Pediatric Nursing

ReD Mapalo – BSN

Pediatric Nursing

GROWTH AND DEVELOPMENT Growing  complex phenomenon of a structure or whole GROWTH • Increase in physical size of a structure or whole • Quantitative • 2 parameters o Weight  Most sensitive measurement for growth
Weight gain: 2x = 5 – 6 mos. 3x = 1 year 4x = 2 – 2½ years

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Height

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ESTROGEN  responsible for increase in height in female TESTOSTERONE  responsible for the increase in height in male Stoppage of height coincide with the eruption of the wisdom teeth
↑ - 1”/ mo – 1 – 6 mos ↑ - 1.5”/ mo – 7 – 12 mos ↑ - 50 % - 1st Year HEIGHT COMPARISON 9 y/o  male = female 12 y/o  Male < Female 13 y/o  Male > Female

DEVELOPMENT • Increase in the skills or capacity to function • Qualitatively • How to measure development o By simply observing the child doing simple task o By noting parent’s description of the child’s progress o Measure by DENVER DEVELOPMENTAL SCREENING TEST (DDST) • MMDST o Metro Manila Developmental Screening Test o Philippine Based exam • Main Rated Categories o LANGUAGE  ability to communicate o PERSONAL/ SOCIAL  ability to interact o FINE MOTOR ADAPTIVE  ability to use hand movements o GROSS MOTOR SKILLS  ability to use large body movements MATURATION • Synonymous with development • Readiness/ learning is effortless COGNITIVE DEVELOPMENT • Ability to learn and understand from experiences, to acquire and retain knowledge, to respond to a new situation and to solve problems LEARNING  change of behavior IQ= [Mental Age/ Chronological Age] x 100 Normal IQ = 90 - 110 GIFTED CHILD  > 130 IQ level

ReD Mapalo – BSN

Pediatric Nursing

BASIC DIVISIONS OF LIFE • Prenatal o Conception to birth • Infancy o Neonatal  first 28 days o Formal Infancy  29th – 1 year • Early Childhood o Toddler  1 – 3 y/o o Preschool  4 – 6 y/o • Middle Childhood o School Age  7 – 12 y/o • Late Childhood o Pre – adolescent  11 – 13 y/o o Adolescent – 12 – 13 y/o to 21 PRINCIPLES OF GROWTH AND DEVELOPMENT • Growth and development is a continuous process (WOMB TO TOMB PRINCIPLE)  begins from conception and ends with death • Not all parts of the body grows at the same time or at the same rate (ASSYCHRONOUS GROWTH) • Each child is unique • Growth and development occurs in a regular direction reflecting definite and predictable patterns or trends o Directional Terms  Cephalocaudal/ Head to Tail  It occurs along bodies long axis in which control over head, mouth and eye movemens and precedes control over upper body torso and legs  Proximo – Distal/ Centro – Distal  Progressing from center of the body to the extremities  Symmetrical/ Each side of the Body  Develop at the same direction at the same time and at the same rate  Mass – Specific  Differentiation – SIMPLE TO COMPLEX; BROAD TO REFINED o Sequential Trend  Involves a predictable sequence of growth and development to which the child normally passes  Locomotion  Creeps → Stands → Walks → Run  Language and Social Skills  Cry → coo o Secular Trend  Refers to the worldwide tend of maturing earlier and growing larger as compared to succeeding generation

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BEHAVIOR → most comprehensive indicator of developmental stages o act @ your age PLAY → universal language A great deal of skills is learned by practice There is optimum time for initiation of experience or learning Neonatal reflexes must be lost first before development can proceed o persistent primitive infantile reflexes is a possible case of cerebral palsy

PATTERNS OF GROWTH AND DEVELOPMENT • Renal → digestive → circulatory → musculoskeletal o childhood

ReD Mapalo – BSN

Pediatric Nursing

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Brain → CNS → Neurologic Tissue  rapidly grows with in 1 – 2 years o Brain achieves its adult proportion @ 5 years o Rapid growth and development of brain from1 – 2 years o Malnutrition may result to Mild Mental Retardation Lymphatic System (Lymph Nodes) o Grows rapidly during infancy and childhood o Provide protection against infection o TONSIL reach its adult proportion @ 5 years Reproductive o Grows rapidly during puberty

RATES OF GROWTH AND DEVELOPMENT • Fetal and Infancy o Period of most rapid growth and development o Prone to develop anemia • Toddler o Period of slow growth and development • Toddler and preschool o Period of alternating rapid and slow growth and development • School Aged o Slower growth and development o Least to develop anemia • Adolescent o Period of rapid growth o Secondary prone to anemia Two Primary Factors Affecting Growth and Development • Heredity o Race o Sex o Intelligence o Nationality • Environment o Quality of Nutrition o Socio Economic Status o Health o Ordinal Position in the family o Parent – Child Relationship

*Universal Principle: F are born < wt. than M by 1 oz.; F are born < lt. than M by 1 in. THEORIES OF DEVELOPMENT Developmental Task • A skill or growth responsibility arising at a particular time in the individual’s life. • The successful achievement of which will provide a foundation for the accomplishments of the future tasks SIGMUND FREUD’S PSYCHOSEXUAL THEORY • 1856 – 1939 • An Austrian Neurologist • Founder of Psychoanalysis • 1st to introduce Personality Development Phase Age Site of Activities Gratificati on Oral 0 – 18 Mouth • Biting

Task

• Provide oral stimulation even if

ReD Mapalo – BSN

Pediatric Nursing

Phase

mos.

Anal Phase (stage where OC are develop ed)

19 mos. – 3 yrs.

Anus

• Crying • Sucking (enjoyment and release of tension) • Elimination • Retention/ Defecation of Feces

baby is place NPO (use pacifier)CBQ • Never discourage thumb sucking • Help the child achieve bowel and bladder control even if the child is hospitalized • Principle of holding on and letting go • Mother wins or child wins • Child Wins o Holding on o Child turns to be hardheaded, antisocial, stubborn, unreliable, irresponsible • Mother Wins o Letting go o Child turns to be kind, obedient, perfectionist o Meticulous, OCs, reliable, responsible • Accept the child fondling his own genetalia as normal area of exploration • Divert attention from masturbation • Answer the child’s question directly • Human sexuality • Help the child achieve (+) experiences so that he’ll be ready to face the conflicts of adolescents

Phallic Phase

4 – 6 yrs.

Genital

• May show exhibitionism • Have or increase knowledge of 2 sexes

Latent Phase

7 – 12 yrs.

School aged

Genital Phase

12 – 18 yrs

Genitalia

• Period of suppression • No obvious development, slower growth • Child’s energy or Libido is diverted into more concrete type of thinking • Achieve sexual maturity and learn to establish satisfactory relationship with the opposite sex

• Give opportunity to relate to opposite sex

ERIK ERICKSON’S STAGES OF PSYCHOSOCIAL THEORY • Former student of Freud • Stresses the importance of culture and society to the development of one’s personality • “environment”

ReD Mapalo – BSN

Pediatric Nursing

1. Trust vs. Mistrust • 0 – 18 months • TRUST is the foundation of all psychosocial tasks • Theme: Give and Receive • Trust is developed via o Satisfying needs of infants on time o Care must be consistent and adequate o Give experiences that will add security  Hugs, kisses, touch, eye to eye contact, soft music 2. Autonomy vs. Shame & Doubt • 18 mos. to 3 years • Theme: independence and self – government • Give opportunity for decision making, offer choices • Encourage the child to make decision rather than judge • Parents has a moral obligations to set limits 3. Initiative vs. Guilt • 4 – 6 years old • Learns how to do BASIC things • Give opportunity exploring new places and events • Right time for amusement park and zoos • Activity recommended: modeling clay and finger painting • Enhances creativity and imagination and facilitates fine motor development 4. Industry vs. Inferiority • 7 – 12 years old • Learns how to do things well • Give appropriate short assignments and projects • Unfinished project will develop inferiority 5. Identity vs. Role Confusion • 12 – 18 or 20 years old • Learns who he is or what kind of person he will become by adjusting to new body image and seeking EMANCIPATION/ freedom from parents 6. Intimacy vs. Isolation • 18 – 25 or 30 years old • Career focus • Looking for a lifetime partner 7. Generativity vs. Stagnation • 30 – 45 years old 8. Ego Integrity vs. Despair • 45 years old and above JEAN PIAGET’S STAGES OF COGNITIVE DEVELOPMENT • Reasoning powers • Swiss Psychologist • Genetic Epistemologist 1. • • Sensorimotor 0 – 2 years old Also called Practical Intelligence o words and symbols are not yet available o communication through senses 1. o o 2. o o Schema 1: Neonatal Reflex 1 month Early reflexes Schema 2: Primary Circular Reaction 1 – 4 months Activities related to body; repetition of behavior

ReD Mapalo – BSN

Pediatric Nursing

3. o o o o 4. o o

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o 5. o o o o 6. o o o 2.

 Example: thumbsucking Schema 3: Secondary Circular Behavior 4 – 8 months Activities not related to the body Discover person and object’s permanence Memory traces are present and anticipate familiar events Schema 4: Coordination of Secondary Reaction 8 – 12 months Exhibit goal directed behavior ↑ sense of permanence and separateness Play activities: Throw and retrieve Schema 5: Tertiary Circular Reaction 12 – 18 months use trial and error to discover characteristic of places and events “Invention” of new means capable of space and time perception Schema 6: Invention of New Means thru Mental Coordination 18 – 24 months Symbolic representation Transitional phase to the pre-operational thought period

Pre-operational Thought 1. Pre – conceptual Thought o 2 – 4 years old o Concrete, literal, static thinking o CBQ EGOCENTRIC – unable to view anothers viewpoint o CBQ (-) REVERSIBILITY – in every action there is opposite reaction; cause and effect o Concept of time is only now and concept of distance is only as far as they can see o CBQ ANIMISM – consider inanimate object as alive 2. Intuitive Thought o Beginning of causation o o o o o Concrete Operational 7 – 12 years old SYSTEMATIC REASONING as solution to problems Concept of (+) reversibility Concept of Conservation – constancy despite of transformation Activity recommended: Collecting and Classifying Formal Operational 12 years old and above Period when cognition achieve its final form Can solve hypothetical problem with SCIENTIFIC REASONING Can deal with past, present and future Capable of ABSTRACT, mature thought and formal reasoning Activity recommended: talk time; focus on opinions and current events

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4. o o o o o o

KOHLBERG’S THEORY OF MORAL DEVELOPMENT • Recognized the theory of moral development as considered to closely approximate cognitive stages of development • Stages of Moral Development o Infancy o Premoral o Amoral o Pre-religious Age Stage Descritption

ReD Mapalo – BSN

Pediatric Nursing

0 – 3 yrs

1

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4 – 7 yrs.

2

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4 – 10 yrs.

3

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10 – 12 yrs.

