1.A Growth and Development Growth - increase in physical size of a structure or whole. - quantitative change. Two parameters of Growth 1. Weight - most sensitive measure of growth, especially low birth rate. Weight doubles - 6 months Triples - 1 year Quadruples - 2 - 2 ½ years 2. Height - increase by 1inch per month during 1 st 6 months - half inch per month by 7 months - average increase in height - 1 st year = 50% - increase in height coincide with eruption of wisdom tooth. Development - increase skills or capability to function - qualitative How to measure development 1. By simply observing a child doing specific task. 2. By noting parent’s description of the child’s progress 3. By DDST- Denver Development Screening Test. MMDST (Phil) Metro Manila Developmental Screening Test. DDST measures mental 4 main rated categories of DDST 1. Language communication 2. personal social - interaction 3. fine motor adaptive - ability to use hand movement; pre Hensile activity 4. gross motor skills - large body movement 3. Maturation - synonymous with development “readiness”; [pagiging handa] 1
Transcript
1.A Growth and Development
Growth - increase in physical size of a structure or whole. - quantitative change.
Two parameters of Growth
1. Weight - most sensitive measure of growth, especially low birth rate. Weight doubles - 6 months Triples - 1 year Quadruples - 2 - 2 ½ years
2. Height - increase by 1inch per month during 1st 6 months - half inch per month by 7 months
- average increase in height - 1st year = 50% - increase in height coincide with eruption of wisdom tooth.
Development - increase skills or capability to function - qualitative
How to measure development
1. By simply observing a child doing specific task.2. By noting parent’s description of the child’s progress 3. By DDST- Denver Development Screening Test.
MMDST (Phil) Metro Manila Developmental Screening Test. DDST measures mental
4 main rated categories of DDST1. Language communication2. personal social - interaction3. fine motor adaptive - ability to use hand movement; pre Hensile activity4. gross motor skills - large body movement
3. Maturation - synonymous with development “readiness”; [pagiging handa]
4. Cognitive development – ability to learn and understand from experience- to acquire and retain knowledge- to respond to a new situation and to solve problems.
Learning – change of behaviorIQ test - test to determine cognitive development
Mental age x 100 = IQChronological age
Average IQ – 90-100Gifted child - > 130 IQGenius - Over 140
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1.B Basic Divisions of LifeStages:I. Prenatal stage
( from conception to birth )
II. Period of infancy1. Neonatal - 1st 28 days of life or 1st 4 weeks of life2. Formal infancy - 29th day – 1 year
III. Early childhood 1. Toddler – 1-3 years2. Pre school 4 - 6 years
IV. Middle childhood1. School age- 7 – 12 yrs
V. Late childhood (Adolescent Period)1. Pre adolescent 11 – 13 years2. Adolescent ( 12 - 18 – 21 ) overlapping of age
1.C Principles of Growth and Development 1. Growth and Development is a continuous process
- begins from conception - ends in death- womb to tomb principles
2. Not all parts of the body grow at the same time or at same rate.- asynchronism or asynchronous growth –
Patterns of Growth and Development 1. ) renal digestive grows sparely smoothly during childhood circulatory
musculoskeletal
2. ) Neuromuscular tissue (CNS, brain, Spinal cord)- grow rapidly 1 - 2 years of life- brain achieved its adult proportion by 5 years.
- infancy and childhood to provide protection - infection
- tonsil achieve its adult proportion by 5 years
4. ) Reproductive Organ - grows rapidly at puberty
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Rates of Growth and Development 1. Fetal and infancy – most rapid Growth and Development 2. Adolescent - rapid Growth and Development 3. Toddler - slow Growth period4. Toddler and preschool - alternating rapid and slow5. School age - slower growth
fetal and infancy - prone to develop anemia
3. Each child is unique
2 primary factors affecting Growth and Development A. Heredity - R – race
I – intelligenceS – sexN - nationality
Females are born less in weight than males by 1 oz.Females are born less in length than males by 1 inch
B. EnvironmentQ – quality of nutritionS – socio economic status H – healthO – ordinal position in family P – parent - child relationship
Eldest - skillful in language and social skillsYounger - toilet trained self
4. Growth and Development occurs in a regular direction reflecting a definitive and predictable patterns or trends.
A. Directional trends - occur in a regular direction reflecting the development of neuromuscular function: these apply to physical, mental, social and emotional developments and includes:
a. Cephalo - caudal “head to tail” It occurs along bodies’ long axis in which control over head,
mouth and eye movements and precedes control over upper body torso and legs.
b. Proximo- distal “Centro distal” - progressing form center of body to extremities.
c. Symmetrical - at side of body develop on same direction at same time at same rate.
d. Mass specific “differentiation”In which the child learns form simple operations before complex
functions or move from a broad general pattern of behavior to a more refined pattern.
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B. Sequential - involves a predictable sequence of Growth and Development to which the child normally passes.
a. Locomotion - example: creep then crawls, sit then stand, walk then run
b. Socio and language skills - example: solitary games, parallel games
C. Secular – refers to the worldwide trend of maturing earlier and growing larger as compared to succeeding generations.
5. Behavioral is the most compressive indicator of developmental status: “Act at your age” 6. Universal language of child - play7. Great deal of skill and behavior is learned by practice. Practice makes perfect.8. There is an optimum time for initiation of experience or learning9. Neonatal reflexes us must be lost before one can proceed.
- rooting reflex – disappear by 6 weeks- plantar reflex - disappear before baby can walk: 8 – 9 months
- moro reflex - disappear before baby can roll : 4 – 5 months - protect himself from the attacker
- persistent primitive infantile reflexes – suspect case of cerebral palsy
1.D Theories of Growth and Development Developmental tasks - different form chronological age
- skills or growth responsibility arising at a particular time in the individuals life.
Theorists 1. Sigmund Freud 1856 - 1939 Austrian neurologists. Founder and Father
of psychoanalysis - offered personality development
Psychosexual theorya.) Oral Phase 0 - 18 months
- mouths site of gratification- activity of infant- biting, sucking crying.- why do babies suck?- enjoyment and release of tension.- provide oral stimulation even if baby was placed on NPO.Significance: Offer pacifier - never discourage thumb sucking.
b.) ANAL - 18 months - 3 years- site of gratification- anus Obsessive Compulsive -anal phase- activity: elimination, retention or defecation of feces may occur * toilet training *- principle of holding on or letting go enters- mother wins or child wins - child wins - stubborn, hardheaded anti social.
(“anak pupu na”, child holds “pupu”,child wins) Impacted stools – Letting Hold- mother wins - obedient, kind, perfectionist, meticulous – Letting GOSignificance: help child achieve bowel and bladder control even if child is hospitalized.
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c.) Phallic – 4 - 6 years - site of gratification - genitals - activity - may show exhibitionism
- increase knowledge of a sexes - accept child fondling his/her own genitalia as normal exploration - answer Childs question directly. Right age to introduce sexuality – preschool
d.) Latent – 7 - 12 years - period of suppression - no obvious development (slower growth)
- Childs libido or energy is diverted to more concrete type of thinking Significance: helps child achieve (+) experience so ready to face conflict of adolescence
e.) Genital – 12 - 18 years opposite sex - site of gratification - genitals - achieve sexual maturity and satisfactory - learns to establish relationships with opposite sex. Significance: give an opportunity to relate to opposite sex.
2. ERIC ERICKSON - trained in psychoanalysis theory - stresses important of culture and society to the
development of ones personalityImportancea. environment
b. culture
Stages of Psychosociala.) Trust vs. Mistrust – 0 - 18 months .Alert!- foundations of all psychosocial task - to give and receive is the psychosocial theme
To know to develop trust on baby1. satisfy needs on time - breastfeed2. care must be consistent and adequate - both parents - 1st 1 year of life3. give an experience that will add to security- touch, hugs and kisses, eye to eye
contact, soft music.
b.) Autonomy vs. Shame and Doubt 18 months - 3 years - independence / self government To develop autonomy on toddler
1. give an opportunity of decision making like offer choices.2. encourage to make decision rather then judge.3. set limits – moral obligations of the parent
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c.) Initiative vs. Guilt – 4 - 6 years- learns how to do basic things well To develop:
- give opportunities to explore new places and events Activities recommended:
- modeling clay, finger painting will enhance imagination and creativity and further enhances fine motor development
d.) Industry vs. Inferiority 7 - 12 yrs - child learns how to do things well
To develop: - give opportunity on short assignments and projects
e.) Identity vs role confusion or diffusion 12 - 18 yrs - learns who he/she is or what kind of person he/ she will become by adjusting
to new body image and seeking emancipation or freedom from parentsf.) Intimacy vs. Isolation 20 – 40 years up to 45 years old
- looking for a lifetime partner and career focusg.) Generatively vs. Stagnation 40 – 45 – 60 – 65 years oldh.) Ego Integrity vs. Despair 60 – 65 years old and above
3. JEAN PIAGET – a Swiss psychologists ; cognitive - develop reasoning power
STAGES OF COGNITIVE DEVELOPMENTA. Sensory Motor 0 - 2 years
- “practical intelligence”- words and symbols not yet available - baby communicates through senses and reflexes. (sub divided)
Schema Age Behavior1.) Neonate Reflex 1 month All reflexes2.) Primary Circular 1 - 4
months- Activity related to body - repetition of behavior ex. thumb sucking
3.) Secondary Circular Reaction 4 - 8 months
- activity not related to body- discover object and person’s permanence- “memory traces are present”- anticipate familiar events.
4.) Coordination of Secondary Reaction
8 - 12 months
- exhibit goal directed behavior- increase of separateness (will search of lost toy, knows mom)
5.) Tertiary Circular Reaction 12 - 18 months
- use trial and error to discover characteristics of places and events -“ invention of new means”- capable of space and time perception(hits fork, spoon on table or drops fork)
6. ) Invention of New Means thru mental combination
18 - 24 months
- transitional phase to the pre operational thought period.
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B. Preoperational Thought 2-7 years
Schema Age BehaviorPreconceptual 2 - 4
years- thinking basically complete literal and static - egocentric - unable to view on others view point- concept of TIME is only now- concept of distance is only as far as they can see. - concept of animism inanimate object is alive(animism is the main reason why they are afraid in the dark places)-not aware of concept of reversibility - in every action there is an opposite reaction or cause and effect
Initiative 4 - 7 years
Beginning of causation
C. Concrete Operational Thought 7 - 12 years1. able to find solution to everyday problems with systematic reasoning. 2. have concept of reversibility- cause and effect ( in every action there is an
opposite reaction )3. have concept of conservation – constancy despite of transformation.Activity Recommended:
- collecting and classifying Such as in collection of stamps, stationeries, dolls, rubber band markers.
D. Formal Operational thought 12 and up.1. Cognition achieved its final form2. can deal with past present and future3. have abstract and mature thoughts.4. can find solutions to hypothetical problems with scientific reasoning. Activity: will sort out opinions and current events.
4. KOHLBERG - recognized the theory of moral development as considered to closely approximate cognitive stages of development (“ sabay” with cognitive development )
2 - 3 years 1 Punishment/ obedience orientation (“heteronomous morality”) Child does right because a parent tells him or her to and to avoid punishment
4 – 7 years 2 Individualism. Instrumental purpose and exchange. Carries out action to satisfy own needs rather than society. Will do something for another if that person does something for the child.
Conventional Level II7 – 10 years 3 Orientation to interpersonal relations of mutuality.
Child follows rules because of a need to be a “good” person in own eyes and eyes of others.
10 – 12 years 4 Maintenance of social order fixed rules and authority. Child finds following rules satisfying. Follows rules of Authority figures as well as parents in an effort to keep the “system” working.
Post-conventional Level IIIAbove 12 years 5 Social contract, utilitarian level making perspectives.
Follows standards of society for good of all people6 Universal ethical Principle orientation. Follows
internalized standards of conduct.
