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Definition of Terms:
Growth – increase in physical size of a structure or whole quantitative structure
2 Parameters of Growth
1. Weight
- Most sensitive especially in low birth weight
- Weight doubles by 6 months
- Triples by 1 year
- Quadruples by 2 ½ year
2. Height
- Increase by 1 inch per month during first 6 months
- And ½ inch per month from 7 – 12 months
I. D. THEORIES OF DEVELOPMENT
2. Eric Erickson
- Trained in psychoanalysis theory
- Transits the importance of culture and society to their development of ones society
STAGES OF PSYCHOSOCIAL THEORY
Trust vs. Mistrust (0 – 18 months)
- Trust is the foundation of all psychosocial task
- To give and to receive is the psychosocial theme
- How trust is developed:
- Satisfy needs on time
- Care must be consistent and adequate
- Give and experience that will add to security (touch, hugs and kisses, eye to
eye contact, soft music
Autonomy vs. Shame and Doubt (18 months – 3 years)
- Autonomy is independence or self governance
- How autonomy is developed
- Give an opportunity for decision making such as offering choices
- Encourage the child to make decisions rather than judge
Initiative vs. Guilt (4 – 6 years)
- Learns to do basic things
- Activity recommended are modeling clay, finger painting
- Develop creativity and imagination to facilitate fine motor development
- How initiative is developed:
- Give an opportunity of exploring new places and events
Industry vs. Inferiority (7 – 12 years)
- Learn how to do things well
- How industry is developed:
- Give an opportunity no short assignment and projects
Identity vs. Role Confusion (12 – 20 years)
- Learn how he/she is or what kind of person he/she will become by adjusting to new
body image
- Seeking emancipation or freedom from parents
Intimacy vs. Isolation (20 – 40 years)
- Focus on career or looking for lifetime partners
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Generativity vs. Stagnation (40 – 60 years)
BEHAVIOR
- Egocentric (unable to view
another point of view)
- Their thinking is basically
concrete and static
Intuitive 4 – 7 years - Their concept of time is only
now and their concept of
distance is only as far as they
can see
- Not yet aware of the
concept of reversibility
- Concept of animism
(inanimate object is alive)
I. E. DEVELOPMENTAL MILESTONE
PERIOD OF INFANCY
a. Play
- Solitary play
- Non interactive
- Priority is safety
- Age who appreciate teddy bears
- Attitude: proper hygiene
b. Fear
- Stranger anxiety
- Begin at 6 – 7 months
1
- Peak at 8 months
- Diminish by 9 months
c. Milestones
1 MONTH
- Dance reflex disappears
- Looks at mobile objects
2 MONTHS
- Holds head up when in prone
- Social smile
- Baby “coos”
- Cry with tears
- Closure of posterior fontanel by 2 – 3 months
- Head lag when pulled to a sitting position
3 MONTHS
- Holds head and chest when in prone
- Follow object past midline
- Grasp and tonic neck reflex are fading
- Hand regards (3 months)
4 MONTHS
- Turns from front to back
- Head control complete
- Bubbling sounds
- Needs space to turn
- Laugh aloud
5 MONTHS
- Roll over
- Turn both ways
- Teething rings
- Handles rattle well
- Moro reflex disappear by 4 – 5 months
6 MONTHS
- Reaches outs in anticipation of being picked up
- Handle bottle well
- Sits with support
- Uses palmar grasp by 6 months
- Eruption of first temporary teeth (2 lower incisors)
- Says vowel sounds “Ah, ah” 1
7 MONTHS
- Transfer objects hand to hand
8 MONTHS
- Sits with support
- Peak of stranger anxiety
- Plantar reflex disappear
9 MONTHS
- Creeps/crawl
- Needs space for creeping
- Pincer grasp reflex
- Combine two syllables “Papa, Mama”
- Priority: safety
10 MONTHS
- Pull self to stand
- Understand word “No”
- Respond to own name
- Peak – a – boo
- Pat a cake since they can clap
11 MONTHS
- Cruises
- Stand with assistance
12 MONTHS
- Stand alone
- Take first step
- Walk with assistance
- Drink from a cup
- Cooperate in dressing
- Says the 2 words “Mama, Papa”
- Toys: pots and pans, pull toy and learn nursery rhymes
E.2. TODDLER
a. Play
- Parallel (2 toddlers playing separately)
- Provide two similar toys (squawky squeeze toy)
- Waddling duck to pull, pull truck, building block and pounding peg
b. Fear
- Separation anxiety
- Do not prolong goodbye, say goodbye firmly
- 3 Phases of separation anxiety
a. Protest
b. Despair
c. Denial
1
c. Milestones
15 months
- Plateau stage
18 months
- Hide of possessiveness
- Bowel control achieved
- No longer rotates a spoon
- Run and jump in place
- Walk up and down stairs holding on (typically places both feet on one step before
advancing)
- Able to name body part
- Speaks 7 – 20 words
24 months
- Can open doors by turning doorknobs
- Unscrew lids
- Walk upstairs alone by still using both feet on the same step at same time
