PEDIATRIC NURSING
Growth and Development
Growth- increase in physical size of a structure or whole.
-quantitative change. Two parameters of Growth
1. Weight- most sensitive measure of growth, especially low birth rate. Wt doubles 6 months
3x 1yr 4x 2-2 ½ yrs
2. Height- increase by 1 inch/mo during 1st 6 months - average increase in ht - 1st year = 50%
*Stoppage of height coincide with eruption of wisdom tooth.
Development- increase skills or capability to function
-qualitative How to measure development
1. Observe child doing specific task. 2. Role description of child’s progress
3. DDST- Denver development screening test.
MMDST (Phil) Metro Manila Developmental Screening Test. DDST measures mental
4 main rated categories of DDST
1. Language communication 2. personal social-interaction
3. fine motor adaptive- ability to use hand movement 4. gross motor skills- large body movement
Maturation- same with development “readiness”
Cognitive development –ability to learn and understand from experience to acquire and
retain knowledge. To respond to a new situation and to solve problems. IQ test- test to determine cognitive development
Mental age x 100 = IQ Chronological age
Average IQ – 90-100 Gifted child- > 130 IQ
Basic Divisions of Life
I. Prenatal stage from conception- birth II. Period of infancy
1. Neonatal- 1st 28 days or 1st 4 weeks of life 2. Formal infancy- 29 day – 1 year
III. Early childhood
1. Toddler – 1-3 yrs 2. Pre school 4-6 years
IV. Middle childhood
1. School age- 7 – 12 yrs
V. Late childhood
1. Pre adolescent 11 – 13 yrs 2. Adolescent 12 - 18 – 21
Principles of G & D
1. G&D is a continuous process
-begins form conception, ends in death - womb to tomb principles
2. not all parts of the body grow at the same time or at same rate.
- asynchronism
Patterns of G&D
1. Renal , digestive, Circulatory, Muscoskeletal - grows rapidly during childhood 2. Neuromuscular tissue (CNS, brain, S. cord)
- grow rapidly 1-2 years of life
- brain achieved its adult proportion by 5 years.
3. Lymphatic system- lymph nodes, spleen grows rapidly- infancy and childhood to provide protection -infection
- tonsil adult proportion by 5 years 4. Repro organ- grows rapidly at puberty
Rates of G&D
1. Fetal and infancy – most rapid G&D 2. Adolescent- rapid G&D
3. Toddler- slow G period
4. Toddler and preschool- alternating rapid and slow 5. School age- slower growth
*fetal and infancy- prone to develop anemia
3. Each child is unique
2 primary factors affecting G&D A. Heredity - R – race
I – intelligence S – sex
Females are born less in weight than males by 1 oz.
Females are born less in length than males by 1 inch B. Environment
Q – Quality of nutrition S – Socio eco. status H – Health
O – Ordinal pos in family P – Parent child relationship
Eldest- skillful in language and social skills
Younger- toilet trained self
5. G&D occurs in a regular direction reflecting a definitive and predictable patterns or trends.
Directional trends- occur in a regular direction reflecting the development
of neuromuscular function. These apply to physical, mental, social and emotional development and includes:
a. Cephalocaudal- “head to tail”
- occurs along bodies long axis in which control over head, mouth and eye movements and precedes control over upper body torso and legs. b. Proximo- distal “Centro distal”
- progressing form center of body to extremities.
c. Symmetrical- at side of body develop on same direction at same time at same rate.
d. Mass specific “differentiation” - child learns form simple operations before
complex function of move from a broad general pattern of behavior. To a bore refined pattern.
Sequential- involves a predictable sequence of G&D to which the child
normally passes.
a. locomotion- creep than crawls, sit then stand.
b. Socio and language skills- solitary games, parallel games
Secular- worldwide trend of maturing earlier and growing larger as compared to succeeding generations.
6. Behavior is the most compressive indicator of developmental status. 7. Universal language of child --- PLAY
8. Great deal of skill and behavior is learned by practice. Practice makes perfect. 9. Neonatal reflexes must be lost before one can proceed.
- plantar reflex should disappear before baby can walk -moro reflex should disappear before baby can roll
Theories of G&D
1. SIGMUND FREUD (1856-1939) Austrian neurologists. Founder of psychoanalysis
Psychosexual theory
a.) Oral Phase 0-18 months - mouth- site of gratification
-activity of infant- biting, sucking crying.
-why do babies suck?- enjoyment and release of tension. -provide oral stimulation even if baby was placed on NPO. -pacifier.
-never discourage thumb sucking. b.) ANAL- 18 months-3 years -site of gratification- anus
-activity- elimination, retention or defecation of feces make take place - principle of holding on or letting go.
-mother wins or child wins
-child wins- stubborn, hardheaded anti social. (anak pupu na, child holds pupu, child wins) -mother wins- obedient, kind, perfectionist, meticulous
OC-anal phase
-help child achieve bowel and bladder control even if child is hospitalized. c.) Phallic- 3-6 years
- site of gratification -genitals - activity- may show exhibitionism -increase knowledge of a sexes
-accept child fondling his/her own genitalia as normal exploration -answer Childs question directly.
Right age to introduce sexuality – preschool
d.) Latent- 7-12 years
-period of suppression- no obvious development.
-Childs libido or energy is diverted to more concrete type of thinking -helps child achieve (+) experience so ready to face conflict of adolescence e.) Genital- 12-18 years
-site of gratification -genitals -achieve sexual maturity
-learns to establish relationships with opposite sex. -give an opportunity to relate to opposite sex.
2. ERIC ERICKSON- psychoanalysis theory
- stresses important of culture and society to the development of ones personality - environment
Stages of psychosocial
a.) Trust vs Mistrust – 0-18 months. -foundations of all psychosocial task
-to give and receive is the psychosocial theme -know to develop trust baby
1. satisfy needs on time - breastfeed
2. care must be consistent and adequate -both parents- 1st 1 year of life
3. give an experience that will add to security- touch, eye to eye contact, soft music. b.) Autonomy vs Shame and doubt 18mos-3 years --- independence /self gov’t develop autonomy on toddler
1. give an opportunity of decision making like offer choices. 2. encourage to make decision rather than judge.
3. set limits
c. Initiative vs Guilt- 4-6 years -learns how to do basic things -let explore new places and events
-activities recommended- modeling clay, finger painting will enhance imagination and creativity and facilitate fine motor dev’t
d. Industry vs Inferiority 7-12 yrs -child learns how to do things well -give short assignments and projects
e. Identity vsRole confusion or diffusion 12-18 yrs
- learns who he/she is or what kind of person he/ she will become by adjusting to new body image and seeking emancipation form parents
-freedom from parents.
f. Intimacy vs Isolation 20-40 yrs -looking for a lifetime partner and career focus g. generatively vs stagnation 40- 60
45-65 yrs
h. ego integrity vs, despair 60-65 3. JEAN PIAGET- Swiss psychologists
-develop reasoning power
STAGES OF COGNITIVE DEVELOPMENT
A- Sensory motor 0-2 yrs
-“practical intelligence”- words and symbols not yet available baby communicates through senses and reflexes.
(sub div.)
Schema Age Behavior
1.) neonate reflex 1 month All reflexes
2.) primary circular 1-4
months
-Activity related to body -repetition of behavior ex. thumb sucking 3.) secondary circular reaction 4-8
months
-activity not related to body
-discover obj and person’s permanence -memory traces present
-anticipate familiar events. Coordination of secondary
reaction
8-12 months
-exhibit goal directed behavior
-increase of separateness (will search of lost toy, knows mom)
Tertiary circular reaction 12-18 months
-use trial and error to discover places and events
-“ invention of new means”
-capable of space and time perception (hits fork, spoon on table or drops fork) Invention of new means there
mental combination
18-24 months
-transitional phase to the pre operational thought period.
