The Royal Pentagon Review Specialist Inc. Pediatric Nursing

The Royal Pentagon Review Specialist Inc.
Pediatric Nursing
GROWTH AND DEVELOPMENT
Growing  complex phenomenon of a structure or whole
GROWTH
• Increase in physical size of a structure or whole

• Quantitative
• 2 parameters o Weight
 Most sensitive measurement for growth
2x = 5 – 6 mos. Weight gain:
3x = 1 year
4x = 2 – 2½ years
o Height
 ESTROGEN  responsible for increase in height in female
 TESTOSTERONE  responsible for the increase in height in male  Stoppage of height
coincide with the eruption of the wisdom teeth
↑ - 1”/ mo – 1 – 6 mos
↑ - 1.5”/ mo – 7 – 12 mos
↑ - 50 % - 1st Year
HEIGHT COMPARISON
9 y/o  male = female
12 y/o  Male < Female
13 y/o  Male > Female
DEVELOPMENT
• Increase in the skills or capacity to function
• Qualitatively
• How to measure development
o By simply observing the child doing simple task
o By noting parent’s description of the child’s progress
o Measure by DENVER DEVELOPMENTAL SCREENING TEST (DDST)
• MMDST
o Metro Manila Developmental Screening Test
o Philippine Based exam
• Main Rated Categories o LANGUAGE  ability to communicate o PERSONAL/ SOCIAL  ability to interact
o FINE MOTOR ADAPTIVE  ability to use hand movements o GROSS MOTOR SKILLS 
ability to use large body movements
MATURATION
• Synonymous with development
• Readiness/ learning is effortless
COGNITIVE DEVELOPMENT
• Ability to learn and understand from experiences, to acquire and retain knowledge, to respond to a new situation and
to solve problems
LEARNING  change of behavior

IQ= [Mental Age/ Chronological Age] x 100 Normal IQ = 90 - 110
Jomar Anthony D. Maxion, BSN, RN PLM BSN 2006

The Royal Pentagon Review Specialist Inc. Pediatric Nursing
GIFTED CHILD  > 130 IQ level
BASIC DIVISIONS OF LIFE

• Prenatal o Conception to birth
• Infancy
oo Neonatal Formal Infancy  first 28 days  29th – 1 year
• Early Childhood o Toddler  1 – 3 y/o o Preschool  4 – 6 y/o
• Middle Childhood o School Age  7 – 12 y/o
• Late Childhood o Pre – adolescent  11 – 13 y/o o Adolescent – 12 – 13 y/o to 21
PRINCIPLES OF GROWTH AND DEVELOPMENT

• Growth and development is a continuous process (WOMB TO TOMB PRINCIPLE)
 begins from conception and ends with death
• Not all parts of the body grow at the same time or at the same rate
(ASSYCHRONOUS GROWTH)
• Each child is unique
• Growth and development occurs in a regular direction reflecting definite and predictable patterns or trends
o Directional Terms
 Cephalocaudal/ Head to Tail
 It
occurs along bodies long axis in which control over head, mouth and eye movements
and precedes control over upper body torso and legs
 Proximo – Distal/ Centro – Distal
 Progressing from center of the body to the extremities
 Symmetrical/ Each side of the Body
 Develop at the same direction at the same time and at the same rate
 Mass – Specific
 Differentiation – SIMPLE TO COMPLEX; BROAD TO
REFINED
o Sequential Trend
 Involves a predictable sequence of growth and development to which the child normally passes
 Locomotion
 Creeps → Stands → Walks → Run

 Language and Social Skills
 Cry → coo
o Secular Trend
 Refers to the worldwide tend of maturing earlier and growing larger as compared to succeeding
generation
• BEHAVIOR → most comprehensive indicator of developmental stages o act @ your age
• PLAY → universal language

• A great deal of skills is learned by practice
• There is optimum time for initiation of experience or learning
• Neonatal reflexes must be lost first before development can proceed o persistent primitive infantile reflexes is a
possible case of cerebral palsy
PATTERNS OF GROWