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Module 6

Maternal for college
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0% found this document useful (0 votes)
17 views38 pages

Module 6

Maternal for college
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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ALDERSGATE COLLEGE NCM107

SCHOOL OF MEDICAL SCIENCES LETICIA D. SERRANO, RN,MAN

Module 6: Growth and Development

OVERVIEW

General Objective:
At the end of the course, the students should have acquired the knowledge, skills and attitudes required in the care for the
normal mothers, infants, children and families and the application of principles and concepts on family and family health
nursing process.

Objectives:
1. To apply the knowledge on the approaches on Growth and Development with the use of Nursing Process
2. To assess fetal growth and development, fundic height, fetal position and presentation.
3. Prioritize nursing diagnosis.

Learning Focus
NURSING CARE OF THE NORMAL PEDIATRIC CLIENT
Related Terms:
1. Growth –denotes an increase in body size, focus is on child’s height and weight. It occurs as cells divide and
synthesize new proteins.
2. Development- is the gradual growth and change from a lower to a more advance state of complexity. It is the
progressive increase in skills and capacity to function. It involves the expansion off the child’s capacities through
growth, maturation and progressive gains in functional ability.
3. Maturation- is the “readiness” of the individual ; states that learning takes place quickly and effectively when the
child is ready. It is the development of traits carried through the genes.
4. Genetics – study of heredity
5. Eugenics – study of ways to improve hereditary traits
6. Euthenics – study of ways to improve health
Principles of Growth and Development:
1. Growth and Development proceed in predictable and orderly sequence and directions:
a. Cephalocaudal (from head to toe) – growth is more advanced at and near the head and gradually progresses
downward to the neck, trunk and extremities
b. Proximo-distal – growth proceeds outward, from the central axis of the body toward the periphery
c. General to specific – e.g., from crying at birth to complete sentences at preschool age
d. Gross to refine/ simple to complex – e.g., from walking at 12 months to pedaling the trike at 3 year
2. Growth and development is a continuous process beginning from conception and ends in death.
3. Behavior is most sensitive and comprehensive indicator of developmental status.
4. Play is central to the life of a child and is the universal language of the child.
5. A great deal of skill and behavior is learned by practice.
6. All aspects of development are interrelated.
7. Children are competent – they are well endowed with the qualities and abilities needed to ensure their survival and
promote their development
8. Children resemble one another – the physical and behavioral characteristics of each age and changes that occur with
increasing age are similar from child to child
9. Each child is a unique individual – the differences from child are due to a combination of:
a. Heredity and constitutional make-up
b. Racial and national characteristics
c. Sex
d. Environment
10. Asynchronous growth – the whole body does not grow at once; different regions and subsystems develop at
different rates and times
Discontinuity of growth rate – there are only 2 periods of very rapid growth: the fetal-infancy period and adolescence.

1 NCM 107
ALDERSGATE COLLEGE NCM107
SCHOOL OF MEDICAL SCIENCES LETICIA D. SERRANO, RN,MAN

11. Development is timely – the notion of readiness or maturation states that learning would come quickly and
effortlessly once the child is ready (also called “critical period”). That is why the most common reason for failure in
toilet training is: the child is not yet ready to be trained.
12. New skills tend to predominate – the current developmental issue becomes a preoccupation for the child.
13. The many aspects of development are interrelated – the personal-social, fine motor-adaptive, gross motor and
language aspects of development act upon and react with one another extensively and inseparably.
14. Different systems do not grow at the same rate.
15. Heredity sets the upper limits of growth and development that cannot be surpassed

Rates of Growth:
1. Infancy: most rapid period of growth
• Doubling time of birth weight at 6 months
• Tripling time of birthweight at 12 months
2. Toddler: slow; plateau
• Trunk grows faster than other tissues
3. Preschooler: Slow, uniform
• Trunk grows faster than other tissues; legs also grow fast
4. Schooler: Slow, uniform
 Limbs grow most rapidly; Bones grow faster than muscles and ligaments ---> tendency to fractures
5. Adolescence: Rapid growth, in spurt both in height and weight
• Girls are ahead by 2 years in spurt
• Growth spurt last for 3 years
• At age 9, boys and girls are the same in size; at age 12, girls are bigger than the boys

Theories of Human Development:

1. Psychoanalytic Theory ( Sigmund Freud 1856 – 1939) – described adult behavior as being the result of an instinctual
drive (libido) from within the person and the conflicts that develop between these instincts (id) ; reality (ego) ; and
society (superego). He described child development as being a series of psychosexual stages in which the child’s
interests become focused on a particular body site.
Sigmund Freud – is an Australian neurologist and founder of psychoanalysts.

2. Psychosocial Development Theory ( Eric Erikson 1902) – considers the importance of culture and society in the
development of the personality.
3.
AGE FREUD’S STAGES OF CHILDHOOD ERIKSON’S STAGES OF CHILDHOOD
GROUP Psychosexual Stage Nursing Implications Developmental Tasks Nursing Implications
Infant Oral Stage: Child Provide oral stimulation by Developmental task is to Provide a primary care-
explores the world by giving pacifiers; do not form a sense of trust vs. giver. Provide
using mouth, especially discourage thumb mistrust. Child learns to experiences that add to
the tounge. sucking. Breastfeeding love and be loved. security, such as soft
may provide more sounds and touch.
stimulation than formula- Provide visual
feeding because it stimulation for active
requires the infant to child involvement.
expend more energy

Toddler Anal Stage: Child Help children achieve Developmental task is to Provide opportunities
learns to control bowel and bladder control form a sense of for decision-making,
urination and without undue emphasis autonomy vs. shame such as offering choices
defecation. on its importance. If at all and doubt. Child learns of clothes to wear or
possible, continue bowel to be independent and toys to play with. Praise
and bladder training while make decisions for self. for ability to make

2 NCM 107
ALDERSGATE COLLEGE NCM107
SCHOOL OF MEDICAL SCIENCES LETICIA D. SERRANO, RN,MAN

child is hospitalized. decision rather than


judging correctness of
any one decision.
Pre- Phallic Stage: Child Accept child’s sexual Developmental task is to Provide opportunities
Schooler learns sexual identity interest, such fondling for form a sense of initiative for exploring new
thru awareness of his or her own genitals, as vs. guilt. Child learns places or activities
genital area. normal area of how to do things ( basic involving water, clay
exploration. Help parents problem-solving ) and ( for modeling) or finger
answer child’s questions that doing things is paint.
about birth or sexual desirable.
differences.
School-age Latent Stage: Child’s Help the child have Developmental task is to Provide opportunities
Child personality positive experiences so form a sense of industry such as allowing child
development appears to his or her self-esteem vs. inferiority. Child to assemble supplies
be non-active or continues to grow and the learns how to do things for a dressing change
dormant. child prepares for the well. ( short projects finished
conflicts of adolescence. completely), so that the
child feels rewarded for
the accomplishment.
Adolescent Genital Stage: Provide opportunities for Developmental task is to Provide opportunities
Adolescent develops the child to relate with the form a sense of identity for the adolescent to
sexual maturity and opposite sex; allow child vs. role confusion. discuss feelings about
learns to establish to verbalize feelings about Adolescent learns who events important to him
satisfactory new relationships. he or she is and what or her. Offer support
relationships with the kind of person he or she and praise for decision-
opposite sex. will be by adjusting to a making.
new body image,
seeking emancipation
from parents, choosing
a vocation and
determining a value
system.
4. Cognitive Development Theory ( Jean Piaget 1896 – 1980) – defines four stages of cognitive development; within each
stage are finer units or schema. Each period is an advancement over the previous one. To progress from one period to
the next, the child reorganizes his or her thinking process to bring them closer to reality.

Stages of Development Age Span Nursing Implication


Neonatal Reflex 1 month Stimuli are assimilated into beginning images. Behavior entirely reflexive.

3 NCM 107
ALDERSGATE COLLEGE NCM107
SCHOOL OF MEDICAL SCIENCES LETICIA D. SERRANO, RN,MAN

Primary Circular 1–4 Hand-to-mouth and ear-eye coordination develops Infant spends much time
Reaction months looking at objects and separating from them. Beginning intention of behavior
is present ( the infant brings the thumb to mouth for a purpose to suck it).
Enjoyable activity for this period: rattle or tape of parent’s voice.

Sensori- Secondary 4–8 Infant learns to initiate, recognize and repeat pleasurable experiences from
motor Circular Reaction months environment. Memory traces are present: infant anticipates familiar events ( a
parent coming near him will pick him up). Good toy for this period: mirror,
good game, peek-a-boo

Coordination of 8 – 12 Infant can plan activities to attain specific goals. Perceives that others can
Secondary months cause activity and that activities of own body are separate from activity of
Reactions. objects. Can search for and retrieve toy that disappears from view.
Recognizes shapes and sizes of familiar objects. Because of increased sense
of separateness, infant experiences separation anxiety when primary care-
giver leaves. Good toy for this period: nesting toys, i.e. colored boxes.

Tertiary Circular 12 – 18 Child is able to experiment to discover new properties of objects and events.
Reactions months Capable of space perception and time perception as well as permanence.
Objects outside self are understood as causes of actions. Good game for this
period: throw and retrieve.

Intervention of 18 – 24 Transitional phase to the preoperational thought period. Uses memory and
new means thru months imitation to act. Can solve basic problems, foresee maneuvers that will
mental succeed or fail. Good toys for this period: those with several uses as blocks,
combinations colored plastic rings.

Pre- 2–7 Thought becomes more symbolic: can arrive at answers mentally instead of
operational years thru physical attempt. Comprehends simple abstractions but thinking is
Thought basically concrete and literal. Child is egocentric . Displays static thinking (
inability to remember what he or she started to talk about so that the end of
the sentence the child is talking about is another topic.) Concept of time is
now and concept of distance is only as far as he or she can see. Unable to
state cause – and – effect relationships, categories or abstractions. Good toy
for this period: items that require imagination, such as modeling clay.

Concrete 7 – 12 Concrete operations includes systematic reasoning. Uses memory learn


Operational years broad concepts (i.e. fruits) and subgroups of concepts(i.e. apples,
Thought oranges).Classifications involving sorting objects objects according to
attributes ( i.e. color). NOTE: Expose the child to other viewpoints such as “
How do you think you’d feel if you were a nurse and had to tell a boy to stay in
bed?”.

4 NCM 107
ALDERSGATE COLLEGE NCM107
SCHOOL OF MEDICAL SCIENCES LETICIA D. SERRANO, RN,MAN

Formal 12 years Can solve hypothetical problems with scientific reasoning: understands
Operational causality and can deal with the past, present and future. Adult or mature
Thought thought. Good activity for this period: “talk time” to sort thru attitudes and
opinions.

5. Theory of Moral Development ( Kohlberg 1984) – describes the different moral as well as cognitive and psychosocial
development children pass thru as they mature to adulthood.

AGE (Year) STAGE DESCRIPTION NURSING IMPLICATIONS


Preconventional (Level I) Punishment/obedience orientation Child needs help to determine
2–3 (“heternomous morality”). Child does what are right actions. Give
1 right because a parent tells him or her to clear instructions to avoid
and to avoid punishment. confusion.

4–7
Individualization, instrumental purpose Child is unable to recognize
2 and exchange. Carries out actions to that like situations require like
satisfy own needs rather than society’s . actions. Unable to take
Will do something for another if that responsibility for self care as
person does something for the child. meeting own needs interferes
with this.

Conventional ( Level II) Orientation to interpersonal relations of Child enjoys helping others
7 – 10 3 mutuality. Child follows rules because of because this is “nice”
a need to be a “good” person in own behavior. Allow child to help
eyes and the eyes of others. with bed making and other like
activities. Praise for desired
Maintenance of social order, fixed rules behavior.
10 – 12 4 and authority. Child finds following rules Child often asks what are the
satisfying. Follows rules of authority, rules and is something “right”.
figures as well as parents in an effort to May have difficulty modifying
keep the “system” working. a procedure because one
method may not be “right”.
Follows self-care measures
only if someone is there to
enforce them.