1.E DEV’T MILESTONES – means major markers of growth and developmentE. 1. Period of infancy - universal language of child - playa.) Play - Infancy- solitary plays
- solo, non interactive example: rattles, mobiles, teeters, music box- facilitate motor and sensory developmentNote: In choosing toys: safety - important age appropriate
b.) Fear of Infancy - stranger anxiety begin Alert: begins at 6 - 7 months; peak - 8 months ; diminishes - 9 months
c.) MilestoneNeonate – largely reflex; complete head lag; hands fisted; cry without tears; visual
fixation for human face1 month - dance reflex disappears looks at mobile
2 months - holds head up when in prone, - social smile, - baby coos “doing sound” - cry with tears
- closure of posterior fontanel 2 - 3 months - head lag when pulled to sitting position.
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3 months - holds head and chest up when prone - follows object past midline - grasp and tonic neck reflex fading - hand regard (looks at hand)
4 months – turns form front to back - head control complete - needs space to turn - Laugh aloud, bubbling sounds
5 months - turn both ways “roll over” - teething rings - handles rattle well
- moro reflex disappears ( 4 - 5 months)
6 months - reaches out in anticipation of being picked up - sits with support - uses palmar grasp - eruption of 1st temp teeth 6-8 months 2 lower central incisors - say vowel sounds “ah”, “oh”, “eh” - handles bottle well
7 months – beginning fear of strangers (6 – 7 months) - transfer object hand to hand
- likes object that are good size
8 months - sits without support - peak of stranger anxiety - plantar reflex disappears 8 - 9 months in preparation for walking
9 months - creeps or crawls - neat finger grasp reflex - combine 2 syllables “mama” and “dada”
- needs space for creeping
10 months – pull self to stand - understands the word “no”
- responds to own name - peak a boo, pat a cake since they can clap
11 months - cruises - stand with assistance
12 months - stand alone take 1st step - walk with assistance - drink from cup, cooperate in dressing
- says 2 words mama and dada - pots and pans, pull toy, nursery rhymes
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E.2. Toddler - parallel play - 2 toddlers playing separately a. Play - provide with similar toys
Examples:- squeaky frog to squeeze- waddling duck to pull - trucks to push- push pull toy ( best parallel toy ) - building blocks, pounding peg- toys to ride on
b. Fear - separation anxietybegin 9 monthspeak 18 months
3 phases of separation anxiety (in order)1. P- protect2. D - despair3. D- denialHow to prevent separation anxiety:- don’t prolong goodbye- say goodbye firmly to develop trust
- puts small pellets into small bowl- holds spoon well- seats self on chair - creep up stairs- 4 - 6 words
- scribbles voluntarily with pencil
18 months - height of possessiveness - favorite word- “mine” - bowel control achieved (bowel contro1st before bladder control)
- no longer rotates spoon - can run and jump in place - walks up and down stairs holding on to persons hand or railing - 7 - 20 words - name, body part - typically places both feet on 1 step before advancing.
24 months - also known as the terrible two - can open doors by turning door knob or unscrew lids - can walk upstairs alone, still using both feet on same step
at same time - 50 - 200 words ( 2 words sentences) - daytime bladder control achieved
(daytime 1st- next nighttime bladder control)
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30 months or 2 ½ years – makes simple lines or stroke or crosses with a pencil - can jump down from chairs - knows full name - copy a circle - holds up finger to show age
- temp teeth complete ( last temporary teeth to appear posterior molars ) ( 20 deciduous teeth )
- beginning of toothbrush – 2 – 2 ½ years - tooth brushing with little assistance 3 years - tooth brushing alone – 6 yrs - right time to bring to dentist- when temp teeth complete
( 2 – 2 1/2 years old )36 months or 3 years – trusting 3
- unbutton buttons (unbutton before learn to button)- draw a +- learns how to share - knows full name and sex (gender identity)- speaks fluently- nighttime bladder control achieved- 300 - 900 words- ride a tricycle
d. Character Traits of toddler1.) Negativistic - “NO!” - way to search for independence
– limit questions; offer options – modify questions to a statement
2.) Rigid, Ritualistic and Stereotyperitualism - for mastering
3.) Temper tantrums- head banging, screaming, stamping feet, holds breath What to do: ignore behavior
Slightly protruding - scaffold abdominal - due to underdeveloped/immaturity of the abdominal muscles
physiologic anorexia- due to preoccupation with environment- food jag that last for short period of time
loves rough and tumbling play steady gait love to stay with daddy loves toilet training failure of toilet training - unreadinessClues of toilet readiness:
1.) can stand, squat walk alone2.) can communicate toilet needs3.) can maintain dry for an interval of 2 hours
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E.3. Pre schoolers - associative or cooperative playa. Play : “bahay-bahayan” – play house
* role playingb. Fear - body mutilation or castration - fear of dark places witches - fear of thunder and lightning
- fear of ghostsc. Milestones
4years old - furious for they are noisy, aggressive, stormy - can button buttons - copy a square 2 – 2 1/2 years - jumps and skips - laces shoes 3 years - vocabulary 1,500 - knows four basic colors
5 years old - frustrating - copy a triangle 4 years
- draw a 6 part man - imaginary playmates
- 2,100 words 5 years
d. Character Traits of Pre-schooler:1.) Curious2.) Creative 3.) Imaginative4.) Imitative5.) 2 favorite words – “why” and “how”6.) complexes- word identification to parent of same sex and attachment to
parent of opposite sexexample: Oedipal complex- boy to mom Electra complex- girl to dad
Cause of incest: marital discord7.) Death-sleep only
Behavior problems Preschool1. telling tall tales - over imagination2. imaginary friend – way to release tension and anxieties 3. sibling rivalry - jealousy to newly delivered baby. 4. regression - going back to early stage
Signs of Regression:- thumb sucking (should be oral stage only)- baby talk- bed wetting- fetal position
5. masturbation- sign of boredomWhat to do: - Accept and do it in private place - Divert attention
- Offer a toy
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E.4. School Agea. Play - competitive play
Example: Tug of war, track and field, basketball, volleyball, softball
b. Fear: 1.) school phobia - orienting the child to a new environment 2.) displacement from school - teacher and peer of same sex
3.) loss of privacy - wants bra 4.) fear of death - 7 – 9 years death is personified
- death - permanent loss of lifePreschooler - death is sleep
c. Significant Developmenta. boys - prone to bone fracture - age 9 – have the same height
age 12 – girls are taller than boys* greenstick fracture
b. mature vision 20/20
d. Milestone
6 years - temporary teeth begin to fall- permanent teeth appear - 1 st molar
- year of constant motion- clumsy movement- recognize all shapes- 1st grade teacher becomes authority figure - nail biting- begin interest in God.
7 years- assimilation age- copy a diamond- enjoys teasing and playing alone- quieting down period
8 years- expansive age- smoother mouth- loves to collect objects- count backwards* homosexual - normal
9 years – coordination improves- tells time correctly- hero worship
- stealing and lying are common- takes care of body needs completely- teacher finds this group difficult to handle
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10 years - age of special talent- writes legibly- ready for competitive games- more considerate and cooperative- joins organizations: girl scouts/boy scouts- well mannered with adult- critical of adults
11 - 12 years – pre adolescents- full of energy and constantly active- secret language are common- share with friends secrets- sense of humor present- social and cooperative
e. Character Traits School Age1. industrious2. modest3. can’t bear to lose - they will cheat4. love collections - stamps
Signs of sexual maturityGIRLS:
I- increase size of breast and genitalia Alert: Menarche - 1st sign sexual maturity in girls
W- widening of hipsA- appearance axillary, pubic
Alert: (adrenarch)M- menarche- last sign sexual maturity in Girls
BOYS:A- appearance axillary, pubic hair
Alert: ( 1st sign sexual maturation)D- deepening voiceD- development of musclesI - increase in size of testes and penis P- production of viable sperm
Alert: ( last sign sexual maturity)
E.5 Adolescent Period – significant others and peers
a. Fear 1. obesity2. acne3. homosexuality4. death5. replacement from friends
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b. Significant Person – opposite sex
c. Significant Development1. Experiences conflict between his needs for sexual satisfaction and societies expectation2. They change of body image and acceptance of opposite sex3. Nocturnal emission – wet dreams; hallmark of adolescent4. Distinctive odor- due to stimulation apocrine glands 5. sperm is viable by age 17 yearsAlert: . testes & scrotum increase until age 17 breast and female genitalia increase until age 18
d. Personality Traits Adolescents1. idealistic2. rebellious3. reformers4. conscious with body image5. adventuresome
e. Problems:1. vehicular accident
Due to peer pressure:2. smoking3. alcoholism4. drug addiction5. pre marital sex
II. IMMEDIATE CARE OF NEWBORN 1st days of life
A. The 8 Priorities of the Newborn in the first days of life:1. Initiation and maintenance of respiration2. Establishment of extra uterine circulation3. Control of body temperature4. Intake of adequate nourishment5. Establishment of waste elimination6. Prevention of infection7. Establishment of an infant-parent relationship8. Developmental care that balances rest and stimulation for Mental
Development
1.) Initiation and maintenance of respirationAlert: 1. 2nd stage of labor- initial airway
2. Initiation of airway is a crucial adjustment among the newborn3. Most neonatal deaths with in the first 24 hours is primarily caused
by inability to initiate airway4. Lung function begins only after birth
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How to initiate airway: A. Remove secretions bulb syringeB. Proper Suctioning with a Catheter
1.) place head to side to facilitate drainage of secretion2,) suction mouth 1 st before nose - neonates are nasal breathers / obligatory nasal breather3.) period of time
- 5 - 10 seconds suctioning, gentle and quick prolonged and deep suctioning can lead to:
a. hypoxiab. laryngo spasmc. bradycardia due to stimulation vagal nerve – located near the
esophagus and anus4.) evaluate for patency
- cover one nostril and when the baby struggles there’s a need for q additional suctioning
C. If not effective, requires effective laryngoscopy to open airway. After deep suctioning an endotracheal tube can be inserted and oxygen
can be administered by an (+) pressure bag and mask with 100% oxygen at 40 – 60 bpm.
Nursing Alert:1. No smoking for it can facilitate combustion2. Always humidify to prevent drying of mucosa (Mask should cover the
nose/mouth not including the eyes)3. Over dosage of oxygen can lead to scarring of retina leading to
blindness ( retro lentalfibroplasia or ROP - retinopathy of prematurity)4. When mecomium stained (greenish) never administer oxygen with pressure ( O2 pressure will push mecomium inside) to prevent
atelectasis
2.) Establishing extra uterine circulation Nursing Alert: circulation is initiated by lung expansion or pulmonary ventilation
and completed by cutting of cord.
FETO PLACENTAL CIRCULATIONPlacenta (simple diffusion) → oxygenated blood is carried by the umbilical vein →
passes liver → ductus venousus → Inferior Vena Cava → Right Atrium 70% blood is shunted to → Foramen Ovale → Left Atrium → Mitral Valve →Left Ventricle → Aorta → Lower Extremities. The remaining 30% → Tricuspid Valve → Right Ventricle → Pulmonary Arteries → Lungs (for nutrition) → vasoconstriction of lungs pushes blood to the → ductus arteriousus to the → aorta → to supply upper extremities. The two arteries carry the unoxygenated blood back to the placenta for oxygenation.