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Older than 12

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6

PRECONVENTIONAL (Level I) PUNISHMENT/ OBEDIENCE/ ORIENTATION o Heteronomous morality o Child does right because PARENT tells him to and to avoid punishment INDIVIDUALISM o Instrumental purpose and exchange o Carries out action to satisfy own needs rather than society o Will do something for another if that person does something for the child CONVENTIONAL (Level II) ORIENTATION TO INTERPERSONAL RELATIONS OF MUTUALITY o Child follows rules because of need to be a “good person” in own eyes and eyes of others MAINTAINANCE OF SOCIAL ORDER, FIXED RULES AND AUTHORITY o Child finds following rules satisfying o Following rules of authority figures as well as parents in an effort to keep the “system” working POST – CONVENTIONAL (Level III) SOCIAL CONTRACT, UTILITARIAN LAW – MAKING PERSPECTIVE o Follows standards of society for the good of the people UNIVERSAL ETHICAL PRINCIPLE ORIENTATION o Follows internalized standards of conduct o Only few people achieved this level o Only saints and holy

DEVELOPMENTAL MILESTONES • Major marker of growth and development • Determines developmental delays TEETH QUESTIONS 6 mos. Eruption of first temporary teeth 2 LOWER CENTRAL INCISORS 30 mos. Temporary teeth complete 20 decidous teeth POSTERIOR MOLAR --> last to appear Time to go to Dentist Begins to brush teeth 3 years Tooth brushing with minimal supervision 6 years Tooth brushing alone Temporary teeth begins to fail 1st permanent teeth → 1st MOLAR Last to appear → WISDOM TOOTH BOWEL/ BLADDER CONTROL Bowel Control → 18 months / 1 ½ years Day Time Bladder Control → 2 years Night Time Bladder Control → 3 years MILESTONES Infancy • Solitary play o Consider when choosing a play  Safety  Age appropriateness  Hygiene

ReD Mapalo – BSN

Pediatric Nursing

•

Fear: Stranger Anxiety o Begins: 6 – 7 months o Peaks: 8 months o Diminishes: 9 months

Neonate • Complete head lag • Largely reflex visual fixation for human face • Hands fisted with thumbs in • Cries without tears because lacrimal glands are not fully developed 1 month • Dance reflex disappears • Looks at mobile; follows midline • Alert to sound, regards face 2 months • Holds head up when in prone • Social smile, cries with tears, cooing sound • Closure of posterior fontanel (2-3 months) • Head lag when pulled to sitting position • No longer clinches fist tightly • Follows object past midline • Recognizes parents 3 months • Holds head and chest up when in prone • Holds hands open at rest • Hand regard, follows object past midline • Grasp and tonic neck reflexes are fading • Reaches for familiar people or object • Anticipates feeding 4 months • Head control complete • Turns front to back; needs space to turn • Laughs aloud; Babbling sound • Babinski Reflex disappears 5 months • Turn both ways (roll over) • Teething rings, handles rattle well • Moro reflex disappears (5 – 6 months) • Enjoys looking around environment 6 months • Reaches out in the anticipation of being picked- up • Sits with support • Puts feet in mouth in supine position • Eruption of first temporary teeth ( Lower 2 central incisors) • Vowel sounds “ah, eh” • Uses palmar grasp; handless bottle well • Recognizes strangers 7 months • Transfer objects from hand to hand (6 – 7 months) • Likes objects that are good sized for transferring 8 months

ReD Mapalo – BSN

Pediatric Nursing

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Sits without support Peak of stranger anxiety Plantar reflex disappear (6-8 months)

9 months • Creeps or crawls; need space for creeping • Neat pincer grasp reflex, probes with forefinger • Finger feeds, combine 2 syllables “mama & dada” 10 months • Pulls self to stand • Understand the word no • Respond to name • Peek – a – boo, pat a cake, since they can clap 11 months • Cruising, stand with assistance • Walking while holding to his crib’s handle • One word other than mama and dada 12 months • Stands alone • Walk with assistance • Drink from cup, cooperates in dressing • Says two words other than mama and dada • Pots & pans, pull toys and nursery rhymes • Imitates actions, comes when called • Follows one – step command and gesture • Uses mature pincer graps, throws objects Toddlerhood • Parallel Play – 2 toddlers playing separately • Provide 2 similar toys for 2 toddlers • Toys o Squeaky frogs to squeeze o Waddling ducks to pull o Trucks to push o Building blocks o Pounding peg • Fear: Separation Anxiety o Begins: 9 months o Peaks: 18 months o 3 stages  Protest  Despair  Denial o Prevent:  Do not prolong goodbye  Say goodbye firmly  Say when you’re back Toddler Characteristic Traits • Negativistic: says no most of the time • Saying no – way of developing independence • Limit questions, offer choices • Rigid, ritualistic and stereotyped • Ritualistic – way to gain mastery • Temper Tantrums

ReD Mapalo – BSN

Pediatric Nursing

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o Stomping of feet o Holding breath o Screaming o Head banging o NC: Ignore the behavior Scaphoid abdomen – underveloped abdominal muscle Physiologic Anorexia  food fad, food jag that last for a short period of time due to the preoccupation to environment

15 Months • Plateau stage • CBQ WALKS ALONE – lateness in walking is a sign of mild mental retardation • Puts small pellets into small bottle • Creep upstairs • 4 – 6 words • Scribbles voluntarily with pencil, holds spoon well, seat self in a chair 18 Months • Height of POSSESIVENESS – favorite word MINE • Bowel control achieved • No longer rotates a spoon • Can run and jump in place • Walks up and downstairs holding on to a person’s hand or railing, typically places both feet on one step before advancing • Names one body part 24 months • TERRIBLE TWOS • Turns pages one at a time, removes shoes, pants, etc • Can open doors by turning door knobs, unscrew lids • 50 – 200 words (2 word sentences), knows 5 body parts • Walk upstairs alone, still using feet on the same step at same time • Daytime Bladder Control • CBQ best time to bring the child to dentist: 2 – 3 years or when temporary teeth is complete 30 months • Makes simple lines or stroke or crosses with pencil • Can jump down from chair • Knows full name, holds up finger to show age • Copy a circle • CBQ Temporary teeth complete (posterior molar: last to erupt) • CBQ 20 deciduous teeth • CBQ tooth brushing: 2 – 3 years 36 months • TRUSTING THREES • Tooth brushing with little supervision • Unbutton buttons • Draws a cross, learns how to share • Knows full name and sex • Speaks fluently, 200 – 900 words • NIGHTIME BLADDER CONTROL achieved • Rides tricycle Preschoolers • Cooperative play – playhouse • Role playing is usual

ReD Mapalo – BSN

Pediatric Nursing

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Fears: o Castration/ Body Mutilation o Dark places and witches o Thunder and lightning o Ghost Curious, creative, imaginative and imitative

Preschooler’s Characteristic Traits • Telling tall tales • Imaginary friend  way of relieving tension and anxiety • Sibling rivalry→ jealousy to a newly delivered baby • Regression o Signs: bedwetting o Thumbsucking o Baby talk o Fetal position • Masturbation o Sign of boredom o Divert attention o Offering toy 4 years old • FURIOUS FOUR • Noisy, aggressive and stormy • Buttons button • Copy square • Catches ball, jumps, skips • Alternates feet going downstairs • CBQ LACES SHOES • Vocabulary of 1500, knows the basic color • Says song or poem from memory 5 years old • FRUSTRATING FIVES • Jumps over low obstacles • Spreads with a knife • Draws 6 part man, copy triangle • Imaginary playmates • 2100 words • Identification with same sex • Attachment to opposite sex School – Aged • Competitive Play: Tug of war • Fears o School Phobia  orienting child to his new environment o Displacement from school o Death • Significant Person o Teacher o Peer of same sex • Stoppage of height coincide with the eruption of wisdom tooth • Prone to fracture: Common Green stick • Mature vision o 20/200 legal blindness • They’ll Cheat → can’t afford to lose 6 years old

ReD Mapalo – BSN

Pediatric Nursing

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Temporary teeth begins to fall, permanent teeth begins to appear (1st: First Molar) Tooth brushing alone A year of continuous motion, clumsy moving 1st grade teacher becomes authority figure o nail biting → sign of strict teacher Beginning interest with God

7 years old • Age of assimilation • Copies a diamond • Enjoys teasing and playing alone • Quieting down phase 8 years old • Expansive age • Smoother movements • Normal homosexual • Loves to collexct objects • Counts backwards 9 years old • Coordination improves • Tells time correctly • Hero worship • Stealing and lying are common • Takes care of body needs completely • Teachers find their group difficult to handle 10 years old • Age of special talents • Write legibly • Ready for competitive games • More considerate and cooperative • Joins organizations • Well mannered with adults and critical with adults 11 – 12 years old • Pre adolescent • Full of energy and constantly active • Secret languages are common • Share secrets with friends • Sense of humor is present • Social and coopoerative School – Aged Characteristic Traits • Industrious • Modest Signs of Sexual Maturity in Female I ncrease in size of breast and genitalia – telarche – 1st sign W idening of hips A ppearance of pubic axilliary and pubic hair - adrenarche M enarche – last sign Signs of Sexual Maturity in Male A ppearance of axilliary and pubic hair D eepening of voice D evelopment of muscle I ncrease in size of penis and scrotum – 1st sign

ReD Mapalo – BSN

Pediatric Nursing

P roduction of viable sperm – last sign Adolescence • Fear o Acne o Obesity o Homosexuality o Death o Replacement from friends • Peer of opposite sex  significant other • Experiences conflicts between his needs for sexual satisfaction and societal expectations • Core Concern o Change of body image o Acceptance of the opposite sex • Nocturnal Emission: Wet dreams o Hallmark of adolescence • CBQ distinctive odor due to stimulation of apocrine gland • Testes and scrotum increases until age 17 • Sperm is viable by age 17 • Breast of female and genitalia increases until age 18 • Signs of sexual maturity • Characteristic traits o Idealistic, rebellious, reformers o Parent child conflict o Very conscious with body image o Peer pressure • Problems o Vehicular accident o Smoking o Alcoholism o Drug Addiction o Pre Marital Sex Concept of Death 6 years old  death is reversible CBQ 7 – 9 years old  personification of death, permanent loss of the corporal life IMMEDIATE CARE OF THE NEWBORN 8 PRIORITIES OF THE NEWBORN IN THE FIRST DAYS OF LIFE 1. Initiation and maintenance of respiration 2. Establishment of extrauterine circulation 3. Control of body temperature 4. Intake of adequate nutrition 5. Establishment of waste elimination 6. Prevention of infection 7. Establishment of an infant – parent relationship 8. Developmental care that balance rest and stimulation for mental developmental INITIATION & MAINTENANCE OF RESPIRATION Alerts!

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Expulsion is @ 2nd stage of labor Most neonatal deaths w/in the first 24 hours is due to INABILITY TO INITIATE AIRWAY Lung function begins only after birth

ReD Mapalo – BSN

Pediatric Nursing

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Support head and remove secretion Proper suctioning with a catheter o Place baby’s head to side  facilitates drainage o Suction the mouth first before nose  newborns are nose breathers o Period of 5 – 10 seconds, should be gentle and quick  Prolonged suctioning can cause hypoxia, laryngospasm and bradycardia due to vagal nerve stimulation o Evaluate patency  Cover 1 nostril, if newborn struggles, additional suctioning needed If not effective requires effective LARYNGOSCOPY to open airway. After deep suctioning, and ET tube can be inserted and O2 administration by (+) Pressure Bag and mask with 100% O2 @ 40 – 60 bpm

Alerts in O2 Administration • No Smoking  O2 is combustible • Must be humidified  prevent drying of mucosa • Cover the nose and mouth only • Scarring Retina  results Retinopathy (O2 overdose) • Meconium Stain  never administer O2 with pressure  causes atelactasis ESTABLISHMENT OF EXTRAUTERINE CIRCULATION Alerts! • Circulation id initiated by LUNG EXPANSION and PULMONARY VENTILATION • Completed by cutting the cord • Assess characteristics of cry o Normal  strong, vigorous, lusty cry o Hypoglycemia/ Increased ICP  high pitched, small cry o Never stimulate crying before all secretion are remove to prevent aspiration Feto – Placental Circulation • Placenta → O2 carried by vein → liver → Inferior Vena Cava → Right atrium → 70% goes to Foramen Ovale →Remaining 30 → tricuspid valve → right ventricle → pulmonary artery → lungs for nutrition → vasoconstriction of lung tissue pushes the blood to DUCTOS VENOSUS → supply extremities → 2 arteries carry unO2 Blood back → placenta Ways to facilitate closure of Foramen Ovale • Tangential Footslap o Cry → expands lung → ↑ pressure from left to right side of the heart • Proper positioning of the Baby o Right side lying position → ↑ pressure on left side of heart facilitating closure Best Position immediately after Birth • CS → supine, crib – level position • NSD Structure Foramen Ovale Ductus Arteriosus Ductus Venosus Umbilical Appropriate Time of Obliteration 1 year 1 month 2 2 – 3 month Complete Closure W/in 24 hrs completed 1 month W/in 24 hrs completed 1 month 2 – 3 months 2 – 3 months Structure Remaining Fossa Ovalis Ligamentum Arteriosum Ligamentum Venosum Lateral Umbilical Artery Failure to Close Atrial Septal Defect Patent Ductus Arteriosus