- Daytime bladder control
- Speak 50 – 200 words
30 months
- 3 year old do tooth brushing with little supervision
- 2 – 3 year old is the right time to bring to the dentist
- Temporary teeth complete and last temporary teeth to appear is the posterior
molars
- 20 deciduous teeth by age 2 ½ years
- Can make simple lines or stroke for crosses with a pencil
- Can jump down from the stairs
- Knows full name
- Copy a circle
- Holds up fingers
36 months
- Trusting three
- Able to unbutton
- Draw a cross
- Learns how to share
- Full name and sex
- speak fluently
- Right time for bladder control (night time control)
- Able to ride a tricycle
- Speak 300 – 400 words 1
- Clues for toilet training
a. Can stand, squat and walk alone
b. Can communicate toilet needs
d. Character Traits
- Negativistic likes to say no (it is their way to search independence)
- Limit questions and offer options
- Temper tantrums (stomping feet and screaming)
- Ignore the behavior
- Rigid ritualistic: stereotype
- Cause: mastering
- Protruded abdomen
- Cause:
- Under development of abdomen
- Unsteady gait
- Physiologic anorexia (give foods that last for a short period of time)
E.3. PRE-SCHOOL
a. Play
- Associative play, Cooperative play
- Play house
- Role playing
b. Fear
- Body mutilation or castration fear
- Dark places and witches
- Thunder and lighting
c. Milestone
4 years
- Furious four (noisy and aggressive)
- Able to button
- Copy a square
- Lace shoes
- Know the 4 basic colors
- Vocabulary of 1500 words
5 years
- Frustrating five
- Copy a triangle
- Draw a 6 part
- Imaginary playmates
- 2100 words
d. Character Traits
- Curious
- Creative
- Imaginative 1
- Imitative
- Why and How
b. Fear
- School phobia
- To prevent phobia orient child to new environment
- Displacement from school
- Significant person is the teacher and peer of the same sex
- Loss of privacy
- Fear of death
c. Significant Development
- Prone to bone fracture (green stick fracture)
- Mature vision
d. Milestones
6 years
- Temporary teeth begins to fall
- Permanent teeth begins to appear (first molar)
- Year of constant motion
- Clumsy movement
- Recognizes all shapes
- Teacher becomes authority figure that may result to nail biting
- Beginning interest with God
7 years
- Age of assimilation
- Copy a diamond
- Enjoys teasing and play alone
- Quieting down period
8 years
- Expansive age
- Smoother movement
- Normal homosexual
- Love to collect objects 1
- Count backwards
9 years
10 years
- Age of special talents
- Writes legibly
- Ready for competitive sports
- More considerate and cooperative
- Joins organization
- Well mannered with adults
- Critical of adults
11-12 years
- Pre adolescent
- Full of energy and constantly active
- Secret language are common
- Share with friends about their secrets
- Sense of humor present
- Social and cooperative
e. Character Traits
- Industrious
- Love to collect objects
- Cant bear to loose they will cheat
- They are modest
SIGNS OF SEXUAL MATURITY
Girls Boys
Increase size of breast and genetalia Appearance of axillary and pubic hair
Widening of hips Deepening of voice
Appearance of axillary and pubic hair Development of muscles
Menarch (last sign) Increase in size of testes and scrotum (1st
- telarch is the 1st sign of sexual maturity sign)
Production of viable sperm (last sign)
a. Fear
- Acne
1
- Obesity
- Homosexuality
- Death
b. Significant Person
- Peer of opposite sex
c. Significant Development
- Experiences conflict between his needs for sexual satisfaction and societies
expectations
- Core concern is change of body image and acceptance from the opposite sex
d. Personality Trait
- Idealistic (parent-child conflict begins)
- Rebellious
- Very conscious with body image
- Reformer
- Adventuresome
e. Problems
- Vehicular accident
- Smoking
- Alcoholism
- Drug addiction
- Pre marital sex
How
A. Removal of secretions by proper suctioning
C. If not effective, requires effective laryngoscopy to open the airway. After deep
suctioning, an endotracheal tube can be inserted and oxygen can be administered by
a positive pressure bag and mask with 100% oxygen at 40 – 60 b/min.
Nursing Alerts:
- No smoking sign to prevent combustion
- Always humidify to prevent drying of mucosa
- Mask should cover nose and mouth
- Overdosage of oxygen may lead to scaring of retina which may lead to blindness
called
RETROLENTAL FIBROPLASIAS (retinopathy of prematurity)
- When meconium stained never administer oxygen because pressure will force
meconium to the alveolar sac and cause atelectasis
The remaining 30% - tricuspid valve – right ventricle – pulmonary artery – lungs (for
nutrition) – vasoconstriction of the lungs pushes the blood to the Ductus arteriosus
to aorta to supply the extremities. The two arteries carry the unoxygenated blood
back to the placenta for reoxygenation.
Alerts: Increase pressure on the left side of heart causes closure of foramen ovale
SHUNTS
1. Ductus Venosus – shunt from umbilical vein to inferior vena cava
2. Foramen Ovale – shunt between 2 atria (begin to close within 24 hours)
3. Ductus Arteriosus – shunt from pulmonary artery to aorta (begin to close within
24 hours)
2. Proper Positioning
3. Temperature Regulation
Alerts:
- The goal in temperature regulation is to maintain it not less than 97.7 oF – 36.5 oC
- Maintenance of temperature is important for preterm and SGA because it may lead
to hypothermia or cold stress
A. Factors Leading to the development of Hypothermia
1. Preterm are born poikilothermic (cold blooded) they easily adapt to temperature
of environment due to immaturity of thermo regulating system of body
2. Inadequate subcutaneous tissue
3. Newborns are not yet capable of shivering (increase basal metabolism)
4. Babies are born wet
B. Process of Heat Loss
1. Evaporation – body to air
2. Conduction – body to cold solid object
1
3. Convection – body to cooler surrounding air
4. Radiation – body to cold object not in contact with body
B. Advantage of Breastfeeding
- Very economical
- Always available
- Promotes bonding
- Helps in rapid involution
- Decrease incidence of breast cancer
- Breast fed babies has higher IQ
- It contains anti body (IgA) lactobacillus bifidus that interfere attack of pathogenic
bacteria in GIT
- Contains macrophages (store in plastic container, good for 6 months when stored in
freezer)
- Disadvantages of breast milk and cow’s milk
- Both has no iron
- Possibility of transfer of HIV, Hepatitis B
- Father cannot feed or bond as well
C. Stages of Breastmilk
1. Colostrum – available 2 – 4 days after delivery
Contents:
- Low fats
- Low carbohydrates
- High protein
- High immunoglobulin 1
- High minerals
- High fat-soluble vitamins
D. Cow’s milk
Contents:
- High fats
- Low carbohydrates (add sugar)
- High protein (casein) has a curd that is hard to digest
- High minerals, has traumatic effect on kidneys of baby
- High phosphorus that may cause inverse proportion with calcium
E. Health Teachings
1. Proper Hygiene
- Importance of hand washing
- Removal of caked colostrum
2. Position
- Upright sitting avoid tension to properly empty breast milk
3. Stimulate and evaluate feeding reflexes
a. Rooting
- touch side of lips or cheek and baby will turn to the stimulus
- purpose: to look for food
- disappear at 6 weeks because baby can already focus
b. Sucking
- by touching the middle of lips then baby will suck
- purpose: take in food
- disappear at 6 months
- easily disappear when not stimulated
c. Swallowing
- food touches posterior portion of tongue automatically swallowed
- never disappear cough, gag, sneeze
d. Extrusion/Protrusion reflex
- food touches anterior portion of tongue and tongue automatically
extruded/protruded
- purpose: prevent from poisoning
- disappear by 4 months because baby can already spit out
4. The criteria of effective sucking
a. baby’s mouth is hike well up to areola 1
b. mother experiences after pain
c. other nipple is flowing with milk
CONTRAINDICATIONS IN BREASTFEEDING
Maternal Conditions
- HIV, Hepatitis B, CMV, comadin/warfarin sulfate intake
Newborn Conditions
- erythroblastosis fetalis
- hydrops fetalis
- phenylketonuria (PKU)
- galactosemia
- tay-sachs disease
5. Establishment of waste-elimination
A. Different stools
1. Meconium
- Physiologic stool
- Blackish green
- Sticky 1
- Tar like
- Odorless (because of sterile intestines)
- No bacteria
2. Transitional
- Become green, loose and slimy that may appear to be a slight diarrhea to the
untrained eye
3. Breastfed stool
- Golden yellow, soft, mushy with sour milk smelling odor frequently passed occurring
almost nearly every feeding
4. Bottle-fed stool
- Light yellow, formed, hard with a typical offensive odor seldom passed 2 – 3 times a
day
CARDIO PULMONARY-RESUSCITATION
Airway (Clear Airway)
1. Shake, no response call for help
2. Place flat on bed
3. Head tilt – chin lift maneuver
- Contraindicated to spinal cord injury
- Over extension may occlude airway
Breathing (Ventilating the lungs)
4. Check for breathlessness
5. Administer 2 rescue breaths
Circulation (by cardiac compression)
6. Check for pulselessness
7. Do CPR (when breathless and pulse less)
B. RESPIRATION EVALUATION
SILVERMAN ANDERSON INDEX CHART
Score
Criteria 0 1 2
Chest movement Synchronized Lag on respiration See saw
Intercostal retraction No retractions Just visible Marked
Xiphoid retraction None Just visible Marked