Pre-Conventional ( Level III) Social contract, utilitarian lawmaking An adolescent can be


Older than 12 5 perspectives. Follows standards of responsible for self-care
society for the good of all people. because he or she views this
as standard of adult behavior.

Universal ethical principle orientation. Many adults do not reach this


6 Follows internalized standards of level of development
conduct.

Specific Behavior/ Significant Developmental Milestones

1. Newborn – when on prone, avoids suffocation by turning his head from side to side
2. One month:
a. Lifts head intermittently when on prone; head sags

5 NCM 107
ALDERSGATE COLLEGE NCM107
SCHOOL OF MEDICAL SCIENCES LETICIA D. SERRANO, RN,MAN

b. Momentary visual fixation on objects and human faces; follows moving objects to midline of vision;
differentiates objects and faces
c. Smiles indiscriminately
d. Crying is differentiated
e. Sweats
3. Two months:
a. “Social smile”
b. Responds to familiar voices by body movements; turns from side to back
c. No head control; head lags when pulled to sitting
d. Sheds tears
e. Holds rattles briefly
f. Posterior fontanel closes

4. Three months:
a. Can raise head but not chest when on prone
b. Head in bobbing motion; some head control when pulled to sit
c. Babbles and coos
d. In 180 degrees visual arc – can follow objects past visual midline; locates food sources
e. Discovers and plays with fingers
f. With hand-to-mouth activity
g. Drools ( needs bib)
5. Four months:
a. Can raise both head and chest when on prone; turns from back to side
b. When on supine, head is maintained in the midline, arms and legs are symmetrical and hands are brought
together in the midline; bald spot over occiput
c. Reaches for objects within reach and brings to mouth (Implication: Starting this age pins, diaper clips, etc
should be kept out of their reach)
d. Head control when pulled to sit, no head lag; no more bobbing, head steady when upright
e. Sustains part of own weight when helped to standing position
f. Laughs aloud
g. Drools a lot
h. Recognizes mother
i. With social interaction
j. Demands attention
k. Starts with solids

6. Five months
a. Rolls over (Important: Keep side rails of crib raised)
b. Raking grasp when picking objects
7. Six months:
a. Doubles birth weight
b. Eruption of first tooth (usually lower central incisor)
c. Sits with minimal support
d. Can be pulled from sitting to standing
e. Transfers objects from one hand to another
f. Begins to imitate sounds
g. Recognizes parents
h. First primary teeth (lower central incisors) erupt (6-7 mos.)
8. Seven months:
a. Plays with own feet
b. Pivots (creeps when on prone (Important: Keep rails on stairs raised and secure)
c. Thumb-finger grasp
d. Fears strangers
9. Eight months

6 NCM 107
ALDERSGATE COLLEGE NCM107
SCHOOL OF MEDICAL SCIENCES LETICIA D. SERRANO, RN,MAN

a. Sits alone steadily for an indefinite period


b. Hitches – moves backwards while seated
c. Discovers feet
10. Nine months:
a. Can hold bottle with good hand to mouth coordination
b. Crawls
c. Understands simple gestures and requests – bye-bye; pat-a-cake
d. Take some steps when held upright
e. Neat pincer grasp
f. Says first word “ma” and “pa” but non-specific
g. Plays “peek-a-boo”
11. Ten months:
a. Pulls self to stand
b. Responds to own name
12. Eleven months:
a. Stands with assistance
b. Attempts to walk with help
13. Twelve months:
a. Stands without support
b. Walks with help (cruises)
c. Triples birth weight
d. Drinks from cup
e. Can say 2 words
f. BREGMA (anterior fontanel) begins to close
g. Knows name
h. Has 4 to 5 words with gesture language
i. Shows emotions
j. Begins to explore environment

Child Health Station (Well-Baby Clinic) Visits – are focused on assessment of growth and development and
administration of immunizations
SCHEDULE:
2 months -----------------------DPT, TOPV 1
4 months -----------------------DPT, TOPV 2
6 months -----------------------DPT, TOPV 3
12 months ---------------------Tuberculin test
15 months ---------------------MMR triple vaccine
18 months ---------------------DPT, TOPV booster
4 – 6 months ----------------- DPT, TOPV booster
14 – 16 years -----------------Tetanus-diphtheria
toxoid, adult type
SPECIFIC CONSIDERATIONS:

1. DPT (Diphtheria, pertussis, tetanus)


TOPV (Trivalent oral polio vaccine)
a. Time interval of 8 weeks is recommended between the first 3 doses for maximum effect
b. An interrupted series need not be restarted; the second/third dose should be given, regardless of length of time it
has elapsed
c. Third TOPV is optional, but recommended in areas with high incidence of poliomyelitis
d. Side effects:
• Child usually fussy and irritable

7 NCM 107
ALDERSGATE COLLEGE NCM107
SCHOOL OF MEDICAL SCIENCES LETICIA D. SERRANO, RN,MAN

• Local tenderness and swelling at the injection site


• Increased temperature
2. Tuberculin test – given before or simultaneous with measles vaccine because the latter can invalidate tuberculin test,
giving a false (-); measles vaccine can activate latent PTB. Frequency of testing depends on risk of exposure of the child
and prevalence of TB in the population group; in high risk situations, intervals should not be more than 6 months.

3. Measles-Mumps-Rubella (MMR):
a. Measles vaccine may be given at 6 months if child is at high risk of contacting the disease, but a second dose will
have to be given at 12 months of age because the earlier dose may not be effective since the maternal antibodies
have not yet been catabolized
b. Pre-adolescent or older males who have not had mumps should be immunized
c. Kindergarten children should be given priority for rubella immunization because they are the major sources of
rubella or viral dissemination; history of rubella illness
4. DPT, TOPV booster doses – given to ensure and maintain immunity, since the immunoresponse is limited in a
significant proportion of young children
5. Tetanus-diphtheria toxoid
a. Tetanus is given every 10 years because it does not confer lifelong immunity
b. For contaminated wounds, a booster dose is given if more than 5 years have passed since the last dose; no booster
is needed for clean, minor wounds if immunizations are up to date and no more than 10 years have passed since the
last dose

Contraindications:
1. Acute febrile infections (common colds, if without fever, is not a contraindication)
2. Generalized malignancy; those receiving steroids and antimetabolites
3. Recent blood transfusion
4. Debilitating conditions (but sickle cell anemia is not a contraindication)
5. Sensitivity/allergy to the animal species in the vaccine
6. Pregnancy (the only immunization that can be given to a pregnant woman is tetanus immunization
DENTITION

A. Important Schedule:
 6-7 mos:eruption of first milk teeth, the lower central incisors
 12 mos:has 8 teeth – lower and upper central and lateral incisors
 24 mos:has 16 teeth
 2 ½ mos:with complete milk teeth – 20
 Late preschooler:eruption of first permanent teeth – first molars
 6 yr:brags about dancig teeth
 12 yr:with all permanent teeth except Final Molars (27-28 teeth)
 17-21 yr:complete permanent teeth – 32
 School Age:to be checked for loose teeth before any surgery.
B. Care of teeth:
1. Brush and floss (with parent’s help) twice daily.
2. Limit concentrated sweets.
3. If water is not fluorinated, supplements can be given: 0.25 to 0.5 mg/day.
4. Do not allow child a bottle of milk or juice to bed because it can lead to bottle caries
5. Have the first dental visit as soon as all primary teeth are out at 2 ½ years.
C. Permanent Teeth
1. 6-7 yr: 4 “six-year-molars”
2. 12-13 yr: 4 additional molars
3. 17-21 yr: 4 molars (wisdom teeth)
LANGUAGE TRAINING

Principles of Language Training


1. Teach one language at a time

8 NCM 107
ALDERSGATE COLLEGE NCM107
SCHOOL OF MEDICAL SCIENCES LETICIA D. SERRANO, RN,MAN

2. Talk to child in simple, clear words


3. Do not baby talk
4. Talk to child at eye level (toddlers fear height)
5. Provide a good model of speech
6. Provide plenty of sensory stimulation
7. Some language milestones
8. 9-10 mos:2 words; “ma”, “pa”
9. 11-12 mos: 4-5 words
10. 18 mos:20 words
11. 2 years: short sentences (1-2 sentences; 300 words; uses/says first name
12. 3 years:900 words; uses first and last name; names 1 color

Some language milestones


1. 5 years: with adult-length sentences; 2000-2100 words with increase 600 words per year; counts 1-10; last year for
normal stuttering (dysfluency)
2. School-age – with passwords, secret language; rapidly expanding vocabulary

DEVELOPMENTAL SCREENING

By means of assessment tolls, e.g., the Denver Development Screening Test (DDST): A screening instrument used to
detect developmental delays in the four aspects of behavior (personal-social, fine motor-adaptive, gross motor and language)
in children 0-6½ years of age

THE NEONATE (The first 28 days of life)

Immediate Care of the Newborn inside the Delivery Room

1. Establish and Maintain Patent Airway

Note: The respiratory system begins to change with the first breath. The neonates’ breathing is a reflex triggered in
response to noise, light, temperature, and pressure changes. Air immediately replaces the fluid that filled the lungs before
birth.
A. With head extended, wipe the mouth first then the nose to clear the air passage and to prevent meconium aspiration.
B. After expulsion : The newborn’s position should be one, which promotes the drainage of secretions, which is slight
Trendelenburg position, head is lower than the rest of the body, around 10 to 15 degree angle, except when there are
signs of increased intracranial pressure as manifested by shrill, high-pitched cry; vomiting; tense and bulging
fontanel; abnormally large head, in which case, the head should be positioned higher than the rest of the body (slight
fowler’s position).

2. Suction the newborn properly:


A. Turn the baby’s head to one side
B. Suction gently and quickly from the mouth to the nose using bulb syringe for shallow suctioning – prolonged and
deep suctioning is contraindicated during the first 5 – 10 minutes after birth as this will stimulate the vagus nerve,
located in the esophagus and will cause bradycardia and laryngospasm.
C. Suction the mouth first before the nose because suctioning the nose first will cause reflex inhalation of pharyngeal
secretions into the trachea and bronchi, thus causing aspiration. Suction the mouth first so as to remove the
pharyngeal secretions.
D. To test for patency of the airway, occlude one nostril at a time (Remember: Newborns are nasal breathers). If the
newborn struggles when a nostril is occluded, additional suctioning is indicated.
E. Oxygenate between suctioning PRN using safe oxygen concentration, which is not more than 40% concentration.
Excessive oxygen concentration can result to oxygen toxicity leading to neonatal blindness: RETROLENTAL
FIBROPLASIA or RETINOPATHY OF PREMATURITY.
3. Maintain Appropriate Body Temperature

9 NCM 107
ALDERSGATE COLLEGE NCM107
SCHOOL OF MEDICAL SCIENCES LETICIA D. SERRANO, RN,MAN

A. Temperature regulation of newborns is poor. Newborn suffers large losses of heat because he is wet at birth, the
Delivery Room is cold, he does not have enough subcutaneous tissues to keep him warm and he does not know how
to shiver. Heat production is accomplished primarily by non-shivering thermogenesis. Changes in neonatal
thermogenesis dependent on environment. In an optimal environment, the neonate can produce sufficient heat, but
rapid heat loss may occur in a suboptimal thermal environment; the major energy source for heat is his brown fat.
Brown fat can be seen only in term babies. Premature babies have less brown fat.
B. The newborn’s high temperature at birth is 37.50C but it drops quickly at birth because of the different processes of
heat loss like evaporation, conduction, convection and radiation
C. Effects of Cold Stress
a. Metabolic acidosis – one of the ways by which heat is produced is by increasing metabolism. When this
occurs, fatty acids accumulate because of the breakdown of brown fat.
b. Hypoglycemia – due to the use of glucose stored as glycogen.
D. Measures to maintain appropriate body heat:
a. Dry the baby immediately and wrap the baby warmly then place the infant next to mother.
b. Put under a droplight or in a Kreisselman/radiant warmer.

Note: Initial temperature of the newborn is checked per axilla as rectal route posts danger of rectal mucosal
perforation. The passage of meconium confirms anal patency and not the checking of the temperature.