ReD Mapalo – BSN

Pediatric Nursing

Arteries Umbilical Vein

2 – 3 months

2 –3 months

(Intrerior Iliac Artery) Ligamentum Teres (Round ligament of the liver)

Signs of Increased ICP • Abnormal large head • Bulged & tensed fontanel • Projectile Vomiting  surest sign of cerebral irritation • Cushing Triad of ↑ ICP o ↑ BP o ↓ PR o ↓ RR • High pitched, shrill cry • Dilopia  normal in newborns, sign of ↑ ICP in older children CONTROL OF BODY TEMPERATURE/ TEMPERATURE REGULATION Alerts! • The goal of temperature regulation is to maintain Temperature not less than 97.7 F or 36.7 C Factors leading to the development of Hypothermia • Preterm are born POIKILOTHERMIC (easily adapt the temperature of environment due to immaturity of thermo regulating center of the body HYPOTHALAMUS) • Inadequate subcutaneous tissues • Newborn are not yet capable of shivering • Newborns are wet Process of Heat Loss • Evaporation → body to air • Conduction → body to solid objects (cold compress) • Convection → body to a cooler surrounding object (fever, aircon) • Radiation → body to a cold subject not in contact with the body (thermal shift) Effects of Hypothermia (COLD STRESS) • ↑ RR → first sign of hypothermia • Hypoglycemia → due to utilization of glucose o Normal  45 – 55 mg/ dl o Average/ borderline → 40 mg/ dl • Metabolic Acidosis → due to the catabolism of BROWN FAT (vest-like, best insulators of newborns) leading to the formation of ketone bodies • High risk for KERNICTERUS (bilirubin in the brain) • Additional fatigue added to already stressful heart Prevention of Cold Stress • Dry and wrap the newborn • Mechanical measures ( radiant warmer, acrylic sided incubator) • Prevent unecesarry exposure→ cover areas not being examined • In case of no electricity o Cover baby with thin foil o Skin to skin contact → human blanket/ kangaroo care ESTABLISHING ADEQUATE NUTRITION Breastfeeding Best time • NSD – ASAP

ReD Mapalo – BSN

Pediatric Nursing

•

CS – after 4 hours

Physiology of Breastmilk Production ↓ Estrogen, ↑ Progesterone → releases PROLACTIN → acts on ACINAR/ ALVEOLI CELLS → produces FOREMILK → store in LACTIFEROUS TUBULES/ COLLECTING TUBULES Sucking → stimulates posterior pituitary gland → release oxytocin → causes Contraction of smooth muscles of Lactiferous Tubules → milk ejection reflex → let down reflex Advantages of Breastfeeding • Economical • Promotes bonding • Contains LACTOBACILLUS BIFIDUS → interfere the attack of pathogenic bacteria in the GIT • Helps in early involution of uterus → oxytocin causes contraction • Always available • ↓ Incidence of breast cancer • Breastfed babies have higher IQ than bottle fed ones • Antibody → IgA • Macrophages Disadvantages of Breastfeeding • No iron • Possibility of transfer of Hepa B, HIV, CMV (13 – 39% possibility) • Father can’t bond with the mother and baby → instead, father can sing, suddle, kiss, put baby to sleep Alerts!

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Freezer → good for 6 mos./ don’t reheat Should be stored in a sterile plastic container Pre – Colostrums → 6 weeks Colostrums → 3

Stages of Breastmilk • COLOSTRUM o Present 2 – 4 days o Contents  ↓ fats  ↓ CHO  ↑ Immunoglobulin  ↑ protein  ↑ fat soluble vitamin  ↑ minerals • TRANSITIONAL MILK o Present 4 – 14 days o Contents  ↑ Lactose  ↑ minerals  ↑ water soluble vitamins o Lactose Intolerance → deficiency in enzyme  Lactase → responsible for digestion of Lactose →sour milk/ smelling of stool • MATURE MILK o Present 14 days and above o Contents  Linoleic Acid → responsible for the development of brain and integrity of skin

ReD Mapalo – BSN

Pediatric Nursing

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↑ CHO (Lactose) Protein (lactabulmin)

COWS MILK • ↑ fats – almost similar to mature milk • Causes constipation • Content o ↑ fats o ↓ CHO → add sugar o ↑ CHON → casein → hard to digest o ↑ Minerals (has traumatic effect to kidneys of babies) o ↑ PHOSPHORUS ( causes inversely proportional effect of Calcium • ↑ water to prevent kidney stones Health Teachings 1. Proper Hygiene • Hand washing, clean areola with cotton and water or NSS • Cleanse the area with CAKE COLOSTRUM 2. Position while Breastfeeding • Upright Sitting (best position) 3. Stimulate and Evaluate Feeding Reflexes • Rooting Reflexes o Stimulate by touching the side of the cheek or side of flip then the baby will turn to the syimulus o Purpose: to look for food o Disappear by 6th weeks • Sucking Reflexes o Stimulate the middle part of the lips and the baby will suck o Disappear by 6 months • Swallowing Reflexes o When the food touches the posterior part of the tongue, the baby will automatically swallow o Never disappears • Extrusion Reflexes o When food touches anterior part of tounge, it will extrude/ protrude o Purpose: prevent poisoning o Disappears @ 4 moths 4. Criteria for effective sucking • Baby’s mouth is hiked well – up @ areola • Mother experiences after pain → sign of releasing oxytocin thereby contracting uterus • The other nipple is also flowing with milk 5. To prevent from crack nipples and initiate proper production of oxytocin • Begin initially for 2 – 3 mins/ breast • ↑ the time 1 min/ breast/ day until it reaches 10 minutes/ breast/ feeding or 20 min/ feeding 6. For proper emptying and continuous milk production per feeding • Feed the baby at the last breast that you fed him/ her Problems experience in Breastfeeding • ENGORGEMENT o Feeling of fullness and tension in the breast (3rd Day) o Breastfeeding mother → apply warm compress o Bottle – Feeding → apply cold compress, wear supportive bra • SORE NIPPLE/ CRACK NIPPLE o Crack, red, painful nipple o Causes

ReD Mapalo – BSN

Pediatric Nursing

o

 Breastfeeding @ one side only  Unhealthy sexual practices Management  Breastfed using the unaffected side  Manually express milk @ affected side  Antibiotic (continue breastfeeding)

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MASTITIS o Inflammation of breast o Causative Agent: STAPHYLOCOCCUS AUREUS o Management  Avoid wearing lined/ wired bra o 4 weeks – Breast Involution

Contraindications for Breastfeeding • Maternal Conditions o HIV o Hepa B o CMV o Coumadin/ Warfarin taking moms → give heparin instead • Newborn Conditions o Erythroblastocis Fetalis o Inborn errors of metabolism  Hydrofetalis  Phenylketonuria  Galactosemia  Tay- Sach’s Diseas ESTABLISHMENT OF WASTE ELIMINATION GIT Obstructions • Hirshsprung Disease • Imperforate Anus • Meconium Ileus (common with Cystic Fibrosis) Different Stools • MECONIUM/ PHYSIOLOGIC STOOL o Blackish green o Odorless (sterile intestine) o Normally passed within 24 hours o Tar like o Sticky • TRANSITIONAL STOOL o Present 4 – 14 days o Green o Loose o Slimy that may appear like diarrhea to the untrained eyes BREASTFED STOOL o Golden yellow o Occur almost nearly after feeding o With sour milk smell o Mushy o Soft BOTTLEFED STOOL o Pale yellow

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ReD Mapalo – BSN

Pediatric Nursing

o Hard → due to casein
o o o Formed Typically offensive odor Seldom passed 2 – 3 days INDICATION OF STOOL CHANGES Light Stool With jaundice Bright Green Under phototherapy Mucus –mixed Milk Allergy Clay Colored Bile Duct Obstruction Black GIT Hemorrhage Blood – Flecked Anal Fissure Curant Jelly Intussuception Fatty, bulky, foul Suspect malabsorption smelling/ Steatorrhea syndrome/ Cystic Fibrosis/ Celiac Disease Ribbon – like Hirshsprung disease

ASSESSMENT OF WELL BEING Apgar Scoring Virginia Apgar Special Consideration • 1st 1 minute → determines general coneral condition of the baby • Next 5 Minute → determines the capability of the baby to adjust extrauterinely (most important) • Next 15 minutes → optional → depndent on the 5 minutes apgar score Components A ppearance P ulse Rate G rimace A ctivity R espiration Color upon birth is slightly cyanotic After first cry baby will be pink Take apical pulse at the lower left nipple Determines reflex irritability using tangential foot slap and catheter insertion To determine the degree of muscle tone

Newborns will cry within 30 seconds upon expulsion ASPHYXIA NEONATORUM → failure to cry within 30 seconds because mother received Demerol NARCAN → antidote of Demerol APGAR SCORING Criteria 0 Heart Rate Absent Respiratory Effort Absent Muscle Tone Flaccid Extremities Reflex Irritability Catheter No Response Tangential FS No Response Color Blue / Pale • High score means healthy baby Interpretation 0-3 • Severely depressed • Needs CPR • Admission at NICU 4-6 Score 1 < 100 Slow RR/ Weak Some reflexes Grimace Grimace Acrocyanosis 2 > 100 Good strong cry Well Flexed Cough or sneeze Cry Pink

ReD Mapalo – BSN

Pediatric Nursing

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Moderate depression Additional suctioning

7 – 10 • Good and healthy CARDIOPULMONARY RESUSCITATION • CPCR → cardiopulmonary and cerebral resuscitation • 5 minutes of 02 deprivation will cause irreversible brain damage • Priority: Airway, Breathing, Circulation AIRWAY • Clear the airway • Shake the baby • If no response, call help • Immediately do 1 minute CPR before calling for help • Flat on bed, put a board if the bed is soft • Head tilt – chin lift maneuver • No head tilt for suspect of cervical damage • Overextension may cause occlusion BREATHING • Ventilating the lungs • Check breathlessness • If breathless → give 2 breaths • If newborn → mouth and nose • If child → mouth and pinch the nose • Force → puff only • Use one way mask to prevent contact with the secretion CIRCULATION • By cardiac compression • Check if pulseless • Use brachial pulse → children • No breath + No pulse → CPR • Infant → 1 finger breadth below nipple line, 2 finger • 1 year old → heal of the palm CPR RATIO Adult → 2:15 Infant → 1:5 REPIRATORY EVALUATION (SILVERMAN – ANDERSON INDEX) Criteria Chest movement Intercoastal retraction Xiphoid Retraction Nares dilatation Expiratory Grunt 0 Synchronized No retraction No retraction No dilatation None Score 1 Long on inspiration Just visible Just visible Minimal Heard by stet only 2 See-saw Marked Marked Marked Heard by ear

Low score means Good condition of the baby Interpretation 0 – 3 → normal, no RDS 4 – 6 → with moderate RDS 7 – 10 → with severe RDS ASSESSMENT OF GESTATIONAL AGE (Ballard and Dubowitz)

ReD Mapalo – BSN

Pediatric Nursing

Criteria Sole creases Breast nodule (dm) Scalp Hair Ear Lobe Testes and Scrotom

Less 36 weeks Anterior transverse only 2 mm Fine and fuzzy Pliable In lower canal, covered testes with rugae

Score 37 – 38 Weeks Occasional 2/3 4 mm (3 – 5 cm) Fine and fuzzy Some Some intermediate

39 weeks and up Sole cover with crease 7 mm (>5cm) Course and silky Thick Testes pendulous, scrotum full, extensive rugae