B. Preoperational thought 2-7 years
Schema age Behavior Preconceptual 2-4
yrs
-thinking basically complete literal and static -egocentric- unable to view others interrupt -concept of dying is only now
-concept of distance is only as fat as they can see. -concept of amenism inanimate object is alive
-not aware of concept of r3eversibility- in every action theories an opposite reaction or cause and effect
Initiative 4-7 yrs
Beginning of causation
C. Concrete Operational thought 7-12 years
1. able to find solution to everyday problems which systematic reasoning. 2. have concept of reversibility- cause and effect
3. have concept of longer duration – constancy despite of transformation. 4. activity recommended- collecting and classifying
5. stamps stationeries, dolls, rubber band markers. D. Formal Operational thought 12 and up. 1. Cognition achieved its final form
2. can deal with past present and future 3. have abstract and mature thoughts.
4. can find solutions to hypothetical problems with scientific reasoning. 5. activity --- will sort out opinions and current events.
4. KOHLBERG- recognized the theory of moral dev’t as considered to closely approximate
cognitive stages of dev’t -“sabay” with cognitive dev;t
Stages of Moral dev’t
Infancy – premoral, prereligious, amoral stage
AGE STAGE DESCRIPTION
Pre-conventional
Level 1
2-3 yrs 1 -Punishment/ obedience oriented (heteronymous morality) child does right cause a parent tells him or her to and to avoid punishment
4-7 2 -Individualism. Instrumental purpose and exch. Carries out action to satisfy own needs rather than society. -Will do something for another if that person does something for the child.
Conventional Level 2
7-10 3 -Orientation to interpersonal relations of mutuality. Child followers rules cause of a need to be a “good” person in own eyes and eyes of others.
10-12 4 -Maintenance of social order fixed rules and authority. Child finds ff. rules satisfying. Follows rules of authority figures.
Post-conventional
Level III
Above 12 yrs 5 -Social contract, utilitarian level making perspectives. Followers standards of society.
6 Universal ethical principle orientation. Follows internalized standards of conduct.
DEVELOPMENTAL MILESTONES
-major markers of growth and dev’t
1. Period of infancy- universal language of child-play a.) Play- Infancy- solitary plays
-solo, mom interactive
-facilitate motor and sensory dev’t -safety- important age appropriate
b.) fear of infancy- stranger anxiety begin 6-7 months peak 8 months diminishes 9 months
1 month- dance reflex disappears looks at mobile 2 months- holds head up when in prone,
social smile,
baby coos “doing sound” cry with tears
-closure of frontal fontanel 2-3 months head lag when pulled to sitting position.
3 months- holds head and chest up when prone
follows obj. past midline
grasp and tonic neck reflex fading hand regard (looks at hand)
4 months – turns form front to back
head control complete needs space to turn
Laugh aloud, bubbling sounds
5 months- turn both ways “roll over”
-teething rings -handles rattle well
-moro reflex disappears ( 4-5 months)
6 months- reaches out in anticipatory of being picked up
-sits with support -uses palmar grasp
-eruption of 1st temp teeth 6-8 months 2 lower incisors
-say vowel sounds “ah”, “oh” -handles bottle well
7 months- transfer obj. hand to hand
-likes obj that are good size
8 months- sits without support
-peak of stranger anxiety
-planters reflex disappears 8-9 months in prep for walking
9 months - creeps or crawls
-neat finger grasp reflex
- combine 2 syllables “mama” and “papa” 10. needs space for creeping
10 months – pull self to stand
-understands “no” -responds to own name -peak a boo, pat a cake -can clap
11 months- cruisse
- stands with assistance
12 months- stand alone take 1st step -walk with assistance
-drink from cup, cooperate in dressing -says 2 words mama and dada
-pots and pans, pull tay, nursery rhymes
2. Toddler- Parallel play- 2 toddlers playing separately
-provide with similar toys -squeaky frog to squeeze -waddling duck to pull
-trucks to push-push pull toy -building blocks, pounding peg -toys to ride on
-fear- separation anxiety -begin 9 months
-peak 18 months
3 phases of separation anxiety (in order)
1. P- protect 2. D- despair 3. D -denial
-don’t prolong goodbye
-say goodbye firmly to develop trust- say when ul be back
15 months – plateau stage
-walks alone
- lateness in walking- mild mental retardation -puts small pellets into small bowl
-holds spoon well - seats self on chair -creeps up stairs - 4 - 6 words
18 months- height of possessiveness
-favorite word- “mine”
-bowel control achieved (bowel 1st before bladder) -no longer rotates spoon
-can run and jump in place
-walks up and down stairs holding railing or persons hand -1-20 words
-name, body part
-puts both feet on 1 step before advancing.
24 months- terrible two
-can open doors by turning door knobs -unscrew lids
-can walk upstairs alone –using both feet on same step at same time -50-200 words ( 2 words sentences)
30 months or 2 ½ years – makes simple lines or stroke for crosses with a pencil
-can jump down from chairs -knows full name
- copy a circle
-holds up finger to show age temp teeth complete
post molar- last temp teeth to appear
how many deciduous teeth -20
beginning of toothbrush – 2-2 ½ yrs
tooth brushing with little assistance 3 yrs
tooth brushing alone – 6 yrs
right time to bring to dentist- when temp teeth complete 36 months or 3 yrs- trusting 3
- unbutton buttons (unbutton before learn to button) -draw a +
- learns how to share
-knows full name and sex (gender identity) - speaks fluently
-nighttime bladder control -300-900 words
-ride a tricycle
Characteristic Traits of toddler
1.) negativistic- “NO!” -way to search for independence –limit questions
–modify questions to a statement 2.) rigid, ritualistic and stereotype
-ritualism- for mastering
3.) Temper tantrums- head banging, screaming, stamping feet, holds breath –ignore behavior
3.) scaffoid abdominal-due to underdeveloped abdominal muscles
4.) physiologic anorexia- due to preoccupation with environment- food jag that last for short period of time
5.) loves rough and tumbling play
6.) loves toilet training- failure of toilet training- unreadiness
Clues of toilet readiness:
1.) can stand, squat walk alone 2.) can communicate toilet needs 3.) can maintain dry for 2 hours
Pre schoolers- associative or cooperative play
2.) role playing
3.) fear-body mutilation or castration fear of dark places witches
fear of thunder and lightning fear of ghosts
4years old- furious 4 , noisy, aggressive, stormy
-can button buttons -copy a square -jumps and skips -laces shoes -vocabulary 1,500 -knows four basic colors
5 years old- frustrating 5
-copy a triangle -draw a 6 part man -imaginary playmates -2,100 words
Character Traits of Pre-schooler:
7.) curious, creative imaginative, imitative 8.) 2. favorite words- why and how
9.) complexes- word identification to parent of same sex and attachment to parent of opposite sex
ex. Oedipal complex- boy to mom Electra complex- girl to dad - Cause of incest marital discord - Concept of Death-sleep only
Behavior problems Preschool
1. telling tall tales-over imagination
2. imaginary friend- to release tension and anxieties 3. sibling rivalry- jealousy to newly delivered baby. 4. regression- going back to early stage
-thumb sucking (should be oral stage only) -baby talk
-bed wetting -fetal position
5. masturbation- sign of boredom -divert attention- offer a toy
School Age
Play- competitive play
Fear. 1.) school phobia
-orient to new environment 2.) displacement from school -teacher and peer of same sex 3. loss of privacy
-wants bra 4.) fear of death
-7-9yrs death is personified -death- permanent loss of life
Significant Development
a. boys- prone to bone fracture b. mature vision 20/20
6 years- temp teeth begin to fall
perm teeth appear- 1st molar 1st temporary teeth- 5 months 1st permanent teeth- 6 yrs -year of constant motion - clensy mou’t
recognize all shapes
-1st grade teacher becomes authority figure -nail biting
-begin interest in God.
