Cardiac rate: 120 160 bpm newborn Apical pulse left lower nipple Radial pulse normally absent.

nt. If present PDA Femoral pulse normal present. If absent- COA - coartation of aorta Congenital Heart Dse Common in girls PDA, ASD atrial septal Common in boys TOGA ( transportation of great arteries) TA tronchus arteriosus TOF tetralogy of fallot Causes: 1. familial 2. exposure to rubella 1st month 3. failure of strucute to progress acyanotic L to R cyanotic R L Acyanotic heart defects L to R 1. ventricular septal defect - opening between 2 ventricles S&Sx 1. systolic murmurs at lower border of sternum and no other significant sign 2. cardiac catheterization reveals increased o2 saturation @ R side of heart 3. ECG reveals hypertrophy of R side of heart Nsg Care: Cardiac catheterization: site Rt femoral vein 1. NPO 6 hrs before procedure 2. protect site of catheterization. Avoid flexion of joints proximal to site. 3. assess for complication infection, thrombus formation check pedal pulses ( dorsalis pedis) Mgt. 1.) 2.) long term antibiotic to prevent subacute bacterial endocarditis open heart surgery-

3. rough systolic sound and thrill 4. ECG- Left ventricular hypertrophy cardiac catheterizationMgt Pulmo Stenosis & Aortic Stenosis 1.) balloon stenostomy 2.) surgery Duplication of Aortic Arch- doubling of arch of aorta causing compression to trachea and 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 and decreased on lower extremities ECG hypertrophy Lft ventricle Mgt: close heart surgery CYANOTIC HEART DEFECTS R to L 1. Transportation of Great Arteries (TOGA) - aorta arising from Rt ventricle pulmo artery arising form Lt ventricle Outstanding Sx: 1. cyanosis after 1st cry (due no exygenation) 2. polycythemia increased RBC =compensatory due to O2 supply=viscous blood =thrombus = embolus = stroke 3. ECG cardiomegaly Cardiac cath decreased O2 saturation Palliative repair rashkind procedure 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 Lft Outstanding Sx: Open foramen ovale Mild to moderate cyanosis Polycythemia = thrombus = embolus = stroke asplenia- absent spleen Mgt: restructuring of heart 3.) Truncus Arteriousus- aorta & pulmo artery is arising fr 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 non fx Left ventricle 1. cynosis 2. polycythemia throm, emb, stroke Mgt: heart transplant 5.) Tricuspid atresia failure of tricuspid valve to open S&SX: open foramen ovale (R to L shunting goes to Lt atrium) cynosis, polycythemia Mgt: fontan procedure open tricuspid valve 6.) Tetralogy of Fallot P pulmonary stenosis V ventricular SD O overriding or dextroposition of aorta R Rt ventricular hypertrophy S &Sx: 1. Rt ventricular hypertrophy 2. high degree of cyanosis 3. polycythemia

2.) ASD failure of foramen ovale to close S&SX 1. systolic murmur @ upper border of sternum 2. result of cardiac catheterization & ECG same with VSD Mgt: open heart surgery 3.) endocardial cushion defects - atrium ventricular (AV) - affects both tricuspid and mitral valve Dx confirmed by cardiac catheterization Mgt: - open heart surgery Antibiotics to prevent subacute bacterial endocarditis 4.) PDA - failure of ductus arteriosus to close - should close within 24 h -complete close 1 month S&Sx 1. continuous machinery like murmurs 2. prominent radial pulse 3. ECG- hypertrophy Left ventricle Drug: 1. endomethazine prostaglandin inhibitor - facilitate closing of PDA 2. ligation of PDA by 3-4 yo 3. thoracotomy procedure- nakadapa child 5.)Pulmunary Stenosis- narrowing of valve of pulmo artery S &Sx: 1.) typical systolic ejection murmur 2. S2 sound widely split 3. ECG- Lt ventricular hypertrophy 6.)Aortic Stenosis narrowing of valve of aorta S & Sx: 1. inactive, sx sme with angina 2. typical murmur

severe dyspnea squatting position relief , inhibit venous return facilitate lung expansion. 5. growth retardation due no O2 6. tet spell or blue spells- short episodes of hypoxia 7. syncope 8. clubbing of fingernails due to chronic tissue hypoxia 9. mental retardation due decreased O2 in brain 10. boot shaped heart x-ray 4. Mgt: 1. 2. 3. 4. 5. O2 no valsalva maneuver , fiber diet laxative morphine hypoxia propranolol decrease heart spasms palliative repair BLT blalock taussig procedure Brock procedure complete procedure

