumbar or
D
E 1st sacral level
○ May appear as a dimple at the
C point of poor fusion; abnormal
O tuffs of hair may be present
• L Meningocele
L ○ Occurs when the meninges
E covering spinal herniates thru
G unformed vertebrae
E ○ Appears as a protruding mass at
the center of the back
S ○ Usually in lumbar region
T
• Myelomeningocele
J ○ The spinal cord, spinal fluid and
U meninges protrude thru the
D vertebral defect
E ○ Results in lower motor neuron
damage
C ○ Flaccid, lack of sensation in lower
O extremities
L ○ Loss of bladder and bowel control
L
• E Management:
G ○ Prevent infection/rupture of
E protruding mass
Put child on prone position
S Do not put diaper
T Cover sac with sterile gauze with NSS or antibiotic
○ Monitor for signs of increase ICP:
J bulging fontanelles, vomiting, high-
U pitched cry, increasing head
D circumference, irritability, increase
E BP, decrease PR, decrease RR
○ Watch out for complications:
C
Hydrocephalus
O
Meningitis
L
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G
E
• Nuchal rigidity
• Photophobia
• Opisthotonus position (arching of the spine)
• Signs of meningeal irritation: vomiting, (+)
kernigs, (+) brudzinski
UTI
Bowel incontinence
Club feet
Hip dislocation
• When this happens, there is less exchange of oxygen and carbon dioxide
leading to: HYPOXIA
• Tissue hypoxia causes the release of lactic acid
• The pathologic feature of RDS is a hyaline-like membrane which prevents
S exchange of O2 & CO2 at the alveolar-blood inter space leading to
T ATELECTASIS
• Assessment:
J ○ Expiratory grunting--a compensatory mechanism
U ○ Cyanosis in room air
D ○ Nasal flaring
E
○ Sternal & subcostal retractions
○ Tachypnea (> 70 breaths/min)
C
○ Rales and diminished breath sounds
O
L
L • Management
E ○ Avoid extreme body temperature because increase in BMR will
G demand for O2
E ○ Give sodium bicarbonate to correct acidosis
○ Monitor VS especially RR every 1-2 hours
S ○ IV fluid may be needed or gavage feeding for hydration because
T the respiratory effort makes the infant too exhausted to suck
○ Administer O2 to maintain normal PO2 and pH levels
J
U 1. Meconium
D • An infant who experienced hypoxia in utero has a vagal reflex relaxation of
E the rectal sphincter releasing meconium into the amniotic fluid. During the
first breath, the baby inhales the amniotic fluid & aspirates meconium. This
C can bring about inflammation of bronchioles or block bronchioles by
O mechanical plugging. Any of these 2 mechanisms will cause severe
L respiratory distress.
• L Characteristics:
E • Has difficulty establishing respirations at birth
G • Tachypnea, retractions, cyanosis
• E Management:
• The infant should be intubated
S • Suction meconium from trachea & bronchi
T • Antibiotic treatment may be given to prevent development of pneumonia
J
U
D VII. PEDIATRIC NURSING
E
D. GENERAL PRINCIPLES OF GROWTH AND DEVELOPMENT
C • Growth- increase in physical size
O quantitative change
L
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G
E
• 2 aspects
○ weight- most sensitive measure of growth
○ birthweight- 2x at 6 mos
3x at 1 year
4x at 2 ½ years
○ height
○ Increase in ht. is 1”/mo from 1 mo- 6 mos.
1/2”/mo from 7 mos. - 12 mos.
C Post conventional
O Level 5 12 & above Social contract. Follows standards of
L Level 6 society. Universal ethical principle
L orientation
E
D. G BEHAVIOR TRAITS/CHARACTERISTICS
1. E INFANTS (0-12 mos.)
• Significant person- mother/caregiver
S • Fear- stranger anxiety
T • Physical growth
• Developmental milestones
J ○ 0-1 month
U largely reflex
D keeps hands fisted, able to follow object to midline
E momentary visual fixation on faces
C ○ 2 months
O holds head up when prone
L social smile
L makes cooling sounds
E differentiates his cry
G
E ○ 3 months
holds head and chest up when prone
S follows objects past midline
T laughs aloud
J ○ 4 months
U no longer has head lag when pulled upright
D bears partial weight on feet when held upright
E grasps objects & brings to mouth
C ○ 5 months
O raking grasp
L
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G
E
turns both ways
○ 6 months
reaches out in anticipation of being picked up
sits unsteadily (with minimal support)
eruption of first tooth
palmar grasp
○ 7 months
transfer objects hand to hand
beginning fears of strangers
○ 8 months
sits securely without support
fear of strangers (peak)
○ 9 months
creeps or crawls
says first word (dada)
○ 10 months
puts self to stand
uses pincer grasp (thumb to finger)
S
○ 11 months
T
walks with support
J
○ 12 months
U
D stands alone
E walks with help
holds cup & spoon well
C
O • Play: solitary
L • Appropriate toys: mobiles, rattles, music box, squeeze toys,
L plastic rings, rubber ducks, teething ring, textured toys
E
G 1. TODDLER (1-3 years)
E • Significant person: parents
• Fear: separation anxiety
S • Physical growth:
T ○ Decrease appetite because of slower growth rate
○ Prominent abdomen because abdominal muscles are not
J yet strong enough to support abdominal contents
U ○ All deciduous teeth are generally present by 2 1/2 – 3
D years
E ○ Should start regular dental care by 2 years
C • Developmental milestones
O ○ Critical for language development
L ○ Favorite word is “NO” (a manifestation of developing
L autonomy)
E ○ Negativistic, obstinate, difficult to manage
G ○ Active, curious, motor ability jumps far ahead of his
E judgment
○ By 18 mos., he imitates the things he sees a parent is
S doing
T ○ They have ritualistic behaviors
○ They go into temper tantrum at one time or another.
