Pediatric Nursing

St. Jude College
Dimasalang cor. Don Quijote St. Sampaloc, Manila

Nursing Enhancement Program
PEDIATRIC NURSING VI. THE NEW BORN A. CARE OF THE NEWBORN IN THE DELIVERY ROOM 5. Maintain patent airway a. Drain secretions • Put the baby in a trendelenburg position for drainage except when signs of increase ICP is observed: bulging fontanelles, high-pitched cry (earliest sign), vomiting (surest sign), increase BP, decrease PR, decrease RR. 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 c. Administer oxygen as needed • Oxygen concentration should be <40% to prevent retinal scarring which may lead to blindness (retrolental fibroplasia). • Oxygen is best administered thru a tent 5. Keep the newborn warm • The body temperature of the newborn at birth is 37.2 C (99 F). Shortly after birth, if falls below normal because of the immature temperatureregulating mechanism and heat loss. In addition, the cold temperature of the delivery room contributes to this. • A newborn losses heat thru the following mechanisms: ○ Conduction: heat is transferred to a cooler solid object in contact with the body ○ Convection: heat flows from the body surface to a cool surrounding air ○ Evaporation: heat loss thru conversion of liquid to vapor (wet skin). ○ Radiation: heat is transferred to a cooler solid object but not in contact with the body • Subcutaneous fats to act as insulators. Shivering is also not present at birth because of this, they are prone to cold stress which may cause metabolic acidosis as fatty acids accumulate due to the breakdown of brown fat Dry newborn immediately Wrap in a blanket Place under a radiant warmer or isolette with a temp of 33-34 C. Place under a droplight which should be 12-18” far from the newborn

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5. Take the Apgar score • Done at 1 minute after birth to know the conditions of the newborn. Then at 5 minutes after to determine how well the newborn is adjusting to extrauterine life. Sign Pediatric Nursing Page 1 of 46 Score

Heart rate Respiratory effort Muscle tone Reflex irritability Color S T J U D E C O L L E G E S T J U D E C O L L E G E S T J U D E C O L L E G E

0 Absent Absent Limp flaccid No response Blue, pale

1 <100 Slow, irregular Weak cry Some flexion of extremities Grimace Extremities blue, body is pink (acrocyanosis)

2 >100 Good, strong cry Well flexed extremities Cry, withdrawal of foot Completely pink

INTERPRETATION:

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0-3 = 4-6 = 7-10 =

This may indicate severe respiratory & CNS depression. The baby is in serious danger needing immediate resuscitation Condition is guarded & may need more suctioning & oxygenation Routine care only, no special care needed

5. Assess gestational age Clinical criteria for gestational age assessment Finding Sole creases Breast nodule diameter Scalp hair Ear lobe Testes scrotum and GESTATIONAL AGE 37-38 WKS crease Occasional creases anterior 2/3 4 mm Fine & fuzzy Some cartilage Intermediate

0-36 WKS Anterior transverse only 2 mm Fine & fuzzy Pliable, no cartilage

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39 WKS Sole covered creases 7 mm

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Testes in lower canal, small scrotum, few rugae

Coarse & silky Stiffened by thick cartilage Test pendulous, full scrotum, extensive rugae

6. Cleanse baby with oil to remove blood, mucus, vernix 7. Cord care • Inspect for the presence of 2 arteries & 1 vein ○ Absence of 1 artery may indicate kidney problem ○ Absence of umbilical blood vessels may indicate heart and kidney problem • • Assess for possible bleeding Dress the cord with alcohol to hasten drying • Keep the cord clean and dry

5. Administer eye care • Crede’s prophylaxis to protect newborn against gonorrheal conjunctivitis acquired from the mother as the infant passes thru the birth canal • Dry newborn’s face • Open one eye at a time by putting pressure on upper and lower lids • Instill 2 drops of 1% silver nitrate into the lower conjunctival sac • If erythromycin ointment is used, squeeze a line of ointment along the lower conjunctival sac from the inner canthus outward. Close eye to allow ointment to spread across conjunctiva. 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. 5. Place proper identification of newborn Pediatric Nursing Page 2 of 46

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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 significant because if colostrums is aspirated, it has no effect on the S lungs). T J U D E C O L L E G E S T J U D E C O L L E G E S T J U D E C O L L E G E

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5. Circumcision Surgical removal of penis foreskin usually done on the 1st or 2nd day of life after the baby has synthesized enough Vitamin K to prevent hemorrhage. Contraindications: hypospadias, epispadias Procedure: ○ Place infant in supine position ○ Restrain the infant ○ Prepare & drape the area around the penis ○ Clamp is fitted over the end of penis, stretching the foreskin taut ○ Prepuce is separated from the glans & a circle of prepuce is existed Complications: hemorrhage, infection, urethral fistula formation Nursing responsibilities: ○ Observe closely & check for bleeding ○ Wrap penis with a strip of petroleum gauze to prevent the diaper from adhering from the circumcised area ○ Don’t want away a film of yellowish mucous which often covers the glans.

A.CARE OF THE NEWBORN IN THE NURSERY 5. Check ID band (wrist or ankle) 6. Take vital statistics (anthropometric measurement) a. Weight • Average birth weight is 6.5 – 7.5 lbs. or 3.0 – 3.4 kg or 3000 – 3400 gm • Arbitary lower limit is 2.5 kg or 55 lb or 2500 gm. Below this weight, the newborn is considered low birth weight infant • Newborns lose 5-10% of birth weight (6-10 oz) during the first few days of life (physiologic wt loss) due to: ○ Newborn is no longer in the influence of maternal hormones ○ Newborn voids & passes stools ○ If breast fed, they have limited intake because colostrum has low caloric content ○ If bottle fed, sucking is not yet effective • Birth weight is doubled by 6 mos, tripled by 1 year, quadrupled by 2 ½ years. a. Length • Average length is 19-21.5 inches or 47-53 cm 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 Pediatric Nursing Page 3 of 46

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Measured at the level of the nipples Head circumference >chest circumference till 2 years of age

a. Abdominal circumference • Normal: 31-33 cm 5. Take vital signs a. Temperature • At birth, it is 37.2 C & must be maintained at 35.5– 36.5 C • Immediately after birth take rectal temp to check patency of anus S T a. Pulse rate • Immediately after birth, PR is 100-180 J beats per minute as the neonate U struggles for respiration D • Normal PR is 120-140 beats/min E • Palpate femoral pulses because absence may suggest possible C coarctation of aorta O • Radial pulses are not ordinarily L palpable L E a. Respiratory rate G • Immediately after birth, it may be as E high as 80/min • Normal RR is 30-60/min S • Observe movement of abdomen T a. Blood pressure J • Not routinely taken unless cardiac U anomaly is suspected D • At birth, BP is 80/46 mm Hg E • After 10 days, Bp is 100/50 • The cuff to be used must not be more C than 2/3 of the length of the upper arm O or thigh L • FLUSH METHOD may be used L ○ Apply cuff to an extremity E ○ Elevate extremity & apply elastic bandage on the distal G part of the extremity E ○ Inflate cuff to 200 mmHg ( extremity is pale) ○ Slowly deflate cuff as you observe extremity S ○ As soon as the extremity turns pink, read the manometer T ○ Only 1 reading is obtained which is the average between the diastolic & systolic pressures J ○ Normal: 60 at birth U 75 after 10 days D 5. E Physical exam a. Skin • Color- most newborns have a ruddy complexion due to increased concentration of rbc in blood vessels and decrease subcutaneous fats. This fades slightly over the first month Acrocyanosis- extremities are blue and the body is pink. This is normal during the first 2 days of life Pallor- may be due to anemia due to blood loss when cord was cut; few iron stores due to poor maternal nutrition; blood incompatibility; fetal-maternal transfusion. Gray- may indicate infection Jaundice- yellowing of the skin & sclerae due to the inability of the newborn to conjugate bilirubin due to immature liver function. Pediatric Nursing Page 4 of 46 C O L L E G E

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Globin (reused by body) Destruction of RBCs Iron (reused by body) Heme Protopporphyrin Indirect bilirubin (Fat soluble)

S T J U D E C O L L E G E S T J U D E C O L L E G E S T J U D E C O L L E G E • • •
glucoronyl transferase

Direct bilirubin

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Physiologic jaundice (Icterus Neonatorum) Onset- 2nd or 3rd day Duration- 5-7 days ○ Babies being breast fed have longer duration of physiologic jaundice because breast milk contain pregnandiol which depresses action of glucoronyl transferase ○ Management of physiologic jaundice: ○ Morning sunlight will stimulate liver to produce glucoronyl transferase & convert indirect bilirubin to direct bilirubin. Harlequin sign- due to immature circulation ○ Neonate lying on his side will appear red on the dependent side of the body & pale on the upper side ○ Change position of infant Birthmarks ○ Hemangiomas- vascular tumor of the skin  Nevus flammeus (port-wine stain)  Macular purple or dark red lesion, usually on the face  Strawberry hemangioma  Elevated, thick, hard  Associated with high estrogen level  Cavernous hemangiomas  Dilated vascular spaces, elevated ○ Mongolian spots- slate gray patches found across the sacrum or buttocks, usually disappears by school age.

