PEDIATRIC NURSING

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.
Wt doubles 6 months
3x 1yr
4x 2-2 ½ yrs
2. Height- increase by 1 inch/mo during 1st 6 months
- average increase in ht - 1st year = 50%
*Stoppage of height coincide with eruption of wisdom tooth.

Development- increase skills or capability to function

-qualitative

How to measure development

1. Observe child doing specific task.
2. Role description of child’s progress
3. 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
4. gross motor skills- large body movement

Maturation- same with development “readiness”

Cognitive development –ability to learn and understand from experience to acquire and
retain knowledge. To respond to a new situation and to solve problems.

IQ test- test to determine cognitive development

Mental age x 100 = IQ
Chronological age

Average IQ – 90-100
Gifted child- > 130 IQ

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Basic Divisions of Life
I. Prenatal stage from conception- birth
II. Period of infancy
1. Neonatal- 1st 28 days or 1st 4 weeks of life
2. Formal infancy- 29 day – 1 year
III. Early childhood
1. Toddler – 1-3 yrs
2. Pre school 4-6 years
IV. Middle childhood
1. School age- 7 – 12 yrs
V. Late childhood
1. Pre adolescent 11 – 13 yrs
2. Adolescent 12 - 18 – 21

Principles of G & D
1. G&D is a continuous process
-begins form 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

Patterns of G&D
1. Renal , digestive, Circulatory, Muscoskeletal - grows rapidly during childhood
2. Neuromuscular tissue (CNS, brain, S. cord)
- grow rapidly 1-2 years of life
- brain achieved its adult proportion by 5 years.
3. Lymphatic system- lymph nodes, spleen grows rapidly- infancy and childhood to
provide protection -infection
- tonsil adult proportion by 5 years
4. Repro organ- grows rapidly at puberty

Rates of G&D
1. Fetal and infancy – most rapid G&D
2. Adolescent- rapid G&D
3. Toddler- slow G period
4. Toddler and preschool- alternating rapid and slow
5. School age- slower growth
*fetal and infancy- prone to develop anemia

3. Each child is unique

2 primary factors affecting G&D
A. Heredity - R – race
I – intelligence
S – sex
N - nationality

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  Females are born less in weight than males by 1 oz.
 Females are born less in length than males by 1 inch

B. Environment
Q – Quality of nutrition
S – Socio eco. status
H – Health
O – Ordinal pos in family
P – Parent child relationship

 Eldest- skillful in language and social skills

 Younger- toilet trained self

5. G&D occurs in a regular direction reflecting a definitive and predictable patterns or

trends.

 Directional trends- occur in a regular direction reflecting the development

of neuromuscular function. These apply to physical, mental, social and
emotional development and includes:
a. Cephalocaudal- “head to tail”
- 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” - child learns form simple operations before
complex function of move from a broad general pattern of behavior. To a bore
refined pattern.

 Sequential- involves a predictable sequence of G&D to which the child

normally passes.
a. locomotion- creep than crawls, sit then stand.
b. Socio and language skills- solitary games, parallel games

 Secular- worldwide trend of maturing earlier and growing larger as

compared to succeeding generations.

6. Behavior is the most compressive indicator of developmental status.

7. Universal language of child --- PLAY
8. Great deal of skill and behavior is learned by practice. Practice makes perfect.
9. Neonatal reflexes must be lost before one can proceed.
- plantar reflex should disappear before baby can walk
-moro reflex should disappear before baby can roll
persistent primitive infantile reflexes- case of cerebral palsy

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Theories of G&D

1. SIGMUND FREUD (1856-1939) Austrian neurologists. Founder of psychoanalysis

Psychosexual theory
a.) Oral Phase 0-18 months
- mouth- 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.
-pacifier.
-never discourage thumb sucking.

b.) ANAL- 18 months-3 years

-site of gratification- anus
-activity- elimination, retention or defecation of feces make take place
- principle of holding on or letting go.
-mother wins or child wins
-child wins- stubborn, hardheaded anti social. (anak pupu na, child holds pupu, child wins)
-mother wins- obedient, kind, perfectionist, meticulous
OC-anal phase
-help child achieve bowel and bladder control even if child is hospitalized.

c.) Phallic- 3-6 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.
-Childs libido or energy is diverted to more concrete type of thinking
-helps child achieve (+) experience so ready to face conflict of adolescence

e.) Genital- 12-18 years

-site of gratification -genitals
-achieve sexual maturity
-learns to establish relationships with opposite sex.
-give an opportunity to relate to opposite sex.

2. ERIC ERICKSON- psychoanalysis theory

- stresses important of culture and society to the development of ones personality
- environment
- culture

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Stages of psychosocial
a.) Trust vs Mistrust – 0-18 months.
-foundations of all psychosocial task
-to give and receive is the psychosocial theme
-know to develop trust baby
1. satisfy needs on time - breastfeed
2. care must be consistent and adequate -both parents- 1st 1 year of life
3. give an experience that will add to security- touch, eye to eye contact, soft music.

b.) Autonomy vs Shame and doubt 18mos-3 years --- independence /self gov’t
develop autonomy on toddler
1. give an opportunity of decision making like offer choices.
2. encourage to make decision rather than judge.
3. set limits

c. Initiative vs Guilt- 4-6 years

-learns how to do basic things
-let explore new places and events
-activities recommended- modeling clay, finger painting will enhance imagination and
creativity and facilitate fine motor dev’t

d. Industry vs Inferiority 7-12 yrs

-child learns how to do things well
-give short assignments and projects

e. Identity vsRole 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 form parents
-freedom from parents.

f. Intimacy vs Isolation 20-40 yrs -looking for a lifetime partner and career focus

g. generatively vs stagnation 40- 60

45-65 yrs
h. ego integrity vs, despair 60-65

3. JEAN PIAGET- Swiss psychologists

-develop reasoning power

STAGES OF COGNITIVE DEVELOPMENT

A- Sensory motor 0-2 yrs
-“practical intelligence”- words and symbols not yet available baby communicates through
senses and reflexes.

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(sub div.)

Schema Age Behavior

1.) neonate reflex 1 month All reflexes
2.) primary circular 1-4 -Activity related to body
months -repetition of behavior
ex. thumb sucking
3.) secondary circular reaction 4-8 -activity not related to body
months -discover obj and person’s permanence
-memory traces present
-anticipate familiar events.
Coordination of secondary 8-12 -exhibit goal directed behavior
reaction months -increase of separateness (will search of
lost toy, knows mom)
Tertiary circular reaction 12-18 -use trial and error to discover places and
months events
-“ invention of new means”
-capable of space and time perception
(hits fork, spoon on table or drops fork)
Invention of new means there 18-24 -transitional phase to the pre operational
mental combination months thought period.

B. Preoperational thought 2-7 years

Schema age Behavior

Preconceptual 2-4 -thinking basically complete literal and static
yrs -egocentric- unable to view others interrupt
-concept of dying is only now
-concept of distance is only as fat as they can see.
-concept of amenism inanimate object is alive
-not aware of concept of r3eversibility- in every action theories an
opposite reaction or cause and effect
Initiative 4-7 Beginning of causation
yrs

C. Concrete Operational thought 7-12 years

1. able to find solution to everyday problems which systematic reasoning.
2. have concept of reversibility- cause and effect
3. have concept of longer duration – constancy despite of transformation.
4. activity recommended- collecting and classifying
5. stamps stationeries, dolls, rubber band markers.

D. Formal Operational thought 12 and up.

1. Cognition achieved its final form
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 2. can deal with past present and future
3. have abstract and mature thoughts.
4. can find solutions to hypothetical problems with scientific reasoning.
5. activity ------- will sort out opinions and current events.

4. KOHLBERG- recognized the theory of moral dev’t as considered to closely approximate

cognitive stages of dev’t
-“sabay” with cognitive dev;t

Stages of Moral dev’t

Infancy – premoral, prereligious, amoral stage

AGE STAGE DESCRIPTION

Pre- Level 1
conventional
2-3 yrs 1 -Punishment/ obedience oriented (heteronymous
morality) child does right cause a parent tells him or her
to and to avoid punishment
4-7 2 -Individualism. Instrumental purpose and exch. 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 2
7-10 3 -Orientation to interpersonal relations of mutuality. Child
followers rules cause of a need to be a “good” person in
own eyes and eyes of others.
10-12 4 -Maintenance of social order fixed rules and authority.
Child finds ff. rules satisfying. Follows rules of authority
figures.
Post- Level III
conventional
Above 12 yrs 5 -Social contract, utilitarian level making perspectives.
Followers standards of society.
6 Universal ethical principle orientation. Follows
internalized standards of conduct.