J
Temper tantrums are a natural consequence of their
U
development. They occur as a response to an unrealistic
D
request by parent, consequence of their development.
E
They occur as a response to an unrealistic request by
parent, or if the parents are saying, “NO” too frequently,
C
O
L
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G
E
or maybe a response to difficulty making choices, or too much pressure
from activities like toilet training
○ Know the cause of the tantrum
○ Tell the child that they disapprove of the tantrum then ignore the
behavior
○ Keep child away from onlookers
○ Don’t accede to the wish of the child nor punish the child
○ Direct the child to more productive activities
○ Toilet training- one of the biggest task during this period; it is an
individualized task for each child
○ 2 important developmental levels before a child can begin toilet
training
○ control of rectal & urethral sphincters—if the child is able to walk
well independently
○ they must understand what it means to hold urine & stools until
they can release them at a certain place and time—when they
begin to be uncomfortable with their wet diapers
○ at 18 mos. Of age, the toddler has bowel control
○ at 2 1/2 years, he has day time bowel control
○ at 3-4 years, he has night time bladder control
• Behaviors
3 years old
○ undresses self
○ runs
○ climbs steps one at a time
○ walks backwards
○ stands on 1 foot
○ vocabulary of 300- 900 words
4 years old
○ can do simple buttons
○ jumps, skips
○ uses alternate steps when climbing stairs
○ vocabulary of 1500 words
5 years old
○ draws a 6-part man
○ throws over hand
○ runs well
○ vocabulary of 2100 words
Developmental milestones
○ They ask questions constantly
○ Favorite word is “WHY”
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○ Answer their questions honestly at the level of their
understanding so that their
S curiosity, vocabulary building &
T questioning are encouraged.
• Developmental milestones
They are modest, industrious
They enjoy collecting items
They are competitive
Stealing is a common problem
6 years old
• jumps, skips, stumbles, hops
• talk in full sentence
• play in groups
• first molars may erupt
7 years old
• central incisors erupt
• difference between sexes become apparent in play
• spends time in quiet play
• can tell time in hours
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8 years old
• improved coordination
• loves collecting clothes
• prefers playmates of own sex
• best friends develop
9 years old
• Always on the go
• They play hard
S
• Gang age
T
10 years old
J
• coordination improves
U
• interest in the opposite sex is apparent
D
• interested in rules and fairness
E
• enjoy privacy
C
11 years old
O
• more active become increasingly interested in the opposite sex
L
L
Play: competitive
E
G
Age-appropriate toys: dolls, table games, comic books,
watching TV, remote control games, collecting items.
E
1. ADOLESCENT (12-18 years old)
S
• Significant person: peers of opposite sex
T
• Fear: fear of acne, homosexuality, obesity, displacement from
friends, death
J
• Physical growth:
U
○ Onset of puberty and cessation of body growth
D
E ○ Physiologic growth is rapid
• Pubertal changes
C ○ Male (testes testosterone)
O sudden growth spurt
L deepening of voice
L increase size of genitals
E pubic & axillary hair
G production of viable sperm
E
○ Female (ovary estrogen & progesterone)
S Sudden growth spurt
T The larche (increase size of breath).
• Starts at 10 years old and ends at 18 years of age
J • Sign to sexual maturation
U Appearance of pubic & axillary hair
D Widening of hips
E Menarche
• Happens between the time the girl develops pubic and
C axillary hair
O • Ovulation starts 1-2 years before menarche
L
L ○ Behaviors
E Rebellious, reformers, idealistic, futuristic
G Use of status symbol
E Conscious of body image
Emancipation from parents becomes an issue
Hero worship (film star, athlete, writer, etc.)