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Vernix caseosa- white cream cheese-like substance noticeable on newborn’s skin at birth Lanugo- fine downy hair covering newborn’s shoulders, back & upper arms ○ Immature newborns has more lanugo than mature infant ○ Disappear by 2 weeks Desquamation- drying of newborn’s skin within 24 hours of birth which results in areas of peeling Pediatric Nursing Page 5 of 46

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Milia- pinpoint white papule (plugged or unopened sebaceous gland) on cheek or across the bridge of the nose ○ Disappear by 2-4 weeks Skin turgor- should be resilient & elastic

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a. Head- 1/4 of the total length; disproportionately large • Large and prominent forehead • Receding chin which quivers if the infant is started or is crying • Well-nourished newborns have full-bodied hair while those poorly nourished or immature newborns have stringy, lifeless hair • Fontanelles should not be sunken (may indicate dehydration) nor bulding (may indicate increase ICP) • Anterior fontanelle (diamond shape) normally closes at 12-18 mos • Posterior fontanelle (triangular in shape) normally closes by the end of the 2nd month • Overriding of suture linens is normal S due to extreme pressure exerted by T passage thru the birth canal. Sutures should never be separated (increased J ICP) U • Infant’s head may appear prominent & D asymmetric due to molding so that it E can fit the cervix contours. This is normal and the head will be restored C to its normal shape within a few days O • Craniotabes which are localized L softening of the cranial bones are due L to pressure of fetal skull against the E mother’s pelvic bone in utero. It is G more common in first born infants E • Caput Succedaneum is edema of the scalp at the presenting part of the S head. It may involve both T hemispheres. Edema will slowly be absorbed about the 3rd day of life. It J needs no treatment U • Cephalhematoma is a collection of D blood between periosteum of skull E bone and the bone itself. Unlike caput Succedaneum, caphalhematoma is C confined to an individual bone and O does not cross suture lines. It usually L takes weeks ofre a cephalhematoma L to be absorbed. E G a. Eyes E • Newborns cry tearlessly due to S T J U D E C O L L E G E ○ immature lacrimal ducts Iris of newborns are gray or blue till the 3rd month of life • Edema is usually present around the orbit or on the eyelids which will remain for 2-3 days • Cornea should be round and adultsized Larger cornea may indicate congenital glaucoma • Pupils are round, dark and regular in shape Key holed pupils- coloboma White pupil- congenital cataract

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There 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 a. Nose- may appear large for the face 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. S T J U D E C O L L E G E S T J U D E C O L L E G E S T J U D E C O L L E G E a. Neck • Short and chubby, creased with skin folds Rigid neck- cogenital torticollis • Strong enough to support the weight of the head • Trachea may be prominent in front of the neck • Thyroid gland is not palpable If palpable, suspect congenital goiter a. Chest • Breast may be engorged due to influence of maternal hormones • Occasionally, breasts of newborns secrete thin, watery fluid (witch’s milk) due to maternal hormones • Should be symmetric in appearance • Retractions should not be present a. Abdomen • contour is slightly protuberant, globular • scaphiod or sunken abdomen – missing abdominal contents • bowel sounds should be heard with in an hour after birth • edge of the liver is palpable at 1-2 cm below the right costal margin • if >3cm – developing CHF • edge of the spleen is palpable 1-2 cm below the coastal margin • for the 1st hr of birth, umbilical cord is white, gelatinous marked with red and blue streaks of umbilical vein and arteries. After 1 hour, cord begins to shrink, dry and be discolored. • 2nd or 3rd day – black • 6th – 10th day – breaks free, leaving a granulating area a few cm across that heals during the following week • right kidney can usually be palpated Pediatric Nursing Page 7 of 46

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 • Supine appears flat in the lumbar & S sacral areas T • Curve starts to form when the child is able to sit & walk J U a.Extremities D • Arms & legs appear short E • Hands are plump & clenched into fists C • Fingernails are soft and smooth & O are long to extend over the L fingertips L • Arms and legs should move E symmetrically G • Check the digits for webbing E (syndactyly), extra toes or fingers (polydactyly), lacking toes or S fingers (oligodactyly) T • Observe for thalidomide effects: complete absence of extremities J (Amelia), absence of distal U extremities (pocomelia), absence D of either upper or lower extremity E (hemmelia). • Check pulses C Radial pulses are normally O nonpapable in the 1st 3 months L due to decrease peripheral L resistance from upper extremities. E If palpable, suspect coarctation of G aorta. E Femoral pulses are normally palpable due to high peripheral S resistance from lower extremities. T If non palpable, conclusive of coarctation of aorta. J U • Abnormal rotation & extension of D foot suggests talipes/club foot E Types: Talipes equinovarusinward rotation of foot, most C common. O L Pediatric Nursing L Page 8 of 46 E G E

Talipes equinovalgus- outward rotation of foot Talipes calcaneous- upward rotation of foot Talipes equinas- downward rotation of foot

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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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○ S T J U D E C O L L E G E a. Urinary system • S T J U D E C O L L E G E S T J U D E C O L L E G E

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Stool of formula fed infants- pale yellow, firm, has a slightly more noticeable odor, passed 2-3x a day Bright green stools— those placed under phototherapy Stool with mucus—milk allergy or other irritant should be suspected Gray/clay colored stoolbile duct obstruction Black/tarry stoolintestinal bleeding

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Newborns void within 24 hours after birth Single voiding is only about 15 ml Daily urine output is 30-60 ml/day Specific gravity- 1.0008-1.010 Proteinuria is normal in the 1st 3 mos. Light in color & odorless because their kidneys do not concentrate urine well Female newborns produce a steady stream when voiding Male newborns void with enough force to produce a small projected arc system Maternal Ab (IgG) cross placenta to the fetus during the last 2 weeks of pregnancy (passive natural immunity) and serve as protection against 6 childhood diseases: poliomyelitis, measles, diphtheria, pertussis, rubella, tetanus. There is little immunity against varicella (Chicken pox) or herpes simplex. Neonate has difficulty forming antibodies against antigens until 2 mos. Of age. That is why immunizations are started at 2 mos. system Limpness or total absence of muscular response to manipulation may indicate narcosis, shock or cerebral injury. Reflexes: ○ 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 Pediatric Nursing Page 10 of 46

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a. Neuromuscular • •

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S T J U D E C O L L E G E S T J U D E C O L L E G E S T J U D E C O L L E G E

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 ○ Moro (startle) reflexmost important reflex indicative of neurological status, this is elicited by startling the newborn with loud noise, jarring the bassinet or the head is allowed to drop backward in a supine position. The newborn will abduct and adduct in his arms and legs. Their fingers assume a typical “C” position. This fades by the end of the 4th and 5th month. ○ Babinski reflex- the infant will fan the toes when the side of the foot is stroked in an inverted “J” curve from the heel upward. This is in contrast to the adult who flexes the toes. It begins to disappear by 3 mos. of age ○ Landau reflexa newborn help in prone position should demonstrate muscle tone. ○ Deep tendon reflex  A patellar reflex can be elicited by tapping the patellar tendon with the tip of the finger. The lower leg will move perceptibly if the infant has a mature reflex. This is a test for spinal nerves L2-L4  A biceps reflex is elicited by placing the thumb of your left hand on the tendon of the biceps muscles. Tap the thumb as it rests on the tendon. You will feel the tendon contract. This is a test for spinal nerves C5-C6.

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Hearing A fetus is able to hear in utero They appear to have difficulty locating sound, not turning toward it consistently They respond with generalized activity to a sound They calm in response to a soothing voice & startle at loud noises They recognize their mother’s voice as if they have heard it in utero Vision Newborns see as soon as they are born Pediatric Nursing Page 11 of 46

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They cannot follow objects past the midline of vision (9-12”) They focus best in black & white objects Touch- most developed & most sensitive of all the senses 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

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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 urine will not irritate the infant’s skin  An ointment such as petroleum jelly may be applied • Sleep patterns ○ A newborn sleeps an average of 16 hrs/day in the first week at home & an average of 4 hours at a time ○ At 4 mos., the baby sleeps 15 hrs/day & 8 hrs at a time ○ Most typical time for wakefulness- 6:00-11:00 PM Nutrition ○ Recommended daily allowance for the newborn ○ Calories- 120 cal/kg body wt (birth-2 mos.) ○ 100 kcal/kg body wt (1 year) ○ Protein- 2.2/kg body wt (birth- 2 mos.)