PRETERM BABIES • babies delivered after 20 weeks and before 37 weeks • sign of preterm – less 36 weeks according to Ballatrd and Dubowitz • plus frog legs or lax position • Hypotonic – prone to repiratory infection • There is a Scarf Sign → elbow passes midline • Square window – wrist 90 deg. Angle • Heal to ear sign • Anterior traverse crease • Abundant lanugo • Prominent labia minora and clitoris POST TERM BABIES • Delivered after 42 weeks • Old mans face – classic sign • Desquamation – pealing of skin • Long and brittle fingernails • Wide and alert eyes NEONATES IN THE NURSERY Nursing Responsibilities upon Receiving the Baby 1. Proper identification o Foot print of the baby and the thumb mark of the mother 2. Take anthropometrics measurement o Length  19. 5 – 21 inches Ave: 20 inches  47.5 – 53 cm Ave: 50 cm. o Head Circumference  13 – 14 inches  33 – 35 cm Ave: 34 cm o Chest Circumference  12 – 13 inches  31 – 33 cm Ave: 32 cm o Abdominal Circumference  12 – 13 inches  31 – 33 inches Ave: 32 cm 3. Bathing the baby o Give oil Bath  To cleanse the baby and spread the vernix caseosa  2 functions of vernix caseosa • insulator • bacteriostatic o Full bath is given when cord falls off o Babies of HIV + mothers will be given a full bath immediately after the birth to lessen the transmission of HIV 4. Dressing the Umbilical Cord

ReD Mapalo – BSN

Pediatric Nursing

Strict asepsis to prevent tetanus neonatorum that is why mothers are given tetanus toxoid while pregnant  CHN – 3 Cleans • Hand • Surface • Cord o Betadine (Povidone Iodine)  Check 3 vessels (AVA)  If only 2 vessels is seen suspect that the baby has a kidney malformation  1 inch above the base of the cord when cutting  But if IV infusion or blood transfusion is going to be given to the newborn, leave at least 8 inches of the umbilical cord  Umbilical cord is the best site for IV and blood transfusion because it has no nerve and no pain  OMPHALAGIA → bleeding of the cord for more than 30 cc, suspect hemophilia  The umbilical cord turns black by the 3rd day and falls of 7 – 10th day  UMBILICAL GRANULATION → failure of the cord to fall after 2 weeks without foul odor, bring the baby to the hospital and will be given Silver Nitrate or will be cauterized  Clean the umbilical cord with saline or 70% alcohol  It should be dry  PATENT URACHUS → itf the cord is always moist, suspect a fistula between the bladder and the umbilicus, do NITRAZINE PAPER TEST (+ for urine if it turns yellow) 5. Crede’s Prophylaxis o Purpose: to prevent opthalmia neonatorum or gonnorheal conjeunctivitis o If mother has an untreated gonorrhea and passed the baby vaginally o ERYTHROMYCIN OPTHALMIC OINTMENT → drug of choice, inner to outer canthus o Before 1989 – 2 drops of 2% silver nitrate at lower conujunctival sac o It should be washed immediately after 1 minute to prevent burning 6. Administration of Vitamin K o Purpose: to prevent hemorrhage related o physiologic hypoprothrobinemia o Other name  Aquamephyton, Phytomenadone, Konakion  0.5 – 10.5 mg IM @ vastus lateralis or lateral anterior thigh o Preterm → give 0.5 mg o Vit. K is synthesized at the intestine o On the 7th day, there is ↑ prothrombin 7. Weight Taking o Normal Weight  3000 – 3400 gm  3 – 3.4 kg  6.5 – 7.5 lbs o Arbitrary Lowe Limit → 2,500 grams o Low Birth Weight  < 2,500 g  it is not the same for gestational age o Small for Gestational Age  Less than the 10th % rank o Large for Gestational Age  > 90% rank  Macrosomia – baby delivered 4,000 g or 4 kilos  Diabetic mother o Appropriate for Gestational Age o Physiologic Weight Loss o

ReD Mapalo – BSN

Pediatric Nursing



5 – 10% physiologic weight loss 10th days after birth

PHYSICAL EXAMINATION AND DEVIATION FROM THE NORMAL Important Consideration • If the client is a newborn, cover areas that is not being examined (prevent hypothermia) • If the client is an infant, he first vital sign to take is the RR because of fear of stranger will change the normal respiration. Begin from at least intrusive to the most intrusive procedure. • If the client is a toddler and preschooler, le them handle the instruments like stethoscope or play syringe. If the client has security blanket (like stuffed toy) give it to them to lessen anxiety • If the client is a school age and adolescent, explain the procedure and respect their modesty Components • Temperature o Temperature of the newborn is taken rectally o Rectal temperature taking is done only once to rule out imperforated anus o Insert thermometer 1 inch inside the anus Types of Imperforated Anus  No Anal Openning • AtreticAgenetice o These two is the most dangerous because there is failure to pass meconium after 24 hours o There is abdominal distention o Foul odor breath o Vomitus of fecal material which might result in aspiration and casue respiratory problems o Management: Surgery with temporary colostomy  With anal openning • Stenos • Membranous Cardiac Rate o Newborn → 120 – 160 bpm irregular o Radial pulse of a newborn is normally absent o If radial pulse is prominent suspect that there is a PDA o Femoral pulse is normally palpable, if absent suspect Coarctation of Aorta o

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CONGENITAL HEART DISEASE • Common in Boys o Transposition of the great artery (TOGA) o Truncus Arteriosus o Tetralogy of Fallot • Common in Girls o Patent Ductus Arteriosus o Atrio Septal Defect Causes o Familial tendency o Exposure to rubella/ German measles – 1st month o Failure of the Heart Structure to progress

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Two Major Types • Acyanotic Heart Defects  shunting from left to right • Cyanotic Heart Defects  from right to left

ReD Mapalo – BSN

Pediatric Nursing

Acyanotic Heart Defects with Increase Pulmonary Blood Flow 1. Vetricular Septal Defect • Opening Between 2 ventricles • Signs and symptoms o Systolic murmur at lower border of the sternum and no other significant sign o Cardiac catheterization reveals increase oxygen saturation at the right side of the heart o ECG reveals hypertrophy of the right side of the heart o Only 50% of the oxygenated blood will go to the aorta • Management o Open heart surgery o Placing the client on a long tern antibiotic therapy to prevent the development of sub-acute bacterial endocarditis o Protect site of catheterization (right femoral vein) o Avoid flexion of joints 2. Atrial Septal Defect • Failure of the foramen ovale to close • Signs and symptoms o Systolic murmur at the upper border of the sternum with no significant sign o Cardiac catheterization reveals increase oxygen saturation at the right side of the heart o 50% of the blood goes to the right atrium • Management o Open heart surgery o Placing the client on a long tern antibiotic therapy to prevent the development of sub-acute bacterial endocarditis 3. Endocardial Cushion Defect • AV canal affecting both the tricuspid and the mitral valve • Signs and symptoms o Only confirmed by cardiaccatheterization o Valves are closed 4. Patent Ductus Arteriosus • Failure of the Ductus Arteriosus to close • Signs and symptoms o Prominent radial pulse o Continuous machinery like murmur o ECG reveals hypertrophy of the left ventricle • Management o Indomethacine – prostaglandin inhibitor that facilitate closure of PDA o Ligation of PDA by 2 – 4 years old Acyanotic Heart Defects with Decrease Pulmonary Blood Flow 1. Pulmonary Stenosis • Narrowing of valve of pulmonary artery • Signs and symptoms o Typical systolic ejection murmur o S2 sound is widely split o ECG reveals right ventricular hypertrophy o Only 50% of the blood goes to the lungs • Management o Balloon Stenotomy

ReD Mapalo – BSN

Pediatric Nursing

2. Aortic Stenosis • Narrowing of valve of aorta • Signs and symptoms o Typical systolic ejection murmur o Murmur o ECG reveals right ventricular hypertrophy o Only 50% of the blood goes to the body o Angina like symptoms may be present when active • Management o Balloon stenotomy 3. Duplication of Aortic Arch • Doubling of arch of the aorta causing compression to the trachea and esophagus • Signs and symptoms o Dysphagia – due to esophageal compression o Dyspnea – due to tracheal compression o Left ventricular hypertrophy o Only 50% of the blood goes to the body • Management o Close heart surgery 4. Coarctation of Aorta • Narrowing of ach of aorta • Outstanding signs o Absent femoral pulse o BP is higher on the upper extremities and ↓ on the lower extremities o Epistaxis o Lesser blood goes to the lower extremities • Management o Take BP on 4 extremities o Close hear surgery Cyanotic Heart Defects with Increase Pulmonary Blood Flow 1. Transposition of Great Arteries • Aorta is arising from the right ventricle while the pulmonary artery is arising from the left • Signs and symptoms o Cyanosis after 1st cry o Polycythemia because of increase production of RBC, a compensatory mechanism to the ↓ oxygen supply to the body, the blood become viscous o Polycythemia will lead to:  Thrombuis  Embolus  Stroke (CVA) o ECG reveals Cardiomegaly • Management o Palliative repair – Rash Kind repair o Complete repair – Mustard repair 2. Total Anomalous Pulmonary Venous Return • Situation wherein pulmonary vein instead of entering the left atrium enters the right atrium or superior vena cava • Signs and symptoms

ReD Mapalo – BSN

Pediatric Nursing

•

o Open foramen ovale o Mild – moderate cyanosis o Absent spleen Management o Restructuring of the heart

3. Truncus Arteriosus • Situation in which pulmonary artery and aorta is arising in one common trunk or a single vessel with ventricular septal defect • Signs and symptoms o Cyanosis after 1st cry o Polycythemia because of increase production of RBC, a compensatory mechanism to the ↓ oxygen supply to the body, the blood become viscous o Polycythemia will lead to:  Thrombuis  Embolus  Stroke (CVA) • Management o Restructuring the heart 4. Hypoplastic Left Heart Syndrome • Non functioning left ventricle • Signs and symptoms o Cyanosis after 1st cry o Polycythemia because of increase production of RBC, a compensatory mechanism to the ↓ oxygen supply to the body, the blood become viscous o Polycythemia will lead to:  Thrombuis  Embolus  Stroke (CVA) • Management o Heart transplant Cyanotic Heart Defects with Decrease Pulmonary Blood Flow 1. Tricuspid Atresia • Failure of the tricuspid valve to open • Signs and symptoms o Open foramen ovale o Cyanosis o Polycythemia because of increase production of RBC, a compensatory mechanism to the ↓ oxygen supply to the body, the blood become viscous o Polycythemia will lead to:  Thrombuis  Embolus  Stroke (CVA) • Management o Fontan Proledum 2. Tetralogy of Fallot • 4 Anomalies Present (PVOR) o Pulmonary Stenosis o Ventricular Septal Defect o Overriding of Aorta o Right Ventricular Hypertrophy

ReD Mapalo – BSN

Pediatric Nursing

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Signs and symptoms o High degree of Cyanosis  outstanding Sign o Polycythemia because of increase production of RBC, a compensatory mechanism to the ↓ oxygen supply to the body, the blood become viscous o Polycythemia will lead to:  Thrombuis  Embolus  Stroke (CVA) o Severe dyspnea  relieved by squatting position because it will prevent venous return and facilitate maximum lung expansion  Knee chest position in infants o There is growth retardation o TET Spells – blue spells or short episode of hypoxia o Syncope – faintaing o Mental retardation o Clubbing in fingernails because of tissue hypoxia – late and last sign o X – ray reveal a boot shape heart Management o Oxygen therapy o Morphine sulfate – for hypoxic episode o Propanolol (inderal) – decrease heart spasm o Palliative repair – BLT or Blalock Taussig Shunt Procedure o Complete repair – Brock Procedure

ACQUIRED HEART DISEASE Rheumatic Heart Disease • Inflammatory disease following an infection caused by Group A Beta Hemoilytic Streptococcus • Affected body parts o Musculoskeletal o Cardiac muscle o Integumentary system o CNS • Tonsillitis due to love of sweets with no oral hygiene serving a good medium for bacterial growth causing inflammation • Group A Beta Hemolytic Streptococcus will release toxin and enters circulation • Group A Beta Hemolytic Streptococcus is an anaerobic organism and will stay at the left side of the heart or the mitral valve as an ASCHOFF BODIES • ASCHOFF BODIES – round nodules with multi nucleated cell and fibroblast that stays in the miral valve • Left sided heart failure because of mitral stenosis due to increase in the size of Aschoff Bodies • Diagnostic Exam: JONE’S CRITERIA Major Minor Polyarthritis – multi joint pain Low grade fever Athralgia – joint pain Diagnostic Exams CHOREA/ Sydenhamm’s Chorea/ • Antibody St. Vitous Dance – involuntary, • C reactive protein purposeless movement of the hand • ESR and shoulder accompanied by • Anti Streptolysin Titer grimacing Carditis – signs of tachycardia Erythema Marginatum – macular rashes Subcutaneous nodules