D. IMMUNIZATIONS
IMMUNITY
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NATURAL ARTIFICIAL
d. Respiratory Dysfunction
1. Disorders of the upper respiratory tract
a. Acute nasopharyngitis (common
cold)
• Most frequent infectious disease in children
• Viral in origin
• Assessment
○ Begins with nasal congestion
○ Watery rhinitis
○ Low grade fever
○ Edematous & erythematous nasal mucous membrane
○ May have thick purulent nasal discharge
b. Tonsilitis
• Infection and inflammation of palatine tonsils
• Assessment:
○ Drooling because the throat is too sore for them to swallow saliva
○ High fever
○ Lethargy
• Management:
○ Antipyretic for fever
○ Analgesic for pain
○ Antibiotics
○ Tonsillectomy—removal of palatine tonsils
○ Adenoidectomy—removal of pharyngeal tonsils
• Both are never done while the organs are infected because operation might
spread the pathogens into the blood which may lead to septicemia
• Pre-op nursing care: complete PE, record bleeding & clotting time, CBC &
urinalysis
• Post-op nursing care:
○ Monitor VS
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○ Place child on abdomen so that head is lower than the chest to drain
blood & unswallowed saliva
○ Assess for subtle signs of hemorrhage: increase PR, increase RR,
frequent swallowing, throat clearing
○ If bleeding occurs, elevate head & turn to side
○ Frequent sips of clear liquid or ice chips may be given if the patient is
awake because this will increase blood supply to the area thus
reducing edema and pain
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○ Provide 5 quick downward thrusts in the lower third of the sternum
b. Bronchial obstruction
• Right main bronchus is straighter and has larger lumen than the left
bronchus in children >2 years of age. That is why an aspirated foreign
object may lodge in the right bronchus. The alveoli distal to the
obstruction will collapse (atelectasis)
• Assessment:
○ Cough
○ Dyspnea
○ Hemoptysis
○ Purulent sputum
○ Localized wheezing
• Monitor VS
• Keep on NPO for at least 1 hour
• Liquefy secretions
a. Bronchiolitis
• Inflammation of fine bronchioles & small bronchi
• Caused by virus
•Assessment:
S ○ 1 or 2 days of upper respiratory tract infection
T ○ nasal flaring
○ intercostal & subcostal retractions
J ○ increase RR
U ○ wheezing
D
E •Management:
○ Provide adequate hydration to keep respiratory membranes moist
C ○ Give moist oxygen
O ○ IV therapy may be started
L ○ Place in semi-fowler’s position for adequate chest expansion
L ○ Some are more comfortable in prone position
E
G a. Pneumonia
E • Inflammation of the lung alveoli
• May be bacterial or viral in origin
S • Aspiration may also cause pneumonia
T • Classification:
○ Pneumococcal
J
• High fever, nasal flaring, restractions, chills, dyspnea, chest pain,
U
tachypnea, tachycardia, rales
D
• Antiobiotics: Penicillin G
E
• Chlamydial
○ Often seen in newborns up to 12 weeks of age
C
○ Nasal congestion, cough, tachypnea, wheezing, rales
O
L • Viral
L ○ Low-grade fever, non productive cough, tachypnea, diminished breath
E sounds, rales rest
G • Mycoplasmal
E ○ More frequently seen in older children
○ Fever, cough, enlarged cervical lymph odes, rhinitis
S ○ Antibiotic: erythromycin
T • Lipid
○ Caused by aspiration of oily or lipid substance (peanuts)
J ○ Cough, dyspnea, respiratory distress
U • Hydrocarbon
D ○ Furniture polish, kerosene, gasoline, insect sprays, lighter fluid
E ○ Nausea & vomiting, drowsy, dyspnea, increase RR
○ Don’t induce vomiting
C ○ Stomach lavage
O ○ Prevent secondary infection
L
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G
E
d. Gastrointestinal Disorders
1. Disorders of motility
a. Diarrhea
• Diarrhea in infants is always serious because they have little
extracellular fluid reserve. Sudden losses of water may lead to
dehydration.
• May be bacterial or viral in origin
• Mild diarrhea
○ 2-10 loose watery stools/day
○ fever, anorexia, irritability, dry mucous membrane, increase PR,
warm skin, good skin turgor, normal urine output
○ Management:
○ Rest the gastrointestinal tract for 1 hour then start rehydration.
• Severe diarrhea:
○ Fever, weak & rapid PR, cool skin, pale, apprehension, listlessness,
lethargy
○ With obvious signs of dehydration: increase PR, depressed
fontanelles, sunken eyes, poor skin turgor, weight loss
○ Bowel movement every few minutes
○ Stool is liquid green with mucus and blood
○ Scanty & concentrated urine
○ Management:
S ○ Maintain fluid and electrolyte balance by replacing lost fluids and
T electrolytes by starting IV infusion
○ Provide skin care because diarrheal stool is irritating
J ○ Wet lips with moisturizing to prevent crackling
U
D a. Constipation
E • Difficulty passing hardened stools
• Abdominal pain, pain on defecation
C • As long as the stool is not hard and no discomfort is felt in passing
O the stool, it is not considered constipation
L • Management:
L ○ Enema may initially be needed
E ○ Give stool softeners
G ○ Advise high fiber, high fluid diet
E ○ Encourage to develop regular bowel habits
S 2. Inflammatory diseases
T b. Appendicitis
• Inflammation of the appendix
J • Most common in school age children
U • Cause is unknown
D • Assessment:
E • Anorexia (12-24 hours)
• At first, the child will feel diffused abdominal pain which gradually
C
localizes at the right lower quadrant. The point of sharpest pain is
O
1/3 of the way between anterior posterior iliac crest and umbilicus,
L
referred to as Mc Burney’s point.