Nares dilation None Minimal Marked
Expiratory grunt None Stethoscope Naked ear
Interpretation of Result
0 – 3: Normal no respiratory distress syndrome
4 – 6: Moderate RDS
7 – 10: Severe RDS
3. Bathing Baby
- Normal oil bath
- Cleanse and spread vernix
- Babies of HIV positive mothers are given full bath to lessen transmission of infection
- Insulator
- Bacteriostatic
- Full bath is safely given when cord falls
5. Credes Prophylaxis
- Purpose: prevent opthalmia neonatorum (use erythromycine ophthalmic ointment)
6. Administration of Vitamin K
- Action: prevent hemorrhage
- Related to physiologic hypoprothrombinemia
- Give Aquamephyton, phytomenadione, konakoib (.5 – 1.5 mg, IM)
7. Weight-taking
Normal Weight: 3000 – 3400 grams/3 – 3.4 kg/6.5 – 7.5 lbs
Arbitrary Lower Limit: 2500 grams
Low Birth Weight: below 2500 grams
Small for Gestational Age: less 10 percentile rank
Large for Gestational Age: more than 90 percentile rank
Appropriate for Gestational Age: within the 2 standard deviation of the mean
Physiological Weight Loss: 5 – 10 percent occurs a few days after birth
3. Truncus Arteriosus
- Pulmonary artery and aorta is arising from one common trunk or single vessel with
VSD
Management
1. Positive cyanosis and polycythemia
2. Restructuring of the heart
2. Tetralogy Fallot
- 4 Anomalies Present
Pulmonary stenosis
VSD
Overriding aorta
Right ventricular hypertrophy
3. Severe dyspnea
- Relieved by squatting position
4. Growth retardation
5. Tet Spells
- Blue spells, short episode of hypoxia
1
Management
1. Morphine – for hypoxic episode
2. Propranolol (Inderal) – decrease heart spasm
Management
- CBR (avoid contact sports)
- Culture and sensitivity (throat swab)
- Antibiotic management (to prevent recurrence)
- Aspirin (anti inflammatory)
- Side Effects: Reye’s Syndrome
- Non recurring encephalopathy accompanied by fatty infiltration of organs such as
liver and brain
RESPIRATION
- Abnormal/diaphragmatic
- Short period of apnea without cyanosis
- Normal apnea of newborn is less than 15 seconds
Respiration Check
Newborn 40-90 5 years 20-25
1 year 20-40 10 years 17-22
2-3 years 20-30 15 and above 12-20
Management
1. Keep head elevated
2. Proper suctioning
- Oxygen administration
- Place on continuous positive airway pressure
- Positive end expiratory pressure (maintain alveoli partially open and prevent
collapse)
3. Monitor skin color, vital signs, ABG
4. Surfactant replacement and rescue
LARYNGOTRACHEOBRONCHITIS
- Infection of larynx, trachea and bronchi
Assessment
- Barking cough/croupy cough
- Respiratory acidosis
Laboratory Studies
a. ABG
b. Throat culture
c. CBC
Diagnostic Studies
a. Chest and neck x-ray (to rule out epiglotitis)
Management
1
a. Bronchodilators
b. Oxygen with increase humidity
c. Prepare tracheostomy set when necessary
BLOOD PRESSURE
- 80/46 mmHg after 10 days 100/50
- Normal blood pressure taking begins by 3 years old
Alerts
- BP cuff must cover 50 – 75% (2/3) of upper arm
- To large cuff results to false low BP
- To small cuff results to false high BP
SKIN
- Acrocyanosis (body pink extremities blue)
- Generalized mottling due to the immaturity of the circulatory system
BIRTHMARKS
1. Mongolian Spots – slate-gray-or-bluish discoloration/patches commonly seen
across he sacrum or buttocks
- Due to increase melanocytes
- Common in asian newborn
- Disappear by 1 year, preschool, 5 years old
2. Milia – plugged unopened sebaceous gland usually seen as white pinpoint patches
on nose, chin and cheek, disappears by 2 – 4 weeks
3. Lanugo – fine downy hair
4. Desquamation – peeling of the newborn skin within 24 hours, common among
post term
5. Stork bites (telengiectasis nevi) – pink patches at the nape of the neck 1
- Never disappear but is covered by hair
6. Erythema Toxicum (flea bite rash) – first self limiting rash to appear
sporadically and unpredictably as to time and place.
10. Vernix Caseosa – white cheese like substance for lubrication; Color of vernix is
same as
amniotic fluid
SKIN COLOR AND THEIR SIGNIFICANCE
Blue – cyanosis/ hypoxia
White – edema
Gray – infection
Yellowish – jaundice/ carotinemia (increase carotin)
Pale – anemia
SKIN DISORDERS
BURN TRAUMA
- Is injury to body tissue cause by excessive heat
Assessment
Depth
1st (partial thickness)
Ex. Sunburn
Involves only the superficial epidermis characterized by erythema, dryness and pain
Heals 1 -10 days
2nd (partial thickness)
Ex. Scalds
Involves the entire epidermis, and portion of dermis characterized by erythema,
blistered and moist from exudates which is extremely painful.