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○ Minerals- calcium is important because of its contribution to
bone growth. The infant born from a mother with adequate intake of iron during pregnancy has Fe stores that will last for the 1st 3 mos. of life Vitamins- Vitamin A,C,D are recommended for the entire 1st year of life Breastfeeding advantages  For the mother • Release oxytocin aids uterine involution • May serve as protective function in preventing breast cancer • Promotes maternal-infant bonding  For the infant • Contain secretory IgA • Contains the ideal electrolyte & composition for human infant growth

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Difference between human milk & cow’s milk  Carbohydrates • Human milk has more carbohydrates  Fats • • Human & cow’s milk has same fat content Linoleic acid needed for growth & skin integrity is 3x higher in human milk proteins

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Protein • Human milk has less proteins than cow’s milk • Casein is the main protein in cow’s milk which is more difficult to digest • Lactalbumin is the main protein in human milk and is easier to digest Minerals • Cow’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

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Similarities  Both are deficient in Iron  Both contain 20 cal/oz  Both should be given by demand feeding

S T J U D E C O L L E G E S T J U D E C O L L E G E S T J U D E C O L L E G E

A. Newborn at Risk 2. Premature Babies (low birth weight infants) b. Anemia of prematurity • Normochromic, normocytic anemia • Develops during the first 3 to 4 mos. of life due to immaturity of the hematopoietic system • Blood transfusions may be done to supply needed blood components until maturity of the hematopoietic system is achieved • Is different from Iron-deficiency anemia also occurring in premature infants because transfer of Fe stores from the mother to the baby occurs during the last 2 weeks of pregnancy. • In this type of anemia, Fe supplements may be given to the baby • • b.Kernictrus Destruction of the brain cells by indirect bilirubin due to excessive breakdown of RBC & immaturity of the liver Monitor indirect bilirubin level Phototherapy—done with the use of artificial blue light to convert indirect bilirubin to its excretable form ○ Undress the baby to expose all areas of the body ○ Cover genitals & eyes ○ Turn the baby every 2 hours ○ Assess skin turgor because the infant may lose considerable fluid thru insensible water loss due to the temperature of the light ○ Increase fluid intake to prevent dehydration ○ Check stools & urine. Their stools usually are frequently loose & bright green due to excessive bilirubin excreted. Urine may be dark-colored from urobilinogen formation b. Infection This is due to immature immune defenses in premature infants In addition, they have a deficiency in IgG (antibodies) which is usually transferred from the mother to the baby during the last 2 weeks of pregnancy 2. Post Mature Babies Born after the 42nd week of pregnancy They are at risk because the placenta is timed to be effectively functioning for 40 weeks, after that, it seems to lose its ability to function Characteristics: • Dry, cracked, leather-like skin due to lack of fluid & absence of vernix Pediatric Nursing Page 13 of 46

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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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2. Hemolytic disease of the newborn Mother develops antibodies against fetal RBC leading to its destruction of hemolysis. This in turn causes severe anemia and hyperbilirubinemia. b. RH incompatibility • If mother is Rh (D) negative and fetus is Rh positive (has D antigen), the mother will begin to form antibodies against the D antigen. However, most AB are formed 72 hours after the delivery of the baby. So during the 2nd pregnancy, there will be a high level of AB D to S destroy fetal RBC. By the end T of the 2nd pregnancy, the fetus may be severely compromised. J U b. ABO incompatibility D • Maternal blood type is O and E fetal blood type is A, B, or AB. Hemolysis of blood begins with C birth O L Characteristics L ○ Doesn’t appear jaundiced E ○ Enlarged spleen and liver G ○ Edema E ○ Progressive jaundice within the first 24 hours of life— hemolytic process S T Management:
J U D E C O L L E G E S T J U D E C O L L E G E Pediatric Nursing Page 14 of 46 ○ ○ ○ ○ Initiative early feeding to stimulate bowel peristalsis Suspend breast feeding for 24 hours to reduce accumulating indirect bilirubin Initiate phototherapy Exchange transfusion  Withdrawing few amounts (2-4 ml) of infant’s blood and then replacing it with equal amounts of donor blood  Monitor vital signs  Keep infant warm 2. Infant of a diabetic mother Characteristics

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Typically longer and weighs more than other babies (macrosomic) due to over stimulation of pituitary growth hormone and extra fat deposits due to high level of glucose during pregnancy Caudal: regression syndrome (hypoplasia of lower extremities) Cushingoid appearance (fat and puffy) Lethargic or limp on the first days of life

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They are usually born by cesarean birth Severe hypoglycemia during the 1st 24 hours (blood sugar <40mg/dl in newborns)

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2. Infant of a drug-dependent mother Characteristics: Tends to be small for gestational age Has withdrawal symptoms shortly after birth ○ Irritable ○ Disturbed sleep pattern ○ May have tremors ○ May sneeze frequently ○ High-pitched cry ○ Hyperreflexia & clonus (neuromuscular irritability) ○ Tachypnea ○ Vomiting & diarrhea which may lead to dehydration

Management • Keep infant in an environment free from excessive stimuli • Maintain fluid & electrolyte balance 2. Infant with fetal alcohol syndrome • Alcohol crosses the placenta • Characteristics: Tremulous, fidgety, irritable Weak sucking reflex Sleep disturbance Mental retardation—most serious, long term effect

S T J U D E C O L L E G E S T J U D E C O L L E G E S T J U D E C O L L E G E

○ ○ ○ ○

7.Inborn errors of metabolism
• • •

A group of hereditary biochemical disorders affecting metabolism May be due to deficiency in a particular enzyme Affect amino acid, protein, carbohydrate & lipid metabolism

a.Phenylketonuria Phenylalanine • Phenylalanine Tyrosine

○ ○

There is absence of phenylalanine hydroxylase which causes the accumulation of phenylalanine in the blood stream & tissues causing permanent brain damage & mental retardation • Phenylpruvic acid spills into the urine which causes it to have a typically musty or “mousey” odor • Characteristics: Child becomes fair-skinned, blonde & blue eyed because tyrosine is needed for building body pigment and thyroxine Fails to meet average growth standard • Management

○ Put the infant in an extremely low phenylalanine formula
a.Galactosemia • Disorder of carbohydrate metabolism characterized by an abnormal amount of galactose in the blood and in the urine • Deficiency in galactose 1- phosphate uridyl transferase which converts galactose into glucose • Characteristics Lethargy Hypotonia Diarrhea and vomiting Hepatomegaly, cirrhosis Pediatric Nursing Page 15 of 46

○ ○ ○ ○

○ •

Jaundice

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 experience pleasure of sucking as soon as S possible T J U D E C O L L E G E S T J U D E C O L L E G E S T J U D E C O L L E G E • • • • • Cleft palate ○ More common among females than males ○ Occurs at approximately 1:2500 live births ○ Cleft lip with cleft palate occurs at approximately 1:1000 live births ○ Genetic, familial, presence of teratogens ○ Characteristics: Opening on the palate which may involve the anterior hard palate, posterior soft palate or both Usually in the midline • Management ○ Cleft palate surgery is not done until the child is around 4-6 mos. Because it can damage the tooth buds Associated problems: ○ Altered nutrition •

 

Pre-op nursing care: Support the baby in an upright position (sitting or semi sitting) while feeding Use a commercial cleft lip nipple Be careful when feeding because this may cause aspiration Burp frequently because they have the tendency to swallow air due to their inability to maintain a closed seal around the nipple

Post-op nursing care • Keep on NPO for at least 4 hours • Avoid placing tension on the suture line • Breast feeding or bottle feeding is contraindicated during the immediate post op period. Use a breck feeder • Do not use straw to drink • After repair of the cleft palate, liquid diet is continued for the first 3-4 days followed by a soft diet until healing is complete • Never use spoon or fork when feeding • Offer water after feeding to rinse suture line Pediatric Nursing Page 16 of 46

○

○

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 cottontipped 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 J U D E C O L L E G E S T J U D E ○ Altered communication pattern

○

a.

•
•

Hydrocephalus Excess of cerebrospinal fluid in the ventricles and subarachnoid spaces of the brain Causes:   Overproduction of fluid by the choroids plexus Obstruction of the passage of fluid Interference with the absorption of fluid from subarachnoid space Communicating or extraventricular hydrocephalus- there is passage of fluid between ventricles and spinal cord Non communicating or intraventricular hydrocephalusthere is block to passage of fluid Increase head size with bulging fontanelles (first sign) Papilledema Edema of optic disk Scalp becomes shiny, scalp veins prominent Sunset eyes Head lag even after 4 mos. Shrill, high-pitched cry Irritable and lethargic


Types 

•



•

C O L L E G E S T J U D E C O L L E G E

Assessment:         Diagnostic studies: Surgical management

• •

Sonogram, CT scan, MRI, skull x-ray Depends on its cause & extent

Pediatric Nursing Page 17 of 46



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

a. Neural tube disorders • Anencephaly ○ Absence of the cerebral hemisphere ○ Children cannot survive with this disorder because of absence of cerebral function • Microcephaly ○ Slow brain S T J U D E C O L L E G E S T J U D E C O L L E G E S T J U D E C O L L E G E   growth due to maternal phenylketonuria or intrauterine infection such as rubella or cytomegalovirus Results in mental retardation Occurs when the posterior laminae or vertebrae fail to fuse More common at the 5th lumbar or 1st sacral level May appear as a dimple at the point of poor fusion; abnormal tuffs of hair may be present Occurs when the meninges covering spinal herniates thru unformed vertebrae Appears as a protruding mass at the center of the back Usually in lumbar region

•

Spina bifida oculta

○ ○

○
○ Meningocele ○

•

○ ○ Myelomeningocele ○

•

○ ○ ○ Management:

The spinal cord, spinal fluid and meninges protrude thru the vertebral defect Results in lower motor neuron damage Flaccid, lack of sensation in lower extremities Loss of bladder and bowel control

•

  

Prevent infection/rupture of protruding mass Put child on prone position Do not put diaper Cover sac with sterile gauze with NSS or antibiotic ○ Monitor for signs of increase ICP: bulging fontanelles, vomiting, highpitched cry, increasing head circumference, irritability, increase BP, decrease PR, decrease RR ○ Watch out for complications: Hydrocephalus Meningitis ○ Pediatric Nursing Page 18 of 46