1.) VESICULAR soft, low pitched, heard over periphery of lungs, inspiration longer then expiration -Normal 2.) BRONCHOVESICULAR- soft, medium pitched, heard over major bronchi, inspiration equals exp. Normal 3.) BRONCHIAL SOUNDS- loud high pitched, heard over trachea, expiration longer than inspiration. Normal 4.) RHONCHI snoring sound made by air moving through mucus in bronchi. Normal 5.) RALES-or crackles like cellophane made by air moving through fluid in alveoli. Abnormal- asthma, foreign body obstruction. 6.) WHEEZING- whistling on expiration made by air being pushed through narrowed bronchi .Abnormal asthma, foreign body obstruction 7.) STRIDOR- crowing or ropster life sound air being pulled through a constricted larynx. Abnormal resp obstruction Asthma- pathognomonic sign expiratory wheezing Pet fish. Sport swimming Drugs amynophylline monitor bp, may lead to hypotension Laryngo Tracheo Bronchitis LTB - inspiratory stridor pathognomonic sign RDS respiratory dist synd or hyaline membrane dis Cause- lack of surfactant for lung expansion Hypotonia, Post surgery, Common to preterm Fibrine hyaline Sx definite with in 1st of life Increase RR with retraction Inspiratory grunting pathognomonic 7 10 severe RDS (silvermenn Anderson index) cyanosis due to atelectasis Mgt: 1. surfactant replacement and rescue 2. pos- head elevated 3. proper suctioning 4. o2 with increase humidity- to prevent drying of mucosa 5. monitor V/S skin color , ABG 6. CPAP- continuous + a/w pressure 7. PEEP - + end expiratory pressure Purpose of #6-7- to maintain alveoli partially open and alveoli collapse LARYNGOTRACHEOBRONCHITIS LTB most common Creup -viral infection of larynx, trachea & bronchi outstanding sx croupy cough or barking pathognomonic stridor labored resp resp acidosis end stage death Lab: 1. ABG 2. neck and throat culture 3. dx- neck x-ray to rule out epiglotitis Nsg Mgt: 1. bronchodilators 2.increase o2 with humidity 3. prepair tracheostomy set BRONCHOLITIS- Inflammation of bronchioles tenatious mucus Causative agaent RSV - Resp sincytial viruses Sx: flu like sx Increased RR Drug: Antiviral Ribavirin End stage epiglotitis EPIGLOTITIS - infl of epiglottis - emer. Condition of URTI Sx: sudden onset

ACQUIRED HEART DSE 1. RHD Rheumatic Heart Disease - inflammation disease ff an infection acquired by group A Beta hemolytic strepto coccus Affected body cardiac muscles and valves , musculoskeletal , CNS, Integumentary Sorethroat before RHD Aschoff rounded nodules with nucleated cells and fibroblasts stays and occludes mitral valve. Jones Criteria Major 1. polyarthritis multi joint pain 2. chorea sydenhamms chores or st. vetaus dance-purposeless involuntary hand and shoulder with grimace 3. carditis tachycardia erythema marginatum - macular rashes SQ nodules Minor 1. arthralgia joint pain 2. low grade fever

3. all lab results increase antibody C reactive protein erythrocyte sedimentation rate anti streptolysin o titer (ASO) Criteria:Presence of 2 major, or 1 major and 2 minor + history of sore throat will confirm the dx. Nsg Care: 1. CBR 2. throat swab culture and sensitivity 3. antibiotic mgt to prevent recurrence 4. aspirin anti-inflammatory. Low grade fever dont give aspirin. S/E of aspirin: Reyes syndrome encephalopathy- fatty infiltration of organs such as liver and brain Respiration Newborn resp 30-60 cpm, irregular abd or diaphramatic with short period of apnea without cyanosis. < 15 secs normal apnea newborn Resp Check Newborn 40 90 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:

Tripod position leaning forward with tongue protrusion never use tongue depressor prepare tracheotomy set < 5 yo unable to cough out, put on mist tent (humidifier o2) or croupe tie Nsg Care: check edges tucked on mist tent Provide washable plastic material No toys with friction due O2 on No hairy toys due moist environment medium for bacterial growth BP 80/46 mmHg newborn BP after 10 days- 100/50 BP taking begins by 3 yo COA take BP on 4 extremities SKIN: Acrocyanosis BIRTHMARKS: 1. Mongolian spots stale gray or bluish discoloration patches commonly seen across the sacrum or buttocks due to accumulation of melanocytes. Disappear by 1 yr old 2. MIlla plugged or unopened sebaceous gland . white pin point patches on nose, chin or cheek. 3. Lanugo fine, downy hair common preterm 4. Desquamation peeling of newborn, extreme dryness that begin sole and palm. 5. Stork bites (Talengeictasi nevi) pink patches nape of neck hair will grow as child grows old 6. Erythema Toxicum (flea bite rash)- 1st self limiting rash appear sporadically & unpredictably as to time & place. 7. Harlequin sign dependent part is pink, independent part is blue (side lying bottom part is dependent pink) 8. Cutis Marmorato transitory mottling of neonates skin when exposed to cold. 9. Hemangiomas vascular tumors of the skin 3 types Hemangiomas a.) Nevus Flammeus port wine stain macular purple or dark red lesions seen on face or thigh. NEVER disappear. Can be removed surgically b.) Strawberry hemangiomas nevus vasculosus dilated capillaries in the entire dermal or subdermal area. Enlarges, disappears at 10 yo. c.) Cavernous hemangiomas communication network of venules in SQ tissue that never disappear with age. - MOST DANGERIOUS intestinal hemorrhage Skin color blue cyanosis or hypoxia White edema Grey inf Yellow jaundice , carotene Vernix Caseosa white cheese like for lubrication, insulator BURN TRAUMA injury to body tissue caused by excessive heat. INFANT ANTERIOR 9.5 1 2 1.5 13 13 13 1 2.5@ 2.75 2.5 1.75 5-9 yo Ant 6.5 1 2 1.5 1.25 13 13 1 2.5 @ 4 3 1.75