DEVELOPMENTAL MILESTONES
-major markers of growth and dev’t
1. Period of infancy- universal language of child-play
a.) Play- Infancy- solitary plays
-solo, mom interactive
-facilitate motor and sensory dev’t
-safety- important age appropriate
-solitary play- mobile, teeter, music box, rattle

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 b.) fear of infancy- stranger anxiety begin 6-7 months peak 8 months diminishes 9
months

1 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 frontal fontanel 2-3 months
head lag when pulled to sitting position.
3 months- holds head and chest up when prone
follows obj. 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 anticipatory of being picked up
-sits with support
-uses palmar grasp
-eruption of 1st temp teeth 6-8 months 2 lower incisors
-say vowel sounds “ah”, “oh”
-handles bottle well
7 months- transfer obj. hand to hand
-likes obj that are good size
8 months- sits without support
-peak of stranger anxiety
-planters reflex disappears 8-9 months in prep for walking
9 months - creeps or crawls
-neat finger grasp reflex
- combine 2 syllables “mama” and “papa”
10. needs space for creeping
10 months – pull self to stand
-understands “no”
-responds to own name
-peak a boo, pat a cake
-can clap
11 months- cruisse
- stands with assistance
12 months- stand alone take 1st step
-walk with assistance

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 -drink from cup, cooperate in dressing
-says 2 words mama and dada
-pots and pans, pull tay, nursery rhymes

2. Toddler- Parallel play- 2 toddlers playing separately

-provide with similar toys
-squeaky frog to squeeze
-waddling duck to pull
-trucks to push-push pull toy
-building blocks, pounding peg
-toys to ride on
-fear- separation anxiety
-begin 9 months
-peak 18 months

3 phases of separation anxiety (in order)

1. P- protect
2. D- despair
3. D -denial
-don’t prolong goodbye
-say goodbye firmly to develop trust- say when ul be back

15 months – plateau stage

-walks alone
- lateness in walking- mild mental retardation
-puts small pellets into small bowl
-holds spoon well
- seats self on chair
-creeps up stairs
- 4 - 6 words
18 months- height of possessiveness
-favorite word- “mine”
-bowel control achieved (bowel 1st before bladder)
-no longer rotates spoon
-can run and jump in place
-walks up and down stairs holding railing or persons hand
-1-20 words
-name, body part
-puts both feet on 1 step before advancing.
24 months- terrible two
-can open doors by turning door knobs
-unscrew lids
-can walk upstairs alone –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 for crosses with a pencil
-can jump down from chairs
-knows full name
- copy a circle
-holds up finger to show age
temp teeth complete

 post molar- last temp teeth to appear

 how many deciduous teeth -20
 beginning of toothbrush – 2-2 ½ yrs
 tooth brushing with little assistance 3 yrs
 tooth brushing alone – 6 yrs
 right time to bring to dentist- when temp teeth complete

36 months or 3 yrs- 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
-300-900 words
-ride a tricycle

Characteristic Traits of toddler

1.) negativistic- “NO!” -way to search for independence
–limit questions
–modify questions to a statement
2.) rigid, ritualistic and stereotype
-ritualism- for mastering
3.) Temper tantrums- head banging, screaming, stamping feet, holds breath
–ignore behavior
3.) scaffoid abdominal-due to underdeveloped abdominal muscles
4.) physiologic anorexia- due to preoccupation with environment- food jag that
last for short period of time
5.) loves rough and tumbling play
6.) loves toilet training- failure of toilet training- unreadiness

Clues of toilet readiness:

1.) can stand, squat walk alone
2.) can communicate toilet needs
3.) can maintain dry for 2 hours

Pre schoolers- associative or cooperative play

1.) bahay-bahayan – play house

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 2.) role playing
3.) fear-body mutilation or castration
fear of dark places witches
fear of thunder and lightning
fear of ghosts

4years old- furious 4 , noisy, aggressive, stormy

-can button buttons
-copy a square
-jumps and skips
-laces shoes
-vocabulary 1,500
-knows four basic colors

5 years old- frustrating 5

-copy a triangle
-draw a 6 part man
-imaginary playmates
-2,100 words

Character Traits of Pre-schooler:

7.) curious, creative imaginative, imitative
8.) 2. favorite words- why and how
9.) complexes- word identification to parent of same sex and attachment to
parent of opposite sex
ex. Oedipal complex- boy to mom
Electra complex- girl to dad
- Cause of incest marital discord
- Concept of Death-sleep only

Behavior problems Preschool

1. telling tall tales-over imagination
2. imaginary friend- to release tension and anxieties
3. sibling rivalry- jealousy to newly delivered baby.
4. regression- going back to early stage
-thumb sucking (should be oral stage only)
-baby talk
-bed wetting
-fetal position
5. masturbation- sign of boredom
-divert attention- offer a toy

School Age
Play- competitive play
Ex. Tug of war, track and field, basket ball

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Fear. 1.) school phobia
-orient to new environment
2.) displacement from school
-teacher and peer of same sex
3. loss of privacy
-wants bra
4.) fear of death
-7-9yrs death is personified
-death- permanent loss of life

Significant Development
a. boys- prone to bone fracture
b. mature vision 20/20

6 years- temp teeth begin to fall

perm teeth appear- 1st molar
1st temporary teeth- 5 months
1st permanent teeth- 6 yrs
-year of constant motion
- clensy mou’t
recognize all shapes
-1st grade teacher becomes authority figure
-nail biting
-begin interest in God.

7 yrs- Assimilation age

-copy a diamond
-enjoys teasing and playing alone
-quieting down period

8 yrs- Expansive age

-smoother mouth
-loves to collect objects
-count backwards

9 yrs –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

10 yrs- age of special talent

-writes legibly
-ready for competitive games
-more considerate and cooperative

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 -joins orgs.
-well mannered with adult
-critical of adults

11-12 yrs – Pre adolescents

-full of energy and constantly active
-secret language are common
-share with friends secrets
-sense of humor present
-social and cooperative

Character Traits School Age

1. industrious-
2. modest
3. can’t bear to lose- will cheat
4. love collections- stamps

Signs of sexual maturity

GIRLS:
I-inc size breast and genitalia (pelarche- 1st sign sexual maturation)
W- widening of hips
A- appearance axillary, pubic ( adrenarch)
M- menarche- last sign sexual maturation for girls

BOYS:
A-appearance axillary, pubic hair ( 1st sign sexual maturation)
D-deepening voice
D- development of muscles
I--inc in testes and penis size
P- production of viable sperm (last sign sexual maturity)

Adolescent
Fear
1. obesity
2. acne
3. homosexuality
4. death
5. replacement from friends
6. significant person- opposite sex.

Significant development
1. experiences conflict bet his needs for sexual satisfaction and societies expectation
2. change of body image and acceptance of opp/sex
3. nocturnal emission – wet dreams
4. distinctive odor- due to stimulation apocrine glands
5. sperm is viable by 17 yrs

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 6. testes & scrotum increase until age 17
7. breast and female genitalia increase until age 18

Personality Traits Adolescents

1. idealistic
2. rebellious
3. reformers
4. conscious with body image
5. adventuresome

Problems:
1. vehicular accident
2. smoking
3. alcoholism
4. drug addiction
5. pre marital sex

IMMEDIATE CARE OF NEWBORN

- 1st days of life

1. initiation and maintenance of respiration

2. establishment of extra uterine circulation
3. control of body temp
4. intake of adequate nourishment
5. establishment of waste elimination
6. prevention of infection
7. establishment of an infant parent relationship
8. dev’t care that balances rest and stimulation or mental dev’t

A.Initiation and maintenance of respiration

-2nd stage of labor- initial airway
-initiation of airway is a crucial adjustment
-most neonatal deaths with in 24 h caused by inability to initiate an airway
-lung function begins after birth only

How to initiate a/w

a.) remove secretions bulb syringe
b. ) Catheter Suctioning
1.) place head to side to facilitate drainage
2,) suction mouth 1st before nose
-neonates are nasal breathers
3.) period of time
-5-10 sec suctioning, gentle and quick
prolonged and deep suctioning can lead to hypoxia, laryngo spasm, brady cardia due
to stimulation vagal nerve

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 4.) evaluate for patency
-cover nostril and baby struggles there’s a need for additional suctioning
c. ) If not effective, requires effective laryngoscopy to open a/w. After deep suctioning
an endotracheal tube can be inserted and oxygen can be administered by an (+) pressure
bag and mask with 100% oxygen at 40-60b/m.

Nsg alert:
1. No smoking
2. Always humidify to prevent drying of mucosa
3. Over dosage of oxygen can lead to scarring of retina leading to blindness ( retro
lentalfibrolasia or retinopathy of prematurity)
4. When mecomium stained (greenish) never administer oxygen with pressure ( O2
pressure will push mecomium inside)

B. Establishing extra uterine circulation

- circulation is initiated by lung expansion or pulmo ventilation and completed by cutting of
cord.

 FETO PLACENTAL CIRCULATION

-Placenta(simple diffusion) –oxygenated blood is carried by the umbilical vein- passes liver-
ductus venousus- IVC- RT atrium 70% blood is shunted to foramen ovale- LT atrium mitral
valve – LT ventricle- aorta-lower extremities.

-Remaining 30%- tricuspid valve- RT ventricle- pulmonary arteries- lungs (for nutrition)
(vasoconstriction of lungs pushes blood to ductus arteriousus to aorta to supply upper
extremities.

SHUNTS-shortcuts
Ductus venosus- -shunts from liver to IVF
Foramen ovale- shunts bet 2 atrias
Ductus arteriosus- from pulmonary artery to aorta

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 Decrease PO2, increase PCO2 acidosis

Will cause 1st breath /cry of baby

Decrease pulmo artery pressure

Increase PO2 Decrease blood Increase pressure to Lt

flow side of heart

Closure of Closure of Closure of foramen

ductus ductus venosus ovale
arteriosus & AVA

What will sustain 1st breath- decreased artery pressure

What will initiate lung circulation-lung expansion
What will complete circulation- cutting of cord

* 2 way to facilitate closure of foramen ovale

a.) Tangential Footstep- slap foot of baby
-never stimulate baby to cry if secretions not fully drained to
prevent aspiration
-check characteristic of cry
normal cry- strong, vigorous and lusty cry
cri-du-chat syndrome-chromosomal obliteration cat like cry
b.) proper position -right side lying pos.
-will increase pressure on left and foramen ovale will close
-Foramen Ovale and Ductus arteriosus will begin to close within 24h

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Obliteration-complete closure

Structure Appropriate time of Structure remaining Failure to close

obliteration
F. Ovale 1yr Fossa Ovalis Atrial Septal
Defect
Ductus 1 month Ligamentum Arteriosum Patent ductus
Arteriosus arteriosus
Ductus 2 months Ligamentum venosum
Venosus
Umbilical 2-3 months 1.) lateral umb. Ligament
artery 2.) interior iliac artery
Umbilical vein 2-3 months -ligamentum teres ( round
ligament of liver)
Position of infant immediately after birth:
NSD-trendelenberg/ T position for drainage
contraindication of trendelenberg position - increase ICP
CS- supine or crib level position

