PEDIATRIC NURSING

SOPHOMORE YEAR | SEM #2 | BY: AYA ♡ PRELIMS EXAM TABLES | PROF. UBANA | FEU NRMF

1.1 NURSING CARE OF HIGH-RISK NEWBORN TO MATURITY

I. IDENTIFICATION OF AT-RISK NEWBORN

- High-risk neonate = NEWBORN (regardless of gestational age OR birth
weight)
~ chance of morbidity ~> conditions or circumstances
CLASSIFICATION OF HIGH-RISK INFANTS
~ associated with birth and the adjustments to extrauterine existence
NEWBORN chance of morbidity within the first 28 days of life
- BEFORE being born
- CAN DEVELOP AFTER being born
● Risk period - 23-28 weeks gestation
- Human growth and development from the time of viability

1.2 NEWBORN CLASSIFICATION BASED ON GESTATIONAL AGE

APPROPRIATE FOR GESTATIONAL SMALL FOR GESTATIONAL AGE LARGE FOR GESTATIONAL AGE
AGE

DEFINITION ● Birth weight falls between 10th ● Birth weight below the 10th percentile ● Birth weight above the 90th percentile
& 90th percentile ● Preterm (<38) or post-term (>42) ● BW more than expected
● Level of growth appropriate for ● Intrauterine growth retardation or restriction ● Macrosomia
the age of the fetus - Failed to grow at expected rate in utero

● Mother’s nutrition; lack of adequate nutrition ● Overproduction of growth hormone; diabetic mothers =
● Placental damage; placental separation poorly controlled glucose levels
● Systemic disease of mother; decrease blood ● Multiparous; each succeeding pregnancy babies grow
flow to placenta (severe diabetes mellitus or larger
pregnancy-induced hypertension)
● Smoking ● Transposition of the great vessels - group of congenital
CAUSES
● Intrauterine infections; adequate nutrient supply heart defects
BUT can’t be absorbed because of the presence ● Beckwith syndrome - overgrowth disorder (increased risk
of infection: rubella or toxoplasmosis of childhood cancer and certain congenital features
● Congenital anomalies (omphalocele) - abnormal
contents (small large intestine, stomach liver) ay
nakalabas sa tiyan

AARAY PERO DI BIBIGAY - AYLM ♡ | 1

 PEDIATRIC NURSING
SOPHOMORE YEAR | SEM #2 | BY: AYA ♡ PRELIMS EXAM TABLES | PROF. UBANA | FEU NRMF

FINDINGS: ● Prenatal assessment: 1. Skin color; jaundice and erythema

- Weight measured in grams 1. Fundic height - do not ake during contractions 2. Motion of upper extremities - moror reflex to detect if
(false increase) clavicle fracture or Erb’s palsy
2. Baby’s length 3. Asymmetry of the anterior chest or unilateral lack of
TERM GESTATION CLASSIFICATION
3. Sonogram movement- diaphragmatic paralysis from edema of the
Preterm 23 37 weeks 4. Non-stress test phenic nerve
5. Placental grading 4. Paralysis
Term 38 42 weeks 6. Amniotic fluid amount 5. Assess for seizure activity - jitteriness, lethargy, and
ASSESSMENT
7. Ultrasound uncoordinated eye = intracranial pressure
Post-term 43 46 weeks
🟰 POOR PLACENTAL FUNCTION 1. Sonogram
2. Non-stress test assess the placenta’s ability to sustain a
large fetus during labor
PROBLEMS RELATED TO 3. Lung maturity; amniocentesis
GESTATIONAL MATURITY 4. Recognized during labor when infant can pass through
the pelvic brim
ELBW 1000 below
(extremely) - 27 weeks or ● weight ● Immature reflexes and low scores on gestational age
lower ● 🖐🏻 skin dry; little fat examinations related to its size
● Wasted appearance ● Extesive bruising
MLBW 1501 2500g ● Poor skin turgor ● Large head
(moderately) ● Skull sutures may be widely separated (lack of ● Molding of head
APPEARANCE normal bone growth) ● Cardiovascular dysfunction
VLBW 1000 2500 ● Dull hair ● Cyanosis
(very) - Before 30 wks of ● Sunken abdomen ● Polycythemia
pregnancy (3- ● Cord dry and yellow ● Hyperbilirubinemia
5oz) ● Better neurological responses ● Hypoglycemia
● Firmer skull
LBW 2500 AGA
(low) - Regardless of
LABS gestational age ● High hematocrit - lack of fluid in utero ● Hyperbilirubinemia - increased bilirubin level =
● Polycythemia - increased RBC due to anoxia absorption of blood from bruising and polycythemia
LGA 3500 above ● Acrocyanosis - blood viscosity = difficult to ● Polycythemia - infant’s systems attempting to fully
(large) circulate thick blood oxygenate all body tissues
● Cyanosis - sign of transposition of the great vessels