L
• Nausea and vomiting
E
• Fever
G
• Leukocytosis
E
• Rebound tenderness
• Reduced bowel sound
S
T
• Management: surgical removal of appendix
• Pre-op nursing care:
J
○ Cathartics & heat are contraindicated because they may cause
U
rupture of appendix
D
○ Shave and wash abdomen & perineum
E
○ Urinalysis and CBC
C ○ Start IV fluid for hydration
O • Post- op nursing care:
L
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G
E
○ Children will return with NGT in place. Keep on NPO until return of
peristalsis
○ Maintain IV fluid
○ Monitor I and O
• If with ruptured appendix
○ Semi-fowler’s position so that infected drainage will drain onward
rather than upward into the lungs
○ Start IV fluid
○ Begin antibiotics
○ Post-operatively, penrose drain are maintained in place to drain
infectious material
○ Examine wound carefully
○ Change dressings as ordered
• Complication: Peritonitis
○ Signs: rigid (board-like) abdomen, shallow respiration, increase
temperature.
a. Intussusception
• Invagination of the portion of the intestine into another
• Assessment:
• Severe abdominal pain which causes them to draw up their legs &
cry
• They may be symptom-free after the pain
• In approximately 15 minutes, the abdominal pain may strike again
• Vomiting
• Blood in stool after 12 hours (“currant jelly” appearance)
S • Distended abdomen
T • Management: surgery to remove invagated portion or reduce the
intussusception
J • Pre-op nursing care:
U ○ Keep on NPO
D ○ Begin IV infusion
E • Post-op nursing care:
○ Keep NGT & IV infusion in place
C
O c. Volvulus
L • Twisting of the intestines leading to obstruction of the passage feces
L • Assessment:
E ○ Intense crying and pain
G ○ Pulling up the legs
E ○ Abdominal distention
○ Vomiting
S ○ Abdominal mass
T
• Management: surgery to relieve vulvolus and reattach bowel
J
U c. Intestinal obstruction
D • Assessment
E ○ The infant does not pass meconium or may pass 1 stool, then stop
○ Distended abdomen
C ○ Vomiting
O
○ Increase bowel sounds
L
L ○ Character of infant’s cry: hard and forceful
E ○ Increase PR
G
E • Management: this is an emergency to prevent dehydration &
electrolyte imbalance. The area of stenosis is removed and the bowel
S is anastomosed
T
c. Hirschsprung disease (A ganglionic megacolon)
J • Absence of ganglionic innervation to the muscle of a section of the
U bowel so that there are no peristalsic waves to further the passage of
D the fecal material
E • Assessment: Symptoms are apparent after 6-12 mos. Of age.
○ History of chronic constipation of intermittent constipation and diarrhea
C ○ Ribbon-like stools
O ○ Abdominal pain
L
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G
E
○ Nausea and vomiting
• Management: surgery (Swenson pull-through) usually done at 12-18 mos of age
because it is difficult to perform the surgery in small abdomen so a temporary
colostomy is done
○ Pre-op nursing care
Daily enemas to achieve bowel movements. Use normal saline
(isotonic) not tap water (hypotonic) because tap water moves rapidly
to the interstitial and intravascular fluid compartments which may lead
to cardiac congestion or cerebral edema
Provide colostomy care
Provide frequent feedings with low residue diet
○ Post-op nursing care
Keep NGT and IV in place
Watch out for abdominal distention
Assess bowel sounds & observe for passage of flatus and stool
When peristalsis returns, give small frequent feedings
2. Structural defects
a. Hernias
• Diaphragmatic hernia
○ Abdominal organ (usually stomach or intestine) protrudes through a defect in
the diaphragm into the chest cavity. This usually occurs on the left side,
displacing the heart to the right of the chest & the left lung collapses
○ Assessment:
S
○ Respiratory difficulty from the time of birth
T
○ Cyanosis
J ○ Intercostals & subcostal retractions
U ○ Sunken abdomen
D ○ Absent breath sound on affected lung
○ E Management:
○ Elevate head to ease breathing
C ○ Turn the infant so that affected lung is down so
O that the unaffected lung will expand completely
L ○ NGT or gastrostomy tube is inserted to prevent
L distention
E ○ Infants with diaphragmatic needs immediate
G surgical repair
E
• Umbilical hernia
S ○ A portion of the intestine protrudes through an
T opening of the umbilical ring
○ The mass is generally 1-2 cm in diameter but
J
usually gets bigger when the child cries or strains
U
○ If fascial ring is <2 cm, closure is spontaneous and
D
E needs no repair
If fascial ring is >2 cm, it needs surgery
C which is done to school age
O
• L Inguinal hernia
L ○ Protrusion of a section of a bowel into the inguinal
E ring
G ○ Assessment:
E Lumpin the groin usually on the right side
Sometimes, hernia is only apparent when
S crying due to increase abdominal pressure
T If pain is present, the bowel has become
incarcerated in the sac (emergency
J situation)
U ○ Management: surgery
D
a. E Imperforate anus
• Failure of the 2 sections of the bowel to meet or if the membrane
C between the 2 surfaces doesn’t dissolve during the 7 th week of
O intrauterine life
L
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G
E
• Assessment:
○ No anal formation
○ Inability to insert rectal thermometer
○ A membrane filled with black meconium is seen protruding from the anus
○ No stool is passed leading to abdominal distention
• Management:
○ Post-op, NGT is inserted for decompression
○ Check bowel sound
○ Small oral feedings are resumed when bowel sounds are present
○ Maintain the suture line clean by irrigating it with normal saline
○ Take temperature thru axilla
a. Peptic ulcer
• Shallow excavation in the mucosal wall of stomach, pylorus or duodenum
• Due to the over secretion of gastric juices or failure of the mucosa to
neutralize gastric secretions
• Causes: administration of adrenocorticotropic hormone or corticosteroids in
neonates: associated with stress (prolonged labor, sepsis: genetic factor
• Assessment:
○ Neonate: hematemesis (blood in vomitus)
Melena (blood in stool)
○ Toddler: feeding problems
Vomiting
○ Pre-school: Pain on arising not relieved be eating, poorly localized
○ Older school age/adolescent: gnawing or aching pain in epigastric
before meals that is relieved by eating, vomiting tenderness in
epigastric region.