4. Assess the Newborn Carefully

Data Base

A. First stage of transition to extrauterine life (period of reactivity)


1. Lasts 0 to 30 minutes
2. Alert and moving
3. Gustatory movements. Heart rate increases to 160 to 180 beats per minutes for 15 minutes and then declines to 100
to 120 beats per minute
4. Respirations are 60 to 80 per minute and irregular; grunting, flaring, and retractions may occur.
B. Second stage of transition to extrauterine life (period of decreased responsiveness)
1. Lasts 30 minutes to 2 hours
2. Relaxation and rest occurs as baby settles down
3. Heart rate between 100 and 120 beats per minute
4. Respirations are fast (as high as 60 per minute), shallow, and synchronous; chest gradually changes shape to
increase anterior-posterior diameter
5. Bowel sounds begin to be heard.

Nursing Care of the Newborn

ASSESSMENT

1. Respiratory rate, heart rate, temperature, and cry


2. Reflexes
3. Weight, length, and head and chest circumference
4. Head to toe assessment for structural deformities, color, molding, vernix, lanugo
5. Glucose screening for presence of hypoglycemia
6. APGAR Score – a standardized evaluation of the newborn to evaluate the neonate’s cardiopulmonary and neurologic
status. It is done at 1 minute after birth to determine his general condition such as the cardio-respiratory-nervous
functioning at birth and then at 5 minutes after birth to determine how well the newborn is adjusting to extrauterine life and
also used for planning nursing care.
Signs to Evaluate and their individual scores:

Signs 0 1 2

10 NCM 107
ALDERSGATE COLLEGE NCM107
SCHOOL OF MEDICAL SCIENCES LETICIA D. SERRANO, RN,MAN

1. Heart Rate* Absent Slow, <100 bpm >100 bpm


1. Respiratory effort Absent or apneic Weak cry Good, strong cry or lusty
cry
3. Muscle tone Limp, flaccid Some flexion of Well-flexed extremities,
extremities Active motion
4. Reflex irritability No response Grimace; weak cry Sneeze; good, strong cry
5. Color Pale, blue, cyanotic Body pink, extremities Pink all over
blue (acrocyanosis)
The most critical sign to be observed is the heart rate
• Color is the least important
• The general attitude of the newborn at birth is that of flexion.
• Acrocyanosis – a cyanosis of the hands and feet resulting from adjustments to extrauterine circulation. It is
normal for the first 24 hours of life.
• A total score of zero means no heart rate.
• A score of 9 means the baby is acrocyanotic.
Interpretation:
0-3 (Poor) = the baby is severely depressed and in serious danger so it needs immediate resuscitation
4-6 (Fair) = the baby’s condition is moderately depressed and guarded so it needs more extensive clearing of the airway
7-10(Good) = the baby is in his best possible health

7. Silverman-Andersen scale: index of respiratory distress (score of 0 is an indication of good respiratory function).

Five signs evaluated in Silverman – Andersen Scale:


A. Upper chest movement: 2 pts for SEE-SAW
B. Lower chest retractions: 2 pts for “MARKED”
C. Xiphoid process retractions: 2 pts for “MARKED”
D. Flaring alae nasi: 2 pts for “MARKED”
E. Expiratory Grunting: 2 pts for severe grunting even on bare ears.
Silverman score of 10: severe distress
Silverman score of 0: normal respiration

8. Expiratory Grunting...
1. Grunting – is like a sound of air pushing past partially closed glottis heard during expiration.
b. Retractions (sternal and intercostals) – is due to use of accessory muscles to aid in breathing.
c. Flaring nares – is due to newborn’s efforts to lessen resistance in narrow nasal passages.
d. Seesaw respiration – is the flattening of chest with inspiration and bulging of abdomen, caused by utilization of
abdominal muscles during prolonged, forced respirations

9. Check for:

A. The head: Take cephalometry to know if with hydrocephalus


a. Suboccipitobregmatic d. Occipitomental
b. Biparietal e. Bitemporal
c. Occipitofrontal f. Bimastoid

10. Assessment of the Newborn

11 NCM 107
ALDERSGATE COLLEGE NCM107
SCHOOL OF MEDICAL SCIENCES LETICIA D. SERRANO, RN,MAN

Clinical Criteria for Gestational Age

1. Preterm (Premature) birth at less than 37 weeks’ gestation, regardless of weight.


2. Term – birth between the 38th and 42nd week of gestation.
3. Post-term birth after 42 weeks’ gestation
4. Postmature – birth after 42 weeks’ gestation subjected to the effects of progressive placental insufficiency.

C. Birth injuries
D. Congenital defects
E. Gross anomalies

11. Proper Identification


Identification of the neonate should be done inside the Delivery Room before transferring to the nursery. Identification
is done before baby is separated from the mother. Foot prints are said to be the best form, although bracelets and
foot tags can be used with maternal name, date and time of delivery hospital number/room number and sex of the
baby.

Care of the Newborn inside the Nursery

A. Continue with measures to keep newborn war


B. Management: Use droplight during admission care
C. Take anthropometric measurements:
a. Length = 19 – 21½ inches (47.5 – 53.75 cm.; ave. – 50 cm))
b. Head circumference = 33 – 35 cm.
c. Chest circumference = 31 – 33 cm.
d. Abdominal circumference = 31 – 33 cm.
D. Take the Temperature

Normal value: Body temperature at birth is 37.50C (990F) but because of the cool Delivery Room and evaporation from
newborn’s moist skin. It will stabilize in 8 hours’ time and must be maintained at 36.20C – 36.60C (970F – 990F) to
prevent acidosis and hypoglycemia due to hypothermia

E. Specific Nursing Measures

1. Skin Care

12 NCM 107
ALDERSGATE COLLEGE NCM107
SCHOOL OF MEDICAL SCIENCES LETICIA D. SERRANO, RN,MAN

Give initial oil bath to cleanse the baby of blood, mucus and vernix caseosa. Oil bath is specifically given to premature and
high-risk newborns and those with plenty of vernix caseosa. Soap and water bath is given to full-term babies.

2. Cord Dressing
Observe strict asceptic technique in dressing the umbilical cord. The umbilical cord is white and gelatinous with two arteries
and one vein and begins to dry within 1 to 2 hours after delivery. Check for 1 vein and 2 arteries, suspect congenital
anomalies if incomplete as such, it needs more thorough physical assessment and closer observation in the ICU. Monitor for
abnormal bleeding in the cord in the first 24 hours of life (OMPHALAGIA). Check for OMPHALOCELE – protrusion of
abdominal viscera into weakened portion of the umbilicus because of absence of normal abdominal wall in the region of the
umbilicus

3. Crede’s Prophylaxis or eye care


A prophylactic treatment of the newborn’s eyes against gonorrheal conjunctivitis (ophthalmia neonatorum) caused by
Neisseria gonorrhea and Chlamydia, which the newborn acquires as he passes through the birth canal of his mother with
untreated gonorrhea. Prophylaxis is mandatory to all newborns.
It can be delayed for 1 – 2 hours in order not to interfere with the bonding process. Eye-to-eye contact is prerequisite to
bonding.
PROCEDURE
a. Wipe the face dry so that it is not slippery
b. Shade the eyes from light and open one eye at a time by putting gentle pressure on the upper and lower lids.
c. Instill two gtts of 1% silver nitrate, one gtt at a time into the lower conjunctival sac. Be careful not to drop any on
the baby’s cheeks because parents may worry about the brownish stain.
d. Wash silver nitrate away with sterile NSS after one minute to prevent chemical conjunctivitis characterized by
inflammation, edema and purulent discharge after 3-5 day

4. Vitamin K administration – a prophylactic treatment against transient deficiency of coagulation factors II, VII, IX, and X.
It is mandatory to all newborns.
Rationale: Vitamin K facilitates production of the clotting factor, thus preventing bleeding. But Vitamin K is
synthesized in the presence of normal bacterial flora in the intestines. Since the newborn’s intestines are
relatively sterile, newborns will not be able to synthesize Vitamin K that is why synthetic Vitamin K has to be given
to prevent hemorrhage.
Method: 1 mg. Aquamephyton (phytonadione) is injected IM into the lateral anterior thigh or vastus lateralis (best
site in children below 12 months of age who have not yet learn how to walk, this is the preferred site of injection
because the gluteal muscles are not yet well developed). Rectus Femoris can be used as an alternate site
5. Weight-taking
a. Average birth weight = 6.5 - 7.5 lbs.; 3 – 3.4 kgs; 3,000 – 3,400 grms (foreign standard)
a. 6 – 6.5 lbs is the average birth weight of Filipino newborns.
b. Arbitrary lower limit normal = below which the newborn is said to be of low birth weight
a. premature = 5.5 lbs; 2.5 kg.; 2,500 gms.
c. Method
• Weigh the clothes first
• Put on the clothes which were weighed
• Weigh the baby with his clothes on
• Subtract the weight of the clothes from the baby’s total weight.
d. Physiologic weight loss of 5–10% of birth weight (6 – 10 oz) during the first 10 days of life because the
newborn:
• Is no longer under the influence of maternal hormones
• Voids and passes out stools
• Has limited intake of dilute formula
• Has beginning difficulty establishing sucking
6. Feeding
a. Initial feeding
• Purpose: a type of feeding in order to find out if the newborn can swallow without aspirating

13 NCM 107
ALDERSGATE COLLEGE NCM107
SCHOOL OF MEDICAL SCIENCES LETICIA D. SERRANO, RN,MAN

• Solution: An oz of sterile water (glucose water has been found to be irritating to the lungs when
aspirated)Initiate breastfeeding as soon as possible after delivery and then feed the infant on demand.
• Position the infant’s mouth slightly differently at each feeding to reduce irritation at one site.
• Burp the infant before switching to the other breast.
• Insert the little finger into a corner of the baby’s mouth to separate the baby from the nipple.
• Experiment with various breast-feeding positions
• Perform thorough breast care to promote cleanliness and comfort.
• Follow a diet that ensures adequate nutrition for the mother and infant (drink at least 8-oz glasses of fluid
daily, increase caloric intake by 200 kcal over the pregnancy requirement of 2,400 kcal, (avoid foods that
cause irritability, gas formation, or diarrhea).
• Consult the doctor before taking any medication
• Know the ingested substances (caffeine, alcohol, and medications) can pass into breast milk.
• Follow the pediatrician’s instructions for preparing and feeding with formula:
• Feed the infant in an upright position, and keep the nipple full of formula to minimize air swallowing.
• Burp the infant after each ounce of formula or more frequently if the infant spits up.
b. Feeding reflexes at birth:
> Rooting > Gagging
> Sucking > Extrusion
> Swallowing
7. Physical Assessment – is done midway between feedings

I. Vital signs

a. Heart rate = 120 to 160, but variable depending on infant’s activity. It may increase to 180 if very much active.
• Soft heart murmur is common for the first month of life
• Rubbing or strange sounds in the heart rate is unusual
b. Pulse
• Apical pulse – is recommended because radial pulses are difficult to obtain in newborns (if radial pulse is
prominent, suspect for congenital heart anomaly).
• Normally irregular
• Rate = 120-140 beats per minute and it can reach up to 160 if the baby is crying;
c. Respiration
• Largely diaphragmatic and abdominal – observe the rise and fall of the chest and the abdomen
• Newborns are nasal breathers
• Respirations are gentle, quiet, rapid but shallow and irregular with periods of apnea. Noisy respiratory
crackling sounds are unexpected
• Rate = 30-60 breathes per minute
• Should be taken 1 full minute
• 140. Should be taken 1 full minute.
d. Blood Pressure
• Not routinely measured unless congenital heart disease, e.g. coarctation of the aorta, is suspected
• Normal Values:
 At birth = 82/46 mmHg (average: 60/40 mmHg – 90/45 mmHg)
 At 10 days of life = 100/50 mm. Hg.
• Size of BP cuff : Must not be more than2/3 the length of the arm/thigh (will result in false low Bp) nor
less than one-half the length of the arm/thigh (will result in false high BP)
Methods:

 Flush Method
Procedure
 Cuff is applied to an extremity
 Extremity is elevated and an elastic bandage is wrapped in the distal part.