7 yrs- Assimilation age
-copy a diamond
-enjoys teasing and playing alone -quieting down period
8 yrs- Expansive age
-smoother mouth -loves to collect objects -count backwards
9 yrs –coordination improves
-tells time correctly -hero worship
-stealing and lying are common -takes care of body needs completely -teacher finds this group difficult to handle
10 yrs- age of special talent
-writes legibly
-ready for competitive games -more considerate and cooperative
-joins orgs.
-well mannered with adult -critical of adults
11-12 yrs – Pre adolescents
-full of energy and constantly active -secret language are common -share with friends secrets -sense of humor present -social and cooperative Character Traits School Age 1. industrious-
2. modest
3. can’t bear to lose- will cheat 4. love collections- stamps
Signs of sexual maturity
GIRLS:
I-inc size breast and genitalia (pelarche- 1st sign sexual maturation) W- widening of hips
A- appearance axillary, pubic ( adrenarch)
M- menarche- last sign sexual maturation for girls
BOYS:
A-appearance axillary, pubic hair ( 1st sign sexual maturation) D-deepening voice
D- development of muscles I--inc in testes and penis size
P- production of viable sperm (last sign sexual maturity)
Adolescent Fear 1. obesity 2. acne 3. homosexuality 4. death
5. replacement from friends 6. significant person- opposite sex.
Significant development
1. experiences conflict bet his needs for sexual satisfaction and societies expectation 2. change of body image and acceptance of opp/sex
3. nocturnal emission – wet dreams
6. testes & scrotum increase until age 17
7. breast and female genitalia increase until age 18
Personality Traits Adolescents
1. idealistic 2. rebellious 3. reformers
4. conscious with body image 5. adventuresome Problems: 1. vehicular accident 2. smoking 3. alcoholism 4. drug addiction 5. pre marital sex
IMMEDIATE CARE OF NEWBORN
- 1st days of life
1. initiation and maintenance of respiration 2. establishment of extra uterine circulation 3. control of body temp
4. intake of adequate nourishment 5. establishment of waste elimination 6. prevention of infection
7. establishment of an infant parent relationship
8. dev’t care that balances rest and stimulation or mental dev’t
A.Initiation and maintenance of respiration
-2nd stage of labor- initial airway
-initiation of airway is a crucial adjustment
-most neonatal deaths with in 24 h caused by inability to initiate an airway -lung function begins after birth only
How to initiate a/w
a.) remove secretions bulb syringe b. ) Catheter Suctioning
1.) place head to side to facilitate drainage 2,) suction mouth 1st before nose
-neonates are nasal breathers 3.) period of time
-5-10 sec suctioning, gentle and quick
prolonged and deep suctioning can lead to hypoxia, laryngo spasm, brady cardia due to stimulation vagal nerve
4.) evaluate for patency
-cover nostril and baby struggles there’s a need for additional suctioning
c. ) If not effective, requires effective laryngoscopy to open a/w. After deep suctioning an endotracheal tube can be inserted and oxygen can be administered by an (+) pressure bag and mask with 100% oxygen at 40-60b/m.
Nsg alert:
1. No smoking
2. Always humidify to prevent drying of mucosa
3. Over dosage of oxygen can lead to scarring of retina leading to blindness ( retro lentalfibrolasia or retinopathy of prematurity)
4. When mecomium stained (greenish) never administer oxygen with pressure ( O2 pressure will push mecomium inside)
B. Establishing extra uterine circulation
- circulation is initiated by lung expansion or pulmo ventilation and completed by cutting of cord.
FETO PLACENTAL CIRCULATION
-Placenta(simple diffusion) –oxygenated blood is carried by the umbilical vein- passes liver-ductus venousus- IVC- RT atrium 70% blood is shunted to foramen ovale- LT atrium mitral valve – LT ventricle- aorta-lower extremities.
-Remaining 30%- tricuspid valve- RT ventricle- pulmonary arteries- lungs (for nutrition) (vasoconstriction of lungs pushes blood to ductus arteriousus to aorta to supply upper extremities.
SHUNTS-shortcuts
Ductus venosus- -shunts from liver to IVF Foramen ovale- shunts bet 2 atrias
What will sustain 1st breath- decreased artery pressure What will initiate lung circulation-lung expansion What will complete circulation- cutting of cord * 2 way to facilitate closure of foramen ovale
a.) Tangential Footstep- slap foot of baby
-never stimulate baby to cry if secretions not fully drained to
prevent aspiration
-check characteristic of cry
normal cry- strong, vigorous and lusty cry
cri-du-chat syndrome-chromosomal obliteration cat like cry
b.) proper position -right side lying pos.
-will increase pressure on left and foramen ovale will close
-Foramen Ovale and Ductus arteriosus will begin to close within 24h Decrease PO2, increase PCO2 acidosis
Will cause 1st breath /cry of baby
Decrease pulmo artery pressure
Increase PO2 Decrease blood flow Increase pressure to Lt side of heart Closure of ductus arteriosus Closure of ductus venosus & AVA Closure of foramen ovale
Obliteration-complete closure
Structure Appropriate time of obliteration
Structure remaining Failure to close
F. Ovale 1yr Fossa Ovalis Atrial Septal
Defect Ductus
Arteriosus
1 month Ligamentum Arteriosum Patent ductus
arteriosus Ductus
Venosus
2 months Ligamentum venosum
Umbilical artery
2-3 months 1.) lateral umb. Ligament 2.) interior iliac artery Umbilical vein 2-3 months -ligamentum teres ( round
ligament of liver) Position of infant immediately after birth:
NSD-trendelenberg/ T position for drainage
contraindication of trendelenberg position - increase ICP
CS- supine or crib level position Signs of increased ICP
1.) abnormally large head 2.) bulging and tense fontanel
3.) increase BP and widening pulse pressure #3 & #4 are Cushings triad of
4.) Decreased RR, decreased PR ICP
5.) projective vomiting- sure sign of cerebral irritation 6.) high deviation – diplopia – sign of ICP older child
4-6 months- normal eye deviation >6 months- lazy eyes
7.) High pitch shrill cry-late sign of ICP
C. Temp Regulation
- goal in temp regulation is to maintain it not less than 97.7% F (36.5 C)
- maintenance of temp is crucial on preterm and SGA (small for gestational age) - babies prone to hypothermia or cold stress
A. factors leading to dev’t of HYPOTHERMIA
1. preterms are born poi kilo thermic- cold blooded
2. babies easily adapt to temp of environment due to immaturity of thermo regulating system of body. Hypothalamus
3. inadequate SQ tissue
4. baby is not capable of shivering 5. babies are born wet
PROCESS OF HEAT LOSS
1. evaporation- body to air (TSB)
2. conduction- body to cold solid object (cold compress) 3. convection- body to cooler surrounding air (aircon) 4. radiation- body to cold object not in contact with body
earliest sign of hypothermia- increase in RR Effects of Hypothermia ( Cold stress)
1.) Hypoglycemia- 45-55 mg/dl normal
50- borderline
2.) met acidosis- catabolism of brown fats (best insulator of newborns body) will form ketones
3.) high risk for kernicterus- bilirubin in brain leading to cerebral palsy 4.) additional fatigue to allergy stressful heart
To Prevent Hypothermia
1. dry and wrap baby
2. mechanical pressure – radiant warmer
i. pre-heated first isolette (or square acrylic sided incubator) 3. prevent an necessary exposure – cover baby
4. cover baby with tin foil or plastic 5. embrace the baby- kangaroo care
D. Establish Adequate Nutritional Intake CS- breastfeeding after 4 hours
NSD- breastfeeding asap
Physiology breast milk production
As you deliver baby, decrease Estrogen, decrease Progesterone- -Anterior Posterior Gland (APG) releases prolactin – acts on acinar cells (or alveoli) – produce foremilk – stored in lactiferous tubules ( or collecting tubules) where breast milk is produced – alveoli post-pit.gland
Sucking- PPG – oxytocin – contraction of lactiferous tubules - milk ejection reflex- let down reflex.