• Management:
○ Medications to decrease gastric acidity (Cimetidine) taken with meals
or at bedtime
○ In infants, give frequent small feedings
○ In children, avoid heavily spiced foods
○ Provide emotional support and relieve stress
2. Hepatic disorders
a. Hepatitis
• Inflammation & infection of the liver
Hepatitis A Hepatitis B
Causative agent Hepa A virus Hepa B virus
Incubation period 25 days 120 days
Period of communicability 2 weeks before onset of Later part of the incubation
jaundice period, acute stage
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• Assessment:
○ Headache, vomiting
○ Generalized aching
○ Right upper quadrant pain
○ Icteric sclera
○ Generalized jaundice
○ White or gray-colored stool
○ Low-grade fever, sore throat, nasal discharge
○ Dark-colored urine after 3-7 days
• Management:
○ Maintain a high-caloric diet
○ Strict hand washing & isolation technique
○ Cool bath to reduce discomfort from pruritus
• Complication: Hepatic coma
S a. Niacin deficiency
T • Pellagra
• Characteristics (4 Ds);
J ○ Dermatitis
U ○ Diarrhea
D ○ Dementia
E ○ Death
C a. Vitamin C deficiency
O • Scurvy
L
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G
E
• Characteristics:
○ Muscle tenderness
○ Petechial hemorrhage of the skin
○ Nose bleeding
○ Swollen gums
• Treatment: Administration of supplementary Vitamin C diet rich in fresh fruits
and vegetables.
a. Vitamin D deficiency
• Rickets
• Characteristics:
○ Poor muscle tone
○ Delayed motor development
○ Delayed tooth eruption
○ Gastrointestinal upset
○ Excessive perspiration of the head
○ Swelling of epiphysis of the long bones
○ Bowlegs, knock-knee deformities
○ Spinal deformities
• Treatment: Administration of Vitamin D
Diet rich in Calcium & Vitamin D
Expose children to sunlight
S a. Iodine deficiency
T • Goiter (hyperplasia of the thyroid gland)
• Has difficulty breathing
J • Treatment: supplemental iodine
U Synthetic thyroxine
D High-iodine diet
E
a. Kwashiorkor
C • Caused by protein deficiency
O • More frequently seen in children ages 1-3 years
L • Characteristics:
L ○ Growth failure
E ○ Muscle wasting
G ○ Irritability
E ○ Iron-deficiency anemia
○ Diarrhea
S
• Treatment: high protein diet
T
a. Nutritional Marasmus
J
○ Deficiency of all food groups
U
D ○ Most commonly seen in children younger than 1 year
E ○ Characteristics:
○ Growth failure
C ○ Muscle wasting
O ○ Iron- deficiency anemia
L ○ Diarrhea
L ○ Treatment: diet rich in nutrients
E
G 2.Poisoning
E • More common between the ages of 2-3 years
• Emergency management of poisoning at home:
S ○ Call for help
T ○ Identify the poison
○ Check the respiration
J If deep, rapid- ACID
U If slow, shallow- ALKALINE
D ○ Remove poison from the body including vomiting
E
○ Give syrup of ipecac: 15 ml (adolescent, school-age child,
preschooler) 10 ml (infant) followed by 200 ml of fluid
C
O
L
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G
E
○ If syrup of Ipecac is not available, induce gagging by placing finger in the
back of the throat
○ Do not induce vomiting if:
The child is comatose
The child has seizure
The poison was caustic, corrosive or hydrocarbon
○ Give antidote (opposite of the poison)
○ Universal antidote (opposite of the poison)
Burned toast
Milk of magnesia
Strong tea
○ Gastric lavage
○ administer saline cathartic (harsh laxatives)
can cause dehydration & fluid electrolyte imbalance
S a. Caustic poisoning
T ○Lye in washing powder, toilet bowl cleaners, hair care products
○S/Sx:
J ○ Pain in mouth & throat
U ○ Drooling
D ○ Mouth turns white due to burn and later turns brown due to edema &
E ulceration
○ Vomiting of blood & mucus
C
○ Tachycardia
O
○ Tachypnea
L
L ○ Pallor
E ○ Hypotension
G ○Management:
E NOTE: Vomiting should never be induced because the corrosive substance will
burn as it moves along the GI tract
S ○Dilute poison with milk or water
T ○Start steroid therapy to decrease chance of permanent
esophageal scarring
J ○Monitor VS
U
D a. Lead poisoning
E ○Interferes with RBC function
○Effects:
C CNS: lethargy, impulsiveness, mental dysfunction
O Hematology: Hypochromic, microctic anemia
L
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G
E
GI: constipation, abdominal pain, vomiting
Kidney: hematuria
○ Management:
○ Chelation therapy to remove lead from soft tissue and bone & eliminate it in the
urine
EDTA (Edetate Calcium Disodium)
BAL (Dimercaprol)
A. CARDIOVASCULAR DYSFUNCTION
Unoxygenated blood
Oxygenated blood
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○ Split heart sound (fixed splitting) which is almost always diagnostic of Atrial
Septal defect.