• • • •

Nuchal rigidity Photophobia Opisthotonus position (arching of the spine) Signs of meningeal irritation: vomiting, kernigs, (+) brudzinski

(+)

   

UTI Bowel incontinence Club feet Hip dislocation

D. BIRTH RELATED STRESSORS 1. Respiratory distress Syndrome of the newborn (RDS)/Hyaline membrane disease • Caused by low level of phosphotidyl glycerol & lecithin component of surfactant which maintains expansion of alveoli Decrease surfactant alveoli • • • • increase surface tension lack of expansion of

S T J U D E C O L L E G E S T J U D E C O L L E G E S T J U D E C O L L E G E

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 exchange of O2 & CO2 at the alveolar-blood inter space leading to ATELECTASIS Assessment: ○ Expiratory grunting--a compensatory mechanism ○ Cyanosis in room air ○ Nasal flaring ○ Sternal & subcostal retractions ○ Tachypnea (> 70 breaths/min) ○ Rales and diminished breath sounds Management ○ Avoid extreme body temperature because increase in BMR will demand for O2 ○ Give sodium bicarbonate to correct acidosis ○ Monitor VS especially RR every 1-2 hours ○ IV fluid may be needed or gavage feeding for hydration because the respiratory effort makes the infant too exhausted to suck ○ Administer O2 to maintain normal PO2 and pH levels

•

• •

1. Meconium • An infant who experienced hypoxia in utero has a vagal reflex relaxation of the rectal sphincter releasing meconium into the amniotic fluid. During the first breath, the baby inhales the amniotic fluid & aspirates meconium. This can bring about inflammation of bronchioles or block bronchioles by mechanical plugging. Any of these 2 mechanisms will cause severe respiratory distress. Characteristics: • Has difficulty establishing respirations at birth • Tachypnea, retractions, cyanosis Management: • The infant should be intubated • Suction meconium from trachea & bronchi • Antibiotic treatment may be given to prevent development of pneumonia

VII. PEDIATRIC NURSING D. GENERAL PRINCIPLES OF GROWTH AND DEVELOPMENT • Growth- increase in physical size quantitative change Pediatric Nursing Page 19 of 46

•

2 aspects ○ weight- most sensitive measure of growth ○ birthweight- 2x at 6 mos 3x at 1 year 4x at 2 ½ years ○ height 1/2”/mo from 7 mos. - 12 mos.

○ Increase in ht. is 1”/mo from 1 mo- 6 mos.
○

rate of growth is rapid during infancy and adolescence, slow during toddler, pre-school, and school age period rapid growth of limb occurs at school age period

○ • •

Development- increase in skill or ability to function - Qualitative change Principles of growth and development ○ Growth and development are continuous process from conception till death ○ Growth and development proceed in an orderly sequence ○ Different children pass thru the predictable stages at different rates ○ All body systems do not develop at the same rate ○ Development is cephalo-caudal ○ Development proceeds from gross to refined skills ○ Development proceeds from proximal to distal body parts ○ There is an optimum time for initiation of experience or learning ○ Neonatal reflexes must be lost before development can proceed ○ A great deal of skill & behavior is learned by practice

S T J U D E C O L L E G E S T J U D E C O L L E G E S T J U D E C O L L E G E

D. THEORIES IN HUMAN DEVELOPMENT 1. Psychoanalytic theory (Sigmund Freud) STAGES Oral Anal Phallic Latency Genital AGE 0-1 year 2-3 years 4-5 years 6-12 years 13 & above CHARACTERISTICS Infant sucks for enjoyment or relief of tension as well as for nourishment Children find pleasure in both the retention & defecation of feces (toilet training Pleasure zone is genital area, masturbation, children’s energy is diverted to physical and intellectual activities Children’s energy is diverted to physical and intellectual activities Energy is directed to attain mature heterosexual relationships

2. Psychosocial development theory (Erikson) STAGE Trust vs. Mistrust Autonomy vs. Shame and Doubt Initiative vs. Guilt Industry Inferiority Intimacy Isolation vs. vs. AGE Birth18 mos. 18 mos. Vs. 3 years 3-5 years 6-12 years 20-25 years IMPLICATIONS Provide experiences that add to security. Children learn to love and be loved Child learns to be independent & make decisions for self. Provide opportunity for decision making Child learns how to do things. Provide opportunities for exploring new places and activities Child learns how to do things well. Offer support

Pediatric Nursing Page 20 of 46

Generativity Stagnation Integrity Despair

vs. vs.

25-65 years 65-death

3. Cognitive development theory (Piaget) STAGES Sensorimotor Preoperational Concrete Operational thought Formal operational thought AGE Birth2 years 2-7 years 7-12 years 12 years and above CHARACTERISTICS Uses reflex behavior; at the end of this stage, infants begin to demonstrate goal-directed behavior Thought becomes more symbolic. Child is egocentric. Language development Systematic reasoning. Understands relationships Can solve reasoning hypothetical problems with scientific

4. Moral development theory (Kohlberg) STAGES S T Level 1 Level 2 CHARACTERISTICS Preconventional 2-3 years Punishment & obedience orientation. 4-7 years Individualism. Instrumental-reletivist orientation 7-10 years 10-12 years Orientation to interpersonal relations of mutuality (good boy, nice girl) Law and order situation AGE

JConventional U Level 3 D E Level 4 C O L L E G E S T J U D E C O L L E G E S T J U D E C O L L E G E Level 5 Level 6

Post conventional 12 & above Social contract. Follows standards of society. Universal ethical principle orientation

D.

1.

BEHAVIOR TRAITS/CHARACTERISTICS INFANTS (0-12 mos.) • Significant person- mother/caregiver • Fear- stranger anxiety • Physical growth • Developmental milestones ○ 0-1 month  largely reflex  keeps hands fisted, able to follow object to midline  momentary visual fixation on faces ○ 2 months holds head up when prone social smile makes cooling sounds differentiates his cry ○ 3 months holds head and chest up when prone follows objects past midline laughs aloud ○ 4 months no longer has head lag when pulled upright bears partial weight on feet when held upright grasps objects & brings to mouth ○ 5 months raking grasp Pediatric Nursing Page 21 of 46

   

  

  



 ○

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) 11 months  walks with support 12 months  stands alone  walks with help  holds cup & spoon well

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S T J U D E C O L L E G E S T J U D E C O L L E G E S T J U D E C O L L E G E

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• •

Play: solitary Appropriate toys: mobiles, rattles, music box, squeeze toys, plastic rings, rubber ducks, teething ring, textured toys

• • •

1. TODDLER (1-3 years) Significant person: parents Fear: separation anxiety Physical growth: ○ Decrease appetite because of slower growth rate ○ Prominent abdomen because abdominal muscles are not yet strong enough to support abdominal contents ○ All deciduous teeth are generally present by 2 1/2 – 3 years ○ Should start regular dental care by 2 years Developmental milestones ○ Critical for language development ○ Favorite word is “NO” (a manifestation of developing autonomy) ○ Negativistic, obstinate, difficult to manage ○ Active, curious, motor ability jumps far ahead of his judgment ○ By 18 mos., he imitates the things he sees a parent is doing ○ They have ritualistic behaviors ○ They go into temper tantrum at one time or another. Temper tantrums are a natural consequence of their development. They occur as a response to an unrealistic request by parent, consequence of their development. They occur as a response to an unrealistic request by parent, or if the parents are saying, “NO” too frequently,

•

Pediatric Nursing Page 22 of 46

○

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 • during • Play: parallel (side by side) This is not unfriendly but is a normal developmental sequence toddler period Appropriate toys: push-pull toys, trucks, toy telephone, building blocks, balls, toy hammer with nail, drums, toys to ride on, pots, pan, swing, slide

• • •

1. PRESCHOOLER (3-6 years) Significant person: basic family (extended) Fear: fear of castration/body mutilation; fear of the dark, ghosts. Witches, thunder, lightning Physical growth  Definite change in body contour: slimmer, taller  Slight weight gain (4.5 lb/year)  Minimal height gain (2-3.5”/year)  Rarely do new teeth erupt because all 20 deciduous teeth area present by 3 years of age
Behaviors ○ ○

•

○
○ ○ ○ 

 3 years old undresses self runs climbs steps one at a time walks backwards stands on 1 foot vocabulary of 300- 900 words

4 years old ○ can do simple buttons ○ jumps, skips ○ uses alternate steps when climbing stairs ○ vocabulary of 1500 words 5 years old ○ draws a 6-part man ○ throws over hand ○ runs well ○ vocabulary of 2100 words Developmental milestones ○ They ask questions constantly Favorite word is “WHY” Pediatric Nursing Page 23 of 46



 ○

○ Answer their questions honestly at the level of their
S T ○ ○ ○ ○ J U D E C O L L E G E S T J U D E C O L L E G E S T J U D E C O L L E G E

understanding so that their curiosity, vocabulary building & questioning are encouraged.