14 NCM 107
ALDERSGATE COLLEGE NCM107
SCHOOL OF MEDICAL SCIENCES LETICIA D. SERRANO, RN,MAN

 Inflate cuff to around 100 mm. Hg.


 Remove the elastic bandage –extremity is expectedly pale
 Slowly deflate the cuff, while watching the pale extremity
 As soon as the extremity turns pink (flushes), read the manometer

 Auscultatory Method
Procedure
 Position child’s arm above heart level
 Wrap the cuff around the upper arm
 Locate the brachial artery, then auscultate the artery while inflating for another 20-30 mm.Hg.
 Lower the arm to heart level
 Then deflate the cuff at the rate of 2-5 mm.Hg./sec.
 Note the pressure on the gauge.

NOTE: Check the V/S in the following order: RR, HRhe first beat or clear sound (this is the systolic pressure, Tempt.

Physical Characteristics of the newborn

1. Skin
 Color is normally ruddy (red color of the skin) because of increased concentration of RBCs and decreased
amount of subcutaneous fat, so that blood vessels are even visible
• Hemoglobin level is high: 14 – 20 g per 100 ml of blood
• White blood cell count is high: 6,000 to 22,000 mm3
• Acrocyanosis
• Gray Color – indicates infection
• Jaundice = yellowish discoloration of the skin and sclerae
 This is due to inability of the newborn to conjugate bilirubin from increased red blood cell (RBC) lysis,
altered bilirubin conjugation, or increased bilirubin reabsorption from the GI tract. The immaturity of the
newborn’s liver cannot cope up with the production of glucoronyl transferase
 Normal Values:
Total serum bilirubin concentration = 15 mg%
Direct bilirubin = 1.7 mg%
Indirect bilirubin = 13.3
 The most accurate method of assessing presence of jaundice is the use of natural light and by blanching the skin on
the chest, forehead or tip of the nose.
 Physiologic or normal jaundice appears after the first 24 hours of extrauterine life. It lasts for 7 days.
 Breastmilk jaundice appears after the first week of extrauterine life when physiologic jaundice is declining, because the
human milk contains pregnanediol, which depresses the action of glucoronyl transferase.

Physiology of Jaundice:

15 NCM 107
ALDERSGATE COLLEGE NCM107
SCHOOL OF MEDICAL SCIENCES LETICIA D. SERRANO, RN,MAN

Pathologic jaundice - 24 hours of life clinical jaundice in the first


- Total serum bilirubin concentration is increasing by more than 5 mg%/day
- Total serum bilirubin concentration exceeding 15 mg% in a full-term infant or 12mg% in a preterm infant
- Clinical jaundice persisting for more than one week in a full-term infant or 2 weeks in a preterm infant

• Harlequin Sign – because of immature circulation, an infant who has been lying on his side will appear red on the
dependent side and pale on the upper side.

• Mongolian spots - slate-grayish-blue patch across the sacrum/buttocks and consists of collection of pigment cells called
melanocyte. Seen only among Asian, Southern European and African children. It disappears by first year up to school
age even without treatment.

• Lanugo - fine, downy hair on skin appearing after 20 weeks of gestation on the entire body, except on the palms and toes
(more on shoulders, back, upper arms and forehead). The more mature the newborn, the less lanugo they have, hence
premature babies have more lanugo while post-term babies rarely have lanugo. It diasappears near term and will totally
disappear in two weeks time.

• Desquamation - dry peeling of the newborn’s skin particularly on the palm and soles and it can be observed more in
post-terms.

• Petechiae on face and neck – due to increased intravascular pressure during delivery

Common Skin Marks

1. Milia - white pinpoint papules on the nose, chin and cheeks due to unopened sebaceous glands or retained
sebaceous secretions. It disappear spontaneously by 2-4 weeks.
2. Erythema toxicum neonatorum – a normal, harmless, transient, pinkish, maculopapular newborn rash
appearing on the body within 24 – 48 hours after birth. It disappears in few days.
3. Port-wine stain (nevus flammeus) – a macular purple or dark-red lesion present on the face or over the thigh
region. It can be located below the dermis. Lesions over the bridge of the nose tends to fade
2. Hemangiomas of the vascular tumor skin
.
a. Strawberry hemangioma (nevus vasculosus) – an elevated areas formed by immature capillaries and
endothelial cells (capillary angioma) located in the dermal and subdermal skin layers indicated by a rough,

16 NCM 107
ALDERSGATE COLLEGE NCM107
SCHOOL OF MEDICAL SCIENCES LETICIA D. SERRANO, RN,MAN

raised, sharply demarcated birthmark. Present at birth and may continue to enlarge up to 1 year, then shrinks
in size or absorbed: total absorption in 10 days.
b. Cavernous Hemangioma – usually raised and resembles strawberry hemangiomas. It is a permanent mark.

3. Head
Proportion: The largest part of the body (¼ of his total length)
Characteristics:
 Forehead is large and prominent
 Chin is receding and quivers when startled or crying

 The neonatal skull has 2 fontanels:


• A diamond-shaped anterior fontanel and a triangular-shaped posterior fontanel. The anterior fontanel is located at
the juncture of the frontal and parietal bones, measures 1 1/8” to 1 5/8” (3 to 4 cm) long and ¾” to 1 1/8” (2 to 3 cm)
wide, and closes in about 18 months.
• The posterior fontanel is located at the juncture of the occipital and parietal bones, measures about ¾” across, and
closes in 8 to 12 weeks.

The fontanels:
• should feel soft to the touch
• shouldn’t be depressed – depressed fontanels may be indicative of dehydration
• shouldn’t bulge – bulging fontanels require immediate attention, as they may indicate increased intracranial
pressure.

 Suture lines should neither be separated nor fontanels prematurely closed (craniosynostosis) as this will lead to
mental retardation

 Molding – refers to asymmetry of cranial sutures due to difficulties during labor.

 Craniotabes = localized softening of the cranial bones and it can be indented by pressure of a finger. It corrects
itself without treatment after some months. It is more common among first-born because of early lightening

 Caput succedaneum – edema of the soft tissue of the scalp.

 Cephalhematoma – edema of the scalp caused by effusion of blood between the bone and the periosteum

17 NCM 107
ALDERSGATE COLLEGE NCM107
SCHOOL OF MEDICAL SCIENCES LETICIA D. SERRANO, RN,MAN

4. Eyes

Method of assessment:
B. Put infant in an upright position.
C. Observe eyes for discharge or irritation; check pupils for reaction to light, equality of eye movements (there is usually
some ocular incoordination); check the sclerae for clarity, jaundice, or hemorrhage.

Characteristics:
1. head
• Characteristics: Blue or gray at birth because of scleral thinness; Permanent eye color is established within 3 – 12
months of age.
• Cry tearlessly during the first 2 months because of immature lacrimal ducts
• Cornea should be round and adult-sized
Characteristics: …
• The neonate may demonstrate transient strabismus
• Doll’s eye reflex – when the head is rotated laterally, the eyes deviate in the opposite direction and it may persists for
about 10 days.
• Pupils should be round, not keyholed-shape called coloboma
• Subconjunctival hemorrhages may appear from vascular tension changes during birth.

5. Ears
The neonate’s ears are characterized by incurving of the pinna and cartilage deposition (flatness is indicative of kidney
anomaly). Level of top part of external ear should be in line or above the outer canthus of the eye, if set lower may be a
sign of kidney malfunction or Down’syndrome/Mongolism/Trisomy 21. Auricles are open but the tympanic membrane are
covered with vernix making otoscopic examination useless (ring bell close to ear – infant should stir). The neonate
should respond to sudden sounds by increasing his heart and respiratory rates.

Note: In instilling eardrops in infants, straighten the auditory canal by pulling the pinna down and back.

18 NCM 107
ALDERSGATE COLLEGE NCM107
SCHOOL OF MEDICAL SCIENCES LETICIA D. SERRANO, RN,MAN

6. Nose
The nose may appear large for the face. There should be no septal deviation. Both nostrils should be patent. Neonates
are obligatory nasal breathers. They instinctively sneeze to clear mucus from nose.

7. Mouth
Characteristics:
• Should open evenly when crying, otherwise, suspect facial nerve injury resulting to facial paralysis (Bells’ Palsy)
• Tongue appears large
• They have usually scant saliva and pink lips
• Palate should be intact, so with the upper lip
• Epstein’s pearls is usually present – one or two small, round, glistening cysts seen in the hard palate or gums
which are due to extra load of calcium while in utero.
• A tooth may be seen, if loose, should be extracted to prevent aspiration when feeding
• Oral Thrush – white or gray patches usually on the tongue and sides of the cheeks, due to Candida albicans
acquired during the passage of the baby through the birth canal of his mother who has untreated Moniliasis. It
usually bleeds when rubbed.

8. Neck
Characteristics:
• Typically short and weak with deep folds of skin
• Thyroid gland is not palpable
• Appears soft, chubby and creased, with skin folds
• Head should rotate firmly on the neck and should be able to flex forward and back

9. Chest
 As large as, or smaller than the head; but never larger than the
 Characterized by cylindrical thorax and flexible ribs
 Should be symmetrical
 Breasts may be engorged – due to influence or transfer of maternal hormones (Gynecomastia – enlargement of
breasts in males).
 Witch’s milk may be present – thin, watery fluid coming out from the breast of the neonate due to the influence
of maternal hormones
 Supernumerary nipples may be located below and medially to the true nipple.

10. Abdomen

Characteristics:
• Liver, spleen and kidneys are palpable at birth. The liver, specifically is about 1- 2 cm. below the right costal
margin.
• Normally dome shaped or cylindrical with some protrusion, if scaphoid, suspect Diaphragmatic Hernia
• Listen to bowel sounds over the abdomen
• Palpate the spleen with fingertips under the left costal margin: tip should be palpable
• Palpate liver on the right side: normally 1 cm below the costal margin
• Observe umbilical cord for redness, odor or discharge; number of vessels present (normally one vein and two
arteries; the presence of only 2 vessels is frequently associated with congenital abnormalities)
• Observe for umbilical hernia when newborn cries
• Palpate the femoral pulses gently at inner aspect of the groin: indicate intact circulation to extremities

11. Anogenital Area

Male Genitalia
b. Scrotum may be edematous – also due to influence of maternal hormones.

19 NCM 107
ALDERSGATE COLLEGE NCM107
SCHOOL OF MEDICAL SCIENCES LETICIA D. SERRANO, RN,MAN

Note: Enlargement of scrotum indicates hydrocele (diagnosis affirmed by transparent appearance of the
scrotum when a flashlight is hold close to the scrotal sac, known as translumination.
c. Foreskin should be retracted to test for phimosis (tight foreskin)
Note: Testes should be present, if not descended the condition is called cryptorchidism. Repair of undescended
testes is called orchidopexy. Doctors claim that cryptorchidism at birth is usually normal but must descend by
puberty or else the sperm will be destroyed by high temperature within the abdominal cavity.
d. Circumcision – may be done prior to discharge from the nursery, preferably by the end of the first week
Opponents claim that early circumcision causes penile ulcerations and meatal stenosis)
Procedure:
 Vitamin K is injected IM
 Infant is restrained, penis is cleansed with soap and water
 Yellen clamp is used
 Petrolatum gauze dressing is applied on the first day to prevent adherence of circumcised site to the
diaper.
Nursing Care:
 Check hourly for bleeding because hemorrhage is the most frequent complication during the first day.
If small amount of bright red blood is observed, apply gentle pressure to the area with the sterile
gauze pad
 Do not attempt to remove exudates or yellow discharge that covers the glans after circumcision which
persists for 2-3 days, this is a part of normal healing and serves as protective covering against
bleeding.
 Diaper must be pinned loosely during the first 2-3 days when the base of the penis is still tender.
 Inform mother before discharge to wash the area with warm water and apply petroleum gauze with
each diaper change. Loosen the petroleum gauze stuck to the penis by pouring warm water over the
area.