AARAY PERO DI BIBIGAY - AYLM ♡ | 2

 PEDIATRIC NURSING
SOPHOMORE YEAR | SEM #2 | BY: AYA ♡ PRELIMS EXAM TABLES | PROF. UBANA | FEU NRMF

● Hypoglycemia ● Hypoglycemia - early hours bc the infant uses up nutrition

-glycogen stores (below 40mg/dL) ● Cardiovascular dysfunction - polycythemia, cyanosis,
-
IVF until able to suck to take feedings hyperbilirubinemia
● Birth Asphyxia ● Intracranial pressure
- Underdeveloped chest muscles
PROBLEMS/ - Risk for developing meconium aspiration
COMPLICATIONS syndrome ~> anoxia during labor
- Fetal hypoxia = reflex relaxation anal sphincter
+ intestinal movement

2.1 PRETERM INFANTS

DEFINITION ● Born before the end of 37 weeks gestation

Late pre-term 34 37 weeks

CLASSIFICATION Early pre-term 24 30 weeks

Post-term 42 weeks

MATERNAL FACTORS FETAL FACTORS OTHER

● Age ● Multiple pregnancies ● Low socioeconomic status

CAUSES ● Smoking ● Infection ● Early termination of pregnancies
● Poor nutrition ● IUGR ● Environmental exposure to harmful substances
● Placental problems ● Iatrogenic causes (elective CS and inducement of labor
● Pre-eclampsia/ eclampsia acc to dates rather than fetal maturity)

CHARACTERISTICS ● Appearance - small and underdeveloped

AARAY PERO DI BIBIGAY - AYLM ♡ | 3

 PEDIATRIC NURSING
SOPHOMORE YEAR | SEM #2 | BY: AYA ♡ PRELIMS EXAM TABLES | PROF. UBANA | FEU NRMF

- Head - large as fuck (disproportionate); 3cm or more larger than chest

- Skin - ruddy (no subcutaneous fat)
- Veins - easily noticeable
- Acrocyanosis
- Anterior and posterior fontanelles = small
- Soles of feet - few to no creases
● Preterm neonate = covered with vernix caseosa
● Very preterm neonate = absent vernix caseosa
● Lanugo (extensive)
● Eyes - small (varying degrees of myopia)
● Cartilage - immature (pinna falls forward)
● Neurologic function - difficult to evaluate
● Activity - feebler and weaker
● Scarf sign
● Square window
● CNS center for respiration - underdeveloped

● Anemia of prematurity
- Normochromic or normocytic anemia
- Blood cells = fragmented or irregularly shaped
● Hyperbilirubinemia
- Immaturity of liver
● Persistent patent ductus arteriosus
POTENTIAL - Preemie infant’s lack of lung surfactant = lungs are non compliant
COMPLICATIONS ● Periventricular/Intraventricular hemorrhage
- Prone to bleeding into the tissue surrounding the ventricles or bleeding into the ventricles