Alerts: Increase Pressure to the left side → closure of foramen ovale
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SHUNTS - shortcutsDuctus Venosus - shunts from liver to Inferior Vena Cava Foramen Ovale - shunts between 2 atriasDuctus Arteriosus - from pulmonary artery to aorta
What will sustain 1st breath - decreased artery pressureWhat will initiate lung circulation - lung expansionWhat will complete circulation - cutting of cord
A. 2 way to facilitate closure - of foramen ovalea.) Tangential Foot slap - slap foot of baby to make the baby cryAlert: - never stimulate the baby to cry if secretions not fully drained to prevent
aspiration - check characteristic of cry normal cry- strong, vigorous and lusty cry “UHA” cri-du-chat syndrome-chromosomal obliteration / cat like cry or meow
like cryb.) Proper Positioning - right side lying position
- will increase pressure on left and foramen ovale will close Foramen Ovale and Ductus arteriosus will begin to close within 24 hoursObliteration - means complete closure
Position of infant immediately after birth:NSD – trendelenberg / T position for drainagecontraindication of trendelenberg position - increase ICPCS - supine or crib level position
Signs of increased ICP1.) abnormally large head2.) bulging and tense fontanel3.) increase BP and widening pulse pressure Cushing Triad of ICP 4.) Decreased Respiratory Rate, decreased Pulse Rate “hypo-brady-brady”5.) projective vomiting - sure sign of cerebral irritation6.) high deviation – diplopia – sign of ICP older child
4 - 6 months - normal eye deviation> 6 months - lazy eyes or indication of ICP
7.) High pitch shrill cry - late sign of ICP or hypoglycemia
3.) Temperature RegulationAlerts:
- goal in temperature regulation is to maintain it not less than 97.7%° F (36.5° C)- maintenance of temperature is crucial on preterm and SGA (small for
gestational age) - babies prone to hypothermia or cold stress
A. Factors Leading to the development of HYPOTHERMIA1. preterms are born per kilo thermic - means cold blooded
- babies easily adapt to temperature of environment due to immaturity of thermo regulating system of body → Hypothalamus
2. inadequate Sub cutaneous tissue3. new born is not capable of shivering4. babies are born wet
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B. PROCESS OF HEAT LOSS1. evaporation - body to air (TSB)2. conduction - body to cold solid object (cold compress)3. convection - body to cooler surrounding air (aircon)4. radiation - body to cold object not in contact with the body earliest sign of hypothermia - increase in Respiratory Rate
C. Effects of Hypothermia ( Cold stress)1.) Hypoglycemia - 45 - 55 mg/dl normal
40 - borderline2.) metabolic acidosis – catabolism (breaking down) of brown fats (best insulator of newborns body) leading to formation of ketones3.) high risk for kermicterus body - bilirubin in brain leading to irreversible brain damage such as cerebral palsy4.) additional fatigue to a stressful heart
D. Prevent Hypothermia1. dry and wrap baby2. mechanical pressure – radiant warmer
i. pre-heated first isolette (or square acrylic sided incubator) 3. prevent an necessary exposure – cover the areas that is not being examine4. cover baby with tin foil or plastic5. embrace the baby - known as kangaroo care
4. Establish Adequate Nutritional IntakeCS- breastfeeding after 4 hours BoardNSD- breastfeeding as soon as possible Question
Alerts:A. Physiology breast milk production As you deliver baby, decrease Estrogen, decrease Progesterone- -Anterior Posterior Gland (APG) releases prolactin – acts on acinar cells (or alveoli) – produce foremilk – stored in lactiferous tubules ( or collecting tubules of the breast ) where breast milk is produced – alveoli posterior pituitary gland
Sucking → PPE → oxytocin → contraction of smooth muscles of lactiferous tubules → milk ejection reflex → let down reflex.B. Advantages of Breastfeeding
1. Very Economical2. Always available3. Facilitates Bonding4. It facilitates rapid involution5. Decrease incidence of breast cancer.6. has antibodies - IgA7. Breastfed babies have higher IQ than bottle fed babies 8. Has lactobacillius bifidus- interferes with attack of pathogenic bacteria
in GastroIntestinalTract9. Has macrophages – engulfs bacteria
Store milk - plastic storage containerStore milk – good for 6 months from freezer - put room temperatrure - don’t heat
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Disadvantages:1. Possibility of transfer HEP B, HIV, cytomegalo virus(CMV)2. No iron3. Father can’t feed & bond as well
C. Stages of Breastmilk:1. Colostrum – 2 - 4 days present
content: decrease fats increase IgA decrease CHO increase CHON increase minerals
content: increase lactose increase water soluble vitamins increase minerals
3. Mature milk - 14 days & upcontent: Increase Fats (linoleic acid) – cause for higher IQ
( responsible for the development of the brain & integrity of skin )
Increase CHO - lactose – easily digested, that is why the baby not constipated ( responsible for sour milk smelling odor of stool )
Lactose intolerance - deficiency of enzyme LACTASE that digest LACTOSE protein - lactoallbumin
D. Cows milk – increase fats Contents: Decrease CHO – that is why we need to add a little sugar
Increase CHON – casein has curd that’s hard to digest – that is why baby is constipated.
Increase Minerals – traumatic effect on kidneys of babies. Can trigger stone formation in the kidney
Increase Phosphorus – reverse proportion in Calcium
E. Health Teachings:1. Proper hygiene - proper hand washing
Care of breast - cotton balls with lukewarm water – “inner to outer”Caked colostrums - dry colostrums on breast
2. Best position in breastfeeding – upright sitting - avoid tension!
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3. Stimulate & evaluate feeding reflexes a.) Rooting reflex - by touching the side of lips/cheeks then baby will turn
to stimulus. Disappear by 6 weeks- by 6 weeks baby can focus. Reflex will be gone
Purpose rooting: to look for food.
b.) Sucking Reflex – when you touch middle of lips then baby will suck - Disappears by 6 months - When not stimulated easily disappear
Purpose: to take food
c.) Swallowing - when food touches posterior of tongue then it will be automatically swallowed
d.) Extrusion/ Protrusion reflex - when food touches anterior portion of tongue then food will be automatically extruded or protruded
Purpose: to prevent from poisoning
Disappear by 4 months & baby can already spit out by 4 months. Extrusion – “no force”Spitting Up – “with force”
4. Criteria Effective Suckinga.) Baby’s mouth is hike up well to areolab.) That Mom experiences after pain. c.) Other nipple is also flowing with milk.
5. To prevent from crack nipples & initiate proper production of oxytocin. - begin 2 - 3 minutes at each breast ( 5 – 7 minutes other authors )
to initiate production of oxytocin - increase 1 minute / day – until reaching 10 minutes at each breast or 20 minutes / feeding.
6. For proper emptying & continuous milk production / feeding - feed baby on last breast that you feed her with alternately ( if not emptied - mastitis)
Problems experienced in Breastfeeding :Changes in breast post partum:a.) Engorgement - feeling of fullness & tension in the breast.
- sometimes accompanied by fever known as MILK FEVER.Management: Warm compress - for breastfeeding mom Cold compress – for bottle feeding & wear snug supportive bra.
When is involution of breast? - 4 weeks
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b.) Sore nipple – cracked, wet and painful nippleManagement:: 1.) exposure to air – remove bra & wear dress
2.) expose to 20 Watt bulb 3.) avoid wearing plastic liner bra – prevent air to enter
- will create moisture, cotton onlyc.) Mastitis- inflammation of breast, cause by staphylococcus aureus
Factors:1. Improper breast emptying2. Unhealthy sexual practices
- contraindicated for breast feeding - manually express inflamed breast - feed on unaffected breast- give antibiotics – can still feed on unaffected breast
Contra Indications in Breast Feeding:Maternal Conditions:1. HIV2. CMV3. Hepatitis B4. Coumadin
A. Different StoolsA.1. Meconium - physiologic stool - black green, sticky, tar like, odorless because of Sterile intestine - will pass with in 24 – 36 hours
failure to pass mecomium after 24 hour - GastroIntestinalTract obstructionexample: 1. Hirschsprungs disease
2. Imperforate anus 3. Mecomium ileus – due to Cystic Fibrosis
A.2. Transitional stool - - green loose & slimy that may appear to be like diarrhea
to the untrained eye
A.3. Breastfed stool - golden yellow, soft, mushy with sour milk smelling odor frequently passed - recurring almost nearly every feeding
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A.4. Bottlefed stool – - pale yellow, formed hard with typical offensive odor
- seldom passed, 2 – 3 times a day - with food added
- brown & odorous
B. Indication of Stool ChangesJaundice baby – light stoolUndergoing phototherapy – bright greenMucus mixed with stool - milk allergyClay colored stool – obstruction to bile ductChalk clay stool – after barium enemaBlack stool – GIT bleeding (melena)Blood flecked stool - anal fissure. Currant jelly stool – intussusceptionsRibbon like stool – hirschsprung diseaseSteatorrhea stool – fatty, bulky foul smelling odor stool
Malabasorption Syndrome 1. celiac disease or 2. cystic fibrosis
Cult blood – stool exam
III Assessment for Well – being
A. APGAR SCORE – Dr. Virginia ApgarSpecial Considerations:1st 1 minute – determine general condition of babyNext 5 minute - determine baby’s capabilities to adjust extra uterinely (most important )Next 15 minute – dependent on the 5 minute
Newly Born Baby:A- appearance - color – slightly cyanotic after 1st cry baby becomes pink.P- pulse rate – apical pulse – left lower nipple G- grimace – reflex irritability
Subcomponents: tangential foot slap, catheter insertion A – activity – degree of flexion or muscle toneR – respiration
New Delivered Baby:Baby cry – within 30 secondsFailure to cry after 30 seconds – asphyxia near the neotorium Respiratory Depression – due mom given Demerol. Administer Naloxone
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APGAR Scoring Chart:
0 1 2Heart Rate - absent < 100 > 100
Respiratory effort - absent - slow, irregular, weak - good strong cryMuscle tone - flaccid extremities - some flexion - well flexed
Reflex irritabilityCatheter - no response - grimace - cough, sneeze
Tangential Foot slap No Reaction - grimace - cryColor - blue / pale - acrocyanosis
Chest movement synchronized Lag on respiration See - sawIntercostal retraction No retraction Just visible MarkedXiphoid retraction None Just visible Marked Nares dilatation None Minimal MarkedExpiratory grunt None Heard on stet only Heard on naked ear
C. Assessment of Gestational Age Tool Used: Ballards & Dobouitz
Findings Less 36 weeks (Preterm)
37 - 38 39 and up
Sole creases Anterior transverse crease only
Occasional creases 2/3 inch
Sole covered with creases
Breast nodules 2 mm 4 mm or 3.5 mm > 5 or 7 mmScalp hair Fine & fuzzy Fine & fuzzy Coarse & silkyEar lobe Pliable Some cartilage Thick cartilage Testes and Scrotum
testes in lower canalScrotum – small few rugae
Some intermediate Testes pendulus Scrotum full extensive rugae
Signs of Preterm BabiesBorn after 20 weeks, after 37 weeks
- frog leg or laxed positon - hypotonic muscle tone- prone to respiratory problem- scarf sign – elbow passes midline - square window wrist – 90 degrees angle of wrist - heel to ear sign - abundant lanugo
Signs of Post term babies:> 42 weeks- classic sign – old man’s face- desquamation – peeling of neonate skin- long brittle finger nails- wide & alert eyes
IV. Neonate in Nursery* Special and Immediate Interventions:
1. Upon receiving baby - proper identification - foot printing, affixing mother thumb print
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2. Take anthropometric measurementNormal Length - 19.5 – 21 inches or 47.5 – 53.75 cm
Average = 20 inches Average = 50 cmHead Circumference 33- 35 cm or 13 – 14 inches
Average = 34 cmHydrocephalus - >14 inches
Chest : 31 – 33 cm or 12 – 13 inchesAbdomen 31 – 33 cm or 12 – 13 inchesNote: Head is bigger than the chest/abdomen
Function of vernix caseosa 1. insulator – “brown fats”2. bacterio - static
Alert: 1. Babies of HIV + mom – immediately give full bath; to lessen transmission of HIV ; 13 – 39 % possibly of transmission of HIV 2. Full Bath - safely given when cord falls
4. Dressing the Umbilical Cord * follow strict asepsis to prevent tetanus neonatorium by giving tetanous toxoid
three cleans in community:1. Clean hand2. Clean cord3. Clean surface
Note: Betadine or Povidone Iodine - used for cleaning the cordUmbilical Granulation – after 2 weeks, umbilical cord does not fall.* Check for three vessels Alert: 1. If 2 vessel cord – suspect kidney malformation
2. Leave about 1 inch of cord* If Blood Transfusion or IV infusion
– leave 8 inches of cord best access – no nerve
* Check cord every 15 minutes for 1st 6 hours – bleeding > 30 cc. of blood – “hemorrhage” to the new born* Bleeding of cord with pus – Omphalitis – suspect
hemophilia/blood dyscrasia * Best access for IV transfusion – Umbilical cord* Cord turns black on 3rd day & fall 7 – 10 days * Faiture to fall after 2 weeks- Umbilical granulation
Management: silver nitrate or catheterization- clean with normal saline solution not alcohol- don’t use “bigkis” – air- persistent moisture-urine, suspect patent uracus – fistula between
the bladder and normal umbilicusDiagnostic Examination: Nitrazine paper test – yellow – urine Management: Surgery
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5. Credes Prophylaxis – Dr. Crede- prevent opthalmia neonatorum or gonorrheal conjunctivitis- how transmitted – mom with gonorrhea/ chlamydiaDrug: Erythromycin Ophthalmic Ointment- inner to outer
silver nitrate (used before) – 2 drops lower conjunctiva (not used due to staining)
6. Vitamin K – to prevent hemorrhage Related To physiologic hypoprothrombinemia
- Aquamephyton, phytomenadione or konakion- .5 – 1.5 ml IM, vastus lateralis or lateral anterior thigh
- 5 ml preterm baby
Vitamin K – synthesized by normal flora of intestine Vitamin K – medication is synthetic due intestine is sterile
7. Weight - Taking: Normal weight: 3.000 – 3400 grams ; 3 – 3.4 kg 6.5 - 7.5 lbs
Arbitrary lower limit 2500 gramsLow birth weight baby delivered < 2500gSmall for gestational age (SGA) < 10th % rank or born smallLarge for gestational age > 90th % rank or macrosomia > 4000 gAppropriate for Gestational Age – within 2 standard deviation of mean Physiologic weight loss – 5 – 10% wt loss few days after birth
Small Gestational Age < (less) 10Large Gestational Age > (more) 90
V. Physical Exam and Deviations from Normal
A. Important Considerations:1. if client is new born, cover areas not being examined 2. if client is infant – the 1st yr of life - the first vital sign to take
* from the least intrusive to the most intrusive area – take Respiratory Rate 1st
3. if client is a toddler and preschool, let them handle an instrument like: - play syringe or stethoscope, security blanket – favorite article. Let baby hold it.