DEPTH 1st degree partial thickness superficial epidermis erythema, dryness, PAIN -sunburn, heals by regeneration from 1 10 days nd 2 degree epidermis & dermis- erythema, blisters, moist, extremely painful scalds 3rd degree full thickness- epidermis, dermis, adipose tissue, fascia, muscle & bone lethargy, white or black, not painful nerve endings destroyed ex. lava burns Mgt: 1.) 1st aid a.) put out flames by rolling child on blanket b.) immerse burned part on cold H2o c.) remove burned clothing of with sterile material d.) cover burn with sterile dressing 2.) a/w a.) suction PRN, o2 with increased humidity b.) endotracheal intubation c.) tracheostomy 3.) Preventiuon of shock & F&E imbalance a. colloids to expand bld volume b. isotonic saline to 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 a.) cleaning & debriding of wound b.) open or close method of wound care c.) whirlpool therapy drum with solution 7.) skin grafting 3rd degree thigh or buttocks (autograft), pigs/ animals xenograft frozen cadaver hallow graft 8,) diet increase CHON, increase calories. ATOPIC DERMATITIS- infantile eczema (galis) Papulo vesicular erythematus lesions with weeping & crusting Cause food allergies: milk, citrus juice, eggs, tomatoes, wheat Sx: extreme pruritus, linear excoriation, weeping crusting; scaly shiny and white lechenification Goal of care: decrease pruritus avoid food allergens Diet: Prosobi or Isomil Hydrate skin, borow solution 1% hydrocortisone cream Prevent infection proper handwahsing, trim nails IMPETIGO- skin disease. Causative agent grp A beta Hemolytic streptococcus papulovesicular surrounded by localized erythema becomes purulent , oozes a honey colored crust Pediculosiscapitis KUTO Mgt: proper hygiene wash soap and H2o, oral penicillin bactroban ointment Can lead to acute glomerulonephritis AGN ACNE- adolescent problem self limiting infl dis sebaceous gland comedones sebum causing white heads sebum- lipids causing acne bulgaris Mgt: proper hygiene- mild soap or sulfur soap- antibacterial retin A or tretinoi ANEMIA-pallor Causes: 1.)early cutting of cord preterm cut umb cord ASAP fullterm cut umb cord when pulsation stops 2.) Bleeding disorders blood dyscrasias

Head Neck Upper arm Lower arm Hand Trunk Back Genital @ buttocks Thigh Leg foot

POSTERIOR 9.5 1 2 1.5 1.25

Post 6.5 1 2 1.5 1.25

2.75 2.5 1.75

4 3 1.75

HEMOPHILIA deficiency of clotting factor. X linked recessive inherited If mom carrier, son affected If father carrier- transmitted to daughter Hemophilia A deficiency of coagulation component factor 8 Hemophilia B or christmas disease, deficiency of clotting factor 9 Hemophilia C deficiency of clotting factor 11 Assessment: umphalagia earliest sign newborn receive maternal clotting factor newborn growing sudden bruising on bump area- marks earliest sign continuous bleeding hematrosis damage or bleeding synovial membrane Dx test : PTT. factor Partial thromboplastin time reveals deficiency in clotting

2. irradiation 3. chemotheraphy Focus Nsg Care: prevent infection 4 LEVELS OF CHEMOTHERAPHY 1. induction goal of tx; to achieve remission meds: IV vincristine L- agpariginase Oral predinisone 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 -adm of methotrisate do weekly WBC check 4. Reinductin 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: alteration in nutrition less body requirement. Based on Maslows heirarchy S/Effect of Chemotherapy 1. N/V adm antiemetic drugs 30 mins before chemo until 1 day after chemo 2. Ulcerations / stomatitis / abscess of oral mucosa- (alteration nutrition less body req) - oral care alcohol free mouthwash , betadine mouthwash - dont brush use cotton pledgets - topical xylocaine before meals diet- soft, bland diet according to childs preference Temporary S/E of chemo: Alopecia altered body image Hirsutism hair -give emotional support to parents ABO incompatibility Most common incompatibility ( mom) O ( fetus) A Most severe incompatibility (Mom) O (Fetus) B Can affect 1st pregnancy Hydrops (h20) Fetalis edematous on lethal state with pathologic jaundice Within 24 h Mgt:

Long Term Goal- prevention of injury Nsg Dx- increase risk of injury HT: avoid contact sport, swimming only, dont stop immunization just change gauge of needle Falls immobilized , elevate affected part, apply pressure-not more then 10 min cold compress -determine case before doing invasive procedure LEUKEMIA- grp of malignant disease rapid proliferation of immature WBC WBC protection from infection, soldiers of body Classification : 1. Lympho affects lymphatic system 2. Myelo affects bone marrow 3. acute / blastic- affects immature cells 4. chronic/ cystic- affects mature cells MOST COMMON CANCER (ALL) Acute Lymphocytic Leukemia S&Sx: 1. from invasion of bone marrow signs of infection a.) fever b.) poor wound healing c.) bone weakness & causes fracture signs of bleeding a.) petecchiae-small, round, flat, dark red spot b.) epistaxis c.) blood in urine/ emesis signs of anemia a.) pallor , body malaise , constipation 2. from invasion of body organ- hepato spenomegaly abd pain , CNS affectation, increase ICP Dx Tests: 1. PBS- peripheral blood smear determine immature RBC 2. CBC determine anemia, leukocytosis, thrombocytopenia neutropenia 3. lumbar puncture (LP) determine CNS involvement. Before LP, fetal pos.- avoid flexion of neck will cause a/w obstruction.C position or shrimp position only. 4. bone marrow aspiration determine blast cells, common site- iliac crest post BMA s/effect bleeding apply pressure. Put pt on affected side to prevent hemorrhage 5. Bone scan determine bone involvement 6. CT scan determine organ involvement Therapeutic Mgt: TRIAD: 1. surgery