ReD Mapalo – BSN

Pediatric Nursing

Presence of 2 major or 1 major and 2 minor plus a history of sore throat will confirm diagnosis • Management o Bed rest o Avoid contact sports o Throat swab for C & S o Antibiotics – purpose is to prevent recurrence o Aspirin Therapy or salicylates – act as an anti-inflammatory agent in RHD o Side effect: Reye’s Syndrome  encephalopathy accompanied by fatty infiltration of the organs such as the heart and liver

RESPIRATION • Normal Values = 30 – 60 bpm irregular • Either abdominal or diaphragmatic breathing with short period of apnea without cyanosis • Normal apnea in newborn is 15 seconds or less Age Newborn 1 year old 2 – 3 years old 5 years old 10 years old 15 and above Rate 40 – 90 20 – 40 20 – 30 20 – 25 18 – 22 12 – 20

Vesicular Normal Bronshovesicular Normal Bronchial Normal Ronchi Normal Rales Abnormal Wheezing Abnormal Stridor

Breath Sounds Heard on Auscultation • Soft, low pitched, heard over periphery of lungs, aspiration is longer than expiration • Soft, medium pitched heard over major bronchi, inspiration equals expiration • Loud, high pitched, heard over the trachea, expiration is longer than inspiration • Snoring sound made by air moving through mucus in bronchi • Crackles (like Celophane) made by air moving through fluid in alveoli • Denotes pneumonia, fluid in the lungs or pulmonary edema • Whistling on expiration made by air being pushed through narrowed bronchi • Denotes children with asthma or foreign body airway obstruction • Crowing or roster like sound made by air being pulled through a constricted larynx • Indicative of Respiratory Obstruction • Loud, low tone, percussion sound over normal lung tissue • Louder, lower sound than resonance, percussion sound over hyperinflated lung tissue

Resonace Hyper Resonance

1. RESPIRATORY DISTRESS SYNDROME • Lack of surfactant within 24 hours of life • Aka Hyalin Membrane Disease • Common in preterm babies • The alveoli cannot expand properly • Signs and symptoms o Present within 4 hours of life o Using the Silverman Anderson Scoring to determine RDS o ↑ RR with retraction (1st sign of RDS) o Expiratory Grunting (major sign) o Xiphoid retraction

ReD Mapalo – BSN

Pediatric Nursing

o Flaring nasal flares o Cyanosis o Respiratory acidosis • Management o Head elevated o Proper suctioning o O2 administration with ↑ humidity o Client placed on  CPAP Continuous Positive Airway Pressure  PEEP Positive End Expiratory Pressure  Purpose id to maintain the alveoli partially open and prevent alveolar collapse o Monitor for acidosis o Surfactant replacement 2. LARYNGOTRACHEO BRONCHITIS (LTB) • Most common form of croup • Viral infection of the larynx, trachea and bronchi • Signs and symptoms o BARKING or CROUPY COUGH  outstanding sign o Inspiratory Stridor o Respiratory acidosis o Cyanosis o Death • Diagnostic Exams o Throat swab for c & s o ABG o Chest and x-ray to ruyle out epiglotitis • Management o Racemic Epinephrine – bronchodilator o Humidified Oxygen 3. BRONCHIOLITIS • Inflammation of the bronchioles characterized by production of tenacious mucus • FLU – LIKE SYMPTOMS – outstanding sign • ↑ RR • Causative Agent: Respiratory Syncitial Virus • Drug: Antiviral – Ribavirin LTB and Bronchiolitis ends with Epiglotitis 4. EPIGLOTITIS • Inflammation of the epiglotitis • Sudden onset • The child always assume the tripod position • Less than 18 months cannot cough – must be placed on mist tent or “Croup tie” – make sure that the edges are tucked in o Provide washable plastic toys or materials o Avoid toys that crate friction o Avoid toys that are hairy or furry Blood Pressure • Newborn – 80 – 46 mmHg • After 10 days – 100/ 50 mmHg • BP taking begins by 3 years old

ReD Mapalo – BSN

Pediatric Nursing

SKIN • If cyanotic after the first cry suspect Transposition of the Great Arteries 2. Generalized Mottling due to the immaturity of the circulatory system 3. Birthmarks a. Mongolian Spots • Slate grya or bluish discoloration/ patches commonly seen across the sacrum or buttock • Related to ↑ melanocyte which is common in Asian newborn • Usually disappear by 1 – 5 years old (preschool) b. Milia • Plugged or unopened sebaceous glands usually seen as a white pinpoint patches at the nose, chin and cheeks and will disappear by 2 – 4 weeks c. Lanugu • Fine downy hair which is common in preterm d. Desquamation • Peeling of the newborn’s skin within 24 hours characterized by extreme dryness that begin in the sole and palm, common in post term babies e. Stork Bites (Talengeiclasis Nevi) • Pink patches at the nape, never disappears f. Erythema Toxicum (Flea Bite Rash) • First self limiting rash to appear sporadically and unpredictably as to time and place g. Harlequin Sign • Dependent part is pink, independent part is blue because of the immaturity of circulation, the RBC settles down h. Cutis Memorata • Transitory motlling of the neonates skin when exposed to cold i. Hemangiomas • Vascular tumors of the skin • Types: o Nevus Flammeus/ Port Wine Stain  Macular purple or dark red lesions usually seen on the face or thigh, disappears and be removed surgically o Nevus Vasculosus/ Strawberry Hemangioma  Dilated capillary in the entire dermal or subdermal area continuing to enlarge but disappear after 10 years old o Cavenous Hemangiomas  Consist of communicating network of venules in the subcutaneous tissue that never disappear with age j. Vernix Caseosa White cream cheese – like substance that serves as skin lubricant SKIN COLOR AND THEIR SIGNIFICANCE 1. Blue  cyanosis , hypoxia 2. White  edema 3. Gray  infection 4. Yellow  jaundice or carotinemia 5. Pale  anemia Burn Trauma • 1st Degree Injury to body tissues caused by excessive heat Characteristic Involves only the superficial epidermis characterized by erethema,

1. Acrocyanosis → body is pink, extremities are blue

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ReD Mapalo – BSN

Pediatric Nursing

Partial Thickness 2nd Degree Partial Thickness 3rd Degree Full Thickness

dryness and pain Ex: Sunburn – heals by regeneration in 1 – 10 weeks Involves the entire epidermis, and portion of the dermis, characterized by erythema, blistered and moist from exudates which is extremely painful Ex: Scalds Involves skin layers, epidermis and dermis, may involve adipose tissue, fascia, muscle and bone. It appears to be leathery, white or black, not sensitive to pain since nerve ending had been destroyed Ex: Lava Burn

Management: •

First Aid Put out the flames by rolling the child on a blanket Immerse the burned part on cold water Removed burned clothing (sterile material) Cover burned part with sterile dressing • Maintainance of patent airway o Suction PRN o O2 administration with ↑ humidity o Endotracheal Intubation o Tracheostomy • Prevention of shock and flued and electrolyte imbalances Colloids to expand blood volume Isotonic saline to replace electrolyte Dextrose in water to provide calories • Booster dose of Tetanus Toxoid • Relief pain such as IV analgesic (morphine sulfate) • Prevention of wound infection Cleaning and debriding the wound Open or close method of wound care Whirl pool therapy • Skin grafting 3rd degree burn get skin from buttocks or pig skin (xenograft) or from frozen cadaver • Diet  ↑ CHON and calories o o o o Atopic Dermatitis • Skin disease characterized by papulo-vesicular eruthematous lesions with weeping and crusting • Usually caused by food allergen o Milk o Eggs o Citrus Juice o Tomatoes o Wheat Signs and symptoms o Extremely pruritus – outstanding sign o Linear excoriation o Crusty o Lichenification  dry and shinny, scaly white skin • Management o Avoid allergens o Prosobes/ Isomil – hypoallergenic milk o Prevent infection by proper handwashing, cut the fingernails o Hydrate with a burrows solution o Topical steroid – 1% hydrocortisone cream

ReD Mapalo – BSN

Pediatric Nursing

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Impetigo • Skin disease caused by Group A Beta Hemolytic Sreptococcuscharacterized by papulovesicular lesions surrounded by localized erythema becoming purulent and ooze forming honey colored crust Before the development, the baby should always been exposed to Pediculosis Capitis (kuto) Management o Proper handwashing o Treated with antibiotic • Complication: AGN

Acne • Self limiting inflammatory disease involving sebaceous gland, common in adolescents • Comadones – composed o sebum that is mainly causing white heads • Sebum – composed of lipids • Management o Proper handwashing wild mild soap (sulfur soap) and water, leave for 5 – 10 minutes or use tretenoin or Retin A – anti acne Anemia/ Pallor • Caused by o Early cutting of the cord o Bleeding disorders/ blood dyscarias BLEEDING DISORDERS/ BLOOD DYSCARIAS Hemophilia • Sex – linked (X) Recessive disorders • The mother is the carrier • The son is affected • The father transmits to daughter • Deficiency in clotting factor o Hemophilia A  factor 8  classic hemophilia o Hemophilia B  Factor 9  Christmas disease o Hemophilia C  Factor 11 • OMPHALAGIA  earliest sign o >300 cc loss of blood during cutting of the cord • the maternal clotting factor is present in the new born that is why there is a delayed diagnosis of hemophilia • in toddlers  sudden bruising • HEMARTHROSIS  major sign repeated bleeding, bleeding of the synovial membrane • Diagnostic exam: PTT • Nursing Diagnosis: High Risk for Injury • Goal: Prevention of injury • Health Teaching o Avoid contact sports o Determine the case before doing any invasive procedure  In immunization  change the needle into a smaller one o In case of fracture/ injury  Immobilize and elevate o Cold compress o Gentle pressure o Blood transfusion of cryoprecipitate Leukemia • Group of malignant disease characterized by rapid proliferation of immature RBC

ReD Mapalo – BSN

Pediatric Nursing

• Ratio is 500 RBC : 1 WBC • The client is immunocompromised • Classification of Leukemia o Lympho – affects the lymphatic system o Myelo – affects the bone marrow o Acute/ Blastic – affects the immature cells o Chronic/ cystic – affects the mature cells Acute Lymphocytic Leukemia • Most common in children • Increase immature WBC • Signs and Symptoms a. Infection i. Fever ii. Poor wound healing b. Bone weakness and causes fractures c. Signs of bleeding i. Blood in the urine ii. Emesis iii. Petechiae iv. Epistaxis d. Signs of anemia i. Pallor ii. Body malaise iii. constipation e. Invasion of the organs i. Hepatomegaly  abdominal pain ii. Spleenomegaly 2. Diagnostic examinations a. Peripheral Blood Smear  reveals immature WBC b. CBC  reveals anemia and thrombocytopenia; neutropenia c. Lumbar Puncture i. To determine CNS involvement ii. Fetal position without flexion of the neck because it will cause airway obstruction iii. C position or shrimp position d. Bone Marrow Aspiration i. Determines the presence of blast cells ii. Site of bone marrow aspiration  iliac Crest  post op : prevent hemorrhage iii. Lie on affected site e. Bone Scan  determines the degree of bone involvement f. CT Scan  determine the degree of organ involvement 3. Management Triad a. Surgery b. Irradiation c. Chemotherapy d. Bone marrow transplant 4. 4 Levels of Chemotherapy a. Induction i. To achieve remission ii. Drugs IV – Vincristine L – Asparagine Oral Prednisone b. Sanctuary i. To treat the leukemic cells that has invaded the testes and CNS ii. Drugs intrathecal methotrexate – via spine cytocine