3. if the client is school age and adolescent, explain procedure and respect their modesty
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B. Components:
1. Vital Signs: * Temperature
rectal - newborn – to rule out imperforate anus- take it once only, 1 inch insertion
Imperforate anus1. atretic – no anal opening 2. agenetic – no anal opening3. stenos – has opening4. membranous – has opening
Earliest sign: 1. no mecomium2. abdominal distention3. foul odor breath4. vomitous of fecal matter5. can aspirate – respiratory problem
Management:Surgery with temporary colostomy
* Cardiac rate: 120 – 160 beats per minute newborn Apical pulse – left lower nippleAlert:Radial pulse – normally absent. If palpable present PDA
( Patent Ductus Arteriosus )Femoral pulse – normal present. If absent- COA ( Coartation of Aorta )
* Common in boys:1. TOGA ( transportation of great arteries)
2. TA – ( tricuspid atresia) 3. TOF – (tetralogy of fallot)
Causes: 1. familial2. exposure to rubella (german measles) – 1st month 3. failure of structure to progress
Two Major Types: 1. acyanotic Left to Right 2. cyanotic Right to Left
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Two Major Types:A. Acyanotic heart defects Left to Right Shunting
* with increase Pulmonary Blood Flow
1. Ventricular Septal Defect - opening between 2 ventricles
Signs & Symptoms: 1. systolic murmurs at lower border of sternum and no other significant signs
2. cardiac catheterization reveals increased oxygen saturation at the Right side of the heart3. ECG reveals hypertrophy of the right ventricle or Right side of the heart
50% - goes to the Upper/Lower extremities50% - right side of the heart – causing hypertrophy of the right ventricle
Nursing Care:Cardiac catheterization: common site – Right femoral vein
1. NPO 6 hours before procedure2. protect site of catheterization.
PROTECTION OF Femoral Vein:a. Avoid flexion of joints proximal to site.b. Observe for the signs and symptoms of complications
3. assess for complication 1. infection2. thrombus formation – possible embolism
4. check pedal pulse ( dorsalis pedis)
Management:1.) self limiting2.) open heart surgery
2. Atrial Septal Defect – failure of foramen ovale to close within 24 hours (closure)
Position: right side lying position
Signs and Symptoms: 1. systolic murmur @ upper border of sternum 2. result of cardiac catheterization & ECG same with
Ventricular Septal Defect
Management: open heart surgery
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3. Endocardial Cushion Defects – also known as atrium ventricular (AV ) – canal between the atria and ventricles ; affects both tricuspid
and mitral valve
Signs and Symptoms: confirmed by cardiac catheterization
Management: open heart surgery
4. PDA – Patent Ductus Arteriosus - failure of ductus arteriosus to close - should close within 24 hours - complete close – 1 month
Signs and Symptoms: 1. continuous machinery like murmurs 2. prominent/ presence radial pulse 3. ECG- hypertrophy Left ventricle
Management:1. Endomethazine – prostaglandin inhibitor - facilitate closing of PDA2. Ligation of PDA by 3 - 4 years old3. thoracotomy procedure- nakadapa child
* with decrease Pulmonary Blood Flow1. Pulmonary Stenosis
2. S2 sound widely split3. ECG - Right ventricular hypertrophy
2. Aortic Stenosis – narrowing of valve of aorta
Signs and Symptoms:1. inactive, symptoms same with angina 2. typical murmur3. rough systolic sound and thrill4. ECG- Left ventricular hypertrophy* If active – the child may exhibit signs of Angina
Management: Pulmonary Stenosis & Aortic Stenosis1.) balloon stenostomy2.) surgery – recurrent so the “least” important
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3. Duplication of Aortic Arch- doubling of arch of aorta causing compression to trachea and esophagus
4.) Hypoplastic Left heart syndrome – non-functioning Left ventricle* Function of the left ventricle is to pump oxygenated blood to aortaSigns and Symptoms:
5.) Tricuspid atresia – failure of tricuspid valve to openSigns and Symptoms: 1. open foramen ovale
(R to L shunting – goes to Lt atrium) 2. cynosis 3. polycythemia
Management: Fontan procedure – open tricuspid valve
6.) Tetralogy of FallotFour Anomalies Present:P – pulmonary stenosisV – ventricular Septal DefectO – overriding or dextroposition of aortaR – Right ventricular hypertrophy
Signs & Symptoms: 1. Right ventricular hypertrophy 2. high degree of cyanosis3. polycythemia4. severe dyspnea – only relieve by squatting position – inhibit venous return - facilitate lung expansion. 5. growth retardation – due no O26. Tet Spell or blue spells - short episodes of hypoxia7. syncope or fainting8. clubbing of fingernails – due to chronic tissue hypoxia9. mental retardation – due decreased O2 in brain
1. RHD Rheumatic Heart Disease- inflammatory disease followed by an infection acquired/caused by group A Beta hemolytic strepto coccusAffected body parts :
1. cardiac muscles and valves2. musculoskeletal 3. CNS 4. Integumentary
* From initial Sorethroat before RHD Tonsillitis (children because they love sweets)* Aschoff Bodies – rounded nodules with multinucleated cells and fibroblasts that stays and occludes mitral valve. Signs and Symptoms:
Jones Criteria Major Minor
1. polyarthritis – multi joint pain 1. arthralgia – joint pain2. chorea – sydenhamms chores or st. vetaus dance - purposeless involuntary hand and movements of shoulder accompanied by grimacing
3. all lab results = elevatedincrease antibody “ C reactive protein “ erythrocyte sedimentation rate “ anti- streptolysin O titer (ASO)
Criteria:Presence of 2 major signs, or 1 major and 2 minors + history of sore throat willconfirm the diagnosis
Diagnostic Tests:1. Antibody2. C-reactive protein3. Erythrocyte Sedimentation Rate4. Anti – Streptolysin O titer (ASO).
Nursing Care:1. Complete Bed Rest2. Avoid contact sports 3. throat swab – prepare culture and sensitivity 4. antibiotic management – to prevent recurrence 5. aspirin – anti-inflammatory. Low grade fever – don’t give aspirin. Side Effects of aspirin:
* Reyes syndrome – “encephalopathy” – accompanied by fatty infiltration of organs such as liver and brain
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RespirationNewborn respiration: 30 - 60 breaths per minute, irregular abdominal or diaphragmatic with short period of apnea (absence of breathing) without cyanosis
< 15 seconds – normal apnea – newborn
Respiratory Check:Newborn – 40 – 90
1 year - 20 – 40 2 – 3 years - 20 – 30 5 years - 20 – 2510 years - 17 – 2215 years & above 12 – 20
BREATH SOUNDS HEARD DURING ASCULTATION:1.) VESICULAR – soft, low pitched, heard over periphery of lungs, inspiration longer than expiration. Normal
2.) BRONCHOVESICULAR - soft, medium-pitched, heard over major bronchi, inspiration equals expiration. Normal
3.) BRONCHIAL SOUNDS - loud high pitched, heard over trachea, expiration longer than inspiration. Normal
4.) RHONCHI – snoring sound made by air moving through mucus in bronchi. Normal
5.) RALES - or crackles ( like cellophane ) made by air moving through fluid in alveoli. Abnormal : denotes pneumonia or pulmonary edema which is fluid in alveoli
6.) WHEEZING - whistling on expiration made by air being pushed through narrowed bronchi .Abnormal: seen in children with asthma or foreign-body obstruction.
7.) STRIDOR - crowing or rooster like sound made by air being pulled through a constricted larynx. Abnormal : seen in children with respiratory obstruction
8.) R ESONANCE – Loud , low tone, percussion sound over normal lung tissue
9.) HYPERRESONANCE – Louder. lower sound than resonance, a percussion sound over normal lung tissue
Asthma - pathognomonic sign – expiratory wheezing Pet – fish. Sport – swimming Drugs – Amynophylline Monitor blood pressure, may lead to hypotension
RDS (respiratory distress syndrome or hyaline membrane disease)Cause: lack of surfactant ( Lecithin) – for lung expansion Hypotonia, Post surgery, Common to preterm
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Fibrine hyaline Symptoms:
1. definite with in 1st 4 hours of life 2. RETRACTION: EARLIEST SIGN
Increase RR with retraction3. Inspiratory grunting – pathognomonic
7 – 10 severe RDS (silvermenn Anderson index)cyanosis due to atelectasis
4. flaring alaenacyManagement:
1. surfactant replacement and rescue 2. position: head elevated 3. proper suctioning – 5 – 10 seconds4. oxygen with increase humidity - to prevent drying of mucosa 5. monitor Vital Signs, skin color , ABG6. CPAP- continuous positive airway pressure7. PEEP - positive end expiratory pressurePurpose of # 6-7 - to maintain alveoli partially open and alveoli collapse
LARYNGOTRACHEOBRONCHITISLTB – most common Croup – refers to the viral infection of larynx (inflamed), trachea & bronchioutstanding symptoms: croupy cough or barking pathognomonic - stridor = signs of carbon dioxide retention ( Respiratory Acidosis)
- labored respiration - respiratory acidosis- end stage – death
Laboratory:1. ABG 2. throat culture3. diagnosis - neck 4. Chest x-ray to rule out epiglotitis
Nursing Management: 1. bronchodilators ( Racemic Epinephrine )2. increase oxygen with humidity 3. prepare tracheostomy set
BRONCHOLITIS - Inflammation of bronchioles – tenacious mucus Causative agent – RSV – Respiratory sincytial virusesSymptoms: flu like symptoms/cold like symptoms Increased Respiratory RateDrug: Antiviral – Ribavirin End stage – epiglotitis
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EPIGLOTITIS - inflammation of epiglottis - emergency condition of Upper Respiratory Tract Infection
Symptoms: sudden onset Tripod position – leaning forward with tongue protrusion
Management: Avoid/never use tongue depressor prepare tracheotomy set < 5 years old – unable to cough out, put on mist tent (humidifier o2) or croupette
Nursing Care: check edges tucked on mist tentProvide washable plastic material toys for mist tent No toys with friction due Oxygen No hairy toys – due moist environment medium for bacterial growth
Drug of Choice: RIBAVIRIN
Blood Pressure Cuff should cover 2/3 or 50 – 75% of the upper arm More than 2/3 = low Blood Pressure Below 2/3 = False high blood pressure
* Blood Pressure – 80/46 mmHg newborn * Blood Pressure after 10 days - 100/50 * Blood Pressure taking begins by 3 years old
COA coartation of aorta – take Blood Pressure on 4 extremities
2. SKIN: Acrocyanosis – Body : pink
- Extremities: blueBIRTHMARKS: 1. Mongolian spots – stale gray or bluish discoloration patches commonly seen across the sacrum or buttocks due to accumulation of melanocytes. Disappear by 1 year old . Common in Asian new borne2. Milla – plugged or unopened sebaceous gland . white pin point patches on nose, chin or cheek. Disappear without treatment by 2 -4 weeks3. Lanugo – fine, downy hair – common preterm 4. Desquamation – peeling of newborn skin within 24 weeks – post term - extreme dryness that begin sole and palm. 5. Stork bites (Talengeictasi nevi) – pink patches at the nape of the neck
hair will grow as child grows old 6. Erythema Toxicum – (flea bite rash) - 1st self limiting rash appear sporadically & unpredictably any time & place. 7. Harlequin sign – dependent part is pink, independent part is blue
(side lying – bottom part is dependent pink) 8. Cutis Marmorato – transitory mottling of neonates skin when exposed to cold. 9. Hemangiomas – vascular tumors of the skin
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3 types Hemangiomas a.) Nevus Flammeus – port wine stain – macular purple or dark red lesions
usually seen on the face or thigh. NEVER disappear but as the child grows it can be removed surgically
b.) Strawberry hemangiomas – nevus vasculosus – dilated capillaries in the entire dermal or subdermal area continuing to enlarge but disappears after 10 years old.