Advantages of Breastfeeding
1. Economical 2. Always available
3. Breastfed babies have higher IQ than bottle fed babies. 4. It facilitates rapid involution
5. Decrease incidence of breast cancer. 6. Has antibodies- IgA
7. Has lactobacillius bifidus- interferes with attack of pathogenic bacteria in GIT 8. Has macrophages
Store milk- plastic storage container
Store milk – good for 6 months from freezer- put rm temp. don’t heat
Disadvantages:
1. Possibility of transfer HEP B, HIV, cytomegalo virus. 2. No iron
3. Father can’t feed & bond as well
Stages of Breastmilk:
1. Colostrum- 2-4 days present
content: decrease fats, increase IgA, dec CHO, dec CHON, inc minerals, inc fat soluble minerals
2. Transitional milk- 4 – 14 days
content: inc lactose, inc water soluble vit., inc minerals 3. Mature milk- 14 & up
content: inc fats (linoleic acid) – resp for devt of brain & integrity of skin inc CHO- lactose – easily digested, baby not constipated.
- resp of sour milk smelling odor of stool.
Lactose intolerance- deficiency of enzyme LACTASE that digest LACTOSE Decrease CHON- lactalbumin
Cows milk – inc fats- Dec CHO
Inc CHON – casing- has curd that’s hard to digest.
Inc minerals–traumatic effect on kidneys of babies. Can trigger stone formation. Inc phosphorus
Health Teachings:
1. Proper hygiene- proper hand washing
Care of breast - cotton balls with lukewarm water Caked colostrum- dry milk on breast
2. Best position in breastfeeding – upright sitting -avoid tension! 3. Stimulate & evaluate feeding reflexes
a.) Rooting reflex- by touching the side of lips/cheeks then baby will turn to stimulus. Disappear by 6 weeks- by 6 weeks baby can focus. Reflex will be gone
- Purpose rooting- to look for food.
b.) Sucking – when you touch middle of lips then baby will suck - Disappears by 6 months
- When not stimulated sucking will stop.
c.) Swallowing- when food touches posterior of tongue then it will be automatically swallowed
d.) Extrusion/ Protrusion reflex
-when food touches anterior portion of tongue then food will be extruded. Purpose: to prevent from poisoning
Criteria Effective Sucking
a.) Baby’s mouth is hiked up to areola b.) Mom experiences after pain.
c.) Other nipple is also flowing with milk.
To prevent from crack nipples & initiate proper production of oxytocin. - begin 2-3 min at @ breast ( 5 – 7 min other authors)
to initiate production of oxytocin
- increase 1 min/ day – until reaching 10 mins @ breast or 20 mins/ feeding. For proper emptying & continuous milk production / feeding
-feed baby on last breast that you feed her with, alternately ( if not emptied - mastitis)
Problems experienced in Breastfeeding :
3RD day changes in breast post partum
a.)Engorged- feeling of fullness & tension in breast.
- sometimes accompanied by fever known as MILK FEVER.
Mgt: Warm compress- for breastfeeding mom
Cold compress – for bottle feeding & wear supportive bra. When is involution of breast- 4 weeks
b.) Sore nipple – cracked with painful nipple
Mgt: 1.) exposure to air – remove bra & wear dress, if not, expose to 20 Watt bulb avoid wearing plastic liner bra
- will create moisture, cotton only
c.) Mastitis- inflammation of breast : staphylococcus aureus
Factors:
1. Improper breast emptying 2. Unhealthy sexual practices -contraindicated for breast feeding - manually express inflamed breast feed on unaffected breast
- give antibiotics – can still feed on unaffected breast
Contra Indications in Breast Feeding:
Maternal Conditions: 1. HIV CMV Hepa B Coumadin
Newborn Condition - Inborn errors of metabolism 1.Erythrobastosis Fetalis – Rh incompatibility Hydrops Fetalis
Phenylketonuria Galactosemia Tay Sachs disease
F. Establish of waste elimination
A. Diff stools
1. Meconium - physiologic stool
- black green, sticky, tar like, odorless (Sterile intestine) will pass with in 24 – 36 hrs
-failure to pass mecomium after 24h- GIT obstruction ex. Hirschsprungs disease
imperforate anus
mecomium ileus – due to Cystic Fibrosis 2. Transitional stool -
- green loose & shiny, like diarrhea to the untrained eye
3. Breastfed stool - golden yellow, soft, mushy with sour milk smell, frequently passed - recur every feeding
4. Bottlefed stool –
- pale yellow, formed hard with typical offensive odor, seldom passed, 2–3 x/day - with food added -brown & odorous
Jaundice baby – light stool Under phototherapy – bright green Mucus mixed with stool - milk allergy
Clay colored stool – obstruction to bile duct Chalk clay stool – after barium enema Black stool – GIT bleeding (melena) Blood flecked stool - anal fissure.
Currant jelly stool – instussusection Ribbon like stool – hirschsprung disease
Steatorrhea stool – fatty, bulky foul smelling odor stool
- malabasorption syndrome ( celiac disease or cystic fibrosis) Cult blood – stool exam
III Assessment for Well–being APGAR SCORE – Dr. Virginia Apgar
Special Considerations: 1st 1 min – determine general condition of baby
Next 5 min- determine baby’s capabilities to adjust extra uterinely
Next 15 min – dependent on the 5 min A- appearance- color – slightly cyanotic after 1st cry baby becomes pink. P- pulse rate – apical pulse – left lower nipple
G- grimace – reflex irritability- tangential foot slap, catheter insertion A – activity – degree of flexion or muscle tone
Failure to cry after 30 secs – asphyxia near the neatorum
Resp. depression – due mom given Demerol. Administer Naloxone
APGAR Scoring Chart:
0 1 2
HR -absent <100 >100
Resp effort -absent - slow, irreg, weak -good strong cry
Muscle tone - flaccid extremities - some flexion - well flexed
Reflex irritability
Catheter - no response - grimace - cough, sneeze
Tangential Footslap - NR - grimace - cry
Color - blue/pale - acrocyanosis
(body- pink extremities-blue)
- pinkish
APGAR result
0 – 3 = severely depressed, need CPR, admission NICU 4 – 6 = moderately depressed, needs add’l suctioning & O2 7 - 10 =good/ healthy
CPR – cardio pulmonary resuscitation or CPR
Cardio pulmonary cerebral resuscitation (CPCR) 5 min no O2 – irreversible brain damage
1. shake, no resp, call for help 2. flat on head
3. head tilt chin lift maneuver except spinal cord injury over extension may occlude airway
Breathing ( ventilating the lungs) 1. check for breathlessness
- if breathless, give 2 breaths- ambu bag > 1 yr old- mouth to mouth, pinch nose < 1 yr – mouth to nose
force – different between baby & child infant – puff
Circulation
Check for pulslessness :carotid- adult Brachial – infants CPR – breathless/pulseless
Compression – inf – 1 finger breath below nipple line or 2 finger breaths or thumb CPR inf 1:5
Adults 2:15
Assessment tool determines respiration of baby
Silvermann Anderson Index Respiration Evaluation – lowest score – best
Criteria 0 1 2
Chest movement synchronized Lag on respiration See - saw Intercostal retraction No retraction Just visible Marked Xiphoid retraction None Just visible Marked
Nares dilatation None Minimal Marked
Expiratory grunt None Heard on stet only Heard on naked ear Interpretation result:
0 -3 – normal, no RDS 4 – 6 – moderate RDS 7 – 10 – severe RDS
Assessment of Gestational Age
-Ballards & Dobowitz
Findings Less 36 weeks (Preterm) 37 - 38 39 and up
Sole creases Anterior transverse crease only
Occasional creases 2/3 in
Covered with creases
Breast nodules 2mm 4mm or 3.5 mm > 5 or 7mm
Scalp hair Fine & fuzzy Fine & fuzzy Coarse & silky
Ear lobe Pliable Some cartilage Thick cartilage
Testes and Scrotum
testes in lower canal Scrotum – small few rugae
Some intermediate Testes pendulus Scrotum full extensive rugae
Signs of Preterm Babies
Born after 20 weeks, after 37 weeks -frog leg or laxed positon
-hypotonic muscle tone- prone resp problem -scarf sign – elbow passes midline pos.