ATOPIC DERMATITIS
- Infantile eczema
- Skin disease characterized by maculo vesicular errythematous lesion with weeping
and crusting
- Cause: allergens (main), milk, eggs, citrus juices, tomatoes and wheat
- Characterized by extreme pruritus
- Sign: linear excoriation, lichenified – scaling
Management
- Treat main cause
- Prosorbbee or Isomil (milk)
- Hydrate skin with burrow’s solution
- Prevent infection
- Cut short the nails
IMPETIGO
- Cause: group A beta hemolytic streptococcus
- Characterized by populo vesicular surrounded by localized errythema becoming
purulent and ooze forming a honey colored crust
- Pediculosis capitis (kuto)
- Give oral penicillin
- AGN complication
ACNE
- Self limiting inflammatory disease affects sebaceous glands common in
adolescence
- Signs: Comedones (sebum causing white heads)
- Sebum is composed of lipids
Management 1
- Proper hygiene
- Wash face with soap and water
- Use sulfur soap or mild soap
Assessment
- Newly delivered baby receive maternal clotting factor
- Sudden bruising of bumped area
- Continuous bleeding to hemarthrosis
- Bleeding or damage of synovial membrane
Diagnostic Test
- High risk for injury (prevent injury)
- Partial thromboplastin time
Management
- Avoid contact sports
- Significance: determine case before doing any invasive procedure
- No aspirin
- Immobilize and elevate upon injury
- Apply gentle pressure
- Cold compress
- Blood transfusion: cryoprecipitate, fresh frozen plasma
LEUKEMIA
- Group of malignant disease characterized by rapid proliferation of immature WBC
- WBC (soldiers of body)
- Ratio: 500 RBC:1WBC
TRIAD
Irradiation Chemotherapy
Therapeutic Management
1. Medications
4 Levels of Chemotherapy
For Induction – achieve remission (main goal)
a. IV Vincristine
b. Laspariginase
c. Oral prednisone
For Sanctuary – treat leukemic cells that has invaded testes and CNS
a. Methothrexate (intrathecally via CNS/spine)
b. Cytocin
c. Arabinoside
d. Extra irradiation
For Maintenance – continue remission
a. Oral Methothrexate 1
b. Oral 6 mercaptopurine
c. Cytarrabine
For Reinduction – treat leukemic cells after relapse occurs
Nursing Management
- Assess for common side effects
- Nausea and vomiting
- Administration of anti emetics 30 minutes before chemo and continue until 1 day
after
- Check for stomatitis, ulcerations and abscess of oral mucosa
- Oral care (alcohol free mouthwash) no toothbrush
- Diet (soft and bland) according to child’s preference
- Alopecia (temporary side effects)
- Hirsutism
- To parents (always repeat instruction)
HEMOLYTIC DISORDER
a. Rh Incompatibility
- Mother negative, fetus positive
- 4th baby affected
- Mother negative, no antigen (no protein factor)
- Erythroblastosis fetalis: hemolysis leading to decrease oxygen carrying capacity
with pathologic jaundice within 24 hours
- Test: Comb’s Test
- Vaccine: Rhogam
- Given to RH negative mother within first 72 hours to destroy fetal RBC therefore
preventing antibody formation
b. ABO Incompatibility
- Mother is type O, fetus is type A, B, AB
- Most common is O, and A
- Severe O and B
- First pregnancy can be affected
Assessment
- Common is Hydrops fetalis, edematous on lethal state with pathologic jaundice
within 24 hours
Management
1. Initiation of feeding, temporary suspension of breast feeding to prevent
kernikterus
2. Pregnandiole – delays action of glucoronyl transferace (liver enzyme that
converts indirect bilirubin to direct bilirubin)
3. Use of Phototherapy
4. Exchange Transfusion of Rh or ABO affectations that tend to cause continuous 1
decrease in hemoglobin during the first 6 months because bone marrow fails to
produce erythrocytes in response to continuing hemolysis.