1. 2. -

initiate breastfeeding to get colostrum Temp suspension of breastfeeding content breast milk pregnanedioles that delays action of glucoronil transferees liver enzymes converts in direct bilirubin to become direct bilirubin 3. Needs phototherapy 4. needs exchange therapy Hyperbilirubinemia - > 12 mg/dL of indirect bilirubin among full term Normal 0-3 mg/dL bilirubin encephalopathy Kemicterus - > 20 mg/dL among full term & >12 mg /dl of indirect preterm =can lead to cerebral palsyPhysiologic jaundice jaundice within 48 -72 h (2-3 days) expose morning sunlight Pathologic Jaundice within 24h. Jaundice during delivery. Breastfeeding jaundice caused by pregnanediole

Assessment of Jaudice : 1. Blanching neonates forehead, nose or sternum - yellow skin & sclera - color of stool light stool - color of urine dark urine Mgt: Phototheraphy photo oxygenation Nsg Resp: 1. cover eyes prevent retinal damage 2. cover genitals prevent priapism painful continuous erection 3. change position regularly even exposed to light 4. increase fld intake due prone to dehydration 5. monitor I&O weigh baby 6. monitor V/S avoid use of oil or lotion due- heat at phototherapy = bronze baby syndrome-transient S/E of phototherapy weigh diaper 1gm = 1cc Head largest part of baby of its length Craniostenosis or craniosinustosis premature closing of fontanel Hydrocephalus ant fontanel open after 18 mos Microcephaly small growing brain due- alcohol & HIV mom Anencepahly absence of cerebral hemisphere Craniotabes localized softening cranial bone. Common 1st born child -due early lightening (2 weeks prior to EDD) Rickets of Vit B deficiency soft cranial bone in older children Caput Succedaneum edema of scalp due prolonged pressure at birth Char: 1. present at birth 2. crosses suture lines 3. disappear after 2-3 days Cephalhematoma- collection of blood due to rapture of pericostal capillaries Char : 1. present after 24 h 2. never cross suture line 3. disappear after 4-6 weeks 4. monitor for developing jaundice Seborrheic Dermatitis craddle cap Scaling, greasy appearing salmon colored patches seen on scalp behind ears and umbilicus Cause: - improper hygiene Mgt: 1. proper hygiene 2. put oil night before shampoo baby oil Hydrocephalus excessive accumulation of CSF 1. communicating extra ventricular hydrocephalus 2. non-communicating- intraventricular hydrocephalus or obstructive hydrocephalus due to tumor obstruction Sx ICP abnormally large head, bulging fontanel cushings triad high pitched cry older child diplopia eye deviation, projectile vomiting fontanel bossing prominent forehead - prominent skull vein sunset eyes Mgt: position to lessen ICP low semi-fowlers 30 degree angle

Administer- osmotic diuretic Mannitol/ Osmitrol , Diamex- Azetam Decrease CSF production Shunting AV shunt or Vp shunt (ventriculoperitoneal shunt) Shave hair in OR to prevent growth of micro org. Nsg Care: 1.) post VP shunt side lying on non operated site - to prevent increase ICP -monitor for good drainage - sign sunken fontanel -bulging fontanel blocked shunt -change fontanel as child is growing SENSES EYES: Assessment 1. check for symmetry 2. sclera normal color light blue then become dirty white pupil round- adult size coloboma- part of iris is missing sign: key hole pupil -whiteness & opacity of lens congenital cataract cornea round & adult size large congenital glaucoma Test for blindness common tests 1. newborn general appearance - can only see 10 12 - visual acuity 20 /200 to 20/ 800 Dolls eyes test- test for blindness done 10th day pupil goes opposite to direction when head is moved Globellars test test for blink reflex. Points near nose baby should blink 2. Infant & children - appearance - ability to follow object past midline 3. 3 yrs school age - general appearance Allen cards test for visual acuity. Show picture 20 ft away Ishiharas plates test for color blindness Prechool E chart - test for stereopsi of depth perception Cover testing test cover 1 eye for 10 15 min. Then remove. Test for strabismus 4. School age adult - general appearance - snellens test Retinobastoma malignant tumor of retina Outstanding sign : oats eye reflex-whitish glow of pupil red painful eye blindness surgery Enucliation removal of eyeball put artificial aye NOSE: 1. 2. Sx: 1. resistance during catheter insertion 2. emer. Surgery within 24 h normal color nasal membrane pinkish rhinitis presence of creases & pale check sense of smell blindfold smell Hair in nose cilia Adolescent no hair with ulceration of nasal mucosa suspect cocaine user Epistasis nosebleed flaring alenase case of RDS cyanosis at rest choanal atresia - post nares obstructed with bone or membrane

sit upright, head slightly forward to facilitate drainage cold compress , apply gentle pressure, epinephrine

most developed sense of newborn sense of touch 1st sense to develop & last to disappear hearing EARS: 1.