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ReD Mapalo – BSN

Pediatric Nursing

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arabinase steroids irradiation c. Maintainance i. To continue remission ii. Drugs oral methotrexate oral 6-mecaptopurine cytarabine d. Reinduction i. Give anti-gout agent To ii. To treat leukemic cells after relapse occurse iii. Treat hyperurecemic neuropathy Alopurinol or zylo[rene 5. Nursing Management a. Assess for common side effects of chemotherapy – nausea and vomiting b. Assess for stomatitis ulceration and abcess of oral mucosa i. Oral care ii. Alcohol free mouthwash iii. Cotton piedgets c. Diet – give food acoording to child’s preference d. Alopecia – temporary side effect of chemotherapy HEMOLYTIC DISORDERS Rh Incompatibility • Rh = monkey  foreign body • Mother (-) – no antigen; no protein factor • Fetus (+), Father (+) – has antigen and protein factor • 4th baby is severely affected • Erythroblastocis Fetalis o hemolysis/ destruction of RBC leading to ↓ O2 carrying capacity leading to IUGR with pathologic jaundice w/in 24 hours • ALERT! Baby is small and yellowish • Management o RHOGAM  Vaccine given to Rh(-) mothers within the first 24 hours or within 72 hours  Given once  If pregnancy was aborted and the mother udergo D & C, RHOGAM must be given w/in 24 hours, if not given within 24 hours, mother will produce antibody  Action: destroys RBC preventing antibody formation • Diagnostic Test  Coomb’s Test

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ABO Incompatibility Mother – Type O; Fetus – Type A  most common Mother – Type O; Fetus – Type B  most severe Hydrops Fetalis Common in abo incompatibility o Newborn is edematous, on lethal state, accompanied by pathologic jaundice w/in 24 hours • Difference from Rh Incompatibility o First pregnancy is affected o NB is yellow and edematous • Management o Initiation of breastfeeding, then temporary suspension of breastfeeding after 4 days ( breastfeeding realeses prenanediole causing kernicterus)

ReD Mapalo – BSN

Pediatric Nursing

o Pregnanediole  delays actions of Glucoonyl transferase ( liver enzyme that
converts indirect bilirubin into direct bilirubin)  Indirect bilirubin     Fat soluble Can’t be excreted by kidneys Causes hyperbilirubenemia causing jaundice Direct Bilirubin  Water soluble  Can be excreted by the kidneys o Use phototherapy o Exchange transfusion for Rh and ABO affectations that tend to casue a continuous decrease in hemoglobin during the first 6 months because the bone marrow fails to produce erythrocytes in reponse to the continuous hemolysis Hyperbilirubenemia • More than 12mg of indirect bilirubin among full terms • Normal Indirect Bilirubin Level: 0 – 3 mg/dl Kernicterus/ Bilirubin Encephalopathy • Irreversible brain damage • > 20 mg/dl of indirect bilirubin among full terms • > 12 mg/ dl of indirect bilirubin among preterm because of immaturity Physiologic Jaundice Normal Within 48 – 72 hours Mx: Expose to early morning sunlight Pathologic Jaundice Within 24 hours Yellow upon birth Possible Rh/ ABO incompatibility Breastfeeding Jaundice Within 6th – 7th day Due to glucoronyl transferase

Assessment of Jaundice • blanching of forehead, nose and sternum • yellow skin, sclera • light stool • dark urine Management • Phototherapy/ Photooxygenation o Nursing Responsibilities  Cover the eyes – prevents retinal damage  Height of light from baby – 18 – 20 inches  Increase Fluid intake  Cover genetalia – prevent priapism ( painful continuous erection  Change position  Avoid lotion and oils  Monitor I&O – best way is to weigh the baby  Monitor VS Bronze Baby Syndrome • Transient bronze discoloration of the skin • Minor side effect of phototherapy HEAD • ¼ of its legth • Structures o sutures o fontanels

ReD Mapalo – BSN

Pediatric Nursing

 anterior/ bregma – 3 x 4 – 12 – 18 mos  posterior/ lambda - 1 x 1 – 2 – 3 mos • Noticeable structures of the Head o Craniotabes  Localized softening of the cranial bone common to first bone chiold due to early lightening  If present in older children; sign of rickets or Vit. D deficiency o Seborrheic dermatitis/ Cradle Cap  Scaling, greasing, appearing salmon – colored patches  Usually seen at the scalp, behind ears and umbilicus  Usually caused by improper hygiene  Management • Application of baby oil the night before shampooing the child o Caput Succedaneum  Edema of the scalp due to prolonged pressure at birth  Present at birth  Crosses the suture line  Disappears 2 – 3 days  Disappears without treatment o Cephalhematoma  Collection of blood due to rupture of capillaries of poriosteal capillaries  Present after 24 hours  Does not cross the suture line  Disappears after 4 – 6 weeks  Disappears without treatment o Hydrocephalus  Excessive accumulation of CSF  Types • Communicating/ extraventricula hydrocephalus • No-communication/ intraventricular hydrocephalus/ obstructive hydrocephalus – caused by tumor  Signs and symproms • Signs of increased ICP o Diplopia – eye deviation @ 6th mos and above o Management  Low semi – fowlers (30 degrees) best position • Frontal bossing 9 prominent forehead) • Sunset eyes • Prominent scalp vein  Therapeutic management • Osmotic Diuretic o Mannitol o Diamox / acetazolamide • Seizure precautions • Surgery – Shunting o AV Shunt - atrioventricular o VP shunt – ventriculoperitonial – most common  Best time to shave the head – just before the surgery – prevent infection  Post VP Shunt management • Position – sidelying on non-operated side ( applicable to all eyes and head surgeries) • Sign of good shunting – sunken fontanel • Sign of blocked shunting – bulging fontanel • Catheter is changed as the child is growing • Child with BP shunt is prone to infection SENSES

ReD Mapalo – BSN

Pediatric Nursing

Sense of Sight Sclera o Normal – light blue o Later Color – dirty white Pupils o Normal – round and adult size o Coloboma – key hole pupils part of the iris is missing o Congenital N Cataract – whiteness/ opacity of the lens Cornea o Normal – round and adult size o Congenital Glaucoma – larger than normal Test for Blindness Age Newborn Can see @ a distance of 10 – 12 inches with visual acuity of 20/200 to 20/ 800 Infant and children 3 years old School age School age – adult Common Test General appearance Check ability to follow object pass midline DOLL’S EYE TEST – done at approximately 10th day GLADELLAR TEST – test for blink reflex, not blinking is a sign of blindness ALLEN’S CARD – test for visual acuity familiar pictures are flashed 20 ft away from the child ISHIARA PLATE – test for color blindness Cover testing test – for strabismus Snellen’s test

RETINOBLASTOMA • malignant tumor of the eye • signs and symptoms o cat’s eye reflex (whitish glow of pupil) o red, painful eye usually accompanied by glaucoma • Management o Surgery  innucleation - removal of the eyeball o Irradiation o Therapy SENSE OF SMELL • Normal nasal membrane - pinkish • Check for sense of smell • Check for nasal flaring Sign of Cocaine User • Ulceration and abscess of nasal mucosa • Absence of hair Epistaxis • Nose bleeding • Management o Position, upright, sitting, head trilted, slightly forward o Gentle pressure o Cold compress o Epinephrine – last resort

SENSE OF HEARING

ReD Mapalo – BSN

Pediatric Nursing

• Normal should be aligned with the outer canthus of the eye • Low Set Ears is a sign of o Kidney malformation • Renal agenesis • Absence of kidney o Chromosomal Abnormalities • Due to advance maternal age - >35y/o • Types o Nondisjunction (uneven divison) • Trisomy 21 • Down Syndrome • Most common type • Extra chromosome 21 • 47xx + 21/ 47xy + 21 • can be related to advance paternal age • signs and symptoms o broad nose o protruding tongue o low- set ears o puppy’s neck o hypotonia prone to URTI o simian crease single traverse line in palm o mental retardation – ranging from educable to institutionalization • Trisomy 18 • Has 3 numbers of 18 chromosomes • Severely cognitively impaire SGA • Low set ears, small jaw, CHD, index finger crosses over the other fingers, rounded soles of feet • Trisomy 13 • Patau’s syndrome • Extra chromosome 13 • Severely cognitively impaired • Signs and symptoms o Microcephaly o Micropthalmia o Cleft-lip and palate o Low-set ears o VSD o Do not survive • Turners • Gonadal Dysgenesia • One functional x chromosome • Short in stature • Neck appear to be webbed and short • COA and kidney problems • Only 1 streak (nonfunctional) gonads • Secondary sex characteristic does not develop except for pubic hair • Lack ovarian function – sterility • Cognitively challenged but mostly normal intelligence • Klinefelter’s syndrome • Males with a XXY chromosome pattern • @ puberty child has poorly developed secondary characteristics and small testes that produces ineffective sperm • boys tend to develop Gynecomastia o Deletion Abnormalities

ReD Mapalo – BSN

Pediatric Nursing

• Cri – du – chat Syndrome • Result of a short arm on chromosome 5 • Cat’s cry • Small head, wide set eyes, downward slant to the palbepral fissure of the eyes • Severe cognitive impairment • Fragile X Syndrome • X linked pattern • One arm of x chromosome is weakened • Most common cause of cognitive impairment in boys • Before puberty, boys typically have maladaptive behavior like hyperactivity and autism • Large head, long face with high forehead, prominent lower jaw, large protruding ears o Translocation abnormalities • Balance translocation Carrier • Unbalanced Translocation Syndrome o Others • Mosaicism • A situation wherein the nondisjunction of chromosome occurs during mitotic cell division after fertilization resulting to different cells contains different numbers of chromosome • Isochromosomes • A situation wherein the chromosome instead of dividing vertically it divides horizontally resulting to chromosomal mismatch Otitis Media Inflammation of the middle ear Common to children due to wider and shorter Eustachian tube Predisposing factors o Bottle propping o Cleft lip/ palate  Signs and symptoms o During otoscopic exam, reveals bulging tympanic membrane o Observe for passage of purulent, foul – smeeling odor discharge  Management o Positioning – sidelying on the affected side o Supportive care  Medical management o Massive dosage of antibiotics o Mucolytics o Ear drops  < 3 y/o – down and back  >3 y/o – up and back o Surgery  Myringectomy – slight incision of tympanic membrane to prevent hearing loss  Side effect – bacterial meningitis MOUTH AND TONGUE • Check for symmetry Bell’s palsy/ Facial Nerve Paralysis • 7th CN injury • usually related to forceps delivery • risk for URTI

ReD Mapalo – BSN

Pediatric Nursing

• Signs and symptoms o Continuous drooling of saliva o Inability to open one eye and close the other • Management o Artificial tear o Self limiting o Refer to PT for rehabilitation TEF/ TEA • No connection between esophagus and stomach • There is a blind pouch • Hydramnios – earliest sign intrauterine • Signs and symptoms o Coughing o Chocking o Cyanosis o Continuous drooling • Management o Emergency surgery Epstein Pearls • White glistening cyst • Usually seen on palate, gum • Related to hypercalcemia Natal Tooth • Tooth at the moment of birth • Related to hypervitaminosis • Management o Manual extraction if rootless Neonatal Tooth • Appearance of tooth within 28 days of life Oral Thrush • White cheese-like, curd like patches • Usually seen in mouth and on toingue • Causative agent  C. Albicans – fungi • Management o Do not remove – can cause wound o Wash with cold, bottled water o Medical – Mycostatin/ Nystatin Kawasaki Disease • Discovered in Korea • Strawberry tongue • Common in asian countries • Criteria for diagnosis o Fever lasting for more than 5 days o Bilateral conjunctivitis o Changes in lips and oral cavity  Dry red fissure lips  Strawberry tongue  Diffuse erythema of mucos membrane o Changes in the peripheral extremities  Erythema on the palms and soles  Erythema on the hands and feet