Assessment
- Blanching the neonates forehead , nose or sternum
- Yellow skin and sclera
- Light stool
- Dark urine
Management
Phototherapy
- Photo oxidation
- Height of 18 – 20 inches away from baby
Nursing Responsibilities
1. Cover the eyes – prevent retinal damage
2. Cover genitals – prevent priapism (painful continuous erection)
3. Change position – for even exposure to light
4. Increase fluid intake – to prevent dehydration
5. Monitor I & O – weigh baby 1 gram:1 cc
6. Monitor Vital Signs
- Avoid use of lotion or oil because it may result to bronze baby syndrome
HEAD
Structures
Sutures: 3
Fontanels: 12 – 18 months close
Anterior fontanel
- Craniostenosis/ craniosinostosis (premature closure of anterior fontanel)
Posterior fontanel
- 1 x 1 cm
- Closes by 2 – 3 months
Microcephaly 1
- Small/slow growing brain
- Fetal alcohol and HIV positive
Anencephaly
2. Caput Succedaneum
- Edema of scalp due to prolonged pressure at birth
- Characteristics
- Present at birth
- Crosses the suture line
- Disappear after 2 – 3 days
3. Cephalhematoma
- Collection of blood due to rupture of periostial capillaries
- Characteristics
- Present after 24 hours
- Never cross the suture line
- Disappear after 4 – 6 weeks
4. Seborrheic Dermatitis
- Cradle cap
- Scaling, greasy appearing salmon colored patches usually seen on scalp, behind
ears and umbilicus
- Primary cause: improper hygiene
- Management: proper hygiene, apply oil the night before shampooing (use baby oil
or coconut oil)
5. Hydrocephalus
- Collection of CSF
2 types
a. Communicating – extra ventricular hydrocephalus
b. Non communicating – intra ventricular hydrocephalus also called obstructive
Signs and Symptoms
- Sign of increase ICP
- Sign of frontal bossing (prominent forehead)
- Prominent scalp vein
- Sunset eyes
Therapeutic Management
- Place client in low semi fowlers position (30o)
- Osmotic diuretic
- Diamox (Acetazolamide) to decrease CSF production
- Seizure precaution
- Surgery (AV shunt, VP shunt) 1
- Shave just before surgery
- Place in side lying position on non operated side
- Monitor for good drainage
SENSES
a. Sense of Sight (Eyes)
Sclera – light blue becomes dirty white
Pupils – round and adult size
a. Coloboma – part of iris is missing
b. Congenital cataract – whiteness and opacity (caused by german measles)
Cornea – round and adult size, larger in congenital glaucoma
Test of blindness
AGE COMMON TEST
1. Newborn - General appearance
- See 10 – 12 inches
- Doll’s eye test done on 10th day
- Glabellars test blink reflex
RETINOBLASTOMA
- Malignant tumor of retina
- Red painful eye often accompanied by glaucoma (pathognomonic sign: cat’s
eye reflex)
- Management: enucleation
2. Chromosomal Aberrations
- More than 35 years
A. Nondisjunction
1. Trisomy 21
- Down syndrome
- Extra chromosome 21
- 47 XX + 21 or 47 XY + 21
- Cause: advance paternal age
- Mongolian slant in eyes
- Low set ears
- Broad flat nose
- Protruding tongue
- Puppy’s neck
- Hypotonic (respiratory problem unable to cough out)
- Simian crease (single transverse line of palm)
- Educable
2. Trisomy 18
3. Trisomy 13
4. Turners
5. Klinefilters Syndrome
B. Deletion Abnormalities
1. Cri-du-chat Syndrome
2. Fragile X Syndrome
C. Translocation Abnormalities
1. Balance Translocation Carrier
2. Unbalanced Translocation Syndrome
D. Others
1. Mosaicism – a situation wherein the nondisjunction of chromosomes occurs during
the mitotic cell division after fertilization resulting to different cells contains different
numbers of chromosomes.
2. Isochromosomes – a situation wherein the chromosomes instead of dividing
vertically it divides horizontally resulting to chromosomal mismatch.
OTITIS MEDIA
- Inflammation of middle ear, common in children due to wider and shorter 1
eustachian tube
- Common with cleft lip and palate
- Bottle propping, may also result to dental caries
b. TEF/TEA
- Tracheo Esophageal Fistula. Tracheo Esophageal Atresia
- No connection between esophagus and stomach
- 4 C’s: coughing, choking, cyanosis, continuous drooling
- Emergency surgery
c. Epstein Pearls
- White glistening cyst usually seen on palate or gums related to hypercalcemia
d. Natal Tooth
- Tooth at moment of birth related to hypervitaminosis (rootless)
e. Neonatal Tooth
- Tooth within 28 days
f. Oral Thrush 1
- Oral moniliasis, white cheese/curd like patches that coats mouth and tongue
- Treat with anti fungal (Nistatin/Mycostatin)
KAWASAKI DISEASE
- Common in Japan
- Mucocutaneous lymph node syndrome
- Drug of choice: Aspirin, Salicylates
CLEFT LIP
- Failure of the median maxillary nasal processes to fuse by 5 – 8 weeks of pregnancy
- Common in boys
- Can be unilateral or bilateral
CLEFT PALATE
- Failure of the palate to fuse by 9 – 12 weeks of pregnancy
- Common in girls
Signs and Symptoms
a. Evident at birth
b. Ultrasound/3 dimensional UTZ
c. Milk escape to the nostril
d. Common URTI (otitis, cholic)
Therapeutic Management
- Surgery
- Cleft lip: cheiloplasty done as early as 1 – 3 months to save sucking reflex
- Cleft palate: uranoplasty done 4 – 6 months to save speech
Nursing Responsibility
(Pre Op)
- Emotional support
- Proper nutrition
- Use Rubber tipped medicine dropper
- Prevention of cholic 1
a. Feed upright position
b. Burp twice
c. Prone position/on abdomen
NECK
- Check for symmetry
a. Congenital Torticolis
- Wry neck
- Birth injury of sternocleidomastoid muscle due to excessive traction during cephalic
delivery
- Management:
- Passive stretching exercises daily
- Surgery (last)
- Complication is scoliosis
CHEST
- Check for symmetry
- Breast produces witch milk a transparent fluid related to hormone changes
ABDOMEN
- Inspection, Auscultation, Palpation, Percussion
A. Diaphragmatic hernia