Properly aligned with outer cantus of eyes low set ear kidney malformation ex. Renal aginesis absence of kidney sign in uterus : oligohydramnios sign in newborn: 2 vessel cord failure to void within 24 h kidney transplant

Bells Palsy- facial nerve #7 paralysis R/T forcep delivery Sx. 1. Continuous drooling saliva 2. inability to open , eye & close either eye Mgt: Refer to PT TEF (Tracheoesophageal Fistula)-TEA- no connection bet esophagus and stomach Outstanding Sx Coughing Choking Continuous drooling Cyanosis

Mgt:

Mgt: Emergency surgery Epstein pearl white glistering cyst at palate & gums related to hypercalcemia Hypervitaminosis Natal tooth tooth at birth. Move with gauze Neonatal tooth tooth within 28days of life Moniliasis oral candidiasis white cheese like, curd like patches that coats tongue oral thrush Nsg Care dont remove, wash with cold boiled H2o Meds nystatin / Mysnastatin antifungal Kawasaki Dse--strawberry tongue - originated in Korea - Dr. Kawasaki discovered it - common in Japan - mucocutaneous Lymphnode Syndrome Sx: -persistent fever 5 days -strawberry tongue , -desquamation of palm & sole - lymph adenopathy > 1.5 cm Drug: aspirin Can lead to MI LIPS- symmetrical Cleft lip failure of median maxillary nasal process to fuse by 5-8 wks of pregnancy common to boys unilateral Cleft Palate- Failed palate to fuse by 9 12 wks of pregnancy common to girls unilateral or bilateral Sx: 1. 2. 3. evident at birth milk escapes to nostril during feeding frequent colic & otitis media or URTI

Chromosomal aberrations : -advance maternal age 1. non disjunction uneven division Trisomy 21 - down syndrome - extra chromosome 47xx + 21 - related to advance paternal age Sx: Mongolian slant Broad flat nose Protruding neck Puppys neck Hypotonic prone to resp problem Simean crease single transverse line on palm. Trisomy 18 endvard syndrome Trisomy 13patau syndrome Turner Monosomy of X synd. 45x0 affected girls signs evident during puberty has poorly developed 2dary sexual char. Sterile Klinefelters Syndrome- has male genitalia - 47 XXY - poorly devt secpndary sexual characteristics - no deepening of voice -small testes, penis -sterile Klinefelter Calvin Kline male Turner Tina Turner female Otitis Media inflammation of middle ear. Common children due to wider & shorter Eustachian tube Causes 1.) bottle propping 2.) Cleft lip/ cleft palate Sx: Otitis 1. bulging tympanic membrane, color pearly gray 2. absence light reflex 3. observe for passage of milky, purulent foul smelling odor discharge 4. observe for URTI Nsg Care: 1. position side lying on affected aside to facilitate drainage 2. supportive care- bedrest, increase fld intake Med Mgt: 1. Massive dosage antibiotic Complication bacterial meningitis 2. Apply ear ointment School age up and down < 3 yo down & back > 3 yo up & back Small child down & back ( no age) surgery (to prevent permanent hearing loss) otitis media myringotmy with tympanostomy tube post surgery position affected side for drainage both put ear plug if tympanous tube falls healed na

Mgt: 1. Surgery cleft lip repair Cheiloplasty =done 1-3 months to save sucking reflex (lost in 6 months ) Cleft Palate- uranoplasty = done 4-6 months to save speech Pre op care 1. emotional support especially to mom 2. proper nutrition 3. prevent colic feed upright seating or prone pos burp frequently 2x at middle and after feedinglower to upper tap 4. orient parents to type of feeding rubber tipped syringe cheiloplasty paper cup/ soup spoon/ plastic cup urano plasty 5. apply restraints elbow restraints