Ambiguous genitalia
a. External genitalia do not allow for clear identification of gender
b. Further studies to determine gender are performed with surgical intervention as required

11. Back
1. On prone, the back appears flat. Curves start to form when the child has learned how to sit or stand.
2. The neonatal spine should be straight and flat, and the anus should be patent without any fissure. Any dimples,
separations, or swellings indicative of spina bifida.

12. Extremities

1. Hands and arms


b. Arms and legs are short, hands are plump and thumb clenched into fists. Wrist angle is 0.
c. Check for number and variation of fingers
d. Check the clavicles and scapulae while putting arms through normal range of motion; clicking or resistance
indicates dislocation or fracture
e. Palpate for fractures: crepitation is indicative
2. Feet and Legs
• All neonates are bowlegged and have flat feet.
• Should move symmetrically
• Check toes: appearance and number
• Abduct and adduct feet through range of motion; there should be to resistance and tightness
• Flex both legs onto lower abdomen; there should be no resistance or tightness; abduct knees and listen for
click (Ortolani’s sign – indicates developmental dysplasia of hip)
• Place both feet on a flat surface and bend the knees; knees should be at the same height (when unequal,
known as Allis’ sign – indicates developmental dysplasia of the hip)
• Observe gluteal folds for symmetry; asymmetry indicates developmental dysplasia of the hip

20 NCM 107
ALDERSGATE COLLEGE NCM107
SCHOOL OF MEDICAL SCIENCES LETICIA D. SERRANO, RN,MAN

13. Cardiovascular system

Major differences in fetal circulation:


1. Exchange of gases takes place in the placenta, NOT in the fetal lungs
2. Because little blood goes to the fetal lungs, pressure on the left side of the fetal heart is less than the pressure in the
right side of the fetal heart
3. Presence of accessory structures:
 Foramen ovale – bypasses the pulmonary circulatory system
 Ductus Venosus – bypasses the liver
 Ductus Arteriosus – fetal communication between pulmonary artery and the aorta
 Umbilical vein – carries the most highly oxygenated blood
 Umbilical arteries – carries deoxygenated blood

• Neonatal (adult) circulation


4. Clamping of cord at birth brings changes in fetal circulation and produce an adult-like circulation within 1 hour after
birth.
5. As soon as breathing has been initiated, oxygenation takes place in the newborn’s lungs.
6. The cardiovascular system changes from the very first breath, which expands the neonate’s lung and decreases
pulmonary vascular resistance.
7. Clamping the umbilical cord increases systemic vascular resistance and left atrial pressure because oxygenation is now
taking place on the newborns’ lungs, which functionally closes the foramen ovale and changes the ductus arteriosus
into ligamentum arteriosum.
8. Fibrosis may take from several weeks to a year.
Since the fetal circulation is now in the lungs:
b. Pressure on the left side of the newborn’s heart is now higher than on the right because oxygenation is now
taking place on the newborn’s lungs, resulting in:
 Closure of the foramen ovale
 Change of the ductus arteriosus into the ligamentum arteriosum
• The decreased pressure on the right side of the newborn’s heart changes the ductus venosus into
a mere ligamentum venosum
c. Since no more blood goes through the umbilical vein and arteries, these vessels atrophy/obliterate

Blood values are all high during the newborn period. The blood volume accounts for 80 to 85 ml/kg of body weight. The
neonate experiences prolonged coagulation time due to lack of Vit. K
• RBC = 6 million/ml3
• Hgb = 14-20 Gms/100 ml of blood
• Hct = 52%
 Implication: It is difficult to diagnose anemia & cyanosis in the newborn because of these high blood values.
• WBC = 6000 to 22,000 mm3
• (Implication): An increased WBC count cannot be considered a sign of infection in the newborn period because with
or without infection, all newborns have high WBC count.

21 NCM 107
ALDERSGATE COLLEGE NCM107
SCHOOL OF MEDICAL SCIENCES LETICIA D. SERRANO, RN,MAN

14. Respiratory system


A child’s respiratory tract differs anatomically from an adult in ways that predispose the child to many respiratory problems.
The child’s respiratory tract differs from an adult in the following ways:
 Lungs are not fully developed at birth.
 Alveoli continue to grow and increase in size till age 8.
 A child’s respiratory tract has a narrowed lumen than an adult until age 5. The narrow airway makes the
young child prone to airway obstruction and respiratory distress from inflammation, mucus secretion, or a
foreign body.
 Elastic connective tissue becomes more abundant with age in the peripheral part of the lung.
 A child’s respiratory rate decreases as body size increases.
15. Gastrointestinal system

1. The GI system is also not fully developed because normal bacteria are not present in the neonate’s GI tract. The lower
intestine contains meconium at birth.
 Meconium is the infant’s first stool. It is sterile, sticky, tarlike, blackish-green, odorless material formed from
mucus, vernix, lanugo, hormones and carbohydrates that have accumulated while in utero.
 Transitional stools occur about 2 to 3 days after ingestion of milk, in response to the feeding patterns. It is slimy,
green-brown, loose, and thinner resembling diarrhea to the untrained eye.
 The stools change to pasty yellow and pungent in bottle-fed infant or loose yellow and sweet-smelling in breast-
fed infant by the 4th day.
 Breastfed babies’ stools is golden yellow, mushy, more frequent (3-4 times/day) and sweet smelling because
human milk is high in lactic acid which reduces bacteria formation
 Bottlefed babies’ stool is pale yellow, firm less frequent (2-3 times/day), with more noticeable odor

2. Change diapers before and after every feeding. Expose the infant’s buttocks to the air and light several times a day for
about 20 minutes to treat diaper rash. Apply ointment to minimize contact with urine and feces.
3. Needs to be bubbled frequently to get rid of air bubbles in the stomach
4. Some aspects of GI development also include:
• Audible bowel sounds 1 hour after birth
• Uncoordinated peristaltic activity in the esophagus for the first few days of life
• A limited ability to digest fats because amylase and lipase are absent at birth
• Frequent regurgitation because of an immature cardiac sphincter.
• Gastric acidity remains low for 2 to 3 months
• Readily digests simple carbohydrates, fats and protein
• Has stores of nutrients from intrauterine existence, therefore needs very little nourishment for the first few days

16. Urinary System

Renal system function doesn’t fully mature until after the 1st year of life, as a result, the neonate has a minimal range of
chemical balance and safety. The neonate’s limited ability to excrete drugs, coupled with excessive neonatal fluid loss, can
rapidly lead to acidosis and fluid imbalances.
Newborns should void within the first 24 hours of life. At 2 weeks of age babies voids 20 times daily which can lead to
dehydration and brick-red stain on the diaper due to the presence of albumin and urate in the urine is one of the manifestation.
• Females should form a strong stream when voiding
• Males should form a small, projected arc when voiding, otherwise, suspect a defect in the urethral meatus.

17. Autoimmune System

The neonatal immune system depends largely on three immunoglobulins (Ig):


 IgG – detected in the fetus at the 3rd month of gestation, is a placentally transferred Ig, providing antibodies to
bacterial and viral agents. The infant synthesizes its own IgG during the first 3 months of life, thus compensating for
concurrent catabolism of maternal anibodies.

22 NCM 107
ALDERSGATE COLLEGE NCM107
SCHOOL OF MEDICAL SCIENCES LETICIA D. SERRANO, RN,MAN

 IgM – synthesized by the 20th week of gestation but undetectable at birth because it doesn’t cross the placenta. High
levels of IgM in the neonate indicate a non-specific infection.
 Secretory IgA – limits bacterial growth in the GI tract, found in colostrums and breast milk.
 Type of immunity transferred from mother to newborn: is called Passive Natural Immunity
 Newborns have antibodies from the mothers against polio, diphtheria, tetanus, pertussis, rubella, measles (measles
anti-bodies are present in the infant for one year) but little immunity against chickenpox that is why chickenpox is
often fatal to newborn.
 Newborns have difficulty forming antibodies until 2 months of age that is why immunization starts at 2 months of age
except BCG.

18. Neuromuscular System


The CNS and brain of all neonates are not yet well developed and so they need constant supply of oxygen.
The full-term neonate’s neurologic system should produce equal strength and symmetry in responses and reflexes.
Diminished or absent reflexes may indicate a serious neurologic problem, and asymmetrical responses may
indicate trauma during birth, including nerve damage, paralysis, or fracture. Some neonatal reflexes gradually
weaken and disappear during the early months.
NEWBORN REFLEXES

A. Protective Reflexes

1. Blink reflex
• Mechanism: Rapid eyelid closure when strong light is shone on eyes
• Purpose: Protect the eyes from bright lights or any objects coming near the eyes.
• Age of disappearance: Always present
2. Sneezing and coughing reflexes – it protects and clear air passages.
3. Yawning reflexes – protects cells from depleted oxygen.

B. Feeding reflexes

1. Rooting reflex – head will turn to the direction where cheek is stroked near the corner of the mouth and search for
the finger
Purpose: Help infant locate foo
Age of disappearance: as early as 3-4 months, when infant can already follow moving objects, and as late as 7
months but may persist for up to 1 year.
Implication of disappearance: Infant is already capable of seeing things past the visual midline
2. Sucking reflex - anything placed between the lips will be sucked
Purpose: For feeding
Age of disappearance: 6 months but may persist throughout pregnancy
IMPORTANT Note: The sucking reflex disappears immediately when not stimulated
IMPLICATION: Any infant put on NPO should be given a pacifier not only for psychological reasons but also to
prevent premature disappearance of the sucking reflex.

3. Extrusion (Spitting-up) reflex – anything placed on the anterior portion of the tongue will be spitted out
Purpose: Prevent swallowing of inedible substances
Age of disappearance: 4 - 6 months
Implication of disappearance: Infant is about ready for semi-solid or solid foods

C. Tonic Neck reflex (TNR)/fencing reflex/boxer reflex – when on his back, if the newborn turns his head to one side,
the arm and leg on this side are extended, while the arm and leg on the opposite side are flexed.
Purpose: When incomplete, it could mean paralysis of an extremity
Age of disappearance: 3-4 months

D. Moro or Startle reflex – when head is allowed to drop backward in supine position (a change in the infant’s equilibrium)
or when the bassinet is jarred, abduction and then adduction of extremities is observed or when lifted above the crib and

23 NCM 107
ALDERSGATE COLLEGE NCM107
SCHOOL OF MEDICAL SCIENCES LETICIA D. SERRANO, RN,MAN

suddenly lowered, the arms and legs symmetrically extend and then abduct while the fingers spread to form a “C” or there
is an embracing motion of the arms.
Purpose: The most significant single reflex indicative of CNS integrity. Its absence means neurological damage or brain
damage. If the response is asymmetric or unilateral it implies injuries of the brachial plexus nerve (Erb-Duchenne
Paralysis), or fracture of the clavicle or humerus.
Age of disappearance: 4-5 months

E. Babinski reflex – fanning or hyperextension of the toes when the sole is stroked from heel upwards (adult curve his
toes). Most acute at 1 month.
Age of disappearance: Disappears gradually from 2 – 12 months

Implication of disappearance: Maturation of the CNS

F. Landau reflex – when on prone, the infant should demonstrate some muscle tone

Purpose: To test spinal cord integrity

G. Palmar grasp reflex – when a finger is placed in each of the neonate’s hands, the neonate’s finger grasp tightly enough
to be pulled to a sitting position.

H. Magnet or plantar reflex – If pressure is applied on the soles of the feet while infant lies supine, he pushes back against
the pressure. It is a test of spinal cord injury.

I. Step-in-place/Dancing/Darwinian reflex – when held upright with the feet touching a flat surface, the neonate exhibits
few, quick alternating steps or dancing or stepping movements. Disappears at 4 weeks.

J. Crossed Extension – If one leg of a newborn lying supine is extended and the sole is irritated by rubbing it with sharp
object, he will raise the other leg and extend it as if trying to push away the hand irritating the first leg. It is a test for spinal
cord integrity.

K. Trunk incurvature – when a finger is stroked laterally down the neonate’s spine, the trunk flexes and the pelvis swings
toward the stimulated side.