- Protrusion of stomach contents through a defect in the diaphragm due to failure of
pleuroperitoneal canal to close
Signs and Symptoms
1. Sunken abdomen
2. Signs of RDS
3. Related to shunting
Management
- CPAP (continuous positive airway pressure)
- Diaphragmatic repair within 24 hours
B. Ompalocele
- Protrusion of stomach contents between junction of abdominal wall and umbilicus
- Small: surgery
- Large:
- Suspension of surgery
- Wrap with sterile wet dressing
- Apply silver sulfadiazine ointment to prevent infection
GASTROINTESTINAL SYSTEM
1. FUNCTIONS
a. Assists in maintaining fluid and electrolyte and acid/base balance
b. Processes and absorbs nutrients to maintain metabolism and support
growth and development
c. Excrete waste products from the digestive system
2. RECOMMENDED DAILY ALLOWANCE
a. Calories: 120 calories per kilo body weight per day (360 – 380 calories)
b. Fluids: 16 – 20 cc per kilo body weight
c. Protein: 2.2 grams per kilo body weight 1
5. ACID-BASE BALANCE
Dependent on the following
a. Chemical buffers
b. Renal and respiratory system involvement
c. Dilution of strong acids and bases on blood
Imbalance of acid
a. Respiratory acidosis
- Carbonic acid excess
- Hypoventilation
- Asthma
- Pneumonia
- Emphysema
- Laryngo tracheo bronchitis
- RDS
b. Respiratory alkalosis
- Carbonic acid deficit
- Hyperventilation
- Fever
- Encephalitis
c. Metabolic acidosis
- Carbonate deficit 1
- Diarrhea
- Severe malnutrition
- Dehydration
d. Metabolic alkalosis
- Carbonate excess
- Uncontrolled vomiting
- Gastric lavage
- NGT aspiration
- Pyloric stenosis
8. OBSTRUCTIVE DISORDERS
PYLORIC STENOSIS
- Hypertrophy of pylorus muscle causing narrowing and obstruction
Assessment
1. Projectile vomiting
Nursing Alerts:
- Vomiting is an initial symptom of upper GI obstruction
- Vomitus of upper GI can be blood tinged not bile streaked
- Vomitus of lower GI is bilous
- Projectile vomiting is either a sign of ICP or GI obstruction
- Abdominal distention is the major symptom of lower GIT obstruction
2. Failure to gain weight
Diagnostic Procedures
1. ABG – metabolic alkalosis 1
2. Serum electrolyte: increase Na and K, decrease chloride
3. Ultrasound
4. X-ray of upper abdomen with barium swallow reveals string sign
INTUSSUSCEPTION
- Telescoping of one portion of the bowel to another
- Complication of peritonitis
Signs and Symptoms
- Acute paroxysmal abdominal pain
- Vomiting
- Curant jelly stool
- Sausage shape mass
Diagnostic test
- X-ray with barium enema reveal staircase sign
Management
- Hypostatic reduction with barium enema
CELIAC DISEASE
- Gluten Enteropathy
LEAD POISONING
- Destroy RBC functioning
- Resulting to hypochromic mycrocytic anemia 1
- Leading to kidney destruction
- That leads to accumulation of amonia
- Then encephalitis
ANOGENITAL
Alerts
Female
- Pseudo menstruation
- Slight bleeding related to hormonal changes
- Rape
- Tearing of forchet
- Concerned with child’s care
- Wound follow different stages of healing
- Identical wound
- Report to authorities within 48 hours (barangay captain, bantay bata)
- Shape of pubic hair is inverted triangle
Male
- Check testes (undescended)
- Cryptorchidism common in preterms and management is orchidopexy
- Warm room and hand
- Check for arch of urine
- Hydrocele: fluid filled scrotum (translumination reveal a glowing sign)
- Phimosis: tight foreskin (balanitis infection of glans penis)
- Varicocele: veins in scrotum is increased
BACK
- Check for symmetry and flatness
Spina bifida Occulta
- Failure of posterior laminae of vertebrae to fuse
- Signs and Symptoms: dimpling at lower back
- Abnormal tuffs of hair
Spina bifida Cystica
- With sac
Types
1. Meningocele – protrusion of CSF and meninges
2. Myelomeningocele – protrusion of CSF, meninges and spinal cord
3. Encephalocele – cranial meningocele or myelomeningocele
Common Complication
- Common problem is rupture of sac (place wet sterile dressing and place in prone
position)
- Infection
- Urinary and fecal incontinence
- Paralysis of lower extremities
- Hydrocephalus (CNS complication)
- Always check for a wet diaper
Treatment
- Surgery to prevent infection
SCOLIOSIS
- Lateral curvature of spine common in school age and adolescent
- Uneven hemline
- S shape back
- When bending 1 hip is higher and 1 shoulder prominent
Management
1. Conservative
a. Exercise
b. Avoid obesity
2. Preventive
a. Milwaukee brace worn 23 hours a day
1
3. Corrective
a. Surgery – insertion of Harrington rod (post op do log rolling or move as 1
unit)
Types
a. Equinos – plantar flexion (horse foot)
b. Calcaneous or Dorsiflexion – the heel is held lower than the foot/the anterior
portion of foot is flexed towards the anterior leg
c. Varus – foot turns in
d. Valgus – foot turns out
Assessment
- Make a habit of straightening legs and flexing to improve to midline position 1
Management
- Corrective shoes (Dennis brown SPLINT)
- Spica cast
2. Swing To
Procedure:
1. Advance both crutches
2. Lift both feet/ swing forward/land feet next to crutches
3. Advance both crutches
4. Lift both feet/ swing forward/land feet next to crutches
- 1 and 2 is indicated if weight bearing is not allowed in both lower
extremities
To Stand Up
1. Move forward to the edge of the chair with the strong leg slightly under the sit
2. Place both crutches in the hand on the side of the affected extremity
3. Push down on the hand piece while raising the body to a standing position
To Go Down Stairs
1. Walk forward as far as possible on the step
2. Advance the crutches to the lower step. The weaker leg is advanced first and then
the stronger one. In this way the stronger extremity shares the work of raising and
lowering the body weight with the patient’s arms.