ReD Mapalo – BSN

Pediatric Nursing

 Membranous desquamation from fingertips o Polymorphous rash (primarily at trunk) o Acute non purulent sweeling of the cervical lymph nodes to > 1.5 cm in diameter • Drug of Choice : ASPIRIN Cleft Lip • Failure of the median maxillary nasal process to fuse • Common to boys • Surgery – cheiloplasty o Done w/in 1 – 3 months o To save sucking reflex • Signs and symptoms o Evident at birth o Milk from nostrils spills o Cold is common o Frequent URTI and otitis media • Post cheilo – sidelying • Nutrition – use rubber tip syringe Cleft Palate • Failure of the palate to fuse • Common to girls • Surgery – Uranoplasty o Done w/in 4 – 6 months o To save speech • Signs and symptoms o Evident at birth o Milk from nostrils spills o Cold is common o Frequent URTI and otitis media • Post cheilo – prone • Nutrition – use paper cup/ plastic cup/ soup spoon Condition to consider for suspension of operation • If child has a cold/ nasopharyngitis – may lead to general septicemia General management • Maintainance of patent airway • Proper nutrition o NPO 4 hours post op o Clear liquid  Popsicle except red and brown in color  Flavore gelatin  No ice cream • Observe for bleeding o Frequent swallowing • Protect suture lines specially LOGAN BAR o Clean using hydrogen peroxide, bubbles traps microorganism, more bubbles more microorganism trapped o Prevent crying by attending to needs Therapeutic Management • Emotional support • Proper Nutrition • Cleft lip nipple (long tip, made by silicon) • Prevent Colic

ReD Mapalo – BSN

Pediatric Nursing

o Burp frequently o One at the middle of the feeding o Another at the end of the feeding o Upright sitting position o Pat at the back – lower to upper o Prone position o Right – sidelying position – facilitates gastric emptying • Educate parents • Apply elbow restraints so the baby can easily adjust post –op NECK • Check for symmetry Congenital Torticollis/ Wry neck • Birth injury of sternocleidomastoid due to excessive traction during cephalic delivery • A case of incompetence to the one giving birth • Management o Passive stretching o Exercise daily o Surgery • Complication o Scoliosis Congenital Critinism/ Congenital Hypothyroidism • Absence or non – functioning thyroid gland • Causes o Due to delayed diagnosis, thyroid is covered by sternocleidomastoid muscle o Hypothyroidism o Thyroid dysgenesis (absence of thyroid) o Baby receive maternal thyroxine • Earliest Signs and Symptoms o Change in sucking o Change in crying o Excessive sleeping (16-20 hours/ day) o Constipation o Edema – moon faced baby o Mental retardation – late sign • Diagnostic Test o Radioimmunoassay Test o Protein bounbd iodine • Treatment o Synthroid / sodium levothyroxine for life CHEST Witch Milk • Transparent • Liquid coming out from newborns breast related to hormonal changes ABDOMEN Abdominal Assessment • Inspection • Ausculation • Percussion • Palpation

ReD Mapalo – BSN

Pediatric Nursing

Diaphragmatic Hernia • Protrusion of stomach contents through a defect in diaphragm due to failure of pleuroperitoneal canal to close • Signs and Symptoms o Sunken abdomen o Signs of RDS o Right to left Shunting • Treatment – diaphragmatic repair w/in 24 hours Omphalocele • Protrusion of stomach content between the the junction of abdominal wall and umbilicus • If small – surgery • If large – suspend surgery • Apply wet dressing GASTROINTESTINAL SYSTEM • Functions o Assist in maintaining fluid and electrolytes and acid and base balance o Processes and absorbs nutrients to maintain and support growth and development o Excrete wasted products from the digestive process Supplementary Feeding • Begin 4 – 6 months • As early as 4 months • Usually at 6 months • Principles o Solid food are often according to the following sequence  Cereals  rich in iron  Fruits  Vegetables  Meat o Begin with small quantities o Finger food are offered @ 6 months o Soft table food is offered @ 1 year o Diluted citrus/ fruit juices @ 6 months o Offer new food one at a time with an interval of 4 – 7 days or 1 week o Never offer half cooked egg  may lead to gastroenteritis/ salmoneliosis Major Concepts of Fluid and Electrolyte Balance • Distribution of Body Fluids o Fluids are greater in ECF in infant and children o Newborns are candidate for dehydration o Total Body fluid is 65 – 85% of their body weight in infants and children Acid – Base Imbalance • Depending upon the following o Chemical buffers o Renal and respiratory system involvement o Dilution of strong acids and bases in blood • Imbalance of Acid o Respiratory Acidosis  Carbonic acid excess  LTB – RDS  Hypoventilation – COPD

ReD Mapalo – BSN

Pediatric Nursing

o Respiratory Alkalosis  Carbonic acid deficit  Hyperventilation  Fever, encephalitis o Metabolic Acidosis  Base bicarbonate deficit  Diarrhea  Severe malnutrition and dehydration  celiac o Metabolic Alkalosis  Base bicarbonate excess due to uncontrolled vomiting  NGT aspiration  Gastric lavage  Pyloric stenosis Conditions that Produce Fluids and Electrolyte Imbalance Vomiting • Forceful expulsion of stomach content • Signs and symptoms o Nausea o Abdominal crumping o Flushing of face o Watery eyes • Assessment o Frequency o Forces  Projectile – increase ICP/ Pyloric stenosis  Non – projectile • Alerts o Vomiting is an initial symptom of GI Obstruction o Vomitus of upper GI can be blood tinged but bot bile streaked o Vomitus of lower GI is bilous o Projectile vomiting is ewither a sign of increased ICP or GI Obstruction o Abdominal distention is the major symptom of lower GIT obstruction • Management o Banana o Rice cereal o Apple sauce o Toast Diarrhea • Exaggerated excretion of intestinal contents • Acute diarrhea is associated with the following o Gastroenteritis/ salmonelliasis o Antibiotic use – penicillin, tetracycline o Dietary indigestion • Chronic non specific diarrhea o Food intolerance o CHO/ CHON malabsorption o Excessive fluid intake • Assessment o Frequemcy o Consistency (best criteria) o Appearance of green colored stool • Complications o Mild dehydration – 5% weight loss o Moderate dehydration – 10% weight loss

ReD Mapalo – BSN

Pediatric Nursing

o Severe dehydration – 15% weight loss • Signs of dehydration o Tachycardia – earliest sign o Tachypnea o Hypontension o Increase temp o Sunken fontanel o Sunken eyeball o Poor skin turgor o Absence of tears o Scanty urine o Oliguria – severe dehy=dration o Weight loss o Prolonged capillary refill time • Management o NPO o IV infusion o KCl – given by doctors  Assess child for ability to void before giving KCl – may lead to hyperkalemnia  Normal K Value – 3.5 – 5.5 o Order Na Bicarbonate, administer slowly to prevent cardiac overload Gastric Motility Disorders Hirschprung’s Disease/ Congenital Aganglionic Megacolon • Absence of ganglion cells needed for peristalsis • Assessment o Neonatal Period  Abdominal distention  Failure to pass meconium within 24 hours o Early childhood  Ribbon like stool  Constipation  Foul smelling stool  Diarrhea  Vomitus of fecal materials • Diagnostic Procedures o Barium enema – reveals narrowed portion of the bowel o Rectal biopsy – reveals absence of ganglion cells o Abdominal x- ray – reveals dilated loops on intestines o Rectal manometry – reveals failure of intestinal sphincter to relax • Therapeutic Management o NGT Feeding  NGT Measurement • Infant – nose-ears – middle of xiphoid process and umbilicus • Adult – nose – ears – xiphoid process o Surgery  Temporary colostomy  Anastomosis and pull through procedure o Diet  Increase CHON  Increase Calorie  ↓ residue diet – pasta foods  no raisin/ prunes Gastroesophageal Reflux • presence of stomach content on esophagus

ReD Mapalo – BSN

Pediatric Nursing

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Assessment o chronic vomiting o failure to thrive syndrome – organic o esophageal bleeding manifested by melena and hematemesis Complications o esophagitis o aspiration pneumonia o esophageal cancer Diagnostic Procedure o barium esophogram o esophageal manometry – reveals lower esophageal pressure o intraesophageal pH content – reveals pH of distal esophagus Medications o anticholinergics  bathanechol/ urecholine • ↑ esophageal tone and peristaltic activity  Methachlopromide (Reglan) • ↓ esophageal pressure by relaxing pyloric and duodenal segments • ↑ peristalsis without stimulating secretions  H2 Blocker/ histamine Receptor Antagonist • ↓ gastric acidity and pepsin secretion  Maalox/ Cimetidine (Tagamet)/ Ranitidine (Zantac) • Neutralizes gastric acid between feedings Surgery: Nissen Fundoplication Diet o Thickened feeding with rice cereal  prevents vomiting o Feed slowly o Burp often every 1 oz o Positioning  < 9 mos – infant sit/ infant supine  > 9 mos – prone with head on mattres slightly elevated on a 30° angle

Obstructive Disorders Pyloric Stenosis • hypertrophy of the muscle of pylorus causing narrowing and obstruction • Assessment o Projectile vomiting o Failure to gain weight o Metabolic alkalosis o Peristaltic wave visible from left to right across epigastrum o Palpation of olived shaped mass • Diagnostic Procedure o ABG o Serum Electrolyte - ↑ Na and K, ↓ Cl o Ultrasound o X-ray of upper abdomen with barium swallow • Management o Pyloromyotomy/ Fredet – Ramstedt Operation Intussusception • Telescoping or invagination of one portion of the bowel into the other • Peritonitis – danger of intussusception • Emergency for URT – epiglotitis • Emergency for GIT – peritonitis • Signs and symptoms

ReD Mapalo – BSN

Pediatric Nursing

• • •

o Acute paroxysmal abdominal pain o Currant jelly stool caused by inflammation and bleeding o Sausage shaped mass Non congenital Caused by fast eating and positioning Management o Hydrostatic reduction with barium enema o Surgery – Anastomosis

Inborn Errors of Digestion Phenylketonuria/ PKU • Deficiency of the liver in Phenyalanine Hydroxylase Transferase (PHT) • PHT is a liver enzyme that coverts protein into amino acid • 9 Essential Amino Acids o Tyrosine / phenylalanine o Histidine o Isoleucine o Leucine o Lysine o Methionine/ cysteine o Threonine o Tryptophan o Valine • Tyrosine or Phenylalanine – responsible for the melanin production • Signs and Symptoms o Fair complexion o Blond hair o Blue eyes o Infantile eczema o Mousy/ musty odor urine o Seizure – due to Phenyl Pyruvic Acid goes to brain o Mental retardation • Guthrie Test o Specimen – Blood o Preparation – Increase Fluid Intake • Management o Diet  ↓ phenylalanine diet indefinitely  Chicken, meat, peanuts, milk, legumes, cheese – contraindicated  Lofenalac – special formula

Celiac Disease/ Malabsorption Syndrome; Gluten Induced Enteropathy • Sensitivity or immunologic response to protein • Assessment o Early signs  Diarrhea, failure to regain weight following diarrheal episode  Constipation  Vomiting  Abdominal pain  Steatorhea o Late signs  Behavioral changes: irritability and apathy  Muscle wasting and loss of subcutaneous fats o Celiac Crisis  Development of infection by a child having a celiac disease

ReD Mapalo – BSN

Pediatric Nursing

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 Acute vomiting and diarrhea Diagnostic Procedure o Stool analysis o Serum antiglandin and antireticulin antibodies o Sweat test Therapeutic management o Vitamin supplements o Mineral supplements o Steroid

Poisoning • Common accident in toddlers – poisoning • Common accident in infants – falls • Principles o Determine the substance taken and assess LOC o Unless poisoning was corrosive, caustic (strong alkali, such as lye) or hydrocarbon, vomiting is the most effective way to remove the poison from the body  Strong acid poisoning – give weak acid to neutralize strong acid o Syrup of ipecac – oral antiemetic to cause vomiting after drug overdose or poisoning  15 ml – adolescent, school age and preschool  10 ml – infant o Universal Antidote  Activated charcoal  Milk of magnesia  Burned toast • Charcoal absorbs toxic substance o Never administer the charcoal before ipecac because giving charcoal first will absorb the effect of ipecac o Antidote for acetaminophen poisoning : Acetylcysteine (mucomyst) o Kerosine/ Gasoline poisoning: Give mineral oil to coat the intestine and prevent poison absorption • Tracheostomy set will be at bed side Lead Poisoning Pencil, paint, crayon Lead ↓ Destruction of RBC Functioning ↓ hyupochromic Microcytic Anemia ↓ Destroys Kidney Function ↓ Accumulation of ammonia ↓ Leading to Encephalitis (Late stage) ↓ Severe mental retardation • Assessment o Beginning symptoms of lethargy o Impulsiveness and learning difficulty o As lead ↑, severe encephalopathy with seizure and permanent mental retardation Diagnostic procedure o Blood smear o Abdominal x-ray o Lone bone Management •