Signs of increased ICP

1.) abnormally large head
2.) bulging and tense fontanel
3.) increase BP and widening pulse pressure #3 & #4 are Cushings triad of
4.) Decreased RR, decreased PR ICP
5.) projective vomiting- sure sign of cerebral irritation
6.) high deviation – diplopia – sign of ICP older child
4-6 months- normal eye deviation
>6 months- lazy eyes
7.) High pitch shrill cry-late sign of ICP

C. Temp Regulation
- goal in temp regulation is to maintain it not less than 97.7% F (36.5 C)
- maintenance of temp is crucial on preterm and SGA (small for gestational age) -
babies prone to hypothermia or cold stress

A. factors leading to dev’t of HYPOTHERMIA

1. preterms are born poi kilo thermic- cold blooded
2. babies easily adapt to temp of environment due to immaturity of thermo
regulating system of body. Hypothalamus
3. inadequate SQ tissue
4. baby is not capable of shivering
5. babies are born wet

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PROCESS OF HEAT LOSS
1. 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 body
earliest sign of hypothermia- increase in RR

Effects of Hypothermia ( Cold stress)

1.) Hypoglycemia- 45-55 mg/dl normal
50- borderline
2.) met acidosis- catabolism of brown fats (best insulator of newborns body)
will form ketones
3.) high risk for kernicterus- bilirubin in brain leading to cerebral palsy
4.) additional fatigue to allergy stressful heart

To Prevent Hypothermia
1. dry and wrap baby
2. mechanical pressure – radiant warmer
i. pre-heated first isolette (or square acrylic sided incubator)
3. prevent an necessary exposure – cover baby
4. cover baby with tin foil or plastic
5. embrace the baby- kangaroo care

D. Establish Adequate Nutritional Intake

CS- breastfeeding after 4 hours

NSD- breastfeeding asap

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) where breast milk is produced – alveoli post-
pit.gland

Sucking- PPG – oxytocin – contraction of lactiferous tubules - milk ejection reflex- let down
reflex.

Advantages of Breastfeeding
1. Economical
2. Always available
3. Breastfed babies have higher IQ than bottle fed babies.
4. It facilitates rapid involution
5. Decrease incidence of breast cancer.
6. Has antibodies- IgA
7. Has lactobacillius bifidus- interferes with attack of pathogenic bacteria in GIT
8. Has macrophages

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 Store milk- plastic storage container
Store milk – good for 6 months from freezer- put rm temp. don’t heat
Disadvantages:
1. Possibility of transfer HEP B, HIV, cytomegalo virus.
2. No iron
3. Father can’t feed & bond as well
Stages of Breastmilk:
1. Colostrum- 2-4 days present
content: decrease fats, increase IgA, dec CHO, dec CHON, inc minerals,
inc fat soluble minerals
2. Transitional milk- 4 – 14 days
content: inc lactose, inc water soluble vit., inc minerals
3. Mature milk- 14 & up
content: inc fats (linoleic acid) – resp for devt of brain & integrity of skin
inc CHO- lactose – easily digested, baby not constipated.
- resp of sour milk smelling odor of stool.

Lactose intolerance- deficiency of enzyme LACTASE that digest LACTOSE

Decrease CHON- lactalbumin
Cows milk – inc fats-
Dec CHO
Inc CHON – casing- has curd that’s hard to digest.
Inc minerals–traumatic effect on kidneys of babies. Can trigger stone formation.
Inc phosphorus

Health Teachings:
1. Proper hygiene- proper hand washing
Care of breast - cotton balls with lukewarm water
Caked colostrum- dry milk on breast
2. Best position in breastfeeding – upright sitting -avoid tension!
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 – when you touch middle of lips then baby will suck
- Disappears by 6 months
- When not stimulated sucking will stop.

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 extruded.
Purpose: to prevent from poisoning
Disappear by 4 months & baby can already spit out by 4 months.

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Criteria Effective Sucking
a.) Baby’s mouth is hiked up to areola
b.) Mom experiences after pain.
c.) Other nipple is also flowing with milk.

To prevent from crack nipples & initiate proper production of oxytocin.

- begin 2-3 min at @ breast ( 5 – 7 min other authors)
to initiate production of oxytocin
- increase 1 min/ day – until reaching 10 mins @ breast or 20 mins/ feeding.

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 :

3RD day changes in breast post partum
a.)Engorged- feeling of fullness & tension in breast.
- sometimes accompanied by fever known as MILK FEVER.

Mgt: Warm compress- for breastfeeding mom

Cold compress – for bottle feeding & wear supportive bra.
When is involution of breast- 4 weeks

b.) Sore nipple – cracked with painful nipple

Mgt: 1.) exposure to air – remove bra & wear dress, if not, expose to 20 Watt bulb
avoid wearing plastic liner bra
- will create moisture, cotton only
c.) Mastitis- inflammation of breast : staphylococcus aureus
Factors:
1. Improper breast emptying
2. 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. HIV CMV
Hepa B Coumadin

Newborn Condition - Inborn errors of metabolism

1.Erythrobastosis Fetalis – Rh incompatibility
Hydrops Fetalis
Phenylketonuria
Galactosemia
Tay Sachs disease

20
F. Establish of waste elimination
A. Diff stools
1. Meconium - physiologic stool
- black green, sticky, tar like, odorless (Sterile intestine)
will pass with in 24 – 36 hrs
-failure to pass mecomium after 24h- GIT obstruction
ex. Hirschsprungs disease
imperforate anus
mecomium ileus – due to Cystic Fibrosis

2. Transitional stool -
- green loose & shiny, like diarrhea to the untrained eye
3. Breastfed stool - golden yellow, soft, mushy with sour milk smell, frequently passed
- recur every feeding
4. Bottlefed stool –
- pale yellow, formed hard with typical offensive odor, seldom passed, 2–3 x/day
- with food added -brown & odorous

Jaundice baby – light stool

Under phototherapy – bright green
Mucus mixed with stool - milk allergy
Clay colored stool – obstruction to bile duct
Chalk clay stool – after barium enema
Black stool – GIT bleeding (melena)
Blood flecked stool - anal fissure.
Currant jelly stool – instussusection
Ribbon like stool – hirschsprung disease
Steatorrhea stool – fatty, bulky foul smelling odor stool
- malabasorption syndrome ( celiac disease or cystic fibrosis)
Cult blood – stool exam

III Assessment for Well–being

APGAR SCORE – Dr. Virginia Apgar
Special Considerations: 1st 1 min – determine general condition of baby
Next 5 min- determine baby’s capabilities to adjust extra
uterinely
Next 15 min – dependent on the 5 min

A- appearance- color – slightly cyanotic after 1st cry baby becomes pink.
P- pulse rate – apical pulse – left lower nipple
G- grimace – reflex irritability- tangential foot slap, catheter insertion
A – activity – degree of flexion or muscle tone
R – respiration

Baby cry – within 30 secs

21
Failure to cry after 30 secs – asphyxia near the neatorum
Resp. depression – due mom given Demerol. Administer Naloxone

APGAR Scoring Chart:

0 1 2
HR -absent <100 >100
Resp effort -absent - slow, irreg, weak -good strong cry
Muscle tone - flaccid extremities - some flexion - well flexed
Reflex irritability
Catheter - no response - grimace - cough, sneeze
Tangential Footslap - NR - grimace - cry
Color - blue/pale - acrocyanosis - pinkish
(body- pink
extremities-blue)

APGAR result
0 – 3 = severely depressed, need CPR, admission NICU
4 – 6 = moderately depressed, needs add’l suctioning & O2
7 - 10 =good/ healthy

CPR – cardio pulmonary resuscitation or CPR

Cardio pulmonary cerebral resuscitation (CPCR)

5 min no O2 – irreversible brain damage

1. shake, no resp, call for help
2. flat on head
3. head tilt chin lift maneuver except spinal cord injury over extension may occlude
airway

Breathing ( ventilating the lungs)

1. check for breathlessness
- if breathless, give 2 breaths- ambu bag
> 1 yr old- mouth to mouth, pinch nose
< 1 yr – mouth to nose
force – different between baby & child
infant – puff

Circulation
Check for pulslessness :carotid- adult
Brachial – infants
CPR – breathless/pulseless
Compression – inf – 1 finger breath below nipple line or 2 finger breaths or thumb

CPR inf 1:5

22
Adults 2:15

Assessment tool determines respiration of baby

Silvermann Anderson Index

Respiration Evaluation – lowest score – best

Criteria 0 1 2
Chest movement synchronized Lag on respiration See - saw
Intercostal retraction No retraction Just visible Marked
Xiphoid retraction None Just visible Marked
Nares dilatation None Minimal Marked
Expiratory grunt None Heard on stet only Heard on naked ear

Interpretation result:
0 -3 – normal, no RDS
4 – 6 – moderate RDS
7 – 10 – severe RDS

Assessment of Gestational Age

-Ballards & Dobowitz
Findings Less 36 weeks (Preterm) 37 - 38 39 and up
Sole creases Anterior transverse Occasional creases Covered with creases
crease only 2/3 in
Breast nodules 2mm 4mm or 3.5 mm > 5 or 7mm
Scalp hair Fine & fuzzy Fine & fuzzy Coarse & silky
Ear lobe Pliable Some cartilage Thick cartilage
Testes and testes in lower canal Some intermediate Testes pendulus
Scrotum Scrotum – small few Scrotum full extensive
rugae rugae

Signs of Preterm Babies

Born after 20 weeks, after 37 weeks
-frog leg or laxed positon
-hypotonic muscle tone- prone resp problem
-scarf sign – elbow passes midline pos.
- square window wrist – 90 degree angle of wrist
- heal to ear sign-
abundant lanugo-

Signs of Post term babies:

> 42 weeks
- classic sign – old man’s face
- desquamation – peeling of skin
- long brittle finger nails
- wide & alert eyes

23
Neonates in Nursery
Nsg responsibility upon receiving baby- proper identification
- foot printing, affixing mother thumb print
- take anthropometic measurement
normal length- 19.5 – 21 inch or 47.5 – 53.75cm, average 50 cm
head circumference 33- 35 cm or 13 – 14 “
Hydrocephalus - >14”
Chest 31 – 33 cm or 12 – 13”
Abd 31 – 33 cm or 12 – 13”