- square window wrist – 90 degree angle of wrist - heal to ear sign-
abundant lanugo-
Signs of Post term babies:
> 42 weeks
- classic sign – old man’s face - desquamation – peeling of skin - long brittle finger nails
Neonates in Nursery
Nsg responsibility upon receiving baby- proper identification - foot printing, affixing mother thumb print
- take anthropometic measurement
normal length- 19.5 – 21 inch or 47.5 – 53.75cm, average 50 cm head circumference 33- 35 cm or 13 – 14 “
Hydrocephalus - >14”
Chest 31 – 33 cm or 12 – 13” Abd 31 – 33 cm or 12 – 13”
Bathing
- oil bath – initial
- to cleanse baby & spread vernix caseosa Fx of vernix caseosa
1. insulator 2. bacterio- static
Babies of HIV + mom – immediately give full bath to lessen transmission of HIV - 13 – 39% possibly of transmission of HIV
Full bath – safely given when cord fall
Dressing the Umbilical Cord – strict asepsis to prevent tetanus
3 cleans in community
1. clean hand 2. clean cord 3. clean surface
betadine or povidone iodine – to clean cord
- check AVA, then draw 3 vessel cord - If 2 vessel cord- suspect kidney malformation - leave about 1” of cord
- if BT or IV infusion – leave 8” of cord best access - no nerve - check cord every 15 min for 1st 6 hrs – bleeding .> 30 cc of blood bleeding of cord – Omphalagia – suspect hemophilia
Cord turns black on 3rd day & fall 7 – 10 days Faiture to fall after 2 weeks- Umbilical granulation
Mgt: silver nitrate or catheterization
- clean with normal saline solution not alcohol - don’t use bigkis – air
- persistent moisture-urine, suspect patent uracus – fistula bet bladder and normal umbilicus
Dx: nitrazine paper test – yellow – urine mgt: surgery
Credes Prophylaxis – Dr. Crede
-prevent opthalmia neonatorum or gonorrheal conjunctivitis - how transmitted – mom with gonorrhea
drug: erythromycin ophthalmic ointment- inner to outer
Vit-K – to prevent hemorrhage R/T physiologic hypoprothrombinemia
- Aquamephyton, phytomenadione or konakion - .5 – 1.5 ml IM, vastus lateral or lateral ant thigh - 5 ml preterm baby
Vit K – synthesized by normal flora of intestine Vit K – meds is synthetic due intestine is sterile
Weight: Normal wt 3.000 – 3400 gms/ 3 – 3.4 kg / 6.5 - 7.5 lbs Arbitrary lower limit 2500 gm
Low birth wt baby delivered < 2500g
Small for gestational age (SGA) < 10th % rank or born small Large for gestational age > 90th % rank or macrosomia >4000 g Appropriate for GA – within 2 standard deviation of mean Physiologic wt loss – 5 – 10% wt loss few days after birth Small GA < (less) 10
Large GA > (more) 90
Physical Exam and Deviations fr Normal
1. if client is new born, cover areas not being examined 2. if client is infant – the 1st yr of life - get VS – take RR 1st
- begin fr least intrusive to the most intrusive area
3. if client is a toddler and preschool, let them handle an instrument like: - play syringe or stet, security blanket – favorite article. Let baby hold it. 4. Explain procedure and respect their modesty - school age and adolescent V/S:
Temp: rectal- newborn – to rule out imperforate anus - take it once only, 1 inch insertion
Imperforate anus
1. atretic – no anal opening 2. agenetic – no anal opening 3. stenos – has opening 4. membranous – has opening
Earliest sign:
3. foul odor breath
4. vomitous of fecal matter 5. can aspirate – resp problem
Mgt:
Surgery with temporary colostomy Cardiac rate: 120 – 160 bpm newborn Apical pulse – left lower nipple
Radial pulse – normally absent. If present PDA
Femoral pulse – normal present. If absent- COA - coartation of aorta
CONGENITAL HEART DISEASES
Common in girls – PDA, ASD atrial septalCommon in boys – TOGA ( transportation of great arteries) TA – tronchus arteriosus
TOF – tetralogy of fallot Causes:
1. familial
2. exposure to rubella – 1st month 3. failure of strucute to progress
Acyanotic L to R Cyanotic R to L
I. ACYANOTIC HEART DISEASE - L to R
A.Ventricular septal defect - opening between 2 ventricles S&Sx
1. systolic murmurs at lower border of sternum and no other significant sign - cardiac catheterization reveals increased o2 saturation @ R side of heart
- ECG reveals hypertrophy of R side of heart Nsg Care:
Cardiac catheterization: site – Rt femoral vein 1. NPO 6 hrs before procedure
2. protect site of catheterization. Avoid flexion of joints proximal to site. 3. assess for complication – infection, thrombus formation – check pedal
pulses (dorsalis pedis) Mgt.
1.) long term antibiotic – to prevent subacute bacterial endocarditis 2.) open heart surgery-
B. ASD – failure of foramen ovale to close S&SX
1. systolic murmur @ upper border of sternum
2. result of cardiac catheterization & ECG same with VSD Mgt: open heart surgery
C. Endocardial cushion defects - atrium ventricular (AV) - affects both tricuspid and mitral valve
Dx – confirmed by cardiac catheterization Mgt: - open heart surgery
Antibiotics to prevent subacute bacterial endocarditis
D. PATENT DUCTUS ARTERIOSUS- failure of ductus arteriosus to close - should close within 24 h -complete close – 1 month
S&Sx
1. continuous machinery like murmurs 2. prominent radial pulse
3. ECG- hypertrophy Left ventricle Drug:
1. endomethazine – prostaglandin inhibitor - facilitate closing of PDA 2. ligation of PDA by 3-4 yo
3. thoracotomy procedure- nakadapa child
D. Pulmunary Stenosis- narrowing of valve of pulmo artery S &Sx: 1.) typical systolic ejection murmur
2. S2 sound widely split
3. ECG- Lt ventricular hypertrophy E. Aortic Stenosis – narrowing of valve of aorta S & Sx: 1. inactive, sx sme with angina
2. typical murmur
3. rough systolic sound and thrill 4. ECG- Left ventricular hypertrophy Mgt Pulmo Stenosis & Aortic Stenosis
1.) balloon stenostomy 2.) surgery
Duplication of Aortic Arch- doubling of arch of aorta causing compression to trachea and esophagus
S&Sx : 1. dysphagia 2. dyspnea 3. left ventricular hypertrophy Mgt: - close heart surgery
E. Coartation of Aorta – narrowing of arch of aorta Outstanding Sx : absent femoral pulse
ECG – hypertrophy Lft ventricle Mgt: close heart surgery
CYANOTIC HEART DEFECTS R to L
1. Transportation of Great Arteries (TOGA) - aorta arising from Rt ventricle pulmo artery arising form Lt ventricle Outstanding Sx:
1. cyanosis after 1st cry (due no exygenation)
2. polycythemia – increased RBC =compensatory due to O2 supply=viscous blood =thrombus = embolus = stroke
3. ECG – cardiomegaly
Cardiac cath – decreased O2 saturation Palliative repair – rashkind procedure Complete repair – mustard repair 2.) Total Anomalous Pulmonary
venous return – pulmo vein instead of entering Lt atrium, enters Rt atrium or SVC Increased pressure on Rt so blood goes to Lft
Outstanding Sx: Open foramen ovale Mild to moderate cyanosis
Polycythemia = thrombus = embolus = stroke asplenia- absent spleen
Mgt: restructuring of heart
3.) Truncus Arteriousus- aorta & pulmo artery is arising fr 1 single vessel or common trunk with VSD
S & Sx 1. cyanosis
2. polycythemia – thrombus = embolus = stroke Mgt: Heart transplant
4.) Hypoplastic Left heart syndrome – non fx Left ventricle 1. cynosis
2. polycythemia – throm, emb, stroke Mgt: heart transplant
5.) Tricuspid atresia – failure of tricuspid valve to open S&SX: open foramen ovale
(R to L shunting – goes to Lt atrium) cynosis, polycythemia
Mgt: fontan procedure – open tricuspid valve 6.) Tetralogy of Fallot
P – pulmonary stenosis V – ventricular SD
R – Rt ventricular hypertrophy S &Sx:
1. Rt ventricular hypertrophy 2. high degree of cyanosis 3. polycythemia
4. severe dyspnea – squatting position – relief , inhibit venous return facilitate lung expansion.