○ ○ ○ ○ ○ ○ Do ○

They are self-centered They have active imaginations, fantasies Imitative Age of OEDIPUS COMPLEX (strong emotional attachment of a preschool boy for his mother) and ELECTRA COMPLEX (attachment of a preschool girl to her father). ○ Each child competes with the same sex parent for the love & attention of the other parent. They typically have some speech difficulty. They may begin to repeat words or syllables (broken fluency) Sibling rivalry Spend separate time with each other Involve the child in caring for the second child Preschoolers may engage in masturbation not punish the child Divert their attention (give toys to play with) ○ They may question about genital organs or sex, answer them honestly at the level of their understanding Play: associative, cooperative, dramatic, imaginary playmates  Appropriate toys: dolls, housekeeping toys, water colors, clays, coloring book, dress-up clothes, simple puzzles. 1. SCHOOL AGED CHILD (6-12 years old) Significant person: peers of the same sex, teacher Physical growth: Mature slowly but steadily Weight gain of 3-5 lbs/years Increase in height of 1-2”/year By age 10, brain growth is complete  Hypothalamus transmits enzyme to anterior pituitary gland to produce gonadotropic hormones that activate changes in testes and ovaries (10-14 years of age) Deciduous teeth are lost and permanent teeth erupt



• •    

 •     

Developmental milestones They are modest, industrious They enjoy collecting items They are competitive Stealing is a common problem 6 years old • jumps, skips, stumbles, hops • talk in full sentence • play in groups • first molars may erupt

• • • •

 7 years old central incisors erupt difference between sexes become apparent in play spends time in quiet play can tell time in hours Pediatric Nursing Page 24 of 46

• • • •

 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 Gang age 10 years old coordination improves interest in the opposite sex is apparent interested in rules and fairness enjoy privacy 11 years old • more active become increasingly interested in the opposite sex Play: competitive  Age-appropriate toys: dolls, table games, comic books, watching TV, remote control games, collecting items. 1. ADOLESCENT (12-18 years old) • Significant person: peers of opposite sex • Fear: fear of acne, homosexuality, obesity, displacement from friends, death • Physical growth: Onset of puberty and cessation of body growth Physiologic growth is rapid • Pubertal changes Male (testes testosterone)  sudden growth spurt  deepening of voice  increase size of genitals  pubic & axillary hair  production of viable sperm estrogen & progesterone) Sudden growth spurt The larche (increase size of breath). • Starts at 10 years old and ends at 18 years of age • Sign to sexual maturation Appearance of pubic & axillary hair Widening of hips Menarche • Happens between the time the girl develops pubic and axillary hair • Ovulation starts 1-2 years before menarche

S T J U D E C O L L E G E S T J U D E C O L L E G E S T J U D E C O L L E G E

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○ ○

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○ Female (ovary
 

  

○

Behaviors  Rebellious, reformers, idealistic, futuristic  Use of status symbol  Conscious of body image  Emancipation from parents becomes an issue  Hero worship (film star, athlete, writer, etc.)

D. IMMUNIZATIONS Immunity- ability to destroy a particular antigen
IMMUNITY

Pediatric Nursing Page 25 of 46

NATURAL

ARTIFICIAL

ACTIVE

PASSIVE

ACTIVE

PASSIVE

Suffered the disease. Exposed to the disease carrier

Placental transfer. Breast feeding

Receiving vaccines for immunizable diseases

Receiving toxoid (IgG serum (Hepa)

IMMUNIZATION BCG DPT (3 doses at 1 mo. Interval) OPV (3 doses at 1 mo. Interval) Measles Hepa B (3 doses)

AGE 1.1 year School entrants 2 ½ mos. 3 ½ mos. 4 ½ mos. 1 ½ mos. 2 ½ mos. 3 ½ mos. 9 mos. 6 wks. – 11 mos

SITE Right deltoid Left deltoid ID Vastus lateralis Oral Deltoid Vastus lateralis

ROUTE DOSE ID .05 ml ID 0.1 ml IM 0.5 ml Oral SQ IM 2- drops 0.5 ml 0.5- 1 mo. interval

VIII. CHILDREN AT RISK d. Respiratory Dysfunction 1. Disorders of the upper respiratory tract

a.

○ ○ ○ ○ ○

Acute nasopharyngitis 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 • Management: symptoms no specific treatment, control

(common

signs

and

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 Pediatric Nursing Page 26 of 46

○ ○ ○ ○

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

b. Epistaxis (nose bleed) • May be due to trauma, hot dry environment, after a strenuous exercise, or during a respiratory illness • Management: ○ Keep in an upright position with head tilted slightly forward to decrease pressure in the nasal vessels ○ Apply pressure to the sides of the nose with S fingers T ○ Calm the child because crying will increase pressure in the blood vessels of the head J U b.Croup (Laryngotracheobronchitis) D • Inflammation of larynx, trachea & major bronchi E • Cause is usually viral infection • Assessment: C ○ Barking (croupy) cough mostly during the O night L ○ Inspiratory stridor—sharp, high-pitched L sound E ○ Marked retractions G ○ May have a low-grade fever E ○ Signs of respiratory distress (restlessness, increase PR and RR) S T • Management: ○ Supply cool moist air thru a mist tent J (plastic canopy that stretches over a child’s U bed) D ○Note: bedding may become wet & cold easily so keep linens dry E ○Monitor VS every 15 minutes C ○Comfort the child to prevent crying O ○Dexamethasone is given to reduce edema L ○Racemic epinephrine for bronchodilation L E b.Aspiration G • Inhalation of foreign object into the airway E • When a child aspirates an object, the initial S T J U D E C O L L E G E ○

reaction is choking & forceful coughing which usually dislodges the object • If the cough has no sound or there are signs of increasing respiratory difficulty, Heimlich maneuver (children), back blows & chest thrust (infants) should be done. ○ Heimlich maneuver • Stand behind the child (if lying on his back, stand at the head of the bed or table) • Embrace the child & grip your fist with your other hand • Pull back & up with a rapid thrust • Back blows & chest thrusts ○Turn the infant prone over your arm ○ Using the heel of your hand, give 5 quick back blows between the infant’s shoulder blades If the object is not expelled, place in a supine position Pediatric Nursing Page 27 of 46

○

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 2. Disorders of the lower respiratory tract a. Bronchiolitis • Inflammation of fine bronchioles & small bronchi • Caused by virus •Assessment: ○ 1 or 2 days of upper respiratory tract infection S ○ nasal flaring T ○ intercostal & subcostal retractions ○ increase RR J ○ wheezing U D E •Management: ○ Provide adequate hydration to keep respiratory membranes moist C ○ Give moist oxygen O ○ IV therapy may be started L ○ Place in semi-fowler’s position for adequate chest expansion L ○ Some are more comfortable in prone position E G a. Pneumonia E • Inflammation of the lung alveoli S T J U D E C O L L E G E S T J U D E C O L L E G E ○

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• May be bacterial or viral in origin • Aspiration may also cause pneumonia • Classification: Pneumococcal • High fever, nasal flaring, restractions, chills, dyspnea, chest pain, tachypnea, tachycardia, rales • Antiobiotics: Penicillin G • Chlamydial Often seen in newborns up to 12 weeks of age Nasal congestion, cough, tachypnea, wheezing, rales • Viral Low-grade fever, non productive cough, tachypnea, diminished breath sounds, rales rest • Mycoplasmal More frequently seen in older children Fever, cough, enlarged cervical lymph odes, rhinitis Antibiotic: erythromycin • Lipid Caused by aspiration of oily or lipid substance (peanuts) Cough, dyspnea, respiratory distress • Hydrocarbon Furniture polish, kerosene, gasoline, insect sprays, lighter fluid Nausea & vomiting, drowsy, dyspnea, increase RR Don’t induce vomiting Stomach lavage Prevent secondary infection Pediatric Nursing Page 28 of 46

S T J U D E C O L L E G E S T J U D E C O L L E G E S T J U D E C O L L E 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: ○ Maintain fluid and electrolyte balance by replacing lost fluids and electrolytes by starting IV infusion ○ Provide skin care because diarrheal stool is irritating ○ Wet lips with moisturizing to prevent crackling a. Constipation • Difficulty passing hardened stools • Abdominal pain, pain on defecation • As long as the stool is not hard and no discomfort is felt in passing the stool, it is not considered constipation • Management: ○ Enema may initially be needed ○ Give stool softeners ○ Advise high fiber, high fluid diet ○ Encourage to develop regular bowel habits

2. Inflammatory diseases b. Appendicitis • Inflammation of the appendix • Most common in school age children • Cause is unknown • Assessment: • Anorexia (12-24 hours) • At first, the child will feel diffused abdominal pain which gradually localizes at the right lower quadrant. The point of sharpest pain is 1/3 of the way between anterior posterior iliac crest and umbilicus, referred to as Mc Burney’s point. • Nausea and vomiting • Fever • Leukocytosis • Rebound tenderness • Reduced bowel sound Management: surgical removal of appendix Pre-op nursing care: ○ Cathartics & heat are contraindicated because they may cause rupture of appendix Shave and wash abdomen & perineum Urinalysis and CBC Start IV fluid for hydration • Post- op nursing care: Pediatric Nursing Page 29 of 46 • •

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○ Children will return with NGT in place. Keep on NPO until return of
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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.