Bathing
- oil bath – initial
- to cleanse baby & spread vernix caseosa
Fx of vernix caseosa
1. insulator
2. bacterio- static
Babies of HIV + mom – immediately give full bath to lessen transmission of HIV
- 13 – 39% possibly of transmission of HIV

Full bath – safely given when cord fall

Dressing the Umbilical Cord – strict asepsis to prevent tetanus

3 cleans in community
1. clean hand
2. clean cord
3. clean surface

betadine or povidone iodine – to clean cord

- check AVA, then draw 3 vessel cord
- If 2 vessel cord- suspect kidney malformation
- leave about 1” of cord
- if BT or IV infusion – leave 8” of cord best access - no nerve
- check cord every 15 min for 1st 6 hrs – bleeding .> 30 cc of blood
bleeding of cord – Omphalagia – suspect hemophilia

Cord turns black on 3rd day & fall 7 – 10 days

Faiture to fall after 2 weeks- Umbilical granulation
Mgt: silver nitrate or catheterization
- clean with normal saline solution not alcohol
- don’t use bigkis – air
- persistent moisture-urine, suspect patent uracus – fistula bet bladder and normal
umbilicus
Dx: nitrazine paper test – yellow – urine
mgt: surgery

24
Credes Prophylaxis – Dr. Crede
-prevent opthalmia neonatorum or gonorrheal conjunctivitis
- how transmitted – mom with gonorrhea
drug: erythromycin ophthalmic ointment- inner to outer

Vit-K – to prevent hemorrhage R/T physiologic hypoprothrombinemia

- Aquamephyton, phytomenadione or konakion
- .5 – 1.5 ml IM, vastus lateral or lateral ant thigh
- 5 ml preterm baby

Vit K – synthesized by normal flora of intestine

Vit K – meds is synthetic due intestine is sterile

Weight: Normal wt 3.000 – 3400 gms/ 3 – 3.4 kg / 6.5 - 7.5 lbs

Arbitrary lower limit 2500 gm

Low birth wt baby delivered < 2500g
Small for gestational age (SGA) < 10th % rank or born small
Large for gestational age > 90th % rank or macrosomia >4000 g
Appropriate for GA – within 2 standard deviation of mean
Physiologic wt loss – 5 – 10% wt loss few days after birth

Small GA < (less) 10

Large GA > (more) 90

Physical Exam and Deviations fr Normal

1. if client is new born, cover areas not being examined
2. if client is infant – the 1st yr of life - get VS – take RR 1st
- begin fr least intrusive to the most intrusive area
3. if client is a toddler and preschool, let them handle an instrument like:
- play syringe or stet, security blanket – favorite article. Let baby hold it.
4. Explain procedure and respect their modesty - school age and adolescent

V/S:
Temp: rectal- newborn – to rule out imperforate anus
- take it once only, 1 inch insertion

Imperforate anus
1. atretic – no anal opening
2. agenetic – no anal opening
3. stenos – has opening
4. membranous – has opening

Earliest sign:
1. no mecomium
2. abd destention

25
 3. foul odor breath
4. vomitous of fecal matter
5. can aspirate – resp problem
Mgt:
Surgery with temporary colostomy

Cardiac rate: 120 – 160 bpm newborn

Apical pulse – left lower nipple
Radial pulse – normally absent. If present PDA
Femoral pulse – normal present. If absent- COA - coartation of aorta

CONGENITAL HEART DISEASES

Common in girls – PDA, ASD atrial septal
Common in boys – TOGA ( transportation of great arteries)
TA – tronchus arteriosus
TOF – tetralogy of fallot
Causes:
1. familial
2. exposure to rubella – 1st month
3. failure of strucute to progress

Acyanotic L to R
Cyanotic R to L

I. ACYANOTIC HEART DISEASE - L to R

A.Ventricular septal defect - opening between 2 ventricles
S&Sx
1. systolic murmurs at lower border of sternum and no other significant sign
- cardiac catheterization reveals increased o2 saturation @ R side of
heart
- ECG reveals hypertrophy of R side of heart

Nsg Care:
Cardiac catheterization: site – Rt femoral vein
1. NPO 6 hrs before procedure
2. protect site of catheterization. Avoid flexion of joints proximal to site.
3. assess for complication – infection, thrombus formation – check pedal
pulses (dorsalis pedis)

Mgt.
1.) long term antibiotic – to prevent subacute bacterial endocarditis
2.) open heart surgery-

26
 B. ASD – failure of foramen ovale to close
S&SX
1. systolic murmur @ upper border of sternum
2. result of cardiac catheterization & ECG same with VSD

Mgt: open heart surgery

C. Endocardial cushion defects - atrium ventricular (AV) - affects both tricuspid and
mitral valve
Dx – confirmed by cardiac catheterization
Mgt: - open heart surgery
Antibiotics to prevent subacute bacterial endocarditis

D. PATENT DUCTUS ARTERIOSUS- failure of ductus arteriosus to close

- should close within 24 h -complete close – 1 month
S&Sx
1. continuous machinery like murmurs
2. prominent radial pulse
3. ECG- hypertrophy Left ventricle
Drug:
1. endomethazine – prostaglandin inhibitor - facilitate closing of PDA
2. ligation of PDA by 3-4 yo
3. thoracotomy procedure- nakadapa child

D. Pulmunary Stenosis- narrowing of valve of pulmo artery

S &Sx: 1.) typical systolic ejection murmur
2. S2 sound widely split
3. ECG- Lt ventricular hypertrophy
E. Aortic Stenosis – narrowing of valve of aorta
S & Sx: 1. inactive, sx sme with angina
2. typical murmur
3. rough systolic sound and thrill
4. ECG- Left ventricular hypertrophy
Mgt Pulmo Stenosis & Aortic Stenosis
1.) balloon stenostomy
2.) surgery

Duplication of Aortic Arch- doubling of arch of aorta causing compression to trachea and
esophagus
S&Sx : 1. dysphagia 2. dyspnea
3. left ventricular hypertrophy
Mgt: - close heart surgery

E. Coartation of Aorta – narrowing of arch of aorta

Outstanding Sx : absent femoral pulse
BP increased on upper extremities and decreased on lower extremities

27
 ECG – hypertrophy Lft ventricle
Mgt: close heart surgery

CYANOTIC HEART DEFECTS R to L

1. Transportation of Great Arteries (TOGA) - aorta arising from Rt ventricle

pulmo artery arising form Lt ventricle

Outstanding Sx:
1. cyanosis after 1st cry (due no exygenation)
2. polycythemia – increased RBC =compensatory due to O2 supply=viscous blood
=thrombus = embolus = stroke
3. ECG – cardiomegaly
Cardiac cath – decreased O2 saturation
Palliative repair – rashkind procedure
Complete repair – mustard repair
2.) Total Anomalous Pulmonary
venous return – pulmo vein instead of entering Lt atrium, enters Rt atrium or SVC
Increased pressure on Rt so blood goes to Lft

Outstanding Sx: Open foramen ovale

Mild to moderate cyanosis
Polycythemia = thrombus = embolus = stroke
asplenia- absent spleen
Mgt: restructuring of heart

3.) Truncus Arteriousus- aorta & pulmo artery is arising fr 1 single vessel or common trunk
with VSD
S & Sx 1. cyanosis
2. polycythemia – thrombus = embolus = stroke
Mgt: Heart transplant

4.) Hypoplastic Left heart syndrome – non fx Left ventricle

1. cynosis
2. polycythemia – throm, emb, stroke
Mgt: heart transplant

5.) Tricuspid atresia – failure of tricuspid valve to open

S&SX: open foramen ovale
(R to L shunting – goes to Lt atrium)
cynosis, polycythemia
Mgt: fontan procedure – open tricuspid valve
6.) Tetralogy of Fallot
P – pulmonary stenosis
V – ventricular SD
O – overriding or dextroposition of aorta

28
 R – Rt ventricular hypertrophy
S &Sx:
1. Rt ventricular hypertrophy
2. high degree of cyanosis
3. polycythemia
4. severe dyspnea – squatting position – relief , inhibit venous return facilitate lung
expansion.
5. growth retardation – due no O2
6. tet spell or blue spells- short episodes of hypoxia
7. syncope
8. clubbing of fingernails – due to chronic tissue hypoxia
9. mental retardation – due decreased O2 in brain
10. boot shaped heart – x-ray
Mgt:
1. O2
2. no valsalva maneuver , fiber diet laxative
3. morphine – hypoxia
4. propranolol – decrease heart spasms
5. palliative repair –
BLT blalock taussig procedure
Brock procedure – complete procedure

ACQUIRED HEART DSE

1. RHD Rheumatic Heart Disease

- inflammation disease ff an infection acquired by group A Beta hemolytic strepto coccus

Affected body – cardiac muscles and valves , musculoskeletal , CNS, Integumentary

 Sorethroat before RHD
 Aschoff – rounded nodules with nucleated cells and fibroblasts – stays and
occludes mitral valve.
Jones Criteria

Major Minor
1. polyarthritis – multi joint pain 1. arthralgia – joint pain
2. chorea – sydenhamms chores or 2. low grade fever
st. vetaus dance-purposeless involuntary hand and
shoulder with grimace
3. carditis – tachycardia 3. all lab results
erythema marginatum - macular rashes increase antibody
SQ nodules “ C reactive protein
“ erythrocyte
sedimentation rate
“ anti streptolysin
o titer (ASO)

29
Criteria:Presence of 2 major, or 1 major and 2 minor + history of sore throat will confirm
the dx.

Nsg Care:
1. CBR
2. throat swab – culture and sensitivity
3. antibiotic mgt – to prevent recurrence
4. aspirin – anti-inflammatory. Low grade fever – don’t give aspirin.