L. Withdrawal reflex – slight pinprick to the side of the infant’s foot, the leg flexed

Note: At age 3 months, the most primitive reflexes begin to disappear, except for the protective and postural reflexes (blink,
parachute, cough, swallow, and gag reflexes), which remain for life. The infant reaches out voluntarily but is uncoordinated.
Breathing, sucking, and crying are early neural activities necessary for the infant’s survival.

19. Endocrine System

a. Enlargement of breast in males (gynecomastia) and females is normal as a result of hormones transmitted to infant
by mother.
b. Female infants may have blood in the vagina (pseudomenstratuation) because of withdrawal of maternal hormones

Senses

All are functional at birth

a. Seeing – all newborns can see at birth but their vision is poor. Neonate fixates momentarily on light. Their visual
field is 20-22 cm. or 9”, although they cannot follow objects past their visual midline, not until 6-8 wks.
b. Hearing – as soon as amniotic fluid has been absorbed, the newborn can hear. Well developed in a neonate.
c. Taste – as soon as secretions have been suctioned from the mouth, newborns can taste.

24 NCM 107
ALDERSGATE COLLEGE NCM107
SCHOOL OF MEDICAL SCIENCES LETICIA D. SERRANO, RN,MAN

d. Smell – as soon as the nose has been suctioned of secretions, newborns can smell.
e. Touch – the most developed of all the senses.

Day-to-day Care of the Newborn – feelings of motherliness develop gradually as the mother cares for her baby

A. Bathing - may be given anytime convenient to the parents as long as it is not within 30 minutes after feeding because
increased handling during bathing can cause regurgitation. Sponge baths only are done when the cord has not yet fallen
off. Chord usually falls off from the 7th to the 14th day of life.

B. Cord care
1. Fold down diapers until the cord falls off so that the cord will not get wet during voiding.
2. Dab 70% rubbing alcohol once or twice a day or every diaper change.
3. Report any odor, discharge, or signs of skin irritation around the cord.
4. A small, pink granulating area may be observed on the day the cord falls off. If it remains to be so for a week,
advise mother to bring baby to the doctor’s clinic where cautery with silver nitrate stick will be done to speed up
healing
C. Nutrition
Recommended Daily Allowances:
a. Calories – 110 to 130 calories/kg body weight/day or 50-60 calories/lb of body weight/day or more or less 380
calories/day
b. Proteins – 2.0 to 2.2 Gms/KBW/day from birth to 6 months of age and 1.8 g / KBW/day from 6 to 12 months of
age.
c. Fluids – 160-200 cc/KBW/day = 2.5-3 oz per lb. body weight/day = more or less 20 oz/day
d. Vitamins – necessary for bottle-fed and breastfed babies during the entire first year of life. Vitamins A,C and D
are very important

Differences between human milk and cow’s milk:


 Human milk contains less protein. The newborn kidneys become overwhelmed with the higher protein content of cows’
milk that is why cows’ milk needs to be diluted before it can be given to newborns.
 The main protein in human milk is lactalbumin, the main protein to cow’s milk is casein. The curd tension in milk is
related to the amount of casein. Thus the curd in cows’ milk is large, tough and difficult to digest. Heating will reduce
the curd that is why cows’ milk must first be sterilized or pasteurized so newborns can digest it. For this same reason,
constipation is a common problem of bottle fed babies
 Human milk and cow’s milk have almost similar fat content. But linoleic acid, an essential fatty acid necessary for
growth and skin integrity, is three times higher in human milk than in cow’s milk, besides, human milk has larger fat
globules.
 Human milk contains more carbohydrates. Lactose in human milk appears to be the most easily digestible of the
carbohydrates that is why breastfed babies pass out stools more often and seldom experience constipation. Cow’s milk
needs added carbohydrates or sugar (Karo syrup) to bring the carbohydrate content up to that of human milk.

25 NCM 107
ALDERSGATE COLLEGE NCM107
SCHOOL OF MEDICAL SCIENCES LETICIA D. SERRANO, RN,MAN

 Human milk contains less minerals than cow’s milk. The newborns kidneys become overwhelmed with the high mineral
content of cow’s milk that is why it has to be diluted before it can be given to newborns

BREASTFEEDING

A. Start:
1. For bonding: right on DR table
2. For nutrition: 30 minutes after normal spontaneous delivery; 4 hours after C/S
B. Duration: 10 minutes per breast – the first 10 min is for nourishment, next 10 min is for sucking pleasure
C. Colostrum: First Breastmilk – Higher in antibodies, protein and vitamins and minerals compared to the true
breastmilk
D. True Breastmilk:
1. Rich in antibodies – IgA – the secretory Ig: anti-viral, anti-bacterial, anti-E. Coli
2. More in carbohydrates (giving it slight bluish color) compared to cow’s milk.
• Sugar is added to cow’s milk because diluted cow’s milk does not meet carbohydrate requirement of infants
3. Less protein – lactalbumin – but better in quality.
4. One ounce of breastmilk contains 20 calories (same as caloric contents of cow’s milk)
E. Breastfeeding Reflexes:
1. Milk secretion Reflex (Prolactin Reflex)
a. Responsible for acini cells’ secretion of milk
b. Effect of stimulation by prolactin hormone or lactogenic hormone secreted by APG
c. Total breast emptying: best stimulus to milk secretion
2. Milk Ejection Reflex (Letdown Reflex)
a. Responsible for breast tubules’ ejecting milk
b. Effect of stimulation by oxytocin hormone secreted by PPG
c. Licking, sucking of nipples plus positive/ relaxed maternal attitude stimulate this reflex
d. Most important to successful breastfeeding

F. Advantages

1. Maternal:
a. Psychologic value of closeness and satisfaction in beginning mother – child relationship promoting
bonding
b. Assists in involution of uterus
c. Delays fertility (but not safe when used as sole means of family planning)
d. Economical in time, effort and money and readily accessible
e. Less incidence of breast cancer
2. Baby:
a. Promotes attachment
b. Optimum nutritional value for infant for the first 6 months of life but it does not contain fluoride and
vitamin D.
c. Infant is less likely to be allergic to mother’s milk also with less incidence of colic, constipation,
diarrhea, allergy, aspiration, vomiting.
a. Comes in clean, uncontaminated form direct from the source
b. Develops facial muscles, jaw, and nasal passages of infant because stronger sucking is necessary
c. Reduces chances of infection because of maternal antibodies present in colostrums and milk specifically
IgA that protects against GI-causing infections

G. Prerequisites
1. Psychologic readiness of mother is a major factor in successful breastfeeding
2. Adequate diet to ensure high-quality milk; extra milk, protein, calories, and non-caffeinated fluids are necessary
3. Suitable rest and exercise
4. Infant’s sucking at the breast stimulates the maternal posterior pituitary to produce oxytocin, the properties of which,
in the blood system, constrict the lactiferous sinuses to move the milk down through the nipple ducts: known as the

26 NCM 107
ALDERSGATE COLLEGE NCM107
SCHOOL OF MEDICAL SCIENCES LETICIA D. SERRANO, RN,MAN

let-down reflex; a poor sucking reflex of the child will inhibit the let-down of milk; sucking also stimulates prolactin
secretion
5. Family support and absence of emotional stress in the mother, because anxiety inhibits the let-down reflex

H. Contraindications
1. In mother: active tuberculosis; acute contagious disease; HIV positive; chronic disease such as cancer, advanced
nephritis, cardiac disease; extensive surgery; narcotic addiction
2. In infant: cleft lip or palate or any other condition that interferes with or prevents grasp of the nipple is the only real
contraindication.

Nursing Care of the Breastfeeding Mother and Infant

A. ASSESSMENT
1. Condition of the nipples
2. desire to breastfeed
3. level of anxiety regarding breastfeeding
4. knowledge of breastfeeding and breast care
5. family support
B. ANALYSIS / NURSING DIAGNOSES
1. Risk for infection related to cracked nipples
2. Ineffective / interrupted breastfeeding related to improper breastfeeding techniques, condition of nipples, and infant’s
sucking ability
C. PLANNING/IMPLEMENTATION
1. Teach feeding schedule
a. Self-demand schedule is desirable; usually 2 – 3 hours
b. Length of feeding time is usually 20 minutes, with greatest quantity of milk consumed in first 5 to 10 minutes
2. Teach feeding techniques
a. Mother and infant in comfortable position, such as semi-reclining or in comfortable chair
b. Entire body of infant should be turned toward mother’s breast; alternate starting breast and use both breasts at
each feeding
c. Initiating feeding by stimulating rooting reflex and direct nipple straight into infant’s mouth (stroking cheek toward
breast, being careful not to stroke other cheek, because this will confuse infant)
d. Baby’s mouth covers most of the areolar surface
e. Burp or bubble infant during and after feeding to allow for escape of air: sit infant on lap, flexed forward; rub or
pat back (avoid jarring infant)
f. Breast milk intake similar to formula intake: 130 to 200 ml of milk per kilogram (2 to 3 oz of milk per pound) of
infant’s weight; from 1/6 to 1/7 of infant’s weight per day
g. After lactation has been established, occasional bottlefeeding can be substituted
h. Length of time for continuing breastfeeding is variable (may be discontinued when teeth erupt, because this can
be uncomfortable for mother)
i. The presence of at least 6-8 wet diapers each day indicates sufficient breast milk intake
3. Teach care of breasts
a. Cleanse with plain water once daily (soap or alcohol can cause irritation or dryness)
b. Support breasts day and night with properly fitting brassiere
c. Nursing pads should be placed inside bra cup to absorb any milk leaking between feedings; allow nipples to air
dry at intervals
d. Plastic bra liners should be avoided because they increase heat and perspiration and decrease air circulation
necessary for drying of the nipple
e. If breasts are engorged, teach mother to take warm showers and put infant to breast more frequently
D. EVALUATION/OUTCOMES
1. Mother demonstrates effective breastfeeding techniques
2. Mother remains free from nipple cracking and infection
3. infant produces six or more wet diapers daily
4. infant gains weight

27 NCM 107
ALDERSGATE COLLEGE NCM107
SCHOOL OF MEDICAL SCIENCES LETICIA D. SERRANO, RN,MAN

BOTTLEFEEDING
Advantages
1. Provide and alternative to breastfeeding
2. Less restrictive than breastfeeding; may meet needs of working mothers
3. allows a more accurate assessment of intake
4. may be indicated in the presence of a congenital anomaly such as cleft palate
5. may be necessary for infants who require special formulas because of allergies or inborn errors of metabolism
Types of formulas
1. Commercial liquid or powdered formulas
2. Special formulas
3. Unmodified regular cow’s milk, liquid or reconstituted; not appropriate for infants before 12 months of age; cows milk
contains more protein and calcium and less vitamin C, iron and carbohydrate than breast milk
Contraindications
1. Deficient knowledge of formula preparation
2. poor storage and refrigeration purposes
3. contaminated water supply
4. cost of formula and equipment
5. lack of equipment to adequately prepare bottles
ARTIFICIAL FEEDING
 Terminal Heat Method: most commonly used method of formula preparation and it does not require pre-
sterilization of bottles and utensils before feeding.
Technique
1. Pour formula into clean bottles; apply nipples then cover
2. Place bottles in rack/sterilizer
3. Fill sterilizer with water up to about midpoint the bottles then cover
4. Boil for 25 minutes
5. Remove bottles from sterilizer and place in a container with cold water and let stay for 10 minutes
6. Tighten caps then refrigerate – enough for 24 hours
7. Slightly before feeding time, get 1 bottle from the refrigerator, warm formula by immersing into warm until
equal to body temperature.