5. growth retardation – due no O2
6. tet spell or blue spells- short episodes of hypoxia 7. syncope
8. clubbing of fingernails – due to chronic tissue hypoxia 9. mental retardation – due decreased O2 in brain 10. boot shaped heart – x-ray
Mgt: 1. O2
2. no valsalva maneuver , fiber diet laxative 3. morphine – hypoxia
4. propranolol – decrease heart spasms 5. palliative repair –
BLT blalock taussig procedure
Brock procedure – complete procedure
ACQUIRED HEART DSE
1. RHD Rheumatic Heart Disease
- inflammation disease ff an infection acquired by group A Beta hemolytic strepto coccus Affected body – cardiac muscles and valves , musculoskeletal , CNS, Integumentary
Sorethroat before RHD
Aschoff – rounded nodules with nucleated cells and fibroblasts – stays and occludes mitral valve.
Jones Criteria
Major Minor
1. polyarthritis – multi joint pain 1. arthralgia – joint pain 2. chorea – sydenhamms chores or
st. vetaus dance-purposeless involuntary hand and shoulder with grimace
2. low grade fever
3. carditis – tachycardia
erythema marginatum - macular rashes SQ nodules
3. all lab results increase antibody
“ C reactive protein “ erythrocyte sedimentation rate “ anti streptolysin
Criteria:Presence of 2 major, or 1 major and 2 minor + history of sore throat will confirm the dx.
Nsg Care: 1. CBR
2. throat swab – culture and sensitivity 3. antibiotic mgt – to prevent recurrence
4. aspirin – anti-inflammatory. Low grade fever – don’t give aspirin. S/E of aspirin:
- Reyes syndrome – encephalopathy- fatty infiltration of organs such as liver and brain Respiration
Newborn resp – 30-60 cpm, irregular abd or diaphramatic with short period of apnea without cyanosis.
< 15 secs – normal apnea –newborn Resp Check Newborn – 40 – 90 1 yr - 20 – 40 2-3yr 20 – 30 5 yrs 20 – 25 10 yrs 17 – 22 15 & above 12- 20
BREATH SOUNDS HEARD DURING ASCULTATION:
1.) VESICULAR – soft, low pitched, heard over periphery of lungs, inspiration longer then expiration -Normal
2.) BRONCHOVESICULAR- soft, medium pitched, heard over major bronchi, inspiration equals exp. Normal
3.) BRONCHIAL SOUNDS- loud high pitched, heard over trachea, expiration longer than inspiration. Normal
4.) RHONCHI – snoring sound made by air moving through mucus in bronchi. Normal 5.) RALES-or crackles – like cellophane – made by air moving through fluid in alveoli. Abnormal- asthma, foreign body obstruction.
6.) WHEEZING- whistling on expiration made by air being pushed through narrowed bronchi .Abnormal – asthma, foreign body obstruction
7.)STRIDOR- crowing or ropster life sound – air being pulled through a constricted larynx.
Abnormal – resp obstruction
Asthma- pathognomonic sign – expiratory wheezing
Pet – fish. Sport – swimming
Laryngo Tracheo Bronchitis LTB
- inspiratory stridor – pathognomonic sign
RDS respiratory dist synd or hyaline membrane dis
Cause- lack of surfactant – for lung expansion
Hypotonia, Post surgery, Common to preterm
Fibrine hyaline
Sx – definite with in 1st of life Increase RR with retraction
Inspiratory grunting – pathognomonic
7 – 10 severe RDS (silvermenn Anderson index) cyanosis due to atelectasis
Mgt:
1. surfactant replacement and rescue 2. pos- head elevated
3. proper suctioning
4. o2 with increase humidity- to prevent drying of mucosa 5. monitor V/S skin color , ABG
6. CPAP- continuous + a/w pressure 7. PEEP - + end expiratory pressure
Purpose of #6-7- to maintain alveoli partially open and alveoli collapse
LARYNGOTRACHEOBRONCHITIS
LTB – most common Creup -viral infection of larynx, trachea & bronchi outstanding sx - croupy cough or barking
pathognomonic - stridor - labored resp
- resp acidosis - end stage – death Lab:
1. ABG
2. neck and throat culture
3. dx- neck x-ray to rule out epiglotitis Nsg Mgt:
1. bronchodilators
2.increase o2 with humidity 3. prepair tracheostomy set
BRONCHOLITIS- Inflammation of bronchioles – tenatious mucus
Causative agaent – RSV - Resp sincytial viruses Sx: flu like sx
Increased RR Drug: Antiviral – Ribavirin
EPIGLOTITIS - infl of epiglottis
- emer. Condition of URTI Sx: sudden onset
Tripod position – leaning forward with tongue protrusion - never use tongue depressor
prepare tracheotomy set
< 5 yo – unable to cough out, put on mist tent (humidifier o2) or croupe tie Nsg Care: check edges tucked on mist tent
Provide washable plastic material No toys with friction due O2 on
No hairy toys – due moist environment medium for bacterial growth BP – 80/46 mmHg newborn
BP after 10 days- 100/50 BP taking begins by 3 yo
COA – take BP on 4 extremities
SKIN:
Acrocyanosis
BIRTHMARKS:
1. Mongolian spots – stale gray or bluish discoloration patches commonly seen across the sacrum or buttocks due to accumulation of melanocytes. Disappear by 1 yr old 2. MIlla – plugged or unopened sebaceous gland . white pin point patches on nose,
chin or cheek.
3. Lanugo – fine, downy hair – common preterm
4. Desquamation – peeling of newborn, extreme dryness that begin sole and palm. 5. Stork bites (Talengeictasi nevi) – pink patches nape of neck
hair will grow as child grows old
6. Erythema Toxicum – (flea bite rash)- 1st self limiting rash appear sporadically & unpredictably as to time & place.
7. Harlequin sign – dependent part is pink, independent part is blue (side lying – bottom part is dependent pink)
8. Cutis Marmorato – transitory mottling of neonates skin when exposed to cold. 9. Hemangiomas – vascular tumors of the skin
3 types Hemangiomas
a.) Nevus Flammeus – port wine stain – macular purple or dark red lesions seen on face or thigh. NEVER disappear. Can be removed surgically
b.) Strawberry hemangiomas – nevus vasculosus – dilated capillaries in the entire dermal or subdermal area. Enlarges, disappears at 10 yo.
c.) Cavernous hemangiomas – communication network of venules in SQ tissue that never disappear with age. - MOST DANGERIOUS – intestinal hemorrhage
Skin color blue – cyanosis or hypoxia White – edema
Grey – inf
Yellow – jaundice , carotene
Vernix Caseosa – white cheese like for lubrication, insulator BURN TRAUMA – injury to body tissue caused by excessive heat.