S/E of aspirin:
- Reyes syndrome – encephalopathy- fatty infiltration of organs such as liver and brain

Respiration
Newborn resp – 30-60 cpm, irregular abd or diaphramatic with short period of apnea
without cyanosis.
< 15 secs – normal apnea –newborn

Resp Check
Newborn – 40 – 90
1 yr - 20 – 40
2-3yr 20 – 30
5 yrs 20 – 25
10 yrs 17 – 22
15 & above 12- 20

BREATH SOUNDS HEARD DURING ASCULTATION:

1.) VESICULAR – soft, low pitched, heard over periphery of lungs, inspiration longer then
expiration -Normal

2.) BRONCHOVESICULAR- soft, medium pitched, heard over major bronchi, inspiration
equals exp. Normal

3.) BRONCHIAL SOUNDS- loud high pitched, heard over trachea, expiration longer than
inspiration. Normal

4.) RHONCHI – snoring sound made by air moving through mucus in bronchi. Normal
5.) RALES-or crackles – like cellophane – made by air moving through fluid in alveoli.
Abnormal- asthma, foreign body obstruction.
6.) WHEEZING- whistling on expiration made by air being pushed through narrowed bronchi
.Abnormal – asthma, foreign body obstruction
7.)STRIDOR- crowing or ropster life sound – air being pulled through a constricted larynx.
Abnormal – resp obstruction
Asthma- pathognomonic sign – expiratory wheezing
Pet – fish. Sport – swimming
Drugs – amynophylline – monitor bp, may lead to hypotension

30
Laryngo Tracheo Bronchitis LTB
- inspiratory stridor – pathognomonic sign

RDS respiratory dist synd or hyaline membrane dis

Cause- lack of surfactant – for lung expansion
Hypotonia, Post surgery, Common to preterm

Fibrine hyaline
Sx – definite with in 1st of life
Increase RR with retraction
Inspiratory grunting – pathognomonic
7 – 10 severe RDS (silvermenn Anderson index)
cyanosis due to atelectasis
Mgt:
1. surfactant replacement and rescue
2. pos- head elevated
3. proper suctioning
4. o2 with increase humidity- to prevent drying of mucosa
5. monitor V/S skin color , ABG

6. CPAP- continuous + a/w pressure

7. PEEP - + end expiratory pressure
Purpose of #6-7- to maintain alveoli partially open and alveoli collapse

LARYNGOTRACHEOBRONCHITIS
LTB – most common Creup -viral infection of larynx, trachea & bronchi
outstanding sx - croupy cough or barking
pathognomonic - stridor
- labored resp
- resp acidosis
- end stage – death
Lab:
1. ABG
2. neck and throat culture
3. dx- neck x-ray to rule out epiglotitis
Nsg Mgt:
1. bronchodilators
2.increase o2 with humidity
3. prepair tracheostomy set

BRONCHOLITIS- Inflammation of bronchioles – tenatious mucus

Causative agaent – RSV - Resp sincytial viruses
Sx: flu like sx
Increased RR
Drug: Antiviral – Ribavirin
End stage – epiglotitis

31
EPIGLOTITIS - infl of epiglottis
- emer. Condition of URTI
Sx: sudden onset
Tripod position – leaning forward with tongue protrusion
- never use tongue depressor
prepare tracheotomy set
< 5 yo – unable to cough out, put on mist tent (humidifier o2) or croupe tie
Nsg Care: check edges tucked on mist tent
Provide washable plastic material
No toys with friction due O2 on
No hairy toys – due moist environment medium for bacterial growth

BP – 80/46 mmHg newborn

BP after 10 days- 100/50
BP taking begins by 3 yo
COA – take BP on 4 extremities

SKIN:
Acrocyanosis
BIRTHMARKS:
1. Mongolian spots – stale gray or bluish discoloration patches commonly seen across
the sacrum or buttocks due to accumulation of melanocytes. Disappear by 1 yr old
2. MIlla – plugged or unopened sebaceous gland . white pin point patches on nose,
chin or cheek.
3. Lanugo – fine, downy hair – common preterm
4. Desquamation – peeling of newborn, extreme dryness that begin sole and palm.
5. Stork bites (Talengeictasi nevi) – pink patches nape of neck
 hair will grow as child grows old
6. Erythema Toxicum – (flea bite rash)- 1st self limiting rash appear sporadically &
unpredictably as to time & place.
7. Harlequin sign – dependent part is pink, independent part is blue
(side lying – bottom part is dependent pink)
8. Cutis Marmorato – transitory mottling of neonates skin when exposed to cold.
9. Hemangiomas – vascular tumors of the skin

3 types Hemangiomas
a.) Nevus Flammeus – port wine stain – macular purple or dark red lesions seen on face or
thigh. NEVER disappear. Can be removed surgically
b.) Strawberry hemangiomas – nevus vasculosus – dilated capillaries in the entire dermal or
subdermal area. Enlarges, disappears at 10 yo.
c.) Cavernous hemangiomas – communication network of venules in SQ tissue that never
disappear with age. - MOST DANGERIOUS – intestinal hemorrhage
Skin color blue – cyanosis or hypoxia
White – edema

32
 Grey – inf
Yellow – jaundice , carotene
Vernix Caseosa – white cheese like for lubrication, insulator

BURN TRAUMA – injury to body tissue caused by excessive heat.

INFANT 5-9 yo
ANTERIOR POSTERIOR Ant Post
Head 9.5 9.5 6.5 6.5
Neck 1 1 1 1
Upper arm 2 2 2 2
Lower arm 1.5 1.5 1.5 1.5
Hand 13 1.25 1.25 1.25
Trunk 13 13
Back 13 13
Genital 1 1
@ buttocks 2.5@ 2.5 @
Thigh 2.75 2.75 4 4
Leg 2.5 2.5 3 3
foot 1.75 1.75 1.75 1.75

DEPTH
1st degree – partial thickness – superficial epidermis - erythema, dryness, PAIN
-sunburn, heals by regeneration from 1 – 10 days
2nd degree – epidermis & dermis- erythema, blisters, moist, extremely painful
 scalds
rd
3 degree – full thickness- epidermis, dermis, adipose tissue, fascia, muscle & bone
 lethargy, white or black, not painful – nerve endings destroyed
 ex. lava burns

Mgt:
1.) 1st aid a.) put out flames by rolling child on blanket
b.) immerse burned part on cold H2o
c.) remove burned clothing of with sterile material
d.) cover burn with sterile dressing
2.) a/w
a.) suction PRN, o2 with increased humidity
b.) endotracheal intubation
c.) tracheostomy
3.) Preventiuon of shock & F&E imbalance
a. colloids to expand bld volume
b. isotonic saline to replace electrolytes
c. dextrose & H2o to provide calories
4.) Tetanus toxoid booster
5.) Relief of pain – IV analgesic MORPHINE SO4 – needed for 2nd degree – very painful
33
6.) 1st defense of body – intact skin
prevention of wound infection
a.) cleaning & debriding of wound
b.) open or close method of wound care
c.) whirlpool therapy – drum with solution
7.) skin grafting – 3rd degree – thigh or buttocks (autograft), pigs/ animals – xenograft
frozen cadaver – hallow graft
8,) diet – increase CHON, increase calories.

ATOPIC DERMATITIS- infantile eczema (galis)

Papulo vesicular erythematus lesions with weeping & crusting
Cause – food allergies: milk, citrus juice, eggs, tomatoes, wheat
Sx: - extreme pruritus, linear excoriation, weeping crusting; scaly shiny and white
– lechenification

Goal of care: decrease pruritus – avoid food allergens

Diet: Prosobi or Isomil
Hydrate skin, borow solution 1% hydrocortisone cream
Prevent infection – proper handwahsing, trim nails

IMPETIGO- skin disease.

Causative agent – grp A beta Hemolytic streptococcus
- papulovesicular surrounded by localized erythema –becomes purulent , oozes a
honey colored crust
Pediculosiscapitis –“KUTO”
- Mgt: proper hygiene – wash soap and H2o, oral penicillin – bactroban ointment
Can lead to acute glomerulonephritis AGN

ACNE- adolescent problem

- self limiting infl dis – sebaceous gland comedones – sebum causing white heads
- sebum- lipids causing acne bulgaris
Mgt: - proper hygiene- mild soap or sulfur soap- antibacterial retin A or tretinoi

ANEMIA-pallor
Causes:
1.)early cutting of cord – preterm – cut umb cord ASAP
fullterm – cut umb cord when pulsation stops
2.) Bleeding disorders – blood dyscrasias

HEMOPHILIA – deficiency of clotting factor. X linked recessive – inherited

If mom – carrier, son – affected
If father carrier- transmitted to daughter

Hemophilia A – deficiency of coagulation component factor 8

34
Hemophilia B –or christmas disease, deficiency of clotting factor 9
Hemophilia C – deficiency of clotting factor 11

Assessment:
- umphalagia – earliest sign
- newborn receive maternal clotting factor
- newborn growing – sudden bruising on bump area- marks earliest sign
- continuous bleeding – hematrosis – damage or bleeding synovial membrane

Dx test :
PTT. Partial thromboplastin time – reveals deficiency in clotting factor
Long Term Goal- prevention of injury
Nsg Dx- increase risk of injury
HT: avoid contact sport, swimming only, don’t stop immunization – just change gauge of
needle
Falls – immobilized , elevate affected part, apply pressure-not more then 10 min
cold compress
-determine case before doing invasive procedure

LEUKEMIA- grp of malignant disease

- rapid proliferation of immature WBC
- WBC – protection from infection, soldiers of body

Classification :
1. Lympho – affects lymphatic system
2. Myelo – affects bone marrow
3. acute / blastic- affects immature cells
4. chronic/ cystic- affects mature cells

MOST COMMON CANCER – (ALL) – Acute Lymphocytic Leukemia

S&Sx:
1. from invasion of bone marrow
signs of infection
a.) fever
b.) poor wound healing
c.) bone weakness & causes fracture
signs of bleeding
a.) petecchiae-small, round, flat, dark red spot
b.) epistaxis
c.) blood in urine/ emesis
signs of anemia
a.) pallor , body malaise , constipation