○ Diagnostics: Echocardiography reveals enlarged right side of the heart and
increase pulmonary circulation
S ○ Management: Open heart surgery
T
○ Patent Ductus Arteriosus
J ○ The ductus arteriosus is an accessory fetal vessel that closes at
U birth or be completed at 3 mos. of age in some infants. It connects
D the pulmonary artery and aorta. If it fails to close, oxygenated
E blood from the aorta will go back to the pulmonary artery back into
the lungs for reoxygenation. This puts additional strain on the left
C ventricle causing hypertrophy.
O ○ Assessment:
L
○ Wide pulse pressure
L
○ Continuous “machinery” murmur on upper right sternal border or
E
G under the left clavicle in older children
E ○ Diagnostics: ECG or x-ray reveals ventricular hypertrophy
○ Management:
S ○ Administration of oral or IV Indomethacin
T ○ Ligate patient ductus arteriosus
○ If surgery is not done, there is increased risk of Congestive Heart
J Failure and infectious endocarditis.
U
D ○ Pulmonary Stenosis
E ○ Narrowing of pulmonary valve or pulmonary artery distal to the
vavle. Due to this, the right ventricle cannot effectively empty
C blood by the way of pulmonary artery which will lead to right
O ventricular hypertrophy
L ○ Assessment:
L ○ Systolic ejection murmur at upper left sternal border
E ○ Thrill may be present in left upper sternal area or the suprasternal
G notch
E ○ Diagnostics: ECG reveals right ventricular hypertrophy; cardiac
catheter will reveal degree of stenosis
S
○ Management: balloon stenotomy
T
○ Aortic Stenosis
J
U ○ Narrowing of aortic valve which prevents left ventricle from
D effectively emptying blood to the aorta. This causes increase
E pressure in the left ventricle as it attempts to force blood to the
stenosed valve.
C ○ Assessment:
O ○ May be asymptomatic
L ○ Murmur loudest at the 2nd right ICS
L ○ Thrill may be present at the suprasaternal notch
E ○ Diagnostics: ECG reveals right ventricular hypertrophy; cardiac
G catheter reveals degree of stenosis
E ○ Management: balloon stenotomy, surgical repair
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○ Leg pain on exertion because of decreased blood supply to the lower
extremities
○ Murmur may occasionally be present
○ Diagnostics: x-ray, ECG reveals left side hypertrophy
○ Management: surgery between 3-4 years of age
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Tachycardia
Tachypnea, dsypnea
Rales
Bloody sputum
Easy fatigability
Feeding difficulty
Cyanosis
• Diagnostics: chest x-ray, echocardiography & fluoroscopy reveals an enlarged heart.
On PE, apical heart beat is displaced laterally & downward
• Management:
○ Reduce workload of heart:
Provide rest, minimal handling
Small frequent feedings
S ○ Evacuate accumulated fluids:
T Diuretics
Low-Na diet
J ○ Improve cardiac contractility:
U Digitalis
D
E 1. Rheumatic fever
• An autoimmune disease caused by group-A-beta-hemolytic streptococcal
C infection. This often follows an attack of Group-A beta-hemolytic strep
O infection like tonsillitis, phrayngitis, scarlet fever or impetigo
• L This disease is diagnosed if there are 2 major or 1 minor symptoms present
L plus a previous history of streptoinfection (Jone’s criteria)
E ○ Major manifestations:
G Chorea:
E • most striking symptom
• loss of voluntary muscle control
S • dysfunctional speech
T • weak hand grasp
Carditis- most serious; presence of systolic murmur
J Erythema marginatum- macular rash over the trunk & extremities
U Subcutaneous nodules painless lumps on joints
D Polyarthritis- large joints becomes red, swollen, hot & tender
E ○ Minor manifestations:
Fever
C Previous strep infection
O Arthralgia
L Elevated ESR (inflammation)
L (+) C reactive protein
E Leukocytosis
G Prolonged P-R interval (ECG)
E
• Management:
S ○ Bed rest to reduce cardiac workload until ESR, C reactive
T protein, PR return to normal
○ Take VS especially apical pulse
J ○ Provide diet high in protein and calorie
U
○ Drugs:
D
Penicillin to eliminate group-A-beta-hemolytic streptococcus
E
Salicylates to reduce inflammation & pain
Phenobarbital to reduce purposeful movements of chorea
C
Corticosteroids to reduce inflammation
O
L
A.HEMATOLOGIC DYSFUNCTION
L
1. RBC Disorder: Anemia
E
• Decrease in the number or function of erythrocytes
G
E
a. Normochromic, normocytic anemias
• RBCs are normal in both color and size but too few in
number
• Acute blood-loss anemia
○ May be caused by trauma such as accident, acute nephritis,
placenta previa; abruptio placenta
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○ Assessment:
Pallor
Tachycardia
Tachypnea
Gasping respiration
Sternal retractions
Cyanosis