Nursing Care of the Bottle feeding Mother and Infant

A. ASSESSMENT
1. Desire to bottle feed.
2. Sucking ability of infant
3. Knowledge of formulas and formula preparation
B. ANALYSIS/NURSING DIAGNOSES
1. Ineffective infant feeding pattern related to infant sucking difficulties
2. infant’s imbalanced nutrition: less than body requirements related to formula that does not meet infant’s needs
C. PLANNING/IMPLEMENTATION
1. Teach preparation of formula
a. Calculation of formula to yield 110 to 130 calories and 130 to 200 ml of fluid per kilogram of body weight; caution
regarding dangers of over dilution (water intoxication) and under dilution (excess weight gain)
b. Proper sterilization of formula by terminal heat method
c. Teach about commercial formulas
d. Proper refrigeration of formula
2. Teach feeding techniques
a. Always hold infant (Cradle hold) during feeding to provide warm body contact (bottle propping may contribute to
aspiration of formula)
b. Hold bottle so nipple is always filled with milk to prevent excessive air ingestion that will lead to colic
c. Adjust size of nipple hole to needs of infant (a premature infant needs a larger hole that requires less sucking)
d. Burp during and after feeding using the shoulder hold;
e. Hold infant upright for 30 minutes then place infant on his right side to promote gastric emptying and prevent

28 NCM 107
ALDERSGATE COLLEGE NCM107
SCHOOL OF MEDICAL SCIENCES LETICIA D. SERRANO, RN,MAN

vomiting and aspiration


f. Feeding should be offered on demand to meet the infant’s needs
D. EVALUATION/OUTCOMES
1. Mother demonstrates effective bottle-feeding techniques
2. infants produces 6 or more wet diapers daily
3. infant gains weight
Similarities between human milk and cow’s milk:
 Both human milk and cow’s milk are deficient in iron.
 Energy value per ounce of human milk and cow’s milk is the same = 20 calories per ounce.
 Both bottle-fed and breastfed babies should be burped/bubbled twice during a feeding, midway and after a feeding.
 Both bottle-fed & breastfed babies should be positioned on abdomen or right side to prevent aspiration of milk and
mucus.
SUPPLEMENTARY FEEDING
When to start? When there is
1. Fading extrusion and sucking reflexes
2. Ability to sit with support
3. A nutritional need for iron to be met
4. Developed salivary glands and presence of intestinal enzymes needed for digestion
When to introduce solids: 4-6 months
Simple rules to follow:
1. Allow few sucks of ilk before a new food to increase infant’s patience for the new food
2. Introduce 1 new food at a time, small amount (1 tsp) each time with interval of 1 week between new foods
3. Do not mix new food with formula

THE INFANT (The child from 0 – 12 months of age)


Important Information:
A. Psychosexual stage (Freud): Oral phase; stage of the ID
B. Psychosocial stage (Erickson): Trust vs. Mistrust
C. Cognitive stage (Piaget): Sensorimotor (0 – 2 years)
D. Play
Purposes:
a. To practice motor skills
b. To gain coordination
c. To relate to objects and people
2. Type: Solitary – they play with their own body or toys
3. Age-appropriate toys – should stimulate all senses and should be bright colors:
a. Crib-mobiles
b. Rattles
c. Musical box
d. Squeeze toys
e. Teething rings; pacifiers
f. Textured, colorful balls
g. Large-soft, cuddly toys
4. Greatest fear: Stranger anxiety – starts at 6 months when the child recognizes the parents; peak at 7-8
months.

GROWTH AND DEVELOPMENT

Specific Behavior/ Significant Developmental Milestones


1. Newborn – when on prone, avoids suffocation by turning his head from side to side
a. One month:
 Lifts head intermittently when on prone; head sags
 Momentary visual fixation on objects and human faces; follows moving objects to midline of vision;
differentiates objects and faces

29 NCM 107
ALDERSGATE COLLEGE NCM107
SCHOOL OF MEDICAL SCIENCES LETICIA D. SERRANO, RN,MAN

 Smiles indiscriminately
 Crying is differentiated
 Sweats
b. Two months:
a. “Social smile”
b. Responds to familiar voices by body movements; turns from side to back
c. No head control; head lags when pulled to sitting
d. Sheds tears
e. Holds rattles briefly
f. Posterior fontanel closes
c. Three months:
h. Can raise head but not chest when on prone
i. Head in bobbing motion; some head control when pulled to sit
j. Babbles and coos
k. In 180 degrees visual arc – can follow objects past visual midline; locates food sources
l. Discovers and plays with fingers
m. With hand-to-mouth activity
n. Drools ( needs bib)
d. Four months:
l. Can raise both head and chest when on prone; turns from back to side
m. When on supine, head is maintained in the midline, arms and legs are symmetrical and hands are brought
together in the midline; bald spot over occiput
n. Reaches for objects within reach and brings to mouth (Implication: Starting this age pins, diaper clips, etc
should be kept out of their reach)
o. Head control when pulled to sit, no head lag; no more bobbing, head steady when upright
p. Sustains part of own weight when helped to standing position
q. Laughs aloud
r. Drools a lot
s. Recognizes mother
t. With social interaction
u. Demands attention
v. Starts with solids
e. Five months
a. Rolls over (Important: Keep side rails of crib raised)
b. Raking grasp when picking objects
f. Six months:
a. Doubles birth weight
b. Eruption of first tooth (usually lower central incisor)
c. Sits with minimal support
d. Can be pulled from sitting to standing
e. Transfers objects from one hand to another
f. Begins to imitate sounds
g. Recognizes parents
h. First primary teeth (lower central incisors) erupt (6-7 mos.)
g. Seven months:
a. Plays with own feet
b. Pivots (creeps when on prone (Important: Keep rails on stairs raised and secure)
c. Thumb-finger grasp
d. Fears strangers
h. Eight months
a. Sits alone steadily for an indefinite period
b. Hitches – moves backwards while seated
c. Discovers feet
i. Nine months:

30 NCM 107
ALDERSGATE COLLEGE NCM107
SCHOOL OF MEDICAL SCIENCES LETICIA D. SERRANO, RN,MAN

a. Can hold bottle with good hand to mouth coordination


b. Crawls
c. Understands simple gestures and requests – bye-bye; pat-a-cake
d. Take some steps when held upright
e. Neat pincer grasp
f. Says first word “ma” and “pa” but non-specific
g. Plays “peek-a-boo”
j. Ten months:
a. Pulls self to stand
b. Responds to own name
k. Eleven months:
a. Stands with assistance
b. Attempts to walk with help
l. Twelve months:
a. Stands without support
b. Walks with help (cruises)
c. Triples birth weight
d. Drinks from cup
e. Can say 2 words
f. BREGMA (anterior fontanel) begins to close
g. Knows name
h. Has 4 to 5 words with gesture language
i. Shows emotions
j. Begins to explore environment
Child Health Station (Well-Baby Clinic) Visits – are focused on assessment of growth and development and
administration of immunizations
SCHEDULE:
2 months -----------------------DPT, TOPV 1
4 months -----------------------DPT, TOPV 2
6 months -----------------------DPT, TOPV 3
12 months ---------------------Tuberculin test
15 months ---------------------MMR triple vaccine
18 months ---------------------DPT, TOPV booster
4 – 6 months ----------------- DPT, TOPV booster
14 – 16 years -----------------Tetanus-diphtheria
toxoid, adult type

THE TODDLER (The child from 1 to 3 years of age.)

Important Information:

1. Psychosexual stage (Freud): Anal phase; stage of the “EGO”


2. Psychosocial stage (Erickson): Autonomy vs. Shame and Doubt
3. Cognitive stage (Piaget): Stage I (Preconceptual stage) of the Preoperational Thought Period – 2-4 years = characterized
by egocentricity expressed in relating everything to himself; lacks the concept of sharing.
 uses about 11, 000 words by age 3.

4. Play
a. Type: Parallel = they play together but not with one another; no sharing
b. Age – appropriate toys:
 Push and pull toys (best)
 Shape sorter – toddlers are interested in how things fit together
 Sandbox – except for those with chronic lung disease because sand is irritating when inhaled

31 NCM 107
ALDERSGATE COLLEGE NCM107
SCHOOL OF MEDICAL SCIENCES LETICIA D. SERRANO, RN,MAN

 Building blocks: build tower of 2 blocks at 12 to 18 months to 2 years and 8 blocks at 2 to 2 ½ years.
 Throwing and retrieving games (balls)
 Toys to ride on
 Outlets for aggressive behavior like pounding pegs, plastic hammer, drums, pots and pans, balls
 Stuffed toys
 Play telephone: age of language training
5. Greatest Fear: Separation anxiety – most acute at 2 to 2 ½ years of age
6. Significant persons: Parents (mother and father)
7. Behavior traits
 Toddlers are headstrong and negativistic (their favorite word is “NO!” an attempt to show their AUTONOMY) –
because they are slowly moving out of infancy and are more closely defining their own independent activity.
8. Management:
a. Do not ask questions answerable by “yes” or “no”
b. Offer choices if there are; be FIRM, if none
c. They are naturally active, mobile and curious, which makes them vulnerable to accidents- so set limits an exerts
external control (Remember: Love and consistency are the two most important, concepts in child rearing.) Follows
the parents whenever he or she goes.
d. There is a distinct decrease in appetite because of slower growth rate; Slow growth period
9. Pattern of weight gains:
First 6 months of life = 6-8 oz./week
Second 6 months = 4-6 oz/week
Second year of life = 1/2lb/month
10. Characteristics:
Dawdling at meals
Fetish with foods
Note: Appetite for three-year-olds is more capricious than that of one-year-olds
11. They are rigid, and stereotyped in their behavior. When things are rearranged or are strange, when persons or places are
unfamiliar, or when confronted with conflict or achieving autonomy and relinquishing dependence on other toddlers go
into temper tantrums (crying and screaming when he does not get what he wants) in order to control self and others. This
is another attempt to show autonomy and is not a sign of poor discipline

Management of Temper Tantrums:


Ignore the behavior or direct him to activities that he can master; Do not give in; allow to cry until tired.
12. Ritualism – doing things over and over again
Management:
a. Respect his rituals; adhere to his rituals
b. If hospitalized, adhere to his home routines to minimize separation anxiety

13. Dawdling – slowness in accomplishing tasks


Management:
a. Be patient
b. Allow to dawdle
c. Do not give him tasks he cannot accomplish
14. Egocentricity/Selfishness/Not wanting to share: normal trait
Management: Do not force him to share
15. Since all 20 deciduous (milk) teeth are out by 1 ½ to 3 years, start teaching brushing of teeth at about this time
and bring him to the dentist regularly for check-up.
16. Always explain at the level of their understanding finger puppetry is effective in giving information regarding diagnostic
procedures or treatment.
17. Since it is the age of autonomy, help them practice independence by allowing them to make simple decisions (e.g., what
color of a dress to wear, how to take a medication, etc.)