2. from invasion of body organ- hepato spenomegaly – abd pain ,

CNS affectation, increase ICP
Dx Tests:

35
 1. PBS- peripheral blood smear – determine immature RBC
2. CBC – determine anemia, leukocytosis, thrombocytopenia neutropenia
3. lumbar puncture (LP) – determine CNS involvement. Before LP, fetal pos.- avoid
flexion of neck – will cause a/w obstruction.“C” position or shrimp position only.
4. bone marrow aspiration – determine blast cells,
- common site- iliac crest
- post BMA s/effect – bleeding
- apply pressure. Put pt on affected side to prevent hemorrhage
5. Bone scan – determine bone involvement
6. CT scan – determine organ involvement

Therapeutic Mgt:
TRIAD:
1. surgery
2. irradiation
3. chemotheraphy
Focus Nsg Care: prevent infection

4 LEVELS OF CHEMOTHERAPHY
1. induction – goal of tx; to achieve remission
meds: IV vincristine
L- agpariginase
Oral predinisone
2. Sanctuary- treat leukemic cells that invaded testes & CNS
give: methotrixate- adm intrathecally via CNS or spine
cytocine, Arabinoside, steroids with irradiation

3. maintenance- to continue remission

give: oral methotrisate – check WBC
-adm of methotrisate – do weekly WBC check

4. Reinductin – treat leukemic cells after relapse occurs. Meds – same as induction

- give antigout agents: allopurinol or Zyloprim- treat or prevent hyperurecemic nephropathy.

Nsg mgt: Outstanding nsg dx: alteration in nutrition less body requirement.
Based on Maslow’s heirarchy
S/Effect of Chemotherapy
1. N/V – adm antiemetic drugs 30 mins before chemo until 1 day after chemo
2. Ulcerations / stomatitis / abscess of oral mucosa- (alteration nutrition less body req)
- oral care – alcohol free mouthwash , betadine mouthwash
- don’t brush – use cotton pledgets
- topical xylocaine before meals
diet- soft, bland diet according to child’s preference

Temporary S/E of chemo:

36
 Alopecia – altered body image
Hirsutism – hair
-give emotional support to parents

ABO incompatibility –
Most common incompatibility – ( mom) O – ( fetus) A
Most severe incompatibility (Mom) O– (Fetus) B
Can affect 1st pregnancy

Hydrops (h20) Fetalis – edematous on lethal state with pathologic jaundice

Within 24 h

Mgt:
1. initiate breastfeeding to get colostrum
2. Temp suspension of breastfeeding
- content breast milk pregnanedioles – that delays action of glucoronil transferees
liver enzymes converts in direct bilirubin to become direct bilirubin
3. Needs phototherapy
4. needs exchange therapy

Hyperbilirubinemia - > 12 mg/dL of indirect bilirubin among full term

Normal – 0-3 mg/dL
- bilirubin encephalopathy
- Kemicterus - > 20 mg/dL among full term &
>12 mg /dl of indirect – preterm
=can lead to cerebral palsy-

Physiologic jaundice – jaundice within 48 -72 h (2-3 days) expose morning sunlight
Pathologic Jaundice – within 24h. Jaundice during delivery.

Breastfeeding jaundice – caused by pregnanediole

Assessment of Jaudice :
1. Blanching neonates forehead, nose or sternum
- yellow skin & sclera
- color of stool – light stool
- color of urine – dark urine

Mgt: Phototheraphy – photo oxygenation

Nsg Resp:
1. cover eyes – prevent retinal damage
2. cover genitals – prevent priapism – painful continuous erection
3. change position regularly – even exposed to light
4. increase fld intake – due prone to dehydration
5. monitor I&O – weigh baby

37
 6. monitor V/S – avoid use of oil or lotion due- heat at phototherapy
= bronze baby syndrome-transient S/E of phototherapy
weigh diaper 1gm = 1cc

Head – largest part of baby

¼ of its length

Craniostenosis or craniosinustosis – premature closing of fontanel

Hydrocephalus – ant fontanel open after 18 mos
Microcephaly – small growing brain due- alcohol & HIV mom
Anencepahly – absence of cerebral hemisphere
Craniotabes – localized softening cranial bone. Common – 1st born child
-due early lightening (2 weeks prior to EDD)
Rickets of Vit B deficiency – soft cranial bone in older children
Caput Succedaneum – edema of scalp due prolonged pressure at birth
Char:
1. present at birth
2. crosses suture lines
3. disappear after 2-3 days

Cephalhematoma- collection of blood due to rapture of pericostal capillaries

Char :
1. present after 24 h
2. never cross suture line
3. disappear after 4-6 weeks
4. monitor for developing jaundice

Seborrheic Dermatitis – ‘craddle cap”

Scaling, greasy appearing salmon colored patches – seen on scalp behind ears and
umbilicus
Cause: - improper hygiene
Mgt:
1. proper hygiene
2. put oil night before shampoo
- baby oil

Hydrocephalus – excessive accumulation of CSF

1. communicating – extra ventricular hydrocephalus
2. non-communicating- intraventricular hydrocephalus or obstructive hydrocephalus
due to tumor obstruction

Sx – ICP – abnormally large head, bulging fontanel

- cushings triad
- high pitched cry
older child – diplopia – eye deviation, projectile vomiting
- fontanel bossing – prominent forehead

38
 - - prominent skull vein
- sunset eyes
Mgt: position to lessen ICP – low semi-fowlers 30 degree angle
Administer- osmotic diuretic Mannitol/ Osmitrol , Diamex- Azetam
Decrease CSF production
Shunting – AV shunt or Vp shunt (ventriculoperitoneal shunt)
Shave hair – in OR – to prevent growth of micro org.

Nsg Care:
1.) post VP shunt – side lying on non operated site - to prevent increase ICP
monitor for good drainage - sign – sunken fontanel
bulging fontanel – blocked shunt
change fontanel as child is growing
SENSES
EYES: Assessment
1. check for symmetry
2. sclera – normal color – light blue then become dirty white
pupil – round- adult size
coloboma- part of iris is missing
sign: key hole pupil
whiteness & opacity of lens congenital cataract
cornea – round & adult size
large – congenital glaucoma

Test for blindness common tests

1. newborn – general appearance
- can only see 10 – 12 “
- visual acuity 20 /200 to 20/ 800
Doll’s eyes test- test for blindness
- done 10th day
- pupil goes opposite to direction when head is moved
Globellars test – test for blink reflex. Points near nose – baby should blink

2. Infant & children

- appearance
- ability to follow object past midline

3. 3 yrs – school age

- general appearance
Allen cards – test for visual acuity. Show picture 20 ft away

Ishiharas plates – test for color blindness

Prechool E chart - test for stereopsi of depth perception
Cover testing test – cover 1 eye for 10 – 15 min. Then remove. Test for strabismus

4. School age – adult

39
- general appearance
- snellens test

Retinobastoma – malignant tumor of retina

Outstanding sign : oat’s eye reflex-whitish glow of pupil
- red painful eye
- blindness

surgery – Enucliation – removal of eyeball put artificial aye

NOSE:
1. flaring alenase – case of RDS
2. cyanosis at rest – choanal atresia - post nares obstructed with bone or membrane
Sx:
1. resistance during catheter insertion
2. emer. Surgery within 24 h
normal color nasal membrane – pinkish
rhinitis – presence of creases & pale
check sense of smell – blindfold – smell

Hair in nose – cilia

Adolescent no hair with ulceration of nasal mucosa suspect cocaine user

Epistasis – nosebleed
- sit upright, head slightly forward to facilitate drainage
- cold compress , apply gentle pressure, epinephrine

most developed sense of newborn – sense of touch

1st sense to develop & last to disappear – hearing

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

Mgt: kidney transplant

Chromosomal aberrations : -advance maternal age

1. non disjunction – uneven division

Trisomy 21 - down syndrome - extra chromosome

47xx + 21 - related to advance paternal age
Sx:

40
 Mongolian slant
Broad flat nose
Protruding neck
Puppy’s neck
Hypotonic – prone to resp problem
Simean crease – single transverse line on palm.

Trisomy 18 – “endvard syndrome”

Trisomy 13- patau syndrome
Turner – Monosomy of X synd.
- 45x0
- affected girls
- signs evident during puberty
- has poorly developed 2dary sexual char.
- Sterile

Klinefelters Syndrome- has male genitalia - 47 XXY

- poorly devt secpndary sexual characteristics
- no deepening of voice
-small testes, penis -sterile

Klinefelter – Calvin Kline – male

Turner – Tina Turner – female

Otitis Media – inflammation of middle ear. Common children due to wider & shorter
Eustachian tube
Causes
1.) bottle propping
2.) Cleft lip/ cleft palate –
Sx: Otitis
1. bulging tympanic membrane, color – pearly gray
2. absence light reflex
3. observe for passage of milky, purulent foul smelling odor discharge
4. observe for URTI
Nsg Care:
1. position side lying on affected aside – to facilitate drainage
2. supportive care- bedrest, increase fld intake
Med Mgt:
1. Massive dosage antibiotic
Complication – bacterial meningitis
2. Apply ear ointment

School age – up and down

< 3 yo – down & back
> 3 yo – up & back
Small child – down & back ( no age)

41
surgery (to prevent permanent hearing loss)– otitis media – myringotmy with
tympanostomy tube
post surgery – position affected side for drainage
both – put ear plug
if tympanous tube falls – healed na

Bells Palsy- facial nerve #7 paralysis R/T forcep delivery

Sx.
1. Continuous drooling saliva
2. inability to open , eye & close either eye
Mgt:
Refer to PT
TEF (Tracheoesophageal Fistula)-TEA- no connection bet esophagus and stomach

Outstanding Sx – Coughing
Choking
Continuous drooling
Cyanosis
Mgt:
Emergency surgery