c.) Cavernous hemangiomas – consists of communicating network of venules in subcutaneous tissue that never disappear with age.
MOST DANGERIOUS – internal hemorrhage
10. Vernix Caseosa – white cheese like for : 1. lubrication 2. insulator Significance 3. bacterio static
Skin color and their significance:blue – cyanosis or hypoxia Pale skin - anemiaWhite/Shining – edema Grey – infectionYellow – jaundice , carotenimia - ↑ carotene in the skin
* BURN TRAUMA – is an injury to body tissue caused by excessive heat.
INFANT 5 - 9 years oldANTERIOR POSTERIOR Anterior Posterior
Assessment:1. DEPTH1st degree – (partial thickness) – involves only the superficial epidermis characterized by erythema, dryness and PAIN
example: sunburn, heals by regeneration from 1 – 10 days 2nd degree – (partial thickness) – involves the entire epidermis & portion of dermis, characterized by erythema, blisters, moist from exudates which is extremely painful
example: scalds3rd degree – (full thickness) – involves both skin layers, epidermis and dermis/ may involve adipose tissue, fascia, muscle & bone. It is leathery, white or black and not sensitive to pain since nerve endings had been destroyed.
Example: lava burns; flames
Management: 1.) 1st aid a.) put out flames by rolling child on a blanket b.) immerse burned part on cold water c.) remove burned clothing of with sterile material d.) cover burn with sterile dressing 2.) Maintenance of a patent airway
a.) suction if necessary (PRN)b.) administration of oxygen with increased humidity c.) endotracheal intubationd.) tracheostomy
3.) Prevention of shock & Fluid and Electrolyte imbalance a. colloids to expand blood volume b. isotonic saline to replace electrolytes c. dextrose & H2o to provide calories
4.) A booster dose of Tetanus toxoid 5.) Relief of pain such as IV analgesic
MORPHINE SO4 – needed for 2nd degree – very painful 6.) prevention of wound infection
1st defense of body – intact skin a.) cleaning & debriding of woundb.) open or close method of wound carec.) whirlpool therapy – drum with solution
7.) skin grafting – 3rd degree – thigh or buttocks (autograft)(common in children) pigs/ animals – xenograft
* ATOPIC DERMATITIS - infantile eczema (“hika ng balat”)Papulo vesicular erythematus lesions with weeping & crusting
Cause – food allergies: milk, citrus juice, eggs, tomatoes, wheat Symptoms: extreme pruritus, linear excoriation, weeping and crusting; scaly shiny white – lechenification Goal of care: decrease pruritus – avoid food allergens Diet: Isomil or NutramigenHydrate skin with a borow solution topical steroid such as
1% hydrocortisone cream Prevent infection – proper handwashing, trim nails: cut it short
* IMPETIGO - skin disease. Causative agent – cause by group A beta Hemolytic streptococcus characterized by Papulo-vesicular surrounded by localized erythema – becoming purulent and oozes forming a honey colored crust Pediculosiscapitis –“KUTO”
Management: proper hygiene – wash soap and water Sequelae: oral penicillin – bactroban ointment
Can lead to acute glomerulonephritis AGN
* ACNE - adolescent problem (common)- self limiting inflammatory disease that involves sebaceous gland - comedones – sebum causing white heads - sebum - composed of lipids/cholesterol causing acne bulgaris
Management: proper hygiene- mild soap or sulfur soap Body Acne - antibacterial Retin A or Tretinol
* ANEMIA - pallor Possible Causes:
1.) early cutting of cord – preterm – cut umbilical cord ASAP fullterm – cut umbilical cord when pulsation stops
2.) Bleeding disorders – blood dyscrasias
* HEMOPHILIA – deficiency of clotting factor. - X linked recessive – inheritance
* If mom – carrier, son – affected * If father carrier - transmitted to daughter
Hemophilia A – deficiency of coagulation component factor 8 (Classic) Hemophilia B – or Christmas Disease, deficiency of clotting factor 9Hemophilia C – deficiency of clotting factor 11
Assessment:- umphalagia – earliest sign ( excessive bleeding of the cord or after
circumcision- newborn receive maternal clotting factor (no bleeding)- newborn growing – easy bruising on bump area – “marks” earliest sign
Diagnostic test : PTT. Partial thromboplastin time – reveals deficiency in clotting factor Long Term Goal- prevention of injury Nursing Diagnosis: increase risk of injury Health Teaching: 1. avoid contact sport, swimming only2. don’t stop immunization – just change gauge of needle “Falls” – immobilized , elevate affected part, apply gentle pressure
- not more then 10 minutes - cold compress 3. determine case before doing invasive procedure Alert: NO ASPIRIN
* LEUKEMIA - group of malignant disease characterized by rapid proliferation of immature White Blood Cell (5,000 – 10,000 cucmm3 )
WBC – protection from infection, soldiers of body Classification : 1. Lympho – affects lymphatic system 2. acute / blastic- affects immature cell Acute Lymphocytic 3. Myelo – affects bone marrow Leukemia4. chronic/ cystic- affects mature cells (Most common Cancer)Signs & Symptoms:
1. from invasion of bone marrow signs of infection
a.) fever b.) poor wound healingc.) bone weakened & causes fracture
signs of bleeding a.) petechiae - small, round, flat, dark red spot b.) epistaxis – nose bleedingc.) hematuria - blood in urine/ emesis – blood in vomiting
signs of anemia a.) pallor b.) easy fatigability
2. from invasion of body organ - hepato spenomegaly – abdominal pain , CNS affectation, increase ICP
Diagnostic Tests:1. PBS - peripheral blood smear – determine immature RBC 2. CBC – determine anemia, leukocytosis, thrombocytopenia, neutropenia 3. lumbar puncture (LP) – determine CNS involvement. * Before Lumbar Puncture , fetal position - avoid flexion of neck – will cause airway obstruction.“C” position or shrimp position only. 4. bone marrow aspiration – determine blast cells,
- common site - iliac crest - post BMA: side effect – bleeding - apply pressure. Put patient on affected side to prevent hemorrhage
5. Bone scan – determine bone involvement
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6. CT scan – determine organ involvement
Therapeutic Management:TRIAD: for CANCER1. surgery 2. irradiation 3. chemotherapy Focus Nursing Care: prevent infection
4 LEVELS OF CHEMOTHERAPHY1. For Induction – goal of treatment: to achieve remission Medications: IV vincristine
L- agpariginase Oral prednisone
2. For Sanctuary - treat leukemic cells that invaded testes & CNSGive: 1. Methotrixate - administer intrathecally via CNS or spine 2. Cytocine 3. Arabinoside, steroids with irradiation 3. For maintenance - to continue remission Give: oral methotrisate – check WBC
- administration of methotrisate – do weekly White Blood Cell check-up
oral 6 Mercaptopurine; Cytarabine4. For Reinduction – reduce leukemic cells after relapse occurs.
Medications: same as induction 5. Antigout Agents: allopurinol or Zyloprim - treat or prevent hyperurecemic nephropathy.
Nursing Management:1. Assess the common side effects of chemotherapyOutstanding nursing diagnosis: alteration in nutrition less body requirement.
Based on Maslow’s hierarchy “ Physiologic” – always the first prioritySide Effect of Chemotherapy: 1. Nausea and Vomiting – administer antiemetic drugs 30 minutes before chemotherapy and continue until 1 day after chemotherapy 2. Ulcerations / stomatitis / abscess of oral mucosa- (alteration nutrition less than body requirement)
Mother (-) = no antigen (no protein factor) Father (+) = has antigen (protein factor)Erythroblastosis Fetalis – Hemolysis - ↓oxygen carrying → IUGR with pathological jaundice within 24 hoursRhogan – a vaccine given to Rh (-) given to mother within 72 hours to destroy fetal RBC hence preventing Rh sensitization after 72 hours – should not be given
Destroyed RBC
HEME GLOBULIN
IRON PROTOPORPHYRIN
Indirect Bilirubin FAT SOLUBLE - Direct Bilirubin WATER SOLUBLE
Can be excreted by kidneys
ABO incompatibility – Most common incompatibility – ( mom) O – ( fetus) A,B,ABMost severe incompatibility (Mom) O– (Fetus) BCan affect 1st pregnancy
“O” – universal donor ; AB – universal recipient Hydrops (h20) Fetalis – edematous on lethal state with pathologic jaundice
Within 24 hours ( most common ABO incompatibility)Management: 1. initiate feeding2. Temporary suspension of breastfeeding
glucoronil transferase content breast milk pregnanedioles – that delays action of glucoronil transferaseglucoronil transferase – is a liver enzymes converts “indirect bilirubin”
(fat soluble ) to become direct bilirubin (water soluble) * Life span of RBC – 20 days
3. Use of phototherapy
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4. Exchange transfusion for Rh or ABO affectations that tend to cause continuous decrease in hemoglobin during the first 6 months because the bone marrow fails to produce erythrocytes in response to continuing hemolysis.