○ Treatment:
Control bleeding
Place in a supine position to provide circulation to the brain
cells
Keep child warm with blanket
Blood transfusion may be necessary
• Aplastic Anemia
S ○ Results from depression of hematopoietic activity in bone marrow
T ○ Formation of WBC, RBC and platelets are affected
○ Maybe due to excessive exposure to radiation, drugs, chemicals
J which cause bone marrow damage (chloramphenicol, sulfonamides,
U arsenic, benzene, quinine)
D ○ Assessment:
E Pallor
Easy fatigability
C Anorexia
O Petechiae
L Nose bleeding
L GI bleeding
E Prone to infection
G ○ Management:
E Suppress abnormal bone marrow with anti-thymocyte
globulin (ATG) or anti-lymphocyte globulin (ALG)
S Packed RBC & platelet transfusion may be necessary
T Corticosteroids & testosterone may be given
Strict hand washing to prevent infection
J
U a. Hypochromic anemias
D • RBCs are pale
E • Iron deficiency anemia
• Most common anemia of infancy & childhood due to poor intake
C of dietary iron
O • Causes: dietary deficiency, chronic blood loss, low birth weight
L infants, excessive demands
L • Assessment:
E ○ Pale mucous membranes
G ○ Poor muscle tone
E ○ Reduced activity
○ Heart may be enlarged
S
○ Spleen may be slightly enlarged
T
• Management:
○ Treat underlying cause
J
U ○ Diet rich in Iron
D ○ Give Ferrous sulfate—should be taken after meal to reduce GI
E irritation. Vitamin C may be given together with Fe to increase
absorption.
C ○ Imferon (Iron-dextran injecton) given IM
O ○ Stains skin
L ○ Irritating unless given by deep Z-track technique
L
E a. Macrocytic (Megaloblastic) Anemia
G ○ RBCs are abnormally large and immature
E • Folic Acid deficiency
○ Anemia, neutropenia, thrombocytopenia
○ Oral administration of Folic acid
• Pernicious anemia
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○ Caused by deficiency or inability to use
Vitamin B12 due to lack of intrinsic factor
in the gastric mucosa
○ Assessment:
Pallor, anorexia
Irritability
Chronic diarrhea
Ataxia, hyporeflexia, paresthesia
○ Treatment: lifelong monthly injection of Vitamin B12 (IM)
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○ Has a history of recent respiratory infection or impetigo
○ Gross hematuria, proteinuria, oliguria
○ Hypertension
○ Abdominal pain
○ Low-grade fever
○ Periorbital edema
○ Anorexia
○ Vomiting, headache
○ Diagnostics:
○ Hypoalbuminemia
○ Mild anemia
○ Increase ESR
○ Increase BUN and creatinine
○ Elevated antistreptolysin O
○ Management:
○ Place in semi-fowler’s position
○ Oxygen administration may be necessary
○ Diet should be low in protein, low salt
○ Weigh daily
○ Medications: antihypertensive, digitalis, penicillin
S
T 3. Nephrotic Syndrome (Neprhosis)]
• Increased glomerular permeability which causes abnormal loss
J of protein in the urine
U • May be caused by hypersensitivity to Ag-Ab reaction of an
D autoimmune process
E
Increase glomerular permeability
C
O
L
L Protein lost in urine
E
G
E PROTEINURIA HYPOALBUMINEMIA
S
T Fluid shifts from Liver
intravascular to compensates by
interstitial increase
J tissue production of
U lipoproteins
D
E
C
O EDEMA
HYPEREDEMA
L
L
E A.NEUROLOGIC DSYFUNCTIONS
G 1. Cerebral Palsy
E ○ Group of disorders affecting the upper motor neuron resulting
in motor dysfunctions
S ○ Frequently caused by brain anoxia leading to cell destruction
T ○ May be caused before, during or shortly after birth (placenta,
previa, abruptio placenta, maternal infection, nutritional
J
deficiency, prematurity, prolonged labor, forceps delivery, RDS,
U
neonatal infections, traumatic head injury)
D
○ Types:
E
○ Spastic—hyperactive, hypertonic muscles, exaggeration of deep
C tendon reflexes, abnormal reflexes
O ○ Athetoid type- abnormal involuntary movement, limp, flaccid
L early in life, worm-like movement, drooling
L
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G Page 43 of 46
E
○ Ataxic type—awkward, wide-based gait, primary incoordination
○ Mixed type
○ Assessment:
○ Delayed motor development
○ Abnormal head circumference (may be smaller due to slow brain growth)
○ Abnormal postures
○ Abnormal reflexes
○ Abnormal motor performance
○ May have sensory disturbances: strabismus, visual problems, speech problem
○ Irritable, impulsive, short attention span
○ May have mental retardation
○ Management:
○ Maintain safe environment & prevent injuries
○ Facilitate passive & active ROM exercises
○ Prevent contractures
○ Assist in doing self-care (dressing)
○ Provide adequate nutrition
○ High roughage to prevent constipation
○ Soft diet to children who cannot chew or swallow well
○ Be patient because these children take longer time eating