Epstein pearl – white glistering cyst at palate & gums related to hypercalcemia

Hypervitaminosis
Natal tooth – tooth at birth. Move with gauze
Neonatal tooth – tooth within 28days of life

Moniliasis – oral candidiasis

- white cheese like, curd like patches that coats tongue
- oral thrush
- Nsg Care – don’t remove, wash with cold boiled H2o
Meds – nystatin / Mysnastatin – antifungal

Kawasaki Dse--strawberry tongue - originated in Korea

- Dr. Kawasaki discovered it
- common in Japan
- “mucocutaneous Lymphnode Syndrome”
Sx:
-persistent fever – 5 days
-strawberry tongue ,
-desquamation of palm & sole
- lymph adenopathy > 1.5 cm
Drug: aspirin
Can lead to MI

LIPS- symmetrical

42
Cleft lip – failure of median maxillary nasal process to fuse by 5-8 wks of pregnancy
- common to boys
- unilateral

Cleft Palate- Failed palate to fuse by 9 – 12 wks of pregnancy

- common to girls
- unilateral or bilateral

Sx:
1. evident at birth
2. milk escapes to nostril during feeding
3. frequent colic & otitis media or URTI

Mgt:
1. Surgery
cleft lip repair – Cheiloplasty =done 1-3 months to save sucking reflex (lost in 6 months )
Cleft Palate- uranoplasty = done 4-6 months to save speech

Pre op care
1. emotional support especially to mom
2. proper nutrition
3. prevent colic
feed – upright seating or prone pos
burp frequently 2x at middle and after feeding-lower to upper tap
4. orient parents to type of feeding
rubber tipped syringe – cheiloplasty
paper cup/ soup spoon/ plastic cup – urano plasty
5. apply restraints – elbow restraints
so baby can adjust post op

Condition that warrants suspension of operation

- colds & pharyngitis = can lead to generalized infection – septicemia

Post Op Nsg Care :

1. airway – positon post cheilopasty – side lying for drainage
post uranoplasty (tonsillectomy)- prone
2. assess for RDS sx bleeding
3. assess for bleeding – freq swallowing. 6-7 days after surgery – bleeding
4. proper nutrition
- clear liquids- ( gelatin except red or brown color due may mask bleeding)
- ( popsicle- not ice cream)
full liquid
soft diet
regular diet
5. Maintain integrity of suture line such as:
Logan bar – wash ½ strength Hydrogen Peroxide & saline solution- Bubbling effect

43
 traps microorganism
- prevent baby form crying
for pain- analgesic

NECK-
1.) check symmetry
Congenital torticolis- “ wryneck”-burn injury of sternocleidomsstoid muscle during
delivery – due to excessive traction at cephalic delivery

Mgt: passive stretching exercise , Surgery

Complication – scoliosis

THYROID gland – for basal metabolism

Congenial cretinism – absence or non functioning thyroid glands

reasons for delaying dx:

1. Thyroid glands covered by sternocleidomastoid muscles in newborn
2. baby received maternal thyroxine
3. baby sleeps 16 – 20 h a day
earliest sign:
1. change in crying
2. change in sucking
3. sleep excessively
4. constipation
5. edema – moon face
late sign
1. mental retardation
prognosis : mental retardation preventable when Dx is early
Dx:
1. PPI-protein
2. radioimmunoassay test
3. radioactive iodine uptake

Mgt: synthroid – sodium Levothyrosine -synthetic thyroid given lifetime

- check pulse rate before giving synthroid
- tachycardia – Sx of hyperthyroidism

CHEST
1. symmetry
2. breast - transparent fluid coming out from newborn related to hormonal changes-
3. chest has retroactive – RDS
4. sternum sunken – pectus excavation

ABDOMEN (in order)

1. inspection I

44
 2. Auscultation A
3. percussion P
4. Palpation P = Will change bowel sounds, so do last

Normal contour of abd – slightly protruding

Sunken abd- diaphramatic hernia – protrusion of stomach content through a defective
diaphragm due to failure of puroperitoneal canal to close.
Sx:
1. sunken abd
2. Sx of RDS
3. R to L shunting
Mgt:
Emergency surgery within 24h

Omphalocele – protrusion of stomach contents in between junction of abd wall and

umbilicus.
Mgt- very small surgery
If large – suspension surgery
Nsg Mgt: protect sac- sterile wet dressing

Gastrochisis – absence of abd wall

Nsg Mgt: sterile wet dressing

Fx of GIT
1. assists in maintaining F&E & acid base balance
2. Processes & absorbs nutrients to maintain metabolism & support G & D
3. excrete waste products from digestive process

Recommended Daily Allowance

Calories : 120 cal / Kbw/day (kilo body wt)
360 – 380 cal/ day

CHON_ 2.2g /Kbw/day

Principles in Supplementary Feeding

Supplementary Feeding usually – 6 mos
Supplementary feeding given – 4 mos.

a.) solid food offered to ff sequence!

1. cereals – rich in iron
2. fruits
3. veg
4. meat
b.) begin with small quantities
c,) finger foods – offered 6 months
d.) soft table food – “modified family menu” given 1 yr

45
 e.) dilute fruit juices – 6 mos
f.) never give half cooked eggs – usually causes of salmoneliosis
g.) don’t give honey – infant botulism
h.) offered new food one at a time – interval of 4 – 7days or 1 week – determines
food allergens

Total Body Fluids- comprises 65 - 85% of body wt of infants & children

Where fluids are greater in infants
Extracellular fld – prone to develop dehydration

Acid Base Balance dependent on the ff:

a. chemical buffers
b. renal & resp system involvement
c. dilution of strong acids and bases in bld
Resp Acidosis – carbonic acid excess
- hypoventilation
- RDS
- COPD
- Laryngotracheobronchitis (LTB)
Resp Alkalosis – carbonic acid deficit
- hyperventilation
- fever
- encephalopathy
Met. Acidosis – base HCO3 deficit
- diarrhea
- severe dehydration
- malnutrition
- ciliac crisis
Met Alkalosis – base HCO3 excess
- uncontrolled vomiting
- NGT aspiration
- Gastric lavage

PROBLEMS LEADIING TO F&E IMBALANCE

1. vomiting – forceful expulsion of stomach content
Sx:
1. nausea
2. dizziness
3. facial flushing
4. abd cramping

assess: amt, freq, force

projectile vomiting= increase ICP or pyloric stenosis

Mgt: BRAT diet - banana, rice – cereal, apple sauce, toast

46
2. Diarrhea – exaggerated excretion of intestinal contents
Types:
Acute diarrhea – related to gastroenteritis, salmoneliosis
- dietary indiscretions
- antibiotic use

Chronic non specific diarrhea

Cause:
1. food intolerance
2. excessive fld intake
3. CHO, CHON malabsorption

Assess: freq, consistency, appearance of given colored stool.

Best criteria to determine diarrhea : consistency

Complication = dehydration
Mild dehydration 5% wt loss
Moderate dehydration 10% wt loss
Severe dehydration 15 % wt loss

Earliest sx of dehydration
tachycardia increase temp weight loss
tachypnea sunken fontanel & eyeballs scanty urine
hypotension absence of tears

Severe dehydration:
Oliguria , Prolonged capillary refill time

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

Gastric Motility Disorder:

HIRSCHPRUNGS DISEASE – congenital aganglionic megacolon
Aganglionic – absence of ganglion cells needed for peristalis

Earliest sign
1. failure to pass mecomium after 24h
2. abd distension
3. vomitus of fecal material
early childhood – ribbon like stool
foul smelling stool
47
 constipations
diarrhea
Dx:
1. Barium enema – reveals narrowed portion of bowel
2. Rectal Biopsy – reveals absence of ganglionic cells
3. abd x-ray – reveals dilated loops on intestine
4. rectal manometry – revels failure of intestine sphincter to relax

Therapeutic Mgt/Nsg care

1. NGT feeding – measure tube fr nose to ear to midline of xyphoid & umbilicus
2. surgery
a.) temp colostomy
b.) anastomosis & pull through procedure
Diet:
Increase CHON, increase calories , decrease residue – pasta

GER- Gastroesophageal Reflux

Chalasia – presence of stomach contents to esophagus
Will lead to esophagitis complication – aspiration pneumonia

Esophageal cancer
Assessment :
1. chronic vomiting
2. faiture to thrive syndrome
3. organic – organ affected
4. melena or hematemesis – esophageal bleeding
Dx procedure
1. barium esophogram – reveals reflux
2. esophageal manometry – reveals lower esophageal sphincter pressure
3. intra esophageal pH content – reveals pH of distal esophagus.
Meds of GERD
Anti-cholinergic
a.) Betanicol ( urecholine) – increase esophageal tone & peristaltic activity
b.) Metachloporomide (Reglam) – decrease esophageal pressure by relaxing pyloric &
duodenal segments
- increase peristalsis without stimulating secretions
c.) H2 Histamine Receptor Antagonist – decrease gastric acidity & pepsin secretion
- Zimetidine, Ranitidine (Zantac) – take 30 min before meals
d.) antacid – neutralizes gastric acid between feedings - Maalox

Surgery: Nissen funduplication :

Chronic vomiting –
- thickened feeding with baby cereals - effective if without vomiting
- feed slowly, burp often every 1 ounce
- positioning
< 9 months – infant sit with infant supine

48
 > 9 months – prone with head of mattress slightly elevated 30 degree angle

OBSTRUCTIVE DISORDERS
A. PYLORIC STENOSIS – hypertrophy of muscles of pylorus causing narrowing &
obstruction.
1.) outstanding Sx- projectile vomiting
- vomiting is an initial sx of upper GI obstruction
- vomitus of upper GI can be blood tinged not bile streaked. (with blood)
- vomitus of lower GI is bilous ( with pupu)
- projectile vomiting – increase ICP or GI obstruction
- abd distension – major sx of lower GIT obst
2.) met alk
3.) failure to gain wt
4.) olive shaped mass – on palpation
5.)serum electrolyte – increase Na & K, decrease chloride
6.) ultrasound
7.) x ray of upper abd with barium swallow reveal “string sign”