● RDS
● Apnea
● Retinopathy of prematurity
● Necrotizing enterocolitis

DIAGNOSTIC
● Cranial Ultrasound done after first few days of life to detect if hemorrhage occured
INTERVENTIONS

AARAY PERO DI BIBIGAY - AYLM ♡ | 4

 PEDIATRIC NURSING
SOPHOMORE YEAR | SEM #2 | BY: AYA ♡ PRELIMS EXAM TABLES | PROF. UBANA | FEU NRMF

2.1.0 APNEA OF PREMATURITY

● Common phenomenon in preterm

DEFINITION ● Lapse of spontaneous breathing for 20 seconds / shorter pauses with hypotonia, bradycardia or color change
● <33 wks gestation and healthy <30 wks gestation ~ resolves as the infant approaches 37 weeks genstation

● Absence of diaphragm function

Central Apnea ● = causes lack of respiratory effort
● CNS does not transmit signals to respi muscle

CLASSIFICATION ● Air flow ceases because of upper airway obstruction

Obstructive Apnea
BUT chest or abdominal wall movement is present

● Combination of central and obstructive

Mixed apnea
● Most common

● Immature and purely refined neurologic and chemical respiratory control mechanisms in preemie infants,
- Not responsive to hypercarbia and hypoxemia
PATHOPHYSIOLOG - Respiratory reflexes are significantly less mature
Y ● Overall weakness of the thorax, diaphragm and upper airway
- REM sleep
- Worsened by variety of factors

● Methylxanthines ~ stimulate breathing

● Observe for symptoms of toxicity
THERAPEUTIC ● Serum theophylline levels are determined by the infection, intracranial hemorrhage, or infant’s weight, gestational age and chronological age and maintained
MANAGEMENT within a therapeutic drug
● Caffeine has fewer side effects
● Nasal CPAP IMV maintain airway patency

NURSING CARE ● Monitoring respiration and heart rate.

- Cardiorespiratory monitors alert staff-preset delay time-15-20 seconds.
● If begun early, gentle tactile stimulation (rubbing back and chest gently, turning infant to supine position)
- If tactile stimulation fails to reinstitute respiration, flow-by oxygen and suctioning of nose and throat, if breathing does not begin, the chin is raised
gently to open the airway, and resuscitate by mask and bag to lift the rib cage. Never shake the baby.
● If breathing is restored, assess infant for temperature, abdominal distention.

AARAY PERO DI BIBIGAY - AYLM ♡ | 5

 PEDIATRIC NURSING
SOPHOMORE YEAR | SEM #2 | BY: AYA ♡ PRELIMS EXAM TABLES | PROF. UBANA | FEU NRMF

- Use pulse oximetry.

● Record apneic episodes.
● If persistent and recurrent apnea, put baby on mechanical ventilation / CPAP. (continuous positive airway pressure)

● IVF given to prevent hypoglycemia and supply feedings = fluids HALTED until infant has stabilized respiratory efforts
● Fed by total parenteral nutrition until stable
- Breastfeeding/gavage/bottle feeding ~ begun if keri na ni baby Breast Milk
best milk for preterm
● Preemie = small stomach capacity 🟰 fed more often (in smaller amounts) because the immunologic properties

● Preemie: 115 - 140 cal/kg/day

Calories
● Term: 100-110 cal/kg/day

● Preemie: 3 - 3.5 g/kg

Protein
● Term: 2 - 2.5 g/kg

● Gavage feeding
FEEDING SCHEDULE - gag reflex is not intact until an infant is 32 weeks gestation.
- Coordination of sucking and swallowing ~ 34 weeks
- THUS all preemies (32-34 wks) are started with gavage feeding (not coordinated yung swallowing and sucking)
● When inserting NGT measure from EARLOBE to TIP OF NOSE TO DISTAL END OF STERNUM
- Check correct placement:
1. Aspirate gastric contents (Acidic = NGT ✅)
2. Inject 5cc of air and auscultate (No sound = not in stomach ❌)
Caloric Concentration PREEMIE: 24 cal/oz | TERM: 20 cal/oz

Vitamin A important in improving healing & possibly reducing the incidence of lung disease.