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b. Necrotizing Enterocolitis (NEC) Bowel develops necrotic patches which interferes with digestion & may lead to paralytic ileus More common in immature infants Assessment: ○ Distended & tense abdomen S ○ Inability to empty stomach on next feeding T ○ (+) occult blood on stool ○ decrease BP J U Management: D ○ Temporary colostomy may be needed E ○ Provide colostomy care ○ Start IV infusion C ○ Antibiotics may be given to prevent secondary O infection L L b. Inflammatory bowel disease: Ulcerative colitis & Chron’s E disease G • Ulceration in the mucosa & submucosa of the colon & rectum E Wall of the colon becomes thickened & inflamed which leads to a “cobble-stone” appearance of the mucosa S • In Ulcerative colitis, entire lower bowel is affected T In Chron’s disease, involved segments are separated by normal bowel tissue & usually, areas affected are higher in the intestine J • Assessment: U ○ Abdominal pain D ○ Diarrhea & steatorrhea E ○ Blood in the stool ○ Weight loss C ○ Growth failure O L ○ Recurring fever L • Management: E ○ Rest G ○ TPN may be needed E ○ Provide high protein, high carbohydrate, high vitamin diet ○ Anti-inflammatory drug (Prednisone) may be given S ○ Provide emotional support T • J U D E C O L L E G E Obstructive disorders a. Pyloric stenosis Difficulty of the stomach to empty its contents due to hyperthrophy or hyperplasia of the muscle surrounding the pylorus (valve between the stomach & beginning portion of the intestine) Assessment: ○ Projectile vomiting after 1 or 2 feedings Pediatric Nursing Page 30 of 46

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Vomitus smells sour because it has been in contact with stomach enzymes

○ Olive-shaped mass palpated on upper quadrant of abdomen
Gastric peristaltic waves passing from left to right as the infant drinks ○ Signs of dehydration: dry mucous membrane of mouth, depressed fontanelles, fever, decrease urine output, poor skin turgor, weight loss Management: ○ Pre-op nursing care:  Administer IV fluids  Determine baseline weight ○ Post op  Frequent feedings of small amount of fluids  Monitor daily weight  Report if vomiting occurs 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) • Distended abdomen • Management: surgery to remove invagated portion or reduce the intussusception • Pre-op nursing care: Keep on NPO Begin IV infusion • Post-op nursing care: Keep NGT & IV infusion in place • •

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c. Volvulus • Twisting of the intestines leading to obstruction of the passage feces • Assessment: ○ Intense crying and pain ○ Pulling up the legs ○ Abdominal distention ○ Vomiting ○ Abdominal mass • Management: surgery to relieve vulvolus and reattach bowel

c. Intestinal obstruction • Assessment ○ The infant does not pass meconium or may pass 1 stool, then stop ○ Distended abdomen ○ Vomiting ○ Increase bowel sounds ○ Character of infant’s cry: hard and forceful ○ Increase PR • Management: this is an emergency to prevent dehydration & electrolyte imbalance. The area of stenosis is removed and the bowel is anastomosed

c. Hirschsprung disease (A ganglionic megacolon) • Absence of ganglionic innervation to the muscle of a section of the bowel so that there are no peristalsic waves to further the passage of the fecal material • Assessment: Symptoms are apparent after 6-12 mos. Of age. ○ History of chronic constipation of intermittent constipation and diarrhea ○ Ribbon-like stools ○ Abdominal pain Pediatric Nursing Page 31 of 46

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○ Nausea and vomiting Management: surgery (Swenson pull-through) usually done at 12-18 mos of age because it is difficult to perform the surgery in small abdomen so a temporary colostomy is done ○ Pre-op nursing care  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 ○ Intercostals & subcostal retractions J ○ Sunken abdomen U ○ Absent breath sound on affected lung D ○ Management: E ○ Elevate head to ease breathing C ○ Turn the infant so that affected lung is down so O that the unaffected lung will expand completely L ○ NGT or gastrostomy tube is inserted to prevent L distention E ○ Infants with diaphragmatic needs immediate G surgical repair E • S T J U D E C O L L E G E S T J U D E C O L L E G E ○ Umbilical hernia ○ A portion of the intestine protrudes through an opening of the umbilical ring ○ The mass is generally 1-2 cm in diameter but usually gets bigger when the child cries or strains ○ If fascial ring is <2 cm, closure is spontaneous and needs no repair  If fascial ring is >2 cm, it needs surgery which is done to school age Inguinal hernia ○ ○ Protrusion of a section of a bowel into the inguinal ring Assessment:  Lumpin the groin usually on the right side  Sometimes, hernia is only apparent when crying due to increase abdominal pressure  If pain is present, the bowel has become incarcerated in the sac (emergency situation) Management: surgery

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Imperforate anus Failure of the 2 sections of the bowel to meet or if the membrane between the 2 surfaces doesn’t dissolve during the 7 th week of intrauterine life Pediatric Nursing Page 32 of 46

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Assessment: ○ No anal formation ○ Inability to insert rectal thermometer ○ A membrane filled with black meconium is seen protruding from the anus ○ No stool is passed leading to abdominal distention Management: ○ Post-op, NGT is inserted for decompression ○ Check bowel sound ○ Small oral feedings are resumed when bowel sounds are present ○ Maintain the suture line clean by irrigating it with normal saline ○ Take temperature thru axilla

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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. Malabsorption syndrome (Celiac disease) • Sensitivity or immunologic response to protein, particularly the gluten factor of protein found in grains • Upon ingestion of these foods, changes occur in the intestinal mucosa thus preventing the absorption of foods across the intestinal villi into the blood stream • Assessment: ○ Anorexia ○ Irritability ○ Distended abdomen ○ Steatorrhea ○ Malnutrition • Management: gluten-free diet for life • Foods containing gluten: wheat, oats, barley products 2. Hepatic disorders a. Hepatitis • Inflammation & infection of the liver Causative agent Incubation period Period of communicability Mode of transmission Hepatitis A Hepa A virus 25 days 2 weeks before onset jaundice Hepatitis B Hepa B virus 120 days Later part of the incubation period, acute stage Contaminated blood, plasma or semen, placental transmission, contaminated syringe

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ingestion of contaminated water, sexual transmission from oral intercourse

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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

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a. Obstruction of the bile ducts • Bile cannot enter intestinal tract & accumulates in the liver, bile enters the blood stream so that infant appears jaundice • Assessment: ○ Jaundice after 2 weeks ○ Rise in direct bilirubin ○ Elevated alkaline & phosphatase level ○ Poor absorption of fat-soluble vitamins ○ White stools due to lack of bile pigments • Management: ○ If mucus plug is suspected, give MgSO4 or dehydrochloric acid ○ It atresia of bile duct is suspected, surgery is needed ○ Pre-op nursing care:  Low-fat, high protein pre-op diet  Give vitamins A, D, K ○ Post-op nursing care:  Keep NGT in place until peristalsis returns  Observe for abdominal distention  Monitor stool 2. Nutritional deficiencies a. Vitamin A deficiency • Night blindness- earliest sign • Xerophthalmia- conjuctive becomes dry and lusterless • Keratomalacia- necrosis of the cornea with perforation, loss of ocular fluid, blindness • Treatment: administration of supplementary Vitamin A Diet rich in Vitamin A a. Thiamine (Vitamin B1) deficiency • Beriberi • Earliest signs: ○ Tingling or numbness of extremities ○ Occasional heart palpation ○ Exhaustion • Treatment: Administration of Thiamine Thiamine rich diet a. Niacin deficiency • Pellagra • Characteristics (4 Ds); ○ Dermatitis ○ Diarrhea ○ Dementia ○ Death a. Vitamin C deficiency • Scurvy Pediatric Nursing Page 34 of 46

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Characteristics: ○ Muscle tenderness ○ Petechial hemorrhage of the skin ○ Nose bleeding ○ Swollen gums Treatment: Administration of supplementary Vitamin C diet rich in fresh fruits and vegetables.

a. 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 T J U D E C O L L E G E S T J U D E C O L L E G E S T J U D E C O L L E G E a. Iodine deficiency • Goiter (hyperplasia of the thyroid gland) • Has difficulty breathing • Treatment: supplemental iodine Synthetic thyroxine High-iodine diet a. Kwashiorkor • Caused by protein deficiency • More frequently seen in children ages 1-3 years • Characteristics: ○ Growth failure ○ Muscle wasting ○ Irritability ○ Iron-deficiency anemia ○ Diarrhea • Treatment: high protein diet a. Nutritional Marasmus ○ Deficiency of all food groups ○ Most commonly seen in children younger than 1 year ○ Characteristics: ○ Growth failure ○ Muscle wasting ○ Iron- deficiency anemia ○ Diarrhea ○ Treatment: diet rich in nutrients 2.Poisoning • More common between the ages of 2-3 years • Emergency management of poisoning at home: ○ Call for help ○ Identify the poison ○ Check the respiration  If deep, rapid- ACID  If slow, shallow- ALKALINE ○ Remove poison from the body including vomiting ○ Give syrup of ipecac: 15 ml (adolescent, school-age child, preschooler) 10 ml (infant) followed by 200 ml of fluid