32 NCM 107
ALDERSGATE COLLEGE NCM107
SCHOOL OF MEDICAL SCIENCES LETICIA D. SERRANO, RN,MAN

18. Toddlers have very poor sense of time. Their time schedules revolve around their activities, not around the clock.
19. Nurses and other adults should talk to toddlers at eye level. The great disparity in size between an adult and a toddler can
cause fear in the letter.
20. For nurses to be able to gain rapport with the child, they should first establish rapport with the mother.
21. Hospitalization leads to separation anxiety.
Phases of separation anxiety:
a. Protest – incessant crying and screaming
b. Despair – withdrawn, depressed behavior; refusal to eat, leave the room or relate with anyone.
c. Denial – appears not to care or mind the parents when they visit.
Management:
a. Leave familiar items (toys, pillows, blankets, mother’s coin purse, etc.) with the hospitalized child.
b. Consistency among hospital staff regarding parent’s visiting hours
c. Stay with the child as much as possible

Note: Clue to tolerance to short periods of separation: If toddler is already able to play peek-a-boo or hide-and-seek, this
means that he can already keep an image in mind even when it is hidden or out of sight (object permanence)

22. Toddlerhood is the critical period or period of readiness/maturation for toilet training.

Clue to readiness for toilet training:


a. Certain degree of sphincter control – most important
b. Can already stand alone – tracts of the spinal cord are myelinated down to the anal level.
c. Can walk steadily
d. Can keep himself dry for intervals of at least 2 hours
e. Can demonstrate awareness of voiding or defecating
f. Is able to use words or gestures regarding toileting needs
g. Is desirous of pleasing the primary caretaker

Principles of toilet training


1. Positive maternal attitudes
2. place for such activities
3. Firmness but not strictness

Age at which toilet training is achieved:


 18 months to 2 years - START
 2 to 2 ½ years – Bowel trained
 2 ½ to 3 years – Bladder trained (daytime)
 3 to 4 years – Bladder trained (night time)
 Toilet training accidents

Enuresis – bedwetting; uncontrollable passage of urine after the period of training

Encopress - uncontrollable passage of stools after the period of training


 In case of toilet training accidents, just tell the child to remind the caregiver next time he has to go. Do not
punish, threaten nor be angry.
 Failures in toilet training could be attributed mostly to starting too early when the child is not yet ready.
Physical Assessment
 Pulse rate – 100 beats/minute
 Respiratory Rate – 26 breaths/minute
 Blood Pressure – 99/64 mmHg
 Weight Gain – 4-9 lb. (2 to 4 leg) over 2 years

33 NCM 107
ALDERSGATE COLLEGE NCM107
SCHOOL OF MEDICAL SCIENCES LETICIA D. SERRANO, RN,MAN

 Day dryness is achieved between 18 months and 3 years and night dryness between ages 2 and 5

Physical Development
a. Plants his feet wide apart and walks by age 15 months
b. Climbs stairs at 21 months, runs fairly well, jumps, walks up and down stairs one foot after another, uses spoon
without spilling, scribbles and bowel trained by age 2. At 2 ½ they jump from stairs and furniture, balances on one
foot, walk backwards, drinks from a straw, feeds self well, with complete primary teeth (20); with daytime bladder
control (2 ½ - 3 years)
c. By age 3 they rides and pedals tricycle; goes upstairs with alter feet; climbs and jumps well; draws a circle and a
cross; stands on one foot; attempts to print letters; with nighttime bladder control (3-4 years)
d. Uses at least 400 words as well as two-to three-word phrases and comprehends may more (by age 2)

THE PRESCHOOLER (The child from 3-6 years of age)

Important Information:

A. Psychosexual stage (Freud): Phallic; stage of the “SUPEREGO”

Phallic – attachment to the parent of the opposite sex and jealousy towards the parent of the same sex
Oedipal Complex – son’s attachment to his mother and jealousy towards his father
Electra Complex – daughter’s attachment to her father and jealousy towards her mother

B. Psychosocial stage (Erickson): Initiative Vs. Guilt

C. Cognitive stage (Piaget): Stage II (Perceptual – Intuitive stage) of the Preoperational Thought Period – reason
can be given for beliefs and actions but still considered pre-logical and termed as preoperational – intuitive behavior.
D. Play
Type: Cooperative play
- The child exhibits parallel play, associative play, and group play in activities with few or no rules and independent play
accompanied by sharing or talking.
E. Age appropriate toys
a. Housekeeping toys
b. Playground equipment (swing, seesaw, slide, monkey bars)
c. Tricycles
d. Watercolors, fingerpaints, clay
e. Picture / coloring books
f. Materials for cutting / pasting
g. Simple jigsaw puzzles
h. Playhouse
i. Superheroes costumes
j. Dress-up dolls
k. Throws and catches ball, and rides tricycle at 5 years of age
F. Behavioral Traits:
1. They love to watch adults and imitate their behavior.
2. They are very imaginative. Imaginary playmates are common. They talk to self at play
3. Allow the preschooler to play with “them” but do not admit that they exist. Give toys to play with instead.
4. They are very creative and curious that is why their favorite word is “WHY?”
5. They love to tell tales/tattling/lying, to brag and boast in order to impress others.
6. Magical thinking.
7. Age of transductive reasoning – thinks of one idea at a time but unable to think of all parts in terms of whole.
Conclusions are based on immediate visual perception.
8. They are fond of offensive language/ bad language.
9. Age of Oedipal and or Electra complex.

34 NCM 107
ALDERSGATE COLLEGE NCM107
SCHOOL OF MEDICAL SCIENCES LETICIA D. SERRANO, RN,MAN

10. Age of sibling rivalry.


11. Questions about sex should be answered honestly at the level of their understanding. Sex education – start 5
years; parents – sources of information
12. Masturbation may be observed: Do not punish or do not make fuss about it.
13. Give alternative sources of satisfaction. E.g., toys to play with as a substitute.
14. Develops a body image.
15. May count but not understand what numbers mean.
16. May recognize some letters of the alphabet.
17. Dresses without help but may be unable to tie shoes.
18. Speaks in grammatically correct, complete sentences.
19. Gets along without parents for short periods.
20. They are fond of hurting others
21. Regression: thumb sucking, bedwetting, negativism
H. Physical Development:
1. Three years of age:
a. Pedals trike
b. Walks backward
c. Climbs stairs
d. Uses scissors
e. Strings large beads
f. Helps dress himself
g. Unbuttons buttons
h. 300 to 900 word vocabulary
2. Four years of age:
a. Goes up and down stairs like an adult and jumps well; hops 2 or more times
b. Buttons shirt on front and side; dresses with minimal help
c. Laces shoes
d. Brushes teeth
e. Birth length doubles
f. Catches ball
g. Copies square
3. Five years of age:
a. Runs and hops well, jumps rope
b. Roller skates
c. Throws and catches a ball well
d. Skips, balances on 1 foot in 8 seconds with eyes closed
e. Ties shoelaces with a bow
f. Dresses without assistance
g. Draws pictures of a person
h. Copies rectangle and triangle
i. Use scissors well
4. Six years of age
a. Active
b. Skips, hops and jumps well with improved balance
c. Prints, cuts, pastes and hammer
I. Physical Assessment
1. Normal pulse rate ranges from 90 to 100 beats per minute.
2. Normal respiratory rate is 25 breaths per minute
3. Normal blood pressure ranges from 85/60 to 90/70 mm Hg.
4. Slow growth continues.

THE SCHOOLAGE CHILD (The child from 6-12 years old).

Important Information:

35 NCM 107
ALDERSGATE COLLEGE NCM107
SCHOOL OF MEDICAL SCIENCES LETICIA D. SERRANO, RN,MAN

Psychosexual stage (Freud): Latency stage; strict “SUPEREGO”


Psychosexual stage (Erickson): Industry vs. Inferiority
Cognitive stage (Piaget): Concrete Operational Thought Period - thinking is now logical there is an ability to relate
external events to each other, without being egocentric; the child can understand classes and relations and can handle
numbers; intellectual development proceeds rapidly during this period; the child learns to read and spell
Significant persons: Teacher, peers of the same sex, neighbors and classmates. Adults are hero-worshipped.

Growth and development


Behavior traits:
a. Moral code/superego becomes rigid
b. They are very modest (to refuse to expose their bodies for physical examination)
c. Although the influence of peers is very strong, eating habits are still determined by the examples set by parents in the
home
d. When they become bored, they are boisterous and are hard to control
e. They keep their thoughts to themselves; share ideas with friends instead of adults
They belong to small groups; have “best friends

Physical development
Seven years of age:
• Appearance of first molars and lateral incisors
• Visual acuity is 20/20
 Numerator of 20 = the distance at which the child is able to see
 Denominator of 20 = the distance at which the child is supposed to see an object
 E.g., a visual acuity of 20/40 means that the child is able to see at 20 feet what he should be seeing at
40 feet
• Withdrawn and moody; likes to be alone watching TV or listening to the radio
• Is seldom able to complete a task
• Psychosomatic illnesses are common
• Card games are indulged in
• Rides a bicycle
• With complete development of hand-to-eye coordination
• With fine hand movements – can print sentences
• Can swim
• Stealing and shoplifting is common
Eight years of age:
• With 10-11 permanent teeth
• Onset of secondary sexual characteristics
• Prefers playmates of own sex
• Are dogmatic and self-righteous
• Collecting objects, e.g., stamps, is a favorite past time
• Are exuberant and expansive
• Writes rather than prints
• With grace and balance even in sports
• With increase smoothness and speed
• Since arms and legs begin to grow, may stumble on furniture and may spill milk
Nine years of age:
• More interested in friends than in family
• Lying and stealing may be common
• Tries to like parent of the same sex
• Worries/complains a great deal
• Consistent right or left handedness id stabilized (Ambidextrous: uses hands interchangeably)

36 NCM 107
ALDERSGATE COLLEGE NCM107
SCHOOL OF MEDICAL SCIENCES LETICIA D. SERRANO, RN,MAN

Ten years of age:


• Cooperative and affectionate
• Are peer-oriented
• With secret language
• Companionship more important than play
Eleven years of age:
• Are critical of adults
• Beginning hero worship
• Are moody
• With beginning interest in the opposite sex
Physical Assessment
• Normal pulse rate ranges from 75 to 115 beats/minute.
• Normal blood pressure ranges from 106/69 to 117/76 mm Hg.
• Normal respiratory rate ranges from 20 to 25 breaths/minute.
• Height increases bout 2” (5cm) a year, and weight double between ages 6 and 12
• The child plays with peers, develops a first true friendship, and develops a sense of belonging, cooperation, and
compromise.
• Accidents are a major cause of death and disability during this period.
• The first primary tooth is displaced by a permanent tooth at age 6, and permanent teeth erupt by age 12 except for final
molars.
• Vision matures by age 6
• Plays with peers, develops a first true friendship, and develops a sense of belonging, cooperation and compromise
• Develops concepts of time and place, cause and effect, reversibility, conversation, and numbers
• Learns to read and spell
• Engages in fantasy play and daydreaming.

THE ADOLESCENT(The period from 12-18 years of age)

Information:
A. Psychosexual stage (Freud): Genital stage
B. Pyschosocial stage (Erickson): Identity vs. Role Confusion
C. Cognitive stage (Piaget): Formal Operational Thought Period – 11 years to adulthood = logical thinking and the ability to
reason; even theoretical hypotheses can be coped with and concrete objects need not be introduced for understanding
D. Greatest Fear: Fear of losing identity; acne, obesity, body odor, homosexuality; fear of unknown disease and death
(altered identity, unfulfilled dreams; HAS MOST fear of death)
E. Significant persons: Peers – the greatest determinant influencing factor of his behavior; models of leadership = sexual
models; partners of same and opposite sex; Adults other than parents are idolized.
F. Type of Play: Leisure, recreation activities, outings, picnics, movies, fantasy and DAYDREAMING, telephone
conversation, reading romance novels, sports games, hobbies

G. General Characteristics:
1. Are bothered by the statement, “Who am I?”
2. Are group oriented
3. Tend to rebel against authority – flexibility of rules is necessary to give way to growing sense of independence;
make available all sorts of needed information
4. Pubescent changes in males usually begin later than females, about 11-14 years
5. It is impossible to tell for sure when a male is physically and sexually mature and could father a child
6. Sports that require strenuous physical exertion should not be abused because muscles are still functionally
immature and can be injured by indiscriminate exercise
7. May easily get tired because body size increases faster than strength
8. Poor posture/ slouchy walk
9. Acne vulgaris – hallmark of the stage

37 NCM 107
ALDERSGATE COLLEGE NCM107
SCHOOL OF MEDICAL SCIENCES LETICIA D. SERRANO, RN,MAN

10. With suicidal attempts (Causes: Anger at another; desire to punish or manipulate someone; to signal distress).
Goal of therapy – Improve self-image
11. Sex education – menstrual hygiene
12. Adolescent pregnancy
13. Alcoholism
14. Drug experimentation (a form of adolescent rebellion)

Learning Activities: Conduct an observation in a normal pediatric client and assess the normal patterns of growth and
development in the child.

REFERENCES:

Hockenberry/Wilson. Wong’s Nursing Care for Infants and Children. 8th Edition. Elsiever Pte.Ltd. 2007
Thompson, Eleonor. Pediatric Nursing, An Introductory Approach Text. 1995
Pillitteri. Maternal newborn nursing care of the childbearing and childbearing family
Catharyn May. Comprehensive Maternity Nursing
Ingalls and Solerno. Maternal and Child Health Nursing
Website:
http//evolve.elseiver.

38 NCM 107

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