so baby can adjust post op Condition that warrants suspension of operation colds & pharyngitis = can lead to generalized infection septicemia Sx: Post Op Nsg Care : 1. airway positon post cheilopasty side lying for drainage post uranoplasty (tonsillectomy)- prone 2. assess for RDS sx bleeding 3. assess for bleeding freq swallowing. 6-7 days after surgery bleeding 4. proper nutrition clear liquids- ( gelatin except red or brown color due may mask bleeding) ( popsicle- not ice cream) full liquid soft diet regular diet 5. Maintain integrity of suture line such as: Logan bar wash strength Hydrogen Peroxide & saline solutionBubbling effect traps microorganism - prevent baby form crying for pain- analgesic NECK1.) check symmetry Congenital torticolis- wryneck-burn injury of sternocleidomsstoid muscle during delivery due to excessive traction at cephalic delivery Mgt: passive stretching exercise , Surgery Complication scoliosis THYROID gland for basal metabolism Congenial cretinism absence or non functioning thyroid glands reasons for delaying dx: 1. Thyroid glands covered by sternocleidomastoid muscles in newborn 2. baby received maternal thyroxine 3. baby sleeps 16 20 h a day earliest sign: 1. change in crying 2. change in sucking 3. sleep excessively 4. constipation 5. edema moon face late sign 1. mental retardation prognosis : mental retardation preventable when Dx is early Dx: 1. PPI-protein 2. radioimmunoassay test 3. radioactive iodine uptake Mgt: synthroid sodium Levothyrosine -synthetic thyroid given lifetime check pulse rate before giving synthroid tachycardia Sx of hyperthyroidism CHEST 1. 2. 3. 4. symmetry breast - transparent fluid coming out from newborn related to hormonal changeschest has retroactive RDS sternum sunken pectus excavation 1. 2. 3. Mgt: Emergency surgery within 24h Omphalocele protrusion of stomach contents in between junction of abd wall and umbilicus. Mgtvery small surgery If large suspension surgery Nsg Mgt: protect sac- sterile wet dressing Gastrochisis absence of abd wall Nsg Mgt: sterile wet dressing Fx of GIT 1. assists in maintaining F&E & acid base balance 2. Processes & absorbs nutrients to maintain metabolism & support G & D 3. excrete waste products from digestive process Recommended Daily Allowance Calories : 120 cal / Kbw/day (kilo body wt) 360 380 cal/ day CHON_ 2.2g /Kbw/day Principles in Supplementary Feeding Supplementary Feeding usually 6 mos Supplementary feeding given 4 mos. a.) solid food offered to ff sequence! 1. cereals rich in iron 2. fruits 3. veg 4. meat b.) begin with small quantities c,) finger foods offered 6 months d.) soft table food modified family menu given 1 yr e.) dilute fruit juices 6 mos f.) never give half cooked eggs usually causes of salmoneliosis g.) dont give honey infant botulism h.) offered new food one at a time interval of 4 7days or 1 week determines food allergens Total Body Fluids- comprises 65 - 85% of body wt of infants & children Where fluids are greater in infants Extracellular fld prone to develop dehydration Acid Base Balance dependent on the ff: a. chemical buffers b. renal & resp system involvement c. dilution of strong acids and bases in bld Resp Acidosis carbonic acid excess hypoventilation RDS COPD Laryngotracheobronchitis (LTB) Resp Alkalosis carbonic acid deficit hyperventilation fever encephalopathy Met. Acidosis base HCO3 deficit diarrhea severe dehydration malnutrition sunken abd Sx of RDS R to L shunting Normal contour of abd slightly protruding Sunken abd- diaphramatic hernia protrusion of stomach content through a defective diaphragm due to failure of puroperitoneal canal to close.

ABDOMEN (in order) 1. inspection I 2. Auscultation A 3. percussion P 4. Palpation P = Will change bowel sounds, so do last

ciliac crisis Met Alkalosis base HCO3 excess uncontrolled vomiting NGT aspiration Gastric lavage PROBLEMS LEADIING TO F&E IMBALANCE 1. vomiting forceful expulsion of stomach content Sx: 1. nausea 2. dizziness 3. facial flushing 4. abd cramping assess: amt, freq, force projectile vomiting= increase ICP or pyloric stenosis

4.

rectal manometry revels failure of intestine sphincter to relax

Therapeutic Mgt/Nsg care 1. NGT feeding measure tube fr nose to ear to midline of xyphoid & umbilicus 2. surgery a.) temp colostomy b.) anastomosis & pull through procedure Diet: Increase CHON, increase calories , decrease residue pasta GER- Gastroesophageal Reflux Chalasia presence of stomach contents to esophagus Will lead to esophagitis complication aspiration pneumonia Esophageal cancer Assessment : 1. chronic vomiting 2. faiture to thrive syndrome 3. organic organ affected 4. melena or hematemesis esophageal bleeding Dx procedure 1. barium esophogram reveals reflux 2. esophageal manometry reveals lower esophageal sphincter pressure 3. intra esophageal pH content reveals pH of distal esophagus. Meds of GERD Anti-cholinergic a.) Betanicol ( urecholine) increase esophageal tone & peristaltic activity b.) Metachloporomide (Reglam) decrease esophageal pressure by relaxing pyloric & duodenal segments increase peristalsis without stimulating secretions c.) H2 Histamine Receptor Antagonist decrease gastric acidity & pepsin secretion Zimetidine, Ranitidine (Zantac) take 30 min before meals d.) antacid neutralizes gastric acid between feedings Maalox Surgery: Nissen funduplication : Chronic vomiting thickened feeding with baby cereals - effective if without vomiting feed slowly, burp often every 1 ounce positioning < 9 months infant sit with infant supine > 9 months prone with head of mattress slightly elevated 30 degree angle OBSTRUCTIVE DISORDERS A. PYLORIC STENOSIS hypertrophy of muscles of pylorus causing narrowing & obstruction. 1.) outstanding Sx- projectile vomiting - vomiting is an initial sx of upper GI obstruction - vomitus of upper GI can be blood tinged not bile streaked. (with blood) - vomitus of lower GI is bilous ( with pupu) - projectile vomiting increase ICP or GI obstruction - abd distension major sx of lower GIT obst 2.) met alk 3.) failure to gain wt 4.) olive shaped mass on palpation 5.)serum electrolyte increase Na & K, decrease chloride 6.) ultrasound 7.) x ray of upper abd with barium swallow reveal string sign Mgt: 1. 2. Pyleromyotomy Fredet Ramstedt procedure