To Go Up Stairs
1. Advance the stronger leg first up to the next step
2. Then advance the crutches and the weaker extremity (Strong leg goes up first and
comes down last.) A memory device for the patients is “up with the good, down with
the bad.”
WALKER
- A walker provides more support than a cane or crutches
The patient is taught to ambulate with the walker as follows:
1. Patient must hold the walker on the hand grips for stability
2. Lift the walker, placing it in front of you while leaning your body slightly forward
3. Walk into the walker, support your body weight on your hands when advancing
your weaker leg permitting partial weight-bearing or non-weight-bearing leg as
prescribed
4. Balance yourself on your feet
5. Lift the walker and place it in front of you again. Continue this pattern of walking
CANE
- A cane is used to help the patient walk with greater balance and support and to
relieve pressure on weight-bearing joints by redistributing the weight. Quad canes 1
(four-footed canes.) The cane is held in the hand opposite to the affected extremity
Therapeutic Exercises
Exercise Description Purpose Action
Passive An exercise carried To retain as much Stabilize the proximal
out by the therapist joint range of motion joint and support the
or the nurse without as possible to distal part. Move the
assistance from the maintain circulation joint smoothly,
patient slowly, and gently
through its full range
of motion. Avoid
producing pain.
Active assistance To encourage normal
An exercise carried muscle function Support the distal
out by the patient part, and encourage
with the assistance of the patient to take
the therapist or the the joint actively
nurse through its range of
motion. Give no more
assistance than is
necessary to
accomplish the
action. Short periods
of activity should be
Active To increase muscle followed by adequate
strength. rest periods.
An exercise
accomplished by the When possible, active
patient without exercise should be
assistance, activities performed against
include turning from gravity. The joint is
side to side and from moved through full
back to abdomen and range of motion
moving up and down without assistance.
in bed. (Make sure that the
patient does not
Resistive To provide resistance substitute another
to increase muscle joint movement for
power. the one intended.)
An active exercise
carried out by the The patient moves
patient working the joint through its
against resistance range of motion while
produced by either the therapist resists
manual or slightly at first and
mechanical means. then with
progressively
increasing resistance.
Sandbags and
weights can be used
Isometric or and are applied at the
muscle setting To maintain strength distal point of the
when a joint is involved joint the
immobilized movement should be
Alternately performed smoothly.
contracting and
relaxing a muscle Contract or tighten
while keeping the the muscle as much
part in a fixed as possible without
position; this exercise moving the joint, hold
is performed by the for several seconds,
patient then let go and relax.
Breathe deeply.
TRACTION 1
- Use to reduce dislocation and immobilize fractures
Skin Traction
- Applied directly to skin
a. Bryant’s traction
- Use to immobilize ages below 3 years old
- 90O angle with buttoks off bed
b. Buck’s extension
- Immobilize fracture ages more than 3 years old
c. Skeletal
- Applied directly to bone
d. Halo traction
- Immobilize spine
Skeletal Traction
Nursing responsibility
1. Assess for circulatory and neurologic impairment
2. It can lead to hypertension
3. Be careful in carrying out nursing functions by not moving the weights
AUTOIMMUNE SYSTEM
Types of immunity
a. Passive Natural – maternal antibodies through placenta or breast milk
b. Active Natural – contract disease and produce memory cells
c. Passive Artificial – receive anti serum with anti bodies from another host
(Hepa B)
d. Active Artificial – receive vaccination and produce memory cell
NEUROMUSCULAR SYSTEM:
Reflexes
a. Blink reflex – rapid eyelid closure when strong light is shown 1
b. Palmar grasp reflex – solid object is placed on palm and baby grasp
object
f. Moro reflex – test for neurological integrity (jarring crib, loud voice)
assume a letter C position (disappear by 4 – 5 months)
g. Magnet reflex – when there is pressure at the sole of the foot he pushes
back against the pressure.
j. Landau reflex – while prone position and the trunk is being supported, the
baby exhibit some muscle tone (test for muscle tone and present by 6 –
9 months)