Vitamin E important in preventing hemolytic anemia in preterm.

Electrolytes sodium, potassium & chloride may be necessary.

● Monitor baby’s weight, urine output and specific gravity and serum electrolytes to ensure adequate fluid intake
NURSING OUTCOME
- Overhydration may lead to non-nutritional weight gain, pulmonary edema and heart failure
EVALUATION

AARAY PERO DI BIBIGAY - AYLM ♡ | 6

 PEDIATRIC NURSING
SOPHOMORE YEAR | SEM #2 | BY: AYA ♡ PRELIMS EXAM TABLES | PROF. UBANA | FEU NRMF

Range of urine output for the first Preterm: 40 - 100 mL in 24 hours

few days of life Term: 10 - 20 mL in 24 hours

Low: 1.012
Specific Gravity
Normal: 1.030
● Test urine for ketones and glucose.
- Hyperglycemia caused by glucose infusion may lead to glucose spillage
- If too little glucose is supplied and body cells are using protein for metabolism, ketone bodies will appear in the urine.
● Blood glucose determination every 4 - 6 hrs = hyperglycemia or hypoglycemia
- Should range between 40 and 60 mg/dl
● Check for blood in stools
- Evaluate if may dugo sa intestinal tract

2.1.2 COMPONENTS OF PHYSICAL MATURITY

2.1.1 NEURO MUSCULAR ASSESSMENT TERM PRETERM POST TERM
TERM PRETERM Translucent and Leathery, cracked ~
POSTURE - SKIN
friable wrinkled
degree of flexion ng braso at legs Moderately flexed at rest Lesser degree of flexion
LANUGO Very Little None Nearly Absent
SQUARE WINDOW - Absent to faint
grasping NB’s forearm and gently PLANTAR/ SOLES Creases all over
Hand touches the wrist Less flexibility of the wrist markings
flexing the wrist towards the inner BREAST Raised to a full
0° angle Greater angle
arm. Do not allow rotation of the Assess in areola Lacked developed
wrist. millimeters Breast buds = 3- breast tissue
ARM RECOIL (breast bud) 10mm diameter
measure arm recoil by flexing and EYE/EAR Well curved pinna
Full recoil to a position of Less curved pinna
holding both forearm for 5 Less flexion Ear cartilage and Firm cartilage
flexion Fused eyelids
seconds = release to allow recoil; pinna shape Ear recoil quick
return to flexion
POPLITEAL ANGLE
Less flexion Straightens
Move foot gently toward head Male:
90° angle 180° angle
until resistance; measure distance - testes descended Male:
SCARF SIGN - Rugae visible - Flat and smooth
Meet resistance before Crosses the elbow past GENITALS
Grasp NB’s hand and attempt to Female: Female:
crossing midline midline
cross over the neck - Labia majora - Prominent clitoris
HEEL TO EAR larger
Resistance almost Come close to touching AARAY PERO DI BIBIGAY - AYLM ♡ | 7
Raise NB’s heel to ear; stop when
immediately heel to ear
met with resistance
 PEDIATRIC NURSING
SOPHOMORE YEAR | SEM #2 | BY: AYA ♡ PRELIMS EXAM TABLES | PROF. UBANA | FEU NRMF

2.2 POST-TERM INFANTS

DEFINITION ● Born after the completion of 42 weeks

● Skin
- Completely absent ~ vernix and lanugo
- Dry, cracked, parchment-like appearance
ASSESSMENT
- Color: Yellow to green (from meconium staining)
● Depleted or little subcutaneous fat = old man appearance (Intrauterine weight
● Hard or long nails extending beyond fingertips

● Ultrasound measure biparietal diameter of fetus

DIAGNOSTIC PROCEDURE ● Non-stress test or biophysical profile if placenta is still functioning
● CS

● Monitor VS
MANAGEMENT
● IVF as ordered

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