Mgt:
1. Pyleromyotomy
2. Fredet Ramstedt procedure

INSTUSSUSCEPTION- invagination or telescoping of position of bowel to another

Common site – ilio-secal junction
Prone pt: person who eats fat
Complication – peritonitis – emergency
Sx:
1.) persistent paroxysmal abd pain
2.) vomiting
3.) currant jelly stool- dye bleeding & inflammation
- palpate sausage shaped mass

Mgt:
1.) Hydrostatic reduction with barium enema
2.) Anastomosis & pull thru procedura

Inborn Errors of Metabolism- deficient liver enzymes

PHENYLKETONURIA (PKU) – deficiency of liver enzymes (PHT)
Phenylalaninehydroxylase Transferase – liver enzyme that converts CHON to amino acid

9 amino acids:
valine isolensine tryptophase
lysine phenylalanine

Thyronine – decrease malanine production

49
 1.) fair complexion
2.) blond hair
3.) blue eyes
Thyroxine – decrease basal metabolism
- accumulation of Phenyl Pyruvic acid
4.) Atopic dermatitis
5.) musty / mousy odor urine
6.) seizure – mental retardation

Test – GUTHRIE TEST – specimen – blood

- preparation increase CHON intake
- test if CHON will convert to amino acid

specimen and urine

mixed with pheric chloride, presence of green spots at diaper a sign of PKU
DIET:
Low phenylalanine diet- food contraindicated- meats, chicken, milk, legumes, cheese,
peanuts
Give Lofenalac- milk with synthetic protein

Galactosemia – deficiency of liver enzyme

- GUPT – Galactose Urovil Phosphatetranferase
- Converts galactose to phosphate tranferace glucose

Galactose – will destroy brain cells if untreated – death within 3 days

Dx:
Beutler test – get blood -done after 1st feeding
presence of glucose in blood – sign of galactosemia
galactose free diet lifetime
neutramigen – milk formula

CELIAC DISEASE – gluten enteropathy

Common gluten food:
Intolerance to food with brow
B- barley
R- rye
O- oat
W- wheat

50
 Gluten – glutamine ( normal absorption)

Gliadin ( toxic to epithelial cells of

villi of intestines, effects is
malabsorption syndrome)

Malabsorption

Fats CHON & CHO Vit D calcium Vit K Iron folic acid
peripheral edema &
malnutrition

Inadequate
blood
coagulation

Steatorrhea Osteomalasia Bleedin anemia

gg

Early Sx:
1. diarrhea – failure to gain wt ff diarrheal episodes
2. constipation
3. vomiting
Late Sx:
1. abd pain – protruberant abd even if with muscle wasting
2. steatorrhea

Celiac Crisis- exaggerated vomiting with bowel inflammation

Dx:
1. lab studies – stool analysis
2. serum antiglyadin – confirmatory of disease

gluten free diet – lifetime

all BROW – not allowed
ok – rice & corn

Mgt:
1. vitamin supplements
2. mineral supplements
3. steroids

POISONING- common in toddlers. (falls- common to infant)

1. determine substance taken, assess LOC

51
 2. unless poison is corrosive, caustic (strong alkali such as lye) or a hydrocarbon,
vomiting is the most effective way to remove poison.
- Give syrup 1 pecac to induce vomiting
3. 1 pecac – 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 1 pecac
6. antidote for acetaminophen poisoning – acetylsysterine ( mucomyst)
7. caustic poisoning ( muriatic acid ) neutralize acid by giving vinegar . Don’t vomit
prepare tracheostomy set
8. Gas- mineral oil will coat intestine

Lead poisoning
Lead = Destroy RBC functioning = Hypochornic Microcytic Anemia = Destroy kidney
functioning
Accumulation of anemia = Encepalopathy

Sx:
1. beginning sx of lethargy
2. impulsiveness, learning difficulties
3. as lead increases, severe encepalopathy with seizure and permanent mental
retardation

Dx:
1. Blood smear
2. abd x ray
3. long bones
Mgt:
1. remove child from source
2. if > 20 ug/dL – need chelation therapy = binds with led & excreted by kidney
=nephrotoxic

Amogenital
Female:
Pseudomenstration slight bleeding on vagina related to hormonal changes

Tearing of fourchette with blood – rape/ child abuse

Rape- Report within 48 h
Shape pubic hair in inverted triangle ( female)

Male:
Undescended testes – cyrptorchidism -common to preterm
surgery – orchidopexy
assess scrotum- warm room & hands

52
baby – pee within 24 h
-check for arch of urination
Epispadias- urinary meatus located dorsal or above glans penis
Hypospadias- urinary meauts loc ventral or below glans penis

Hypospadias with chordee- fibrous band causing penis to curb downward

Mgt:
Surgery

Phimosis- tight foreskin

Balanitis-infection of glands penis – due smegma

Mgt:
Circusicion

Hydroseal – fld filled scrotum

Tst of Dx:
Transillumination with use of flashlight - glowing sign

Varicoseal – enlarged vein of epididimis ( girls- vulvular varicosities)

Renal Disorder Cause Sx Tx NSG CARE

NEPHROTIC infectious 1. Anasarca- gen Prednisone Focus of care:
SYNDROME edema Diuretic monitor edema
2. massive - weigh daily
protenuria Diet:
3. microscopic or Increase CHON
no hematuria Increase K- OJ,
4. serum CHON beef broth,
decreased banana
5. serum lipid Decrease Na
increased
6. fatigue
7. normal or
decreased BP
AGN ( acute Autoimmune 1. (PPP) primary 1. anti HPN 1. weigh daily
Glomerulo Grp A beta peripheral drug 2. monitor BP &
Nephritis) hemolytic periobital - hydralazine neurologiuc status
streptococcus edema or 3. Diet: decrease
3A’s; 2. moderate apresoline K, decrease Na
AGN, protenuria 2. iron
autoimmune, 3. gross hematuria
Grp A ( smokey urine)

53
 4. serum K
increased
5. fatigue
6. increase BP
Complication :
1. hypersensive
encephalopathy
2. anemia

BACK- check for flatness & symmetry

Open Neural Tube Defect- decreased Folic Acid intake

SPINA BIFIDA OCCULTA- failure of post laminae of vertebrae to fuse

Sx: dimpling of back , Abnormal tufts of hair
SPINA BIFIDA CYSTICA- failure of post laminae of vertebrae to fuse with a sac

Types:
1. Meningocele – protrusion of CSF & Meninges
2. Myelomeningocele – protrusion of CSF & Meninges & spinal cord ( most
dangerous)
3. Encephalocele ( CNS complication – hydrocephalus) – cranial meningocele or
myelomeningocele
Most common problem
- rupture of sac
- prone pos
- sterile wet dressing
Most common complication - infection
Myelomeningocele – genitourinary complication- urinary & fecal incontinence
Nsg care: always check diaper
Orthopedic complication – paralysis of lower extremities
Surgery to prevent infection
Post op – prone position

SCOLIOSIS- lateral curvature of the spine

2 types:
1. structural – rye neck
2. postural – improper posture

Dx:
1. uneven hemline
2. bend forward- 1 hip higher
1 shoulder blade more prominent
Nsg care:
1. conservative – avoid obesity, exercise
2. preventive – Milwaukee brace - worn 23 h a day

54
3. corrective surgery – insert Harrington rod
post op- how to move
log rolling- move client as 1 unit

EXTREMITIES:
check # of digits = 20
1. syndactyly – webbing of digits
2. polydactyly – extra digits
3. olidactyly – lack of digits
4. Amelia – total absence of digits
5. pocoamelia- absence of distal part of extremities

ErQ duchennes – paralysis- brachial plexus injury or brachial palsy

- birth injury caused by lateral & excessive traction during a breech injury
Sx:
1. unable to abduct arms from shoulders, rotate arm externally or supinate forearm
2. absence or asymetrical moro reflex
Mgt:
1. abduct arm from shoulders with elbow flex.

CONGENITAL HIP DISLOCATION – head of femur is outside acetabulum

Types;
1. subluxated – most common type
2. dislocated
Sx:
1. shortening of affected leg
2. asymmetrical gluteal fold
3. limited movement – earliest sx
4. (+) ortolanis sign – abnormal clicking sound
5. when able to walk – child limps – late sx- trendelenburg sign

Goal of Mgt:
Facilitate abduction
Mgt.
1. triple diaper
2. carry baby astride
3. Frejka splint
4. Pavlik harness
5. Hip Spica Cast

TALIPES – “clubfoot”
a.) Equinos – plantar flexion – horsefoot
b.) Calcaneous – dorsiflexion – heal lower that foot anterior posterior of foot flexed
towards anterior leg
c.) Varus- foot turns in
d.) Valgus- foot turns out

55
Equino varus- most common

Assessment:
1. Straighten legs & flexing them at midline pos

Mgt:
1. Corrective shoe- Dennis brown shoe, spica cast

Fx: of cast –
- to immobilize
- bone alignment
- prevent muscle spasm
lead pencil – mark area to be amputated
cold H20 – hasten setting process
hot H20- slow setting process

After cast application – how to move pt:

- use open palm not fingers- fingers will cause indention
- dry cast – natural air not blower
- priority check : neurovascular check
C- circulation
M- motion S- sensation

Cast – with bleeding

- mask with ball pen edge of blood to know if bleeding is on going
sign cast is dry = resonant sound, cast cold to touch
-do petaline – making rough surface of cast smooth

CRUTCHES
Fx: To maintain balance
- To support weakened leg

Principles in crutches
- wt of body on palm!
- Brachial pulsing – if wt of body in axila
- Do palm exercise- squeeze ball
Different crutch Gaits:
1. Swing Through
2. Swing to
- no weight bearing are allowed into lower ext
3. Three point Gait
- wt bearing is allowed in 1 ext
4. Four point gait
5. Two point Gait
- wt bearing allowed in 2 lower ext

56