INFANT 5-9 yo
ANTERIOR POSTERIOR Ant Post
Head 9.5 9.5 6.5 6.5 Neck 1 1 1 1 Upper arm 2 2 2 2 Lower arm 1.5 1.5 1.5 1.5 Hand 13 1.25 1.25 1.25 Trunk 13 13 Back 13 13 Genital 1 1 @ buttocks 2.5@ 2.5 @ Thigh 2.75 2.75 4 4 Leg 2.5 2.5 3 3 foot 1.75 1.75 1.75 1.75 DEPTH
1st degree – partial thickness – superficial epidermis - erythema, dryness, PAIN -sunburn, heals by regeneration from 1 – 10 days
2nd degree – epidermis & dermis- erythema, blisters, moist, extremely painful scalds
3rd degree – full thickness- epidermis, dermis, adipose tissue, fascia, muscle & bone lethargy, white or black, not painful – nerve endings destroyed
ex. lava burns Mgt:
1.) 1st aid a.) put out flames by rolling child on blanket b.) immerse burned part on cold H2o
c.) remove burned clothing of with sterile material d.) cover burn with sterile dressing
2.) a/w
a.) suction PRN, o2 with increased humidity b.) endotracheal intubation
c.) tracheostomy
3.) Preventiuon of shock & F&E imbalance a. colloids to expand bld volume
b. isotonic saline to replace electrolytes c. dextrose & H2o to provide calories 4.) Tetanus toxoid booster
6.) 1st defense of body – intact skin prevention of wound infection
a.) cleaning & debriding of wound b.) open or close method of wound care c.) whirlpool therapy – drum with solution
7.) skin grafting – 3rd degree – thigh or buttocks (autograft), pigs/ animals – xenograft frozen cadaver – hallow graft
8,) diet – increase CHON, increase calories.
ATOPIC DERMATITIS- infantile eczema (galis)
Papulo vesicular erythematus lesions with weeping & crusting
Cause – food allergies: milk, citrus juice, eggs, tomatoes, wheat
Sx: - extreme pruritus, linear excoriation, weeping crusting; scaly shiny and white – lechenification
Goal of care: decrease pruritus – avoid food allergens
Diet: Prosobi or Isomil
Hydrate skin, borow solution 1% hydrocortisone cream Prevent infection – proper handwahsing, trim nails
IMPETIGO- skin disease.
Causative agent – grp A beta Hemolytic streptococcus
- papulovesicular surrounded by localized erythema –becomes purulent , oozes a honey colored crust
Pediculosiscapitis –“KUTO”
- Mgt: proper hygiene – wash soap and H2o, oral penicillin – bactroban ointment Can lead to acute glomerulonephritis AGN
ACNE- adolescent problem
- self limiting infl dis – sebaceous gland comedones – sebum causing white heads - sebum- lipids causing acne bulgaris
Mgt: - proper hygiene- mild soap or sulfur soap- antibacterial retin A or tretinoi
ANEMIA-pallor
Causes:
1.)early cutting of cord – preterm – cut umb cord ASAP
fullterm – cut umb cord when pulsation stops 2.) Bleeding disorders – blood dyscrasias
HEMOPHILIA – deficiency of clotting factor. X linked recessive – inherited
If mom – carrier, son – affected If father carrier- transmitted to daughter
Hemophilia B –or christmas disease, deficiency of clotting factor 9 Hemophilia C – deficiency of clotting factor 11
Assessment:
- umphalagia – earliest sign
- newborn receive maternal clotting factor
- newborn growing – sudden bruising on bump area- marks earliest sign - continuous bleeding – hematrosis – damage or bleeding synovial membrane Dx test :
PTT. Partial thromboplastin time – reveals deficiency in clotting factor Long Term Goal- prevention of injury
Nsg Dx- increase risk of injury
HT: avoid contact sport, swimming only, don’t stop immunization – just change gauge of needle
Falls – immobilized , elevate affected part, apply pressure-not more then 10 min cold compress
-determine case before doing invasive procedure
LEUKEMIA- grp of malignant disease
- rapid proliferation of immature WBC
- WBC – protection from infection, soldiers of body Classification :
1. Lympho – affects lymphatic system 2. Myelo – affects bone marrow
3. acute / blastic- affects immature cells 4. chronic/ cystic- affects mature cells
MOST COMMON CANCER – (ALL) – Acute Lymphocytic Leukemia
S&Sx:
1. from invasion of bone marrow signs of infection
a.) fever
b.) poor wound healing
c.) bone weakness & causes fracture signs of bleeding
a.) petecchiae-small, round, flat, dark red spot b.) epistaxis
c.) blood in urine/ emesis signs of anemia
a.) pallor , body malaise , constipation
2. from invasion of body organ- hepato spenomegaly – abd pain , CNS affectation, increase ICP
1. PBS- peripheral blood smear – determine immature RBC
2. CBC – determine anemia, leukocytosis, thrombocytopenia neutropenia
3. lumbar puncture (LP) – determine CNS involvement. Before LP, fetal pos.- avoid flexion of neck – will cause a/w obstruction.“C” position or shrimp position only. 4. bone marrow aspiration – determine blast cells,
- common site- iliac crest - post BMA s/effect – bleeding
- apply pressure. Put pt on affected side to prevent hemorrhage 5. Bone scan – determine bone involvement
6. CT scan – determine organ involvement Therapeutic Mgt:
TRIAD:
1. surgery 2. irradiation 3. chemotheraphy
Focus Nsg Care: prevent infection
4 LEVELS OF CHEMOTHERAPHY
1. induction – goal of tx; to achieve remission meds: IV vincristine
L- agpariginase Oral predinisone
2. Sanctuary- treat leukemic cells that invaded testes & CNS give: methotrixate- adm intrathecally via CNS or spine cytocine, Arabinoside, steroids with irradiation 3. maintenance- to continue remission
give: oral methotrisate – check WBC
-adm of methotrisate – do weekly WBC check
4. Reinductin – treat leukemic cells after relapse occurs. Meds – same as induction
- give antigout agents: allopurinol or Zyloprim- treat or prevent hyperurecemic nephropathy.