Mgt:BRAT diet - banana, rice cereal, apple sauce, toast 2. Diarrhea exaggerated excretion of intestinal contents Types: Acute diarrhea related to gastroenteritis, salmoneliosis dietary indiscretions antibiotic use Chronic non specific diarrhea Cause: 1. food intolerance 2. excessive fld intake 3. CHO, CHON malabsorption Assess: freq, consistency, appearance of given colored stool. Best criteria to determine diarrhea : consistency Complication = dehydration Mild dehydration 5% wt loss Moderate dehydration 10% wt loss Severe dehydration 15 % wt loss Earliest sx of dehydration tachycardia weight loss tachypnea urine hypotension

increase temp sunken fontanel & eyeballs absence of tears scanty

Severe dehydration: Oliguria , Prolonged capillary refill time Mgt: Acute NPO ( rest the bowel ) with fluid replacement IV prone to Hypokalemia give K chloride before adm of K chloride check if baby can void, if cant void hypokalemia Drug: Na HCO3 adm slowly to prevent cardiac overload

Gastric Motility Disorder: HIRSCHPRUNGS DISEASE congenital aganglionic megacolon Aganglionic absence of ganglion cells needed for peristalis Earliest sign 1. failure to pass mecomium after 24h 2. abd distension 3. vomitus of fecal material early childhood ribbon like stool foul smelling stool constipations diarrhea Dx: 1. Barium enema reveals narrowed portion of bowel 2. Rectal Biopsy reveals absence of ganglionic cells 3. abd x-ray reveals dilated loops on intestine

INSTUSSUSCEPTION- invagination or telescoping of position of bowel to another Common site ilio-secal junction Prone pt: person who eats fat Complication peritonitis emergency Sx: 1.) persistent paroxysmal abd pain 2.) vomiting 3.) currant jelly stool- dye bleeding & inflammation palpate sausage shaped mass Mgt: 1.) Hydrostatic reduction with barium enema 2.) Anastomosis & pull thru procedura Inborn Errors of Metabolism- deficient liver enzymes PHENYLKETONURIA (PKU) deficiency of liver enzymes (PHT) Phenylalaninehydroxylase Transferase liver enzyme that converts CHON to amino acid 9 amino acids: valine isolensine tryptophase lysine phenylalanine Thyronine decrease malanine production 1.) fair complexion 2.) blond hair 3.) blue eyes Thyroxine decrease basal metabolism - accumulation of Phenyl Pyruvic acid 4.) Atopic dermatitis 5.) musty / mousy odor urine 6.) seizure mental retardation

Test GUTHRIE TEST specimen blood preparation increase CHON intake test if CHON will convert to amino acid specimen and urine mixed with pheric chloride, presence of green spots at diaper a sign of PKU DIET: Low phenylalanine diet- food contraindicated- meats, chicken, milk, legumes, cheese, peanuts Give Lofenalac- milk with synthetic protein Galactosemia deficiency of liver enzyme GUPT Galactose Urovil Phosphatetranferase Converts galactose to phosphate tranferace glucose Galactose will destroy brain cells if untreated death within 3 days Dx: Beutler test get blood -done after 1st feeding presence of glucose in blood sign of galactosemia galactose free diet lifetime neutramigen milk formula CELIAC DISEASE gluten enteropathy Common gluten food: Intolerance to food with brow B- barley R- rye O- oat W- wheat

Gluten glutamine ( normal absorption)

Gliadin ( toxic to epithelial cells of villi of intestines, effects is malabsorption syndrome)

Malabsorption

Fats

CHON & CHO peripheral edema & malnutrition

Vit D calcium

Vit K

Iron folic acid

Inadequate blood

coagulation
Steatorrhea Osteomalasia
Bleedin

anemia

gg

Early Sx: 1. 2. 3. diarrhea failure to gain wt ff diarrheal episodes constipation vomiting

Late Sx: 1. abd pain protruberant abd even if with muscle wasting 2. steatorrhea Celiac Crisis- exaggerated vomiting with bowel inflammation Dx: 1. lab studies stool analysis 2. serum antiglyadin confirmatory of disease gluten free diet lifetime all BROW not allowed ok rice & corn Mgt: 1. 2. 3. vitamin supplements mineral supplements steroids

POISONING- common in toddlers. (falls- common to infant) 1. determine substance taken, assess LOC 2. unless poison is corrosive, caustic (strong alkali such as lye) or a hydrocarbon, vomiting is the most effective way to remove poison. Give syrup 1 pecac to induce vomiting Renal Cause Sx Tx NSG CARE 3. 1 pecac oral emetic Disorder 15 ml adolescent, school age & pre NEPHROTIC infectious 1. Anasarca- gen Prednisone Focus of care: school SYNDROME edema Diuretic monitor edema 10 ml to infant 2. massive -weigh daily 4. UNIVERSAL ANTIDOTE- charcoal, milk of protenuria Diet: magnesia & burned toast 3. microscopic or Increase CHON 5. Never adm charcoal before 1 pecac no hematuria Increase K- OJ, 6. antidote for acetaminophen poisoning 4. serum CHON beef broth, acetylsysterine ( mucomyst) decreased banana 7. caustic poisoning ( muriatic acid ) neutralize 5. serum lipid Decrease Na acid by giving vinegar . Dont vomit prepare increased tracheostomy set 6. fatigue 8. Gas- mineral oil will coat intestine 7. normal or decreased BP Lead poisoning AGN ( acute Autoimm 1. (PPP) primary 1. anti HPN 1. weigh daily Lead = Destroy RBC functioning = Hypochornic Glomerulo une peripheral drug 2. monitor BP & Microcytic Anemia = Destroy kidney functioning Nephritis) Grp A periobital neurologiuc Accumulation of anemia = Encepalopathy beta edema hydralazine status 3As; hemolytic 2. moderate or 3. Diet: decrease Sx: AGN, streptoco protenuria apresoline K, decrease Na 1. beginning sx of lethargy autoimmune ccus 3. gross hematuria 2. iron 2. impulsiveness, learning difficulties , ( smokey 3. as lead increases, severe encepalopathy Grp A urine) with seizure and permanent 4. serum K mental retardation increased 5. fatigue Dx: 6. increase BP 1. Blood smear Complication : 2. abd x ray 1. hypersensive 3. long bones encephalopathy Mgt: 2. anemia 1. remove child from source 2. if > 20 ug/dL need chelation therapy = binds with led & excreted by kidney =nephrotoxic Amogenital Female: Pseudomenstration slight bleeding on vagina related to hormonal changes Tearing of fourchette with blood rape/ child abuse Rape- Report within 48 h Shape pubic hair in inverted triangle ( female)