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ReD Mapalo – BSN

Pediatric Nursing

o o

Chelation – binds with the lead and excreted via kidneys Ca EDTA/ BAL/ Dimercapro  Nephrotoxic

ANOGENITAL Female • Pseudomenstruation o Slight vaginal bleeding related to hormonal changes • Rape/ Child Abuse o If the client came with a laceration and bleeding at the perineum o Report rape within 48 hours o Preschool are proneto rape because of their innocence o CBQ Report rape cases to barangay chairman first or bantay bata Male • Cryptochirdism o Undecended testes or empty scrotum or ectopic testes  Common in preterm babies  Testes is palpable at lower quadrant  Surgery: Orchioprexy • Preop – warm the room and hands Epispadias o Urinary meatus is located at the dorsal or above the glans penis Hypospadias o Urinary meatus is located at the ventral or below the glans penis o Hypospadias is usually accompanied by Chordee ( A fibrous band causing penis to curved downward) o Both are manage by surgery Phimosis o Tight foreskin o This will cause infection o Circumcision as management Hydrocele o Fluid filled scrotum o Flashlight/ transillumination test to determine Varicocele o Enlarged vein opf the epididymis

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RENAL DISORDERS Renal Disorder Nephrotic Syndrome Causes Infection Assessment Findings Anasarca Massive proteinuria Microscopic or no hematuria ↓ serum CHON ↑ serum lipid Normal or ↓ BP Fatigue Primary pheripheral perioprbital edema Moderate Proteinuria Goss hematuria (smokey urine) ↑ serum K Fatigue HPN Treatment Prednisone Nursing Care Skin Care Weigh the client saily with the same clothing ↑ CHON(Normal Diet) ↓ Na ↑K Monitor weight Skin Care Monitor BP and neurologic status ↓K ↑ Fe ↓ Na

Acute Glomerul onephritis

Autoimmun e Group A beta hemolytic streptyococ cus

AntiHPN Hydralazine Apresoline Complication Hypertensive Encephalopat hy

ReD Mapalo – BSN

Pediatric Nursing

BACK • Check for flatness and symmetry of the back Spina Bifida Occulta • Failure of the posterior lamina or vertebral to fuse • Sampling of the lower back • Abnormal tufts of hair Spina Bifida Cystica • With Sac • Types o Meningocele – protrusion of CSF and Meninges o Myelomeningocele – CSF, Meninges and Spinal cord o Ecephacele  cranial meningocele - CSF and meninges  Myelomeningocele - brain, CSF , meninges • Common Complication o Infection o Rupture of Sac • Treatment o Surgery to prevent infection: post op – prone position Scoliosis • Lateral curvature of the spine, common in school age because of heavy bags • Uneven hemline • Tell the child to bend forward, one hip higher than athe other and one shoulder is most prominent • Types o Structural o Postural • Management o Conserbvative  Exercise  Avoid obesity o Preventive  Milwaukee Braces worn 23 hours a day o Corrective: Surgery EXTREMITIES • Count the number of digits Digits • Syndactyl – webbing of the digits (foot – ginger –like foot) • Polydactyl – extra digits • Olidactyl – lacks digits Erb – Duchennse Paralysis/ Brachial Plexus Injury • Birth injury of breech delivery • Signs o Inabiluity to abduct the arm fronm the shoulder, rotate the arm extremely and supinate the forearm o Assymetrical oor absence of moro reflex • Management o Abduct the arm from the shoulder with the elbow flexed Congenital Hip Dislocation

ReD Mapalo – BSN

Pediatric Nursing

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Congenital hip dysplacia When the head of the femus is outside the scetabulum 2 types o subluxated – most common o dislocated Signs and Symptoms o Shortening of the affected leg o Assymetrical gluteal fold o Limited movement – earliest sign o + ortolanis sign – abnormal clicking of during abduction o when able to walk the child limps (Trendelenburg sign) – late sign Management – facilitate abduction o Triple the diaper o Carry the baby o Frejka Splint o Pavlik Harness o Hip Spica Cast

Talipes • Club foot • 4 types o Equinos – plantar rotation/ horse foot (most common) o Calcenuous – dorsiflexion/ the heel is held lower than the foot/ the anterior portion of the foot is flexed towards the anterior leg o Varus – foot turns in o Valgus – foot turns out • Assessment o Make a habit of straightening the legs and flying it to the midline position • Management o Corrective shoes : Dennis Brown Shoes o Spica Cast  For immobilization  Maintain bone alignment  Prevent muscle spasm  If there is a blood mark on the cast – mark a pen to determine whether there is a hemorrhage  Neurobvascular check • Circulation • Motion • Sensation CRUTCHES • Wait is on the palm not the axilla • Exercise – squeeze ball Different Crutches and Gait Swing Through • Advance both crutches • Lift both feet/ swing forward/ land feet in front of crutches • Advance both crutches • Lift both feet/ swing forward/ land feet in front of crutches Swing To • Advance both crutches • Lift both feet/ swing forward/ land feet next to crutches • Advance both crutches

ReD Mapalo – BSN

Pediatric Nursing

•

Lift both feet/ swing forward/ land feet next to crutches

Three point gait • Advance left foot and both crutches • Advance right foot • Advance left foot and both crutches • Advance right foot Four Point Gait • Advance right crutch • Advance left foot • Advance left crutch • Advance right crutch Two Point Gait • Advance left foot and right crutch • Advance right foot and left crutch • Advance left foot and right crutch • Advance right foot and left crutch Other Crutch – Maneuvering Technique To Sit Down • Grasp the crutches at the hand pieces for control • Bend forward slightly while assuming a sitting position • Place the affected leg forward to prevent weight bearing and flexion To Stand Up • Move forward to the edge of the chair with the strog leg slightly under the seat • Place both crutches in the hand on the side of the affected extremity • Push down on the hand piece while raising the body to a standing position To Go Downstairs • Walk forward as far as possible to the step • Advance the crutches to the lower step. The weaker leg is advanced first and then the stronger leg. In this way, the stronger extremity shares the work of raising and lowering the patient’s body weight with the arms To Go Upstairs • Advance the stronger leg first up to the next step • Then advance the crutches and the weaker extremity ( strong legs goes up first and comes down last.) • A memory device for the patient is “UP WITH THE GOOD, DOWN WITH THE BAD” WALKER • A walker provides more support than cane andf crutches • The patient is taught to ambulate with a walker as follows o Patient must hold the walker on the hand grips for stability o Lift the walker, placing it in front of you while leaning your body slightly forward o Walk into the walker, supporting your body weight on your hands while advancing the weaker leg, permitting partial weight bearing or non weight bearing leg as prescribed o Balance yourself on your feet o Lift the walker and place it in front of you again and continue the pattern of walking. CANE

ReD Mapalo – BSN

Pediatric Nursing

• •

Used to help patient walk with greater balance and support and to relieve the pressure on the weight bearing joints by redistributing the weight. Quad Cane (four – footed cane) is hold on the hand of affected extremity.

METHODS OF TRANSFERRING A PATIENT FROM THE BED TO A WHEELCHAIR • Weight bearing transfe4r from bed to chair. The patient stands up, pivots his back is opposite the new seat and sits down. • (Left) Non weight bearing transfer from chair to bed. (Right) With legs braced. • (Left) Non weight bearing transfer combined method. (Right) Non weight bearing transfer, pull up method.

THERAPEUTIC EXERCISE Exercise Description Passive carried out by the therapist or the nurse without assistance from the patient

Purpose To retain as much joint range of motion as possible To maintain circulation

Active Assistance

Carried out by the patient with the assistance of the therapist or the nurse

To encourage normal muscle function

Active

Accomplished by the patient without assistance, activities include turning from side to side and from back to abdomen and moving up and down in bed

To increase muscle strength

Resistive

An ective exercise carried out by the patient working against the resistance produced by either manual or mechanical means

To provide resistance to increase muscle power

Action Stabiolize the proximal joinyt, and support the distal part. Move the joint smoothly, slowly and gently through its full rang of motion Avoid producing pain. Support the distal part and encourage the patient to take the joint actively through its ROM. Give no more assistance than is necessary to accomplish the action. Short periods of activity should be followed by adequate rest periods. When possible, active exercise should be performed against gravity. The joint is moved through full ROM without assistance. (make sure that the patient does not substitute another joint movement for the one intended) The patient moves the joint through its ROM while the therapist resist slightly at first and the progressively increasing resistance. Sandbagws and

ReD Mapalo – BSN

Pediatric Nursing

Isometric/ Muscle Setting

Alternately contracting and relaxing a muscle while keeping the part in fixed position; performed by the patient

To maintain strength when a joint is immobilized

weights can be used and are applied at the distal point of the joint involved. The movement should be performed smoothly. Contract or tighten the muscle as much as possible without moving the joint. Hold for several seconds, and then let go and relax. Breath deeply.

TRACTION • Use to reduce dislocation Principles of Traction • The client should be in dorsal or supine position • For every traction, there is always a counter traction • Line of pull should be in line with deformity • For traction to be effective it must be continuous • Weight must be freely hanging Types of Traction • Straight traction – weight of the body serves as counter pull • Skin traction – applied directly to the skin o Bryant’s Traction  use to immobilize for < 2 years old at a 90 ° angle with buttocks off the bed o Buck’s extension  For > 2 years old • Halo traction – immobilize the spine • Skeletal traction o Nursing responsibilities  Assess for circulatory and neurology impairment  It can lead to HPN  Be careful to carry out nursing functions by not moving the weights AUTOIMMUNE SYSTEM • Types of Immunity o Passive Natural  Developed via exposure to a disease o Active Natural  Transplacental transfer, IgA from breastmilk o Passive Artificial  Vaccination o Active Artificial  Anti Rabies Serum NEUROMUSCULAR SYSTEM Reflexes

ReD Mapalo – BSN

Pediatric Nursing

Blink reflex • Rapid eye closure when strong light is shown to protect the eyes; never disappears Palmar Grasp Reflex • When a solid object is placed on the palm then the baby will grasp the object • To cling to the mother for safety • Disappears at 3 months Step – in/ Walk – in Place Reflex/ Dance Reflex • Neonate placed on a vertical position with their feet touching on hard surface will take a few quick alternating steps • Placing reflex  almost the same with the dance reflex except that is when you are touching the anterior surface of newborns leg Plantar Grasp Reflex • When an object touches the sole of the newborn’s foot at the base of his toes, the toes grasp in the same manner as the fingers do • Disappears @ 8 – 9 months in preparation for walking Tonic Neck Reflex/ Fencing/ Boxing reflex • When the newborn lies on its bact, their heads usually turns to one side, the arm and the leg on the side to which the head turns extend to the opposite arm and legs contract Moro Reflex/ Startle Reflex • With a loud voice or by a jarring the base of the crib, the baby will assume a c position • Test for neurologic integrity Magnet Reflex • When there is pressure at the sole of the foot, the baby pushes back against the pressure Crossed extension Reflex • While supine and the sole of the foot is stimulated by a sharp object, it causes the foot to raise and the other foot to extend • Test for spinal nerve integrity Trunk Incurvation Reflex/ Galant Reflex • While in prone position and the parabvertebral area is stimulated, it causes flexion of the trunk and swing his pelvis towards the touch Landau reflex • While the infant is placed on a vertical position with the hand underneath supporting the trunk the baby exhibit some muscle tone • Present at 3 months • Test for muscle tone Parachute Reflex • When the infant is placed on a vertical suspension with the change in equilibrium, it causes the extension of the hands and legs • Present at 6 – 9 months Babinski Reflex • When the sole of the foot is stimulated by inverted j, it causes fanning of the toes • Disappears by 2 months but may persist till 2 years old