Nsg mgt: Outstanding nsg dx: alteration in nutrition less body requirement. Based on Maslow’s heirarchy
S/Effect of Chemotherapy
1. N/V – adm antiemetic drugs 30 mins before chemo until 1 day after chemo
2. Ulcerations / stomatitis / abscess of oral mucosa- (alteration nutrition less body req) - oral care – alcohol free mouthwash , betadine mouthwash
- don’t brush – use cotton pledgets - topical xylocaine before meals diet- soft, bland diet according to child’s preference Temporary S/E of chemo:
Alopecia – altered body image Hirsutism – hair
-give emotional support to parents
ABO incompatibility –
Most common incompatibility – ( mom) O – ( fetus) A Most severe incompatibility (Mom) O– (Fetus) B Can affect 1st pregnancy
Hydrops (h20) Fetalis – edematous on lethal state with pathologic jaundice
Within 24 h Mgt:
1. initiate breastfeeding to get colostrum 2. Temp suspension of breastfeeding
- content breast milk pregnanedioles – that delays action of glucoronil transferees liver enzymes converts in direct bilirubin to become direct bilirubin
3. Needs phototherapy 4. needs exchange therapy
Hyperbilirubinemia - > 12 mg/dL of indirect bilirubin among full term Normal – 0-3 mg/dL
- bilirubin encephalopathy
- Kemicterus - > 20 mg/dL among full term & >12 mg /dl of indirect – preterm =can lead to cerebral palsy-
Physiologic jaundice – jaundice within 48 -72 h (2-3 days) expose morning sunlight
Pathologic Jaundice – within 24h. Jaundice during delivery. Breastfeeding jaundice – caused by pregnanediole
Assessment of Jaudice :
1. Blanching neonates forehead, nose or sternum - yellow skin & sclera
- color of stool – light stool - color of urine – dark urine Mgt: Phototheraphy – photo oxygenation Nsg Resp:
1. cover eyes – prevent retinal damage
2. cover genitals – prevent priapism – painful continuous erection 3. change position regularly – even exposed to light
6. monitor V/S – avoid use of oil or lotion due- heat at phototherapy = bronze baby syndrome-transient S/E of phototherapy weigh diaper 1gm = 1cc
Head – largest part of baby ¼ of its length
Craniostenosis or craniosinustosis – premature closing of fontanel
Hydrocephalus – ant fontanel open after 18 mos
Microcephaly – small growing brain due- alcohol & HIV mom Anencepahly – absence of cerebral hemisphere
Craniotabes – localized softening cranial bone. Common – 1st born child -due early lightening (2 weeks prior to EDD)
Rickets of Vit B deficiency – soft cranial bone in older children
Caput Succedaneum – edema of scalp due prolonged pressure at birth Char:
1. present at birth 2. crosses suture lines 3. disappear after 2-3 days
Cephalhematoma- collection of blood due to rapture of pericostal capillaries
Char :
1. present after 24 h 2. never cross suture line 3. disappear after 4-6 weeks 4. monitor for developing jaundice
Seborrheic Dermatitis – ‘craddle cap”
Scaling, greasy appearing salmon colored patches – seen on scalp behind ears and umbilicus
Cause: - improper hygiene Mgt:
1. proper hygiene
2. put oil night before shampoo - baby oil
Hydrocephalus – excessive accumulation of CSF
1. communicating – extra ventricular hydrocephalus
2. non-communicating- intraventricular hydrocephalus or obstructive hydrocephalus due to tumor obstruction
Sx – ICP – abnormally large head, bulging fontanel - cushings triad
- high pitched cry
older child – diplopia – eye deviation, projectile vomiting - fontanel bossing – prominent forehead
- - prominent skull vein - sunset eyes
Mgt: position to lessen ICP – low semi-fowlers 30 degree angle
Administer- osmotic diuretic Mannitol/ Osmitrol , Diamex- Azetam Decrease CSF production
Shunting – AV shunt or Vp shunt (ventriculoperitoneal shunt) Shave hair – in OR – to prevent growth of micro org.
Nsg Care:
1.) post VP shunt – side lying on non operated site - to prevent increase ICP monitor for good drainage - sign – sunken fontanel bulging fontanel – blocked shunt
change fontanel as child is growing
SENSES
EYES: Assessment
1. check for symmetry
2. sclera – normal color – light blue then become dirty white pupil – round- adult size
coloboma- part of iris is missing sign: key hole pupil
whiteness & opacity of lens congenital cataract cornea – round & adult size
large – congenital glaucoma
Test for blindness common tests 1. newborn – general appearance
- can only see 10 – 12 “
- visual acuity 20 /200 to 20/ 800 Doll’s eyes test- test for blindness
- done 10th day
- pupil goes opposite to direction when head is moved
Globellars test – test for blink reflex. Points near nose – baby should blink 2. Infant & children
- appearance
- ability to follow object past midline 3. 3 yrs – school age
- general appearance
Allen cards – test for visual acuity. Show picture 20 ft away Ishiharas plates – test for color blindness
Prechool E chart - test for stereopsi of depth perception
- general appearance - snellens test
Retinobastoma – malignant tumor of retina
Outstanding sign : oat’s eye reflex-whitish glow of pupil - red painful eye
- blindness
surgery – Enucliation – removal of eyeball put artificial aye
NOSE:
1. flaring alenase – case of RDS
2. cyanosis at rest – choanal atresia - post nares obstructed with bone or membrane Sx:
1. resistance during catheter insertion 2. emer. Surgery within 24 h
normal color nasal membrane – pinkish rhinitis – presence of creases & pale check sense of smell – blindfold – smell Hair in nose – cilia
Adolescent no hair with ulceration of nasal mucosa suspect cocaine user
Epistasis – nosebleed
- sit upright, head slightly forward to facilitate drainage - cold compress , apply gentle pressure, epinephrine
most developed sense of newborn – sense of touch 1st sense to develop & last to disappear – hearing
EARS:
1. Properly aligned with outer cantus of eyes low set ear – kidney malformation
ex. Renal aginesis – absence of kidney sign in uterus : oligohydramnios
sign in newborn: 2 vessel cord failure to void within 24 h Mgt: kidney transplant
Chromosomal aberrations : -advance maternal age
1. non disjunction – uneven division
Trisomy 21 - down syndrome - extra chromosome
47xx + 21 - related to advance paternal age Sx:
Mongolian slant Broad flat nose Protruding neck Puppy’s neck
Hypotonic – prone to resp problem
Simean crease – single transverse line on palm.
Trisomy 18 – “endvard syndrome” Trisomy 13- patau syndrome Turner – Monosomy of X synd.
- 45x0
- affected girls
- signs evident during puberty
- has poorly developed 2dary sexual char. - Sterile
Klinefelters Syndrome- has male genitalia - 47 XXY
- poorly devt secpndary sexual characteristics - no deepening of voice
-small testes, penis -sterile Klinefelter – Calvin Kline – male Turner – Tina Turner – female
Otitis Media – inflammation of middle ear. Common children due to wider & shorter
Eustachian tube Causes
1.) bottle propping 2.) Cleft lip/ cleft palate – Sx: Otitis
1. bulging tympanic membrane, color – pearly gray 2. absence light reflex
3. observe for passage of milky, purulent foul smelling odor discharge 4. observe for URTI
Nsg Care:
1. position side lying on affected aside – to facilitate drainage 2. supportive care- bedrest, increase fld intake
Med Mgt:
1. Massive dosage antibiotic
Complication – bacterial meningitis 2. Apply ear ointment
School age – up and down < 3 yo – down & back > 3 yo – up & back
surgery (to prevent permanent hearing loss)– otitis media – myringotmy with tympanostomy tube
post surgery – position affected side for drainage both – put ear plug
if tympanous tube falls – healed na
Bells Palsy- facial nerve #7 paralysis R/T forcep delivery
Sx.
1. Continuous drooling saliva
2. inability to open , eye & close either eye Mgt:
Refer to PT
TEF (Tracheoesophageal Fistula)-TEA- no connection bet esophagus and stomach Outstanding Sx – Coughing Choking Continuous drooling Cyanosis Mgt: Emergency surgery
Epstein pearl – white glistering cyst at palate & gums related to hypercalcemia Hypervitaminosis
Natal tooth – tooth at birth. Move with gauze Neonatal tooth – tooth within 28days of life
Moniliasis – oral candidiasis
- white cheese like, curd like patches that coats tongue - oral thrush
- Nsg Care – don’t remove, wash with cold boiled H2o Meds – nystatin / Mysnastatin – antifungal
Kawasaki Dse--strawberry tongue - originated in Korea
- Dr. Kawasaki discovered it - common in Japan
- “mucocutaneous Lymphnode Syndrome” Sx:
-persistent fever – 5 days -strawberry tongue ,
-desquamation of palm & sole - lymph adenopathy > 1.5 cm Drug: aspirin
Can lead to MI