Male: Undescended testes cyrptorchidism -common to preterm surgery orchidopexy assess scrotum- warm room & hands baby pee within 24 h -check for arch of urination Epispadias- urinary meatus located dorsal or above glans penis Hypospadias- urinary meauts loc ventral or below glans penis Hypospadias with chordee- fibrous band causing penis to curb downward Mgt: Surgery Phimosis- tight foreskin Balanitis-infection of glands penis due smegma Mgt: Circusicion Hydroseal fld filled scrotum Tst of Dx: Transillumination with use of flashlight - glowing sign Varicoseal enlarged vein of epididimis ( girls- vulvular varicosities)

BACK- check for flatness & symmetry Open Neural Tube Defect- decreased Folic Acid intake SPINA BIFIDA OCCULTA- failure of post laminae of vertebrae to fuse Sx: dimpling of back , Abnormal tufts of hair SPINA BIFIDA CYSTICA- failure of post laminae of vertebrae to fuse with a sac Types: 1. Meningocele protrusion of CSF & Meninges 2. Myelomeningocele protrusion of CSF & Meninges & spinal cord ( most dangerous) 3. Encephalocele ( CNS complication hydrocephalus) cranial meningocele or myelomeningocele Most common problem rupture of sac prone pos sterile wet dressing Most common complication - infection Myelomeningocele genitourinary complication- urinary & fecal incontinence Nsg care: always check diaper Orthopedic complication paralysis of lower extremities Surgery to prevent infection Post op prone position SCOLIOSIS- lateral curvature of the spine 2 types: 1. structural rye neck 2. postural improper posture

Dx: 1. 2. uneven hemline bend forward- 1 hip higher 1 shoulder blade more prominent

Nsg care: 1. conservative avoid obesity, exercise 2. preventive Milwaukee brace - worn 23 h a day 3. corrective surgery insert Harrington rod post op- how to move

log rolling- move client as 1 unit EXTREMITIES: check # of digits = 20 1. syndactyly webbing of digits 2. polydactyly extra digits 3. olidactyly lack of digits 4. Amelia total absence of digits 5. pocoamelia- absence of distal part of extremities ErQ duchennes paralysis- brachial plexus injury or brachial palsy birth injury caused by lateral & excessive traction during a breech injury Sx: 1. unable to abduct arms from shoulders, rotate arm externally or supinate forearm 2. absence or asymetrical moro reflex Mgt: 1. abduct arm from shoulders with elbow flex. CONGENITAL HIP DISLOCATION head of femur is outside acetabulum Types; 1. subluxated most common type 2. dislocated Sx: 1. shortening of affected leg 2. asymmetrical gluteal fold 3. limited movement earliest sx 4. (+) ortolanis sign abnormal clicking sound 5. when able to walk child limps late sx- trendelenburg sign Goal of Mgt: Facilitate abduction Mgt. 1. triple diaper 2. carry baby astride 3. Frejka splint 4. Pavlik harness 5. Hip Spica Cast TALIPES clubfoot a.) Equinos plantar flexion horsefoot b.) Calcaneous dorsiflexion heal lower that foot anterior posterior of foot flexed towards anterior leg c.) Varus- foot turns in d.) Valgus- foot turns out Equino varus- most common Assessment: 1. Straighten legs & flexing them at midline pos

Mgt: 1. Corrective shoe- Dennis brown shoe, spica cast Fx: of cast - to immobilize bone alignment prevent muscle spasm lead pencil mark area to be amputated cold H20 hasten setting process hot H20- slow setting process After cast application how to move pt: - use open palm not fingers- fingers will cause indention dry cast natural air not blower priority check : neurovascular check C- circulation M- motion S- sensation Cast with bleeding - mask with ball pen edge of blood to know if bleeding is on going sign cast is dry = resonant sound, cast cold to touch

do petaline making rough surface of cast smooth CRUTCHES Fx: To maintain balance To support weakened leg Principles in crutches wt of body on palm! Brachial pulsing if wt of body in axila Do palm exercise- squeeze ball Different crutch Gaits: 1. Swing Through 2. Swing to no weight bearing are allowed into lower ext 3. Three point Gait - wt bearing is allowed in 1 ext 4. Four point gait 5. Two point Gait - wt bearing allowed in 2 lower ext