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If syrup of Ipecac is not available, induce gagging by placing finger in the back of the throat Do not induce vomiting if:  The child is comatose  The child has seizure  The poison was caustic, corrosive or hydrocarbon Give antidote (opposite of the poison) Universal antidote (opposite of the poison)  Burned toast  Milk of magnesia  Strong tea Gastric lavage administer saline cathartic (harsh laxatives)  can cause dehydration & fluid electrolyte imbalance

a. Salicylate poisoning (aspirin) ○ Toxic dose: 150-200 mg/kg body weight ○ Indicative signs: ○ Hyperventilation leading to respiratory alkalosis ○ Metabolic acidosis ○ High fever ○ Dehydration ○ Tachycardia S ○ Vomiting T ○ Diarrhea ○ Restlessness J ○ Confusion U ○ Tinnitus D ○ Management E ○ Remove poison from the body  Give syrup of ipecac C  Gastric lavage O ○ Offer fluid orally to dilute poison and prevent dehydration L ○ Give sodium bicarbonate to create alkaline urine L ○ Tepid sponge bath, cooling blanket E ○ Start IV fluid G ○ Monitor VS, signs of hypoglycemia, metabolic acidosis E S T J U D E C O L L E G E S T J U D E C O L L E G E a. Caustic poisoning ○Lye in washing powder, toilet bowl cleaners, hair care products ○S/Sx: ○ Pain in mouth & throat ○ Drooling ○ Mouth turns white due to burn and later turns brown due to edema & ulceration ○ Vomiting of blood & mucus ○ Tachycardia ○ Tachypnea ○ Pallor ○ Hypotension ○Management: NOTE: Vomiting should never be induced because the corrosive substance will burn as it moves along the GI tract ○Dilute poison with milk or water ○Start steroid therapy to decrease chance of permanent esophageal scarring ○Monitor VS a. Lead poisoning ○Interferes with RBC function ○Effects:  CNS: lethargy, impulsiveness, mental dysfunction  Hematology: Hypochromic, microctic anemia Pediatric Nursing Page 36 of 46

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 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
Normal Blood Flow Different parts of the body aorta Left Ventricle

Unoxygenated blood Inferior & Superior Vena Cava Mitral valve

Right atrium

Left Atrium

Tricuspid valve

Pulmonary vein Oxygenated blood

Right ventricle

Pulmonary artery

lungs

1. Congenital heart disease a. A Cyanotic Heart Disease There is a presence of left to right shunt. There is a defect that allows the blood to flow from the left side of the heart (higher pressure) back to the right side (lower pressure). Thus, the right heart is subjected at a greater pressure. Also, there is less oxygenated blood being delivered to the different parts of the body which will cause the left heart to compensate by pumping harder. This condition might eventually lead to heart failure. ○ Ventricular Septal Defect ○ Most common of all congenital cardiac defects ○ 2 in every 1,000 live births ○ There is an opening in the septum between the left and right ventricles. Because of this, the oxygenated blood which is supposed to b e delivered to the different parts of the body is shunted back to the to the right ventricle and into the pulmonary circulation for reoxygenation. Thus, there is less oxygenated blood being delivered to the body. ○ Assessment: ○ Loud, harsh systolic murmur along left sternal border at the 3rd or 4th ICS at about 4-8 weeks of age ○ A thrill may be palpable ○ Diagnostics: x-ray, MRI, UTZ which will reveal right ventricular hypertrophy ○ Management: ○ Around 60% of small ventricular septal defects will spontaneously close while the remaining 40% requires open heart surgery Atrial Septal Defect ○ There is an abnormal communication between left and right atriums. Because of this, oxygenated blood from left atrium will go back to the right atrium, so that oxygenated blood which is supposed to be delivered to the body is diminished. ○ Assessment: ○ Harsh systolic murmur over 2nd or 3rd ICS (pulmonic area) Pediatric Nursing Page 37 of 46

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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 ○ Management: Open heart surgery ○ Patent Ductus Arteriosus ○ The ductus arteriosus is an accessory fetal vessel that closes at birth or be completed at 3 mos. of age in some infants. It connects the pulmonary artery and aorta. If it fails to close, oxygenated blood from the aorta will go back to the pulmonary artery back into the lungs for reoxygenation. This puts additional strain on the left ventricle causing hypertrophy. ○ Assessment: Wide pulse pressure ○ Continuous “machinery” murmur on upper right sternal border or under the left clavicle in older children ○ Diagnostics: ECG or x-ray reveals ventricular hypertrophy ○ Management: Administration of oral or IV Indomethacin Ligate patient ductus arteriosus ○ If surgery is not done, there is increased risk of Congestive Heart Failure and infectious endocarditis. Pulmonary Stenosis ○ Narrowing of pulmonary valve or pulmonary artery distal to the vavle. Due to this, the right ventricle cannot effectively empty blood by the way of pulmonary artery which will lead to right ventricular hypertrophy ○ Assessment: ○ Systolic ejection murmur at upper left sternal border ○ Thrill may be present in left upper sternal area or the suprasternal notch ○ Diagnostics: ECG reveals right ventricular hypertrophy; cardiac catheter will reveal degree of stenosis ○ Management: balloon stenotomy Aortic Stenosis ○ Narrowing of aortic valve which prevents left ventricle from effectively emptying blood to the aorta. This causes increase pressure in the left ventricle as it attempts to force blood to the stenosed valve. ○ Assessment: ○ May be asymptomatic ○ Murmur loudest at the 2nd right ICS ○ Thrill may be present at the suprasaternal notch ○ Diagnostics: ECG reveals right ventricular hypertrophy; cardiac catheter reveals degree of stenosis ○ Management: balloon stenotomy, surgical repair

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○ Coarction of Aorta (COA) There is narrowing of the aorta so that oxygenated blood which is supposed to be delivered to the different parts of the body cannot pass thru. This will also cause the left ventricle to pump harder which will eventually lead to ventricular hypertrophy. Assessment: Absence of femoral pulse BP in upper extremities is higher than in lower extremities. Normally, there is higher BP in lower extremities because of peripheral resistance. Vertigo, headache Exceptional irritability in a child <3 years old Epistaxis

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Leg pain 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

Cyanotic heart disease ○ There is presence of right to left shunt. There is a defect that allows an oxygenated blood to enter the general circulation. ○ ○ Transposition of great vessels The pulmonary artery arises from the left ventricle instead of the right while the aorta arises from the right ventricle instead of the left. Thus, blood entering the right atrium goes to the right ventricle, then the aorta, to the different parts of the body which is completely unoxygenated. On the left side of the heart, oxygenated blood from the lungs enter the pulmonary vein to the left atrium to the left ventricle and out to the pulmonary artery to the lungs for re-oxygenation. Assessment: ○ Cyanotic from birth ○ Murmur may be present or not Diagnostics: x-ray film reveals enlarged heart Management: Surgery

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○ Tetralogy of Fallot
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○ 4 anomalies: Pulmonary stenosis- because of this, un-oxygenated blood cannot pass thru it thus increasing the pressure on the right ventricle Ventricular septal defect- there is an opening between the left and right ventricles. Because of the increasing pressure on the right ventricle, unoxygenated blood will flow thru this opening to the heart to the left ventricle Overriding aorta- un- oxygenated septal defect to be delivered to the different parts of the body Right ventricular hypertrophy- because of pulmonary stenosis, the right ventricle will pump harder so as to force blood to the stenosed artery. ○ Assessment: ○ Cyanosis Polycythemia (increase in number of RBC) -- an attempt of the body to provide adequate RBC to supply oxygen to the body. However, this causes the blood to become too thick, predisposing the child to thrombophlebitis, embolus, CVA ○ Severe dyspnea relieved by squatting ○ Clubbing of fingers & toes ○ Growth and mental retardation ○ A loud, harsh murmur may be present ○ Diagnostics: x-ray reveals enlarged heart ECG reveals right ventricular hypertrophy Cardiac catheter ○ Management: surgery at 2-3 years of age

1. Congestive Heart Failure (CHF) Occurs when the heart cannot pump enough blood to supply oxygen & nutrients to body cells. There is pooling of blood in the pulmonary or venous systems • Assessment: ○ Right-sided heart failure:  Tachycardia  Hepatomegaly  Irritable, restlessness due to abdominal pain  Edema-late sign in children  Weight gain ○ Left-sided heart failure: • Pediatric Nursing Page 39 of 46

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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 ○ Evacuate accumulated fluids: S  Diuretics T  Low-Na diet ○ Improve cardiac contractility: J 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 Pediatric Nursing Page 40 of 46

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Assessment:  Pallor  Tachycardia  Tachypnea  Gasping respiration  Sternal retractions  Cyanosis Treatment:  Control bleeding  Place in a supine position to provide circulation to the brain cells  Keep child warm with blanket  Blood transfusion may be necessary