1. Meningitis
S ○ Infection of the cerebral meninges
T ○ Caused by H. Influenzae, Neisseria meningitides, group-B streptococcus
○ Assessment:
J ○ May occur insidiously or suddenly
U ○ 2-3 days of upper respiratory tract infection
D ○ Irritability
E ○ Headache
○ Convulsion
C In newborns:
O ○ Poor sucking
L
○ Weak cry
L
○ Lethargy
E
○ Convulsion
G
E ○ Apnea
○ Bulging and tense fontanelles
S Signs of meningeal irritability:
T ○ Nuchal rigidity
○ (+) Kernigh’s sign (pain on extending the knee when thigh is bent on the
J abdomen)
U ○ (+) Brudzinski’s sign
D ○ Opisthotonus (back is arched & neck hyperextended)
E ○ Diagnostics:
○ Lumbar puncture reveals:
C ○ Increase WBC
O
○ Increase protein
L
○ Decrease glucose
L
○ Increase ICP
E
G ○ Management:
E ○ Antibiotic therapy (Ampicillin, Chloramphenicol) given IV for rapid effect
○ Corticosteroid may be given to decrease ICP
S ○ Provide rest & quiet environment
T ○ Monitor VS, level of consciousness & motor activity
○ Weigh child daily
J ○ Avoid sudden change in position
U
D 3. Encephalitis
E • Inflammation of brain tissues
• Caused by protozoa, bacteria, fungi, virus
C • Assessment:
O ○ Headache
L
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G
E
○ Fever
○ Signs of meningeal irritation
○ Muscle weakness
○ Paralysis
○ Confusion
○ Irritability
• Management:
○ Antipyretic to control fever
○ Antibiotic treatment
○ Anticonvulsant
○ Provide rest
○ Monitor VS, LOC, motor activity & signs of increase ICP
3. Seizures
• Involuntary contraction of muscle due to abnormal electrical brain discharges
• Causes:
In newborns:
○ Trauma at birth
○ Metabolic disorder (hypoglycemia, hypocalcemia, lack of Vitamin B6)
○ Neonatal infection
○ Kernicterus
In infants and toddlers:
○ Infantile spasms
S ○ Poisoning or drugs
T ○ Febrile convulsions (38.9-40 C)
• Active tonic-clonic pattern lasting
J
15-20 seconds
U
○ Types: Psychomotor seizure
D
E • Sudden change in posture (arm
dropping)
C • Child slumps to the ground
O • Unconscious
L • Regains consciousness in less than 5
L minutes
E ○ Focal seizure
G • Originate from a specific brain area
E • Begins in the fingers & spreads to
the wrist, arm & face in a clonic
S contraction
T • May progress to a generalized
seizure
J ○ Absence seizure (Petit Mal)
U • Staring spell lasting for a few
D seconds
E • Rhythmic blinking
• Twitching of mouth or extremity
C • After seizure, child resumes activity
O unaware of what happened
L ○ Tonic-clonic seizure (Grand Mal)
L 4 stages:
E • Prodromal period
G ○ Drowsiness, dizziness, malaise, lack of coordination,
E tension
• Aura- may reflect portion of the
S brain affected
T ○ Smelling unpleasant odors- medial portion of temporal
lobe
J ○ Seeing flash lights- occipital area
U ○ Repeated hallucinations- temporal lobe
D ○ Numbness of extremities- parietal lobe
E ○ “Cheshire cat grin” – frontal lobe
• Tonic-clonic convulsion
C Tonic (20 seconds)
O • All muscles of the body contract
L
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G
E
• Falls to the ground
• Extremities stiffen
• Saliva collects in the mouth
• May bite his tongue
• Clonic (20 seconds)
• Muscles rapidly contract & relax
• Quick jerky motions
• May blow bubbles or foamy saliva
• Post-ictal period
• Child falls into a sound sleep for 1-4 hours
• When he awakens, he appears drowsy, has severe
headache & has no memory of the seizure
○ Status epilepticus
• Occurs in rapid succession without pause
• A medical emergency because the child does not have the time
to aerate the lungs & may lead to brain damage due to
decrease O2 supply
• Management:
○ Protect the child from hurting himself (remove chairs and other objects
that may harm the child)
○ Do not restrain the child
○ Remain calm
○ Loosen clothes
○ Keep the head on 1 side to prevent tongue
S
T from obstructing the airway
○ Ketogenic diet (high fat, low protein and
J carbohydrate)
U ○ Medications:
D • Drug depend on the type of seizure
E • Psychomotor- Phenytoin, Carbamazepine, Primidone
• Absence (Petit Mal)- Ethosuximide (Zarontin), Valproate
C • Tonic-clonic (Grand Mal)- Phenytoin Sodium (Dilantin)
O • Do not discontinue drug abruptly because it may result in
L severe seizure
L • Periodic blood sampling to monitor blood levels of the medicine
E
A. G MISCELLANEOUS
1. E Infantile Eczema (Atopic Dermatitis)
• Skin allergic reaction mainly from food allergy (milk, eggs, wheat,
S citrus, juices, tomatoes)
• T Common in formula-fed infants
• May begin in the 2nd month of lasting until 2-3 years of age
J
U
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E
C
O
L
L
E
G
E
S
T
J
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