Yellow – JaundiceHyperbilirubinemia - > 12 mg/dL of indirect bilirubin among full term Normal – 0 - 3 mg/dL (indirect bilirubin)
- bilirubin encephalopathy - Kemicterus - > 20 mg/dL among full term &
>12 mg /dl of indirect – preterm = can lead to cerebral palsy
Physiologic jaundice – jaundice within 48 -72 hours (2-3 days) expose morning sunlight - also known as Icterus Neonatorium ( Yellow Baby)Pathologic Jaundice – within 24 hours. Jaundice during delivery. Icterus Gravisneonatorium ( Baby Yellow “na”)Breastfeeding jaundice – caused by pregnanediole – delayed reaction of glucoronil transferase; present 6 -7 days
Assessment of Jaundice :1. Blanching neonates forehead, nose or sternum – ( normal cyanotic )2. yellow skin & sclera 3. color of stool – light stool4. color of urine – dark urine Management: Phototherapy – photo oxygenation
Nursing Responsibilities: 1. cover eyes – prevent retinal damage 2. cover genitals – prevent priapism – painful continuous erection 3. change position regularly – even expose to light 4. increase fluid intake – due prone to dehydration 5. monitor Input & Output – weigh baby
weigh diaper 1gm = 1cc6. monitor Vital Signs – avoid use of oil or lotion , due to heat at phototherapy
side effects: bronze baby syndrome - transient Side Effect of phototherapy 18 inches – 20 inches = height of phototherapy light
3. Head – largest part of baby ; ¼ of its length Craniostenosis or craniosinustosis – premature closing of anterior fontanel
Hydrocephalus – ant fontanel open after 18 months Microcephaly – small growing brain - due to alcohol & HIV positive mom withdrawal syndromeAnencepahly – absence of cerebral hemisphere
Noticeable Structures of the Head:1. Craniotabes – localized softening cranial bone. Common to the 1st born child
- due to early lightening (2 weeks prior to EDD)Rickets of Vitamin B deficiency – soft craniotabes in older children
2. Caput Succedaneum – edema of scalp due prolonged pressure at birthCharacteristics:
1. present at birth
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2. crosses suture lines 3. disappear after 2 - 3 days
3. Cephalhematoma - collection of blood due to rapture of periosteal capillaries Characteristics :
1. present after 24 hours2. never cross suture line 3. disappear after 4 - 6 weeks
4. Seborrheic Dermatitis – ‘craddle cap” Scaling, greasy appearing salmon colored patches usually seen on scalp
the behind ears and umbilicus Cause: - improper hygieneManagement:
1. proper hygiene2. application of baby oil before shampooing the child
5. Hydrocephalus – excessive accumulation of CerebroSpinalFluid1. communicating – extra ventricular hydrocephalus 2. non-communicating- intraventricular hydrocephalus or obstructive
hydrocephalus mainly due to tumor obstructionSymptoms: ↑ ICP – abnormally large head, bulging fontanel
- cushings triad : ↑ Blood Pressure ; ↑ Respiratory Rate with widening ; high pitched cry
Management: Position to lessen ICP – low semi-fowlers 30 degrees angle
Administer - osmotic diuretic: Mannitol/ Osmitrol , Diamex- Azetam To decrease CSF production “Surgery” Shunting – AV shunt or VP shunt (ventriculoperitoneal shunt) Shave hair just before the surgery – in OR – to prevent growth of micro organism
Nursing Care:1.) post VP shunt – side lying on non operated site - to prevent increase ICP or increase IOP
monitor for good drainage - sign – sunken fontanel bulging fontanel – blocked shunt
4. SENSES A. Sense of Sight (EYES): Assessment
1. check for symmetry 2. sclera – normal color – light blue then become dirty white 3. pupils – round- adult size
coloboma- part of iris is missing sign: key hole pupil
Test for blindness common tests1. newborn – general appearance
- can only see 10 inches – 12 inches - visual acuity 20 /200 to 20/ 8001.1. Doll’s eyes test - test for blindness
- done 10th day - pupil goes opposite to direction when head is moved
1.2. Globellars test – test for blink reflex. Points near nose – baby should blink (-) blink - - blind
2. Infant & children - general appearance - ability to follow object past midline
3. 3 years – school age - general appearance Allen cards – test for visual acuity. Show picture 20 feet away Ishiharas plates – test for color blindness Prechool E chart - test for stereoptist of depth perception Cover testing test – cover 1 eye for 10 – 15 min. Then remove. Test for strabismus
4. School age – adult - general appearance- snellens test
Retinobastoma – malignant tumor of retina Outstanding sign : oat’s eye reflex-whitish glow of pupil
- red painful eye usually accompanied with glaucoma- blindness
surgery – Enucleation – removal of eyeball put artificial aye Normal – 4 – 6 months –eye deviation
> 6 months – lazy eye: eye patch for covering the eyes
B. Sense of Smell (NOSE):1. flaring alenase – case of RDS 2. cyanosis at rest – choanal atresia - post nares obstructed with bone
or membrane Symptoms:
1. resistance during catheter insertion Management: emergency Surgery within 24 hours
* normal color nasal membrane – pinkish * chronic rhinitis – presence of creases & pale * check sense of smell – blindfold – smell * inflammation/infection – red membrane* Hair in nose – cilia
Adolescent no hair with ulceration of nasal mucosa suspect “cocaine user”
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Epistasis – nosebleed - sit upright, head slightly forward to facilitate drainage- cold compress , apply gentle pressure, epinephrine administration based on
constriction* most developed sense of newborn – sense of touch * 1st sense to develop & last to disappear – hearing
C. Sense of Hearing (EARS): 1. Kidney Malformations :
Properly aligned with outer cantus of eyes low set ear – kidney malformation/ chromosomal aberrations example: Renal aginesis – absence of kidney unilateral – one kidneyBilateral – two kidneyssign in uterus : oligohydramniossign in newborn: 2 vessel cordfailure to void within 24 hours (suspect renal aginesis)
Management: kidney transplant 2. Chromosomal aberrations : related to advance maternal age
A. Nondisjunction – uneven division Classifications:
1.1. Trisomy 21 - down syndrome - extra chromosome 47xx + 21 - related to advance paternal age
47xy + 21Symptoms:Mongolian slant eyes; low set earsBroad flat nose Protruding tongue Puppy’s neck Simean crease (Hands) – single transverse line on palm. Mental Retardation
1.2. Trisomy 18 – “edward syndrome” – sole of foot is rounded called “Rockers Bottom Foot”1.3. Trisomy 13 - patau syndrome - microptamia1.4. Turners – Monosomy of X syndrome
- 45 x 0- affected girls - signs , evident during puberty - has poorly developed secondary sexual characteristics - Sterile
1.5. Klinefilters Syndrome - has male genitalia - 47 XXY - poorly development secondary sexual characteristics - no deepening of voice - characteristics: small testes and penis – sterile
Symptoms: Otitis1. bulging tympanic membrane, color – pearly gray 2. absence light reflex 3. observe for passage of milky, purulent foul smelling odor discharge 4. observe for URTI
Nursing Care:1. position side lying on affected aside – to facilitate drainage 2. supportive care- bed rest, increase fluid intake
Medications :1. Massive dosage antibiotic Complication – bacterial meningitis 2. Apply ear ointment * < 3 years old - down-back (small child)* > 3 years old - up-back (school age)Small child – down & back ( no age)< 3 years old – down & back >3 years old – up & back
School age – up and down Surgery (to prevent permanent hearing loss)– otitis media – myringotmy with tympanostomy tube ↓
post surgery – position affected side for drainage slight incision of both – put ear plug tympanic membrane if tympanous tube falls – healed “na”
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5. Mouth and Tonguea. Bells Palsy - facial nerve; #7 cranial nerve injury or paralysis R/T forcep delivery Symptoms.
1. Continuous drooling of saliva 2. inability to open one eye & close the other eye
Management:Refer to Physical Therapist
b. TEF (Tracheoesophageal Fistula) – self limiting TEA (Tracheoesopageal Atresia ) - there is a pouch; no connection
between the esophagus and stomachOutstanding Symptom:
Coughing Choking Newborn
Continuous drooling 4 C’s Cyanosis
Management:Emergency surgery
c. Epstein pearl – white glistening cyst usually seen at/on palate & gums related to hypercalcemia* Hypervitaminosis
d. Natal tooth – tooth at birth. Move with gauze
e. Neonatal tooth – tooth within 28days of life
f. Oral Moniliasis – oral candidiasis ; oral thrush- white cheese like, curd like patches that coats the mouth and the tongue Nursing Care: don’t remove, wash with cold boiled waterMedications: nystatin / Mysnastatin – antifungal
* Kawasaki Disease -- strawberry tongue - originated in Korea- Dr. Kawasaki discovered it- common in Japan- “mucocutaneous Lymphnode Syndrome” Criteria for diagnosis of Kawasaki Disease:1. persistent fever lasting more than 5 days 2. Bilateral Conjunctivitis3. Changes of lips and oral cavity
a. dry, red fissure lipsb. strawberry tonguec. diffuse erythema of mucous membrane
4. Changes of peripheral extremitiesa. erythema of the palm & sole b. indurative edema of the hands and feetc. membranous desquamation from fingertips
5. Polymorphous rash ( primarily on trunk)
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6. Acute nonpurulent swelling of cervical lymph node to > 1.5 cm in diameter
* lymph adenopathy > 1,5 cm* Drug: aspirin ; administration of gamma globulin* May lead to MI
LIPS- symmetrical Cleft lip – failure of median maxillary nasal process to fuse by 5 - 8 weeks of pregnancy
- common to boys- unilateral
Cleft Palate - Failure of the palate to fuse by 9 – 12 weeks of pregnancy- common to girls - unilateral or bilateral
By means of ULTRASOUND – can be detected at onceSymptoms:
1. evident at birth 2. milk escapes to the nostril during feeding 3. frequent colic 4. otitis media 5. URTI
Management: 1. Surgery
cleft lip repair – Cheiloplasty = done 1 - 3 months to save sucking reflex (lost in 6 months ) Cleft Palate - uranoplasty = done 4 - 6 months to save speech
(palatoplasty)Pre operation care:
1. emotional support for the parents especially to mom2. proper nutrition - if unable to suck – use medicine dropper
- use cleft lip nipple3. prevent colic
feed – upright seating or prone positionburp frequently 2 times at middle and after feeding - lower to upper tap Bootle feeding : every 3 -5 minutesPosition: Right side lying position – to facilitate gastric motility
Post Operative Care:1. orient parents to type of feeding
rubber tipped syringe – cheiloplasty (cleft lip)paper cup/ soup spoon/ plastic cup – urano plasty (tonsillectomy) Position: Prone Position
2.. apply restraints – elbow restraints (apply pre-operatve) so baby can adjust post operation
Position: Prone Position
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Condition that warrants suspension of operation - Check for the presence of colds & nasopharyngitis
= can lead to generalized infection – septicemia
Post Operative Nursing Care :(Priority) 1. airway – positon for post cheilopasty – side lying for drainage
post uranoplasty (tonsillectomy) - prone 2. assess for RDS symptoms : bleeding 3. assess for bleeding – frequent swallowing, 6 - 7 days after surgery – bleeding
4. proper nutrition - clear liquids- (gelatin except red or brown color due may mask
bleeding) - ( popsicle - not ice cream) full liquid soft diet regular diet
5. Maintain integrity of suture line such as:Logan bar – wash ½ strength Hydrogen Peroxide & Saline
Solution - Bubbling effect traps microorganism- prevent baby from crying for pain - analgesic
* “gutom” hungry* wet diaper
NECK- 1.) check symmetry
Congenital torticolis - “ wryneck”- burn injury of sternocleidomastoid muscle during delivery – due to excessive traction at cephalic delivery
( case of incompetence ) Management: passive stretching exerciseLast Management: Surgery Complication: Scoliosis
THYROID gland – for basal metabolism Congenial cretinism – absence or non functioning thyroid glands (Hypothyroidism) Thyroidismgenesis
Reasons for Delaying Diagnosis:1. Thyroid glands covered by sternocleidomastoid muscles in newborn 2. baby received maternal thyroxine 3. baby sleeps 16 – 20 hours a day Earliest sign:1. change in crying 2. change in sucking 3. sleep excessively 4. constipation 5. edema – moon face Late sign 1. mental retardation
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Diagnostic Test:1. PPI - protein purine iodine2. radioimmunoassay test 3. radioactive iodine uptake
Treatment:Synthroid – sodium Levothyrosine - synthetic thyroid given lifetime- check pulse rate before giving synthroid - tachycardia – Symptoms of hyperthyroidism
CHEST 1. check for symmetry 2. breast - transparent (witch milk)fluid coming out from newborn related to
hormonal changes: * enlargement of the left breast is a suspect of Cardiomegaly * enlargement of the chest is a suspect of Atlectasis
ABDOMEN (in order)1. inspection I2. Auscultation A3. percussion P4. Palpation P = Will change bowel sounds, so do last
Normal contour of abdomen – slightly protruding
A. Diaphragmatic Hernia - Sunken abdomen ; protrusion of stomach content through a defective diaphragm due to failure of pleuroperitoneal canal to close.
Symptoms: 1. sunken abdomen2. enlargement of right and left chest3. Symptoms of RDS4. Right to Left shunting
Management:Emergency surgery within 24 hoursCPAP – continuous positive airway pressureCPPB – continuous positive pressure breathingECMO – extra corporeal membranous oxygenation
B. Omphalocele – protrusion of stomach contents in between junction of abdominal wall and umbilicus.
Management: If very small - surgery If large – suspension surgery Silver sulfadioxine ointment
C. Gastrochisis – absence of abdominal wall Nursing Management: sterile wet dressing
Gastrointestinal System
1. Functions: 1. Assists in maintaining Fluids & Electrolytes & acid/ base balance 2. Processes & absorbs nutrients to maintain metabolism & support Growth & Development 3. Excrete waste products from digestive process
2. Recommended Daily Allowance Calories : 120 cal / Kilo body weight per day 360 – 380 cal / day
CHON - 2.2 g / Kbw / day
3. Supplementary Feeding
Principles in Supplementary Feeding : Supplementary Feeding usually – 6 months Supplementary feeding can begiven as early as – 4 months ( 4 – 6 months)
Proper Weaning: done 6 – 9 months when shortening the nursing timePrinciples: Never wean the child if the baby is in crisis condition
a.) Solid food offered according to the following sequence:1. cereals – rich in iron2. fruits 3. vegetables 4. meat
b.) begin/ start with small quantities c,) finger foods – offered 6 months d.) soft table food – “modified family menu” is offered by 1 year
BQ-- e.) dilute fruit juices – 6 months 1:4 – fresh fruits - 1 oz of fruits to 4 oz of water f.) never give half cooked eggs – usually causes of salmoneliosis or gastroenteritisg.) never/don’t give honey – infant botulism – food poisoning
BQ-- h.) offered new food one at a time – interval of 4 – 7days or 1 week to determine food allergens
4. Major Concepts of fluid and electrolyte Balance:Total Body Fluids - comprises 65 - 85% of body weight among infants & children Where fluids are greater in infants Extracellular fuild – prone to develop dehydration
5. Acid Base Balance - dependent on the following:a. chemical buffersb, renal & respiratory system involvement b. dilution of strong acids and bases in blood
Assessment: * assess for the amount, frequency, force, color* projectile vomiting = increase ICP or pyloric stenosis
Management:B – bananaR - rice/cerealA - apple sauceT - toast
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B. Diarrhea – exaggerated excretion of intestinal contents Types:
1. Acute diarrhea are associated with the following:a. related to gastroenteritis, salmoneliosisb. dietary indiscretions c. antibiotic use – Ampicillin and Tetracycline
2. Chronic non specific diarrhea (CNSD) : Dietary Indiscretion: Causes:
Assessment: assess for the frequency, consistency, appearance of green
colored stool. Best criteria to determine diarrhea : consistency
Complications: = dehydration Mild dehydration 5% weight loss Moderate dehydration 10% weight loss Severe dehydration 15 % weight loss
Earliest symptoms of dehydration First sign:tachycardia increase temp weight losstachypnea sunken fontanel & eyeballs scanty urinehypotension absence of tears poor skin turgor – dry skin and mucous “hypotachytachy” membrane
Severe dehydration:Oliguria , Prolonged capillary refill timeSign: weight lossManagement:Acute – NPO ( rest the bowel )- with fluid replacement – IV- electrolyte loss is Poatssium (K)- prone to Hypokalemia – give K chloride Before administering of K chloride – check if baby can void, if cant void – hypokalemiaDrug: Na HCO3 – adminster slowly to prevent cardiac overload
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7. Gastric Motility Disorder:
A. HIRSCHPRUNGS DISEASE – (congenital aganglionic megacolon)Aganglionic – absence of ganglion cells needed for peristalis
Earliest sign 1. failure to pass mecomium after 24 hours2. abdominal distention 3. vomitus of fecal material
early childhood – ribbon like stool foul smelling odor stool constipationsdiarrhea
Diagnostic Procedure: 1. Barium enema – reveals narrowed portion of bowel 2. Rectal Biopsy – reveals absence of ganglionic cells3. abdominal x-ray – reveals dilated loops on intestine 4. rectal manometry – revels failure of intestine sphincter to relax
Therapeutic Management/Nursing Care 1. NGT feeding – measure tube from the nose to ear to midline of xyphoid
& umbilicus 2. surgery a.) temporary colostomy - temporary; close 2 – 3 months after the procedureb.) anastomosis & pull through procedure
Diet:High CHON, high calories , low residue – pasta , spaghetti and chicken
B. GER - Gastroesophageal RefluxChalasia – presence of stomach contents in the esophagus will lead to:
1. esophagitis complication 2. aspiration pneumonia 3. esophageal carcinoma or cancerEsophageal cancer Assessment :
1. chronic vomiting 2. faiture to thrive syndrome 3. organic – organ affected
OFTT ( Organic Failure To Thrive Syndrome)4. melena or hematemesis – esophageal bleeding
a.) Betanicol ( urecholine) – to increase esophageal tone & peristaltic activity b.) Metachloporomide (Reglam) – to decrease esophageal pressure by relaxing pyloric & duodenal segments
- increasing peristalsis without stimulating secretions
Alerts:- vomiting is an initial symptoms of upper GI obstruction- vomitus of upper GI can be blood tinged not bile streaked. (with blood)- vomitus of lower GI is bilous ( with pupu) Outstanding signs: projectile vomiting – increase ICP or GI obstruction - abdominal distention – major symptom of lower GIT obstruction
2.) metabolic alkalosis3.) failure to gain weight4.) peristaltic wave visible from left to right across epigastrium5.) olive shaped mass – on palpation of the abdomen
Diagnostic Procedures:1.) ABG2.)serum electrolyte – increase Na & K, decrease chloride 3.) ultrasound4.) x ray of upper abdomen with barium swallow, reveal “string sign”
B. INSTUSSUSCEPTION- invagination or telescoping of portion of bowel to anotherCommon site – ilio-cecal junction Prone to person who eat fast Complication – peritonitis – emergency Symptoms:
1.) persistent paroxysmal abd pain 2.) vomiting 3.) currant jelly stool - due to bleeding & inflammation
- palpate sausage shaped mass Diagnostic Test:
1.) X ray with barium enema which reveal “ staircase signs”Management:
1.) Hydrostatic reduction with barium enema 2.) Surgery
Diagnostic Test – GUTHRIE TEST – specimen – blood Done: 3 – 4 days after breast or bottle feeding- preparation increase CHON intake - test if CHON will convert to amino acid - specimen and urine
mixed with pheric chloride, presence of green spots at diaper a sign of PKUDIET: Low phenylalanine diet- food contraindicated- meats, chicken, milk, legumes, cheese, peanuts Give: Lofenalac - milk with synthetic protein , special formula for a child with PKU
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Galactosemia – deficiency of liver enzyme - GUPT – Galactose Urovil Phosphatetranferase- Converts galactose to phosphate tranferace glucose Galactose – will destroy brain cells if untreated – death within 3 days Diagnostic Test:Beutler test – get blood -done after 1st feeding presence of glucose in blood – sign of galactosemia galactose free diet lifetime neutramigen – milk formula
B. CELIAC DISEASE – gluten enteropathy Common gluten food:
Intolerance to food with brow B- barley R- rye not rice example: cakes, pastries, bread O- oatW- wheat
Early Symptoms:1. diarrhea – failure to gain wt ff diarrheal episodes 2. constipation 3. vomiting4. abdominal pain – protruberant abdomen even if with muscle wasting
Celiac Crisis- exaggerated vomiting with bowel inflammation
Gluten – glutenine( normal absorption)
Gliadin ( toxic to epithelial cells of villi of intestines, causes malabsorption syndrome)
Malabsorption
Fats CHON & CHO (muscle wasting) peripheral edema & malnutrition
Vitamin D calcium
Vit K Iron folic acid
Inadequate blood coagulation
Steatorrhea Osteomalasia Bleeding anemia
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Diagnostic Test:1. lab studies – stool analysis2. serum antigliadin and antireticulin antibpdies – presence indicates disorder3. Sweat Test – rule out cystic fibrosis
gluten free diet – lifetime all BROW – not allowedok – rice & corn
Management:1. vitamin supplements2. mineral supplements3. steroids – to treat BOWEL inflammation
10. POISONING- common in toddlers. (falls- common to infant)Principles:
1. Determine substance taken, assess LOC2. Unless poison is corrosive, caustic (strong alkali such as LYE) or a hydrocarbon,
vomiting is the most effective way to remove poison.3. Give syrup 1 pecac to induce vomiting
Ipecac – oral emetic * 15 ml – adolescent, school age & pre school * 10 ml to infant
4. UNIVERSAL ANTIDOTE- charcoal, milk of magnesia & burned toast 5. Never adm charcoal before ipecac6. Antidote for Acetaminophen poisoning – Acetylsysterine ( Mucomyst) 7. For caustic poisoning ( muriatic acid ) neutralize acid by giving vinegar . Don’t
vomit prepare tracheostomy set 8. Gas - mineral oil will coat intestine
Lead poisoningLead = Destroy RBC functioning = Hypochormic Microcytic Anemia = Destroy kidney functioning Accumulation of anomia = Encepalopathy
Symptoms:1. beginning sx of lethargy 2. impulsiveness and learning difficulties3. as lead increases, severe encepalopathy with seizure and permanent mental
retardation Diagnostic Test:1. Blood smear 2. abdominal x ray 3. long bones Management:1. remove child from source 2. if > 20 ug/dL – need chelation therapy = binds with lead & excreted by kidney
= nephrotoxic
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8. Amogenital Female:
Pseudomenstration slight bleeding on vagina related to hormonal changes Tearing of fourchette with blood – rape/ child abuse
Proper recordingNo erasuresRape- Report within 48 hours to
BARABGGAY CAPTAINBantay bata 163
Shape pubic hair in inverted triangle ( female)
Male:Undescended testes – cyrptorchidism - common to preterm surgery – orchidopexy assess scrotum- warm room & hands Ectopic Testesbaby – pee within 24 hours
- check for arch of urination Epispadias - urinary meatus located dorsal or above glans penisHypospadias - urinary meauts loc ventral or below glans penisHypospadias with “chordee” - fibrous band causing penis to curve downward
Management: SurgeryUROTHOPLASTY; MEATOBLASTY
Phimosis - tight foreskinBalanitis - infection of glands penis – due smegma (“kupal”)
Management: Circumcision
Hydroseal – fluid filled scrotum Test of Diagnosis:
Transillumination with use of flashlight - glowing sign
1. anti HPN drug - hydralazine or apresoline2. iron
1. weigh daily 2. monitor BP & neurologiuc status 3. Diet: decrease K, decrease Na
9. BACK - check for flatness & symmetry Open Neural Tube Defec - decreased Folic Acid intake a. SPINA BIFIDA OCCULTA - failure of post laminae of vertebrae to fuse
Symptoms: 1. dimpling of back 2. Abnormal tufts of hair
b. SPINA BIFIDA CYSTICA - failure of post laminae of vertebrae to fuse with a sac
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Types:1. Meningocele – protrusion of CSF & Meninges 2. Myelomeningocele – (Cranial Meningocele) protrusion of CSF & Meninges & spinal cord ( most dangerous) 3. Encephalocele ( CNS complication – hydrocephalus) – cranial meningocele or myelomeningoceleMost common problem
- rupture of sac - prone pos- sterile wet dressing
Most common complication - infection Myelomeningocele – genitourinary complication- urinary & fecal incontinence Nursing care: always check diaperOrthopedic complication – paralysis of lower extremities Management:1. Surgery to prevent infection CNS complication: Hydrocephalus2. Post operative position – prone position
SCOLIOSIS- lateral curvature of the spine 2 types:1. structural – rye neck2. postural – improper posture
Diagnosis:1. uneven hemline2. bend forward- 1 hip higher
1 shoulder blade more prominentNursing care:
1. conservative – avoid obesity, exercise 2. preventive – Milwaukee brace - worn 23 h a day 3. corrective surgery – insert Harrington rod
post operative - how to move log rolling - move client as 1 unit
10. EXTREMITIES:I. check # of Digits = 20
1. syndactyly – webbing of digits (ginger like foot)2. polydactyly – extra digits3. olidactyly – lack of digits4. Amelia – total absence of digits5. pocoamelia- absence of distal part of extremities
II. Erb- duchennse – paralysis- brachial plexus injury or brachial palsy - birth injury caused by lateral & excessive traction during
a breech injury Symptoms:
1. unable to abduct arms from shoulders, rotate arm externally or supinate forearm
2. absence or asymetrical moro reflexManagement:
1. Rotate arm from shoulders with elbow flex.
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III. CONGENITAL HIP DISLOCATION – head of femur is outside acetabulum
Types;1. subluxated – most common type2. dislocated
Symptoms:1. shortening of affected leg 2. asymmetrical gluteal fold3. limited movement – earliest sx4. (+) ortolanis sign – abnormal clicking sound5. when able to walk – child limps
– late symptoms: trendelenburg sign Goal of Management:
Cast – with bleeding - mask with ball pen edge of blood to know if bleeding is on going
do petalling – making rough surface of cast smooth
CRUTCHES FUNCTIONS: - To maintain balance
- To support weakened leg
Principles in crutches - weight of body on palm!- Brachial pulsing – if wt of body in axila - Do palm exercise- squeeze ball
Different crutch Gaits:1. Swing Through
Procedure:a. Advance both crutchesb. Lift both feet / swing forward / land feet in front of crutchesc. Advance both crutchesd. Lift both feet / swing forward / land feet in front of crutches
2. Swing to- no weight bearing are allowed into lower extremitiesProcedure:
a. Advance both crutchesb. Lift both feet / swing forward / land feet next to crutchesc. Advance both crutchesd. Lift both feet / swing forward / land feet next to crutches
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3. Three point Gait- weight bearing is allowed in 1 extremitiesProcedure:
a. Advance left foot and both crutchesb. Advance right footc. Advance left foot and both crutchesd. Advance right foot
4. Four point gait- weight bearing allowed in both extremitiesProcedure:
a. Advance right crutchb. Advance left footc. Advance left crutchd. Advance right foot
5. Two point Gait- weight bearing allowed in 2 lower extremitiesProcedure:
a. Advance left foot and right crutchb. Advance right foot and left crutchc. Advance left foot and right crutchd. Advance right foot and left crutch
Other Crutch-Maneuvering Techniques
To Sit Down1. Grasp the crutches at the hand pieces for control2. Bend forward slightly while assuming a sitting position3. Place the affected leg forward to prevent weight-bearing and flexion
To Stand Up1. Move forward to the edge of the chair with the strong leg slightly under the seat2. Place both crutches in the hand on the side of the affected extremity. 3. Push down on the hand piece while raising the body to a standing position
To Go Down Stairs1. Walk forward as far as possible on the step2. Advance crutches to the lower step. The weaker leg is advanced first and then the
stronger one. In this way, the stronger the extremity shares the work of raising and lowering the body weight with the patient’s arms.
To Go Up Stairs1. Advance the stronger leg first up to the next step2. Then advance the crutches and the weaker extremity. (Strong leg goes up first
and comes down last.) A memory device for the patient’s “Up with the good; Down with the bad”.
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Walker – a walker provides more support than a cane or crutches. The patient is taught to ambulate with a walker as follows:
1. Patient must hold the walker on the hand grips for stability2. Lift the walker, placing it in front of you while leaning your body
slightly forward3. Walk into the walker, supporting your body weight on your hands
when advancing your weaker leg, permitting partial weight-bearing or non-weight-bearing leg , as prescribed.
4. Balance yourself on your feet5. Lift the walker and place in front of you again. Continue this
pattern of walking
Cane – a cane is used to help the patient walk with greater balance and support and to relieve the pressure on weight-bearing joints by redistributing the weight. Quad canes (four-footed canes) The cane is held in the hand opposite to the affected extremity.
Methods of Transferring the Patient from the bed to a wheelchair.a. Weight-bearing transfer from bed to chair. The patient stands up, pivots his
back is opposite the new seat, and sits down.b. (Left) Non-weight-bearing transfer from chair to bed. (Right) with legs
Exercise Description Purposes ActionPassive An exercise carried out by
the therapist or the nurse without assistance from the patient
* To retain as much joint range of motion as possible.* To maintain circulation
Stabilize the proximal joint and support the distal part. Move the joint smoothly, slowly, and gently through its full range of motion. Avoid producing pain.
Active Assistance
An exercise carried out by the patient with the assistance of the therapist or the nurse
To encourage normal muscle function
Support the distal part, and encourage the patient to take the joint actively through its full range of motion. Give no more assistance than is necessary to accomplish the action. Short period of activity should be followed by adequate rest periods
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Active An exercise accompanied 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
When possible, active exercise should be performed against gravity. The joint is moved through full range of motion without assistance. (Make sure that the patient does not substitute another joint movement for the one intended.)
Resistive An active exercise carried out by the patient working against resistance produced by either manual or mechanical means
* To provide resistance * To increase muscle power
The patient moves the joint through its range of motion while the therapist resists slightly at first and then with progressively increasing resistance. Sandbags and weights can be used and are applied at the distal point of the involved joint. The movements should be performed smoothly.
Isometric or Muscle Setting
Alternately contracting and relaxing a muscle while keeping the part in a fixed position; this exercise is performed by the patient
To maintain strength when a joint is immobilized
Contract or tighten the muscle as much as possible without moving the joint, hold for several seconds, then let go and relax. Breathe deeply
Traction - use to reduce dislocation and immobilize fractures
Principles of Traction:1. The client should be in dorsal or supine position2. For every traction there is always a counter traction3. Line of pull should be in line with deformity4. For traction to be effective, it must be continuous5. Weight must be hanging freely
Types:Straight Traction
Weight of the body serves as a counter pullSkin Traction
Apply directly to the skin
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Bryant’s TractionUse immobilized fracture for less than 2 years old; 90° angle with
buttocks off the bedBuck’s Traction
For more than 2 years oldSkeletal Traction
Apply directly to the boneHalo Traction
Use to immobilized the spine
Nursing Responsibility:1. Assess for circulatory and neurologic impairment2. It can lead to hypertension3. Be careful in carrying out nursing functions by not moving the weights
11. Autoimmune SystemNewborn has immunity to diphtheria; pertusis; tetanus; measles, polio but they don’t have immunity for chicken pox.This immunity last up to 9 – 12 months
Types of Immunity:a. Passive Natural - receive maternal antibodies thru placenta and breast
milkb. Active Natural – contract a disease and produce memory cellsc. Passive Artificial – receive anti serum with antibodies from another hostd. Active Artificial – receive a vaccine and produce memory cells
12. Neuromuscular SystemReflexes:
A. Blink Reflex – rapid eyelid closure when strong light is shownPurpose: To protect the eyes
B. Palmar Grasp Reflex – when a solid object is placed on palm, then the baby will grasp the object.
Purpose: To cling to their mother for safety“nawawala - - - 6 weeks – 3 months”
C. Step in/ Walk-in Place Reflex – neonate placed on a vertical position with their feet touching a hard surface will take few quick , alternating step. “ Dancing Reflex”
Placing Reflex – almost the same with the step – in place reflex only that you are touching the anterior surface of a NEWBORN’S LEG
D. Plantar Grasp Reflex – when an object touches the sole of a newborn’s foot at the base of the toes, the toes grasp in the same manner as the finger do. “ Disappear: 8 – 9 months in preparation for walking.
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E. Tonic-Neck-Reflex – when newborns lie on their back, their head usually turn to one side or the other. The arm and the leg on the side to which the head turns extend, and the opposite arm and leg contract. “ Fencing Reflex”
F. Moro Reflex – start reflex; “Bigla” reflex – with a loud voice or jarring the base of the crib, the baby assumed a letter “C”, position; Test for neurological Integrity; Disappear 3 – 4 months
G. Magnet Reflex – when there is pressure at the sloe of the foot, he pushes back against the pressure. Test for spinal nerve integrity
H. Crossed Extension Reflex – when the sloe of foot is stimulated by a sharp object, it causes the foot to rise and the other foot extend.
I. Trunk Incurvation Reflex - while in prone position and the paravertical area is stimulated, it causes flexion of the trunk and swing his pelvis towards the touch
J. Landau Reflex – while prone position and the trunk is being supported, the baby exhibit some muscle tone. Test for muscle tone and present by 3 months.
K. Parachute Reaction – while on a ventral suspension, with the sudden change of equilibrium, it causes extension of the hands and legs. Present by 6 – 9 months
L. Babinski Reflex – when the sole of foot is stimulated by an inverted “J”, it causes fanning of toes. Disappear by 2 months and may persist for 2 years.
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AGE HANDS / SKILLS
STAND WORDS TEETH GAMES
2 mos. Head up when in prone
Infancy-solitary playMobile, teeter, music box, rattle
Freud- Oral – 0-18 mosErikson-Trust vs mistrustPiaget-Sensory motor 0-2 years
3 mos. Hand regard Head & chest up when in prone
4 mos. Turn front to back Laugh aloud, bubbling sound
5 mos. Moro reflex disappears4-5mos
Turn both ways
6 mos. Palmar graspHolds bottle well
Sits with support Say vowel sounds “ah” “oh”
1st temp teeth- 2 lower incisors
Rattle, soft toys, bright colors
7 mos. Can transfer object from hand to hand
8 mos. Sits without supportPlantar reflex disappear
9 mos. Neat finger grasp reflex
Creeps 2 syllables-mama,papa
10 mos. Can clapUnderstands “no”Responds to own name
Pull self to stand Peek-a-booPat-a-cake
11mos Stands with assistanceCruisse
12 mos Stand aloneWalk with assistance
2 words-mama, papa
Toddler-parallel play Similar toys, squeaky frogPull toy, building blocks, pounding peg, toys to ride on, pots & pans, -nursery rhymes
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18 mos Achieve bowel control(bowel 1st before bladder)
Can run & jump in place.Walks up/down stairs holding railing or hand.Puts both feet on 1 step before advancing.
Favorite word-“Mine”Can name body part.1-20 words
Freud- Anal - 18mos-3yrsE-Autonomy vs Shame & Doubt.
24 mos Daytime bladder control (daytime 1st before nighttime)
Can open doors by turning knobs.Can unscrew lids.Can walk up stairs alone.
50-200 words2 words sentences.
Piaget- Preoperational- 2-7 years oldKohlberg- 2-7 years old- Pre-conventional
30 mos Can jump down from chair.Copy a circle.Holds up finger to show age
Knows full name Temp teeth complete.Posterior molar last temp teeth to appear.Deciduous/temp teeth-20 total
36mos3years
Unbotton buttonsNighttime bladder controlLearns to share
Draw a +Ride a tricycle
300-900 wordsSpeaks fluentlyKnows full name & gender.
Tricycles, coloring, puzzles, books, videos
F- Phallic- 3-6 yrs
4 years Can button Copy a Jumps,
skipsLace shoes, knows 4 basic colors
1500 words Pre-school 4-6 yrsAssociative/cooperative play.Playhouse, role playing.
5 years Copy a triangleDraw a 6-part man
2100 words Imaginary playmate.
6 years Recognize all shapesNail bitingInterest in God
-perm teeth appear- 1st molar-temp teeth fall.
School Age-7-12 yrs Tug of war, track and field, basket ball
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7 years Copy a diamondEnjoys teasing and playing alone
F-Latent 7-12 yrsE-Industry vs InferiorityP-Concrete operationalK-Conventional
8 years Expansive ageSmoother mouthLoves to collect objectsCount backwards
9 years Coordination improvesTells time correctly-Hero worshipstealing and lying are common-Takes care of body needs completely-Teacher finds this group difficult to handle
10 years
Age of special talentWrites legiblyReady for competitive gamesMore considerate and cooperativeJoins orgs.Well mannered with adultCritical of adults
11-12years
Full of energy and constantly activeSecret language are commonShare with friends secretsSense of humor presentSocial and cooperative