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Aplastic Anemia ○ Results from depression of hematopoietic activity in bone marrow ○ Formation of WBC, RBC and platelets are affected ○ Maybe due to excessive exposure to radiation, drugs, chemicals which cause bone marrow damage (chloramphenicol, sulfonamides, arsenic, benzene, quinine) ○ Assessment:  Pallor  Easy fatigability  Anorexia  Petechiae  Nose bleeding  GI bleeding  Prone to infection ○ Management:  Suppress abnormal bone marrow with anti-thymocyte globulin (ATG) or anti-lymphocyte globulin (ALG)  Packed RBC & platelet transfusion may be necessary  Corticosteroids & testosterone may be given  Strict hand washing to prevent infection Hypochromic anemias RBCs are pale Iron deficiency anemia • Most common anemia of infancy & childhood due to poor intake of dietary iron • Causes: dietary deficiency, chronic blood loss, low birth weight infants, excessive demands • Assessment: ○ Pale mucous membranes ○ Poor muscle tone ○ Reduced activity ○ Heart may be enlarged ○ Spleen may be slightly enlarged • Management: ○ Treat underlying cause ○ Diet rich in Iron ○ Give Ferrous sulfate—should be taken after meal to reduce GI irritation. Vitamin C may be given together with Fe to increase absorption. ○ Imferon (Iron-dextran injecton) given IM ○ Stains skin ○ Irritating unless given by deep Z-track technique Macrocytic (Megaloblastic) Anemia RBCs are abnormally large and immature Anemia, neutropenia, thrombocytopenia Oral administration of Folic acid

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• ○ Folic Acid deficiency ○ ○ Pernicious anemia

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Assessment:  Pallor, anorexia  Irritability  Chronic diarrhea  Ataxia, hyporeflexia, paresthesia Treatment: lifelong monthly injection of Vitamin B12 (IM)

Caused by deficiency or inability to use Vitamin B12 due to lack of intrinsic factor in the gastric mucosa

1. Neoplastic disorder: LEUKEMIA
○ ○ Distorted & uncontrolled proliferation of WBC Most common type of cancer in children • Acute Myelogenous Leukemia (AML) Most common type in adulthood Over proliferation of granulocytes • Acute Lymphocytic Leukemia (ALL) Most common type in children Highest incidence is in children between 3-5 years of age ○ Unknown cause: may be due to prenatal exposure to radiation, drugs and chemicals: family predisposition. Due to rapid proliferation of abnormal WBC:  Decrease RBC- anemia - Pallor, lethargy  Decrease platelets- thrombocytopenia - Petechiae, bleeding, bruise easily  Decrease normal WBC- leukopenia - Prone to infection

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○ Other s/sx: headache, vomiting, ataxia, abdominal
distention, abdominal pain, anorexia, hepatomegaly, splenomegaly, bone pain, painless generalized adenopathy

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 Prevent infection: strict hand washing, skin care,
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oral hygiene Prevent injury Provide proper nutrition Assist in diagnostic procedures: blood transfusion, bone marrow biopsy, chemotherapy

A. RENAL DYSFUNCTION 1. Urinary Tract Infection (UTI) • Occurs from ascending spread from the urethra to the bladder • Occur more often in girls because their urethra is shorter & is located closer to the anus • Assessment: ○ Pain on urination ○ Frequency ○ Burning ○ Hematuria • Cystitits: low-grade fever, abdominal pain, enuresis (bedwetting) • Pylonephritis: fever, abdominal or flank pain, vomiting, malaise • Management: ○ Antibiotics (Amoxicillin, ampicillin) ○ Drink large amount of fluids to “flush” infection out of the urinary tract 1. Acute Glomerulonephritis (AGN) ○ Inflammation of the glomeruli of the kidney that usually occurs as a hypersensitivity reaction to group-A beta-hemolytic bacterial infection Assessment: Pediatric Nursing Page 42 of 46

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Has a history of recent respiratory infection or impetigo Gross hematuria, proteinuria, oliguria Hypertension Abdominal pain Low-grade fever Periorbital edema Anorexia Vomiting, headache Diagnostics: ○ Hypoalbuminemia ○ Mild anemia ○ Increase ESR ○ Increase BUN and creatinine ○ Elevated antistreptolysin O Management: ○ Place in semi-fowler’s position ○ Oxygen administration may be necessary ○ Diet should be low in protein, low salt ○ Weigh daily ○ Medications: antihypertensive, digitalis, penicillin 3. Nephrotic Syndrome (Neprhosis)] • Increased glomerular permeability which causes abnormal loss of protein in the urine • May be caused by hypersensitivity to Ag-Ab reaction of an autoimmune process
Increase glomerular permeability

S T J U D E C O L L E G E S T J U D E C O L L E G E S T J U D E C O L L E G E

Protein lost in urine

PROTEINURIA

HYPOALBUMINEMIA

Fluid shifts from intravascular to interstitial tissue

Liver compensates by increase production of lipoproteins

EDEMA

HYPEREDEMA

A.NEUROLOGIC DSYFUNCTIONS 1. Cerebral Palsy ○ Group of disorders affecting the upper motor neuron resulting in motor dysfunctions ○ Frequently caused by brain anoxia leading to cell destruction ○ May be caused before, during or shortly after birth (placenta, previa, abruptio placenta, maternal infection, nutritional deficiency, prematurity, prolonged labor, forceps delivery, RDS, neonatal infections, traumatic head injury) ○ Types: ○ Spastic—hyperactive, hypertonic muscles, exaggeration of deep tendon reflexes, abnormal reflexes ○ Athetoid type- abnormal involuntary movement, limp, flaccid early in life, worm-like movement, drooling Pediatric Nursing Page 43 of 46

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○ Ataxic type—awkward, wide-based gait, primary incoordination ○ Mixed type Assessment: ○ Delayed motor development ○ Abnormal head circumference (may be smaller due to slow brain growth) ○ Abnormal postures ○ Abnormal reflexes ○ Abnormal motor performance May have sensory disturbances: strabismus, visual problems, speech problem ○ Irritable, impulsive, short attention span ○ May have mental retardation Management: ○ Maintain safe environment & prevent injuries ○ Facilitate passive & active ROM exercises ○ Prevent contractures ○ Assist in doing self-care (dressing) ○ Provide adequate nutrition ○ High roughage to prevent constipation ○ Soft diet to children who cannot chew or swallow well ○ Be patient because these children take longer time eating

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1. Meningitis Infection of the cerebral meninges Caused by H. Influenzae, Neisseria meningitides, group-B streptococcus Assessment: ○ May occur insidiously or suddenly ○ 2-3 days of upper respiratory tract infection ○ Irritability ○ Headache ○ Convulsion In newborns: ○ Poor sucking ○ Weak cry ○ Lethargy ○ Convulsion ○ Apnea ○ Bulging and tense fontanelles Signs of meningeal irritability: ○ Nuchal rigidity (+) Kernigh’s sign (pain on extending the knee when thigh is bent on the abdomen) ○ (+) Brudzinski’s sign ○ Opisthotonus (back is arched & neck hyperextended) Diagnostics: ○ Lumbar puncture reveals: ○ Increase WBC ○ Increase protein ○ Decrease glucose ○ Increase ICP Management: ○ Antibiotic therapy (Ampicillin, Chloramphenicol) given IV for rapid effect ○ Corticosteroid may be given to decrease ICP ○ Provide rest & quiet environment ○ Monitor VS, level of consciousness & motor activity ○ Weigh child daily ○ Avoid sudden change in position
3. Encephalitis Inflammation of brain tissues Caused by protozoa, bacteria, fungi, virus Assessment: ○ Headache Pediatric Nursing Page 44 of 46

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○ 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 • Sudden change in posture (arm E dropping) • Child slumps to the ground C • Unconscious O • Regains consciousness in less than 5 L minutes L ○ Focal seizure E • Originate from a specific brain area G • Begins in the fingers & spreads to E the wrist, arm & face in a clonic contraction S • May progress to a generalized T seizure ○ Absence seizure (Petit Mal) J • Staring spell lasting for a few U seconds D • Rhythmic blinking E • Twitching of mouth or extremity • After seizure, child resumes activity C unaware of what happened O ○ Tonic-clonic seizure (Grand Mal) L 4 stages: L • Prodromal period E ○ Drowsiness, dizziness, malaise, lack of coordination, G tension E • Aura- may reflect portion of the brain affected S ○ Smelling unpleasant odors- medial portion of temporal T lobe ○ Seeing flash lights- occipital area J U ○ Repeated hallucinations- temporal lobe D ○ Numbness of extremities- parietal lobe E ○ “Cheshire cat grin” – frontal lobe • Tonic-clonic convulsion C Tonic (20 seconds) O • All muscles of the body contract L Pediatric Nursing L Page 45 of 46 E G E

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• Falls to the ground • Extremities stiffen • Saliva collects in the mouth • May bite his tongue • Clonic (20 seconds) • Muscles rapidly contract & relax • Quick jerky motions • May blow bubbles or foamy saliva • Post-ictal period • Child falls into a sound sleep for 1-4 hours • When 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 from obstructing the airway T ○ Ketogenic diet (high fat, low protein and carbohydrate) J ○ Medications: U • Drug depend on the type of seizure D • Psychomotor- Phenytoin, Carbamazepine, Primidone E • Absence (Petit Mal)- Ethosuximide (Zarontin), Valproate • Tonic-clonic (Grand Mal)- Phenytoin Sodium (Dilantin) C • Do not discontinue drug abruptly because it may result in O severe seizure L • Periodic blood sampling to monitor blood levels of the medicine L E MISCELLANEOUS G Infantile Eczema (Atopic Dermatitis) E Skin allergic reaction mainly from food allergy (milk, eggs, wheat, citrus, juices, tomatoes) S Common in formula-fed infants T May begin in the 2nd month of lasting until 2-3 years of age J U D E C O L L E G E S T J U D E C O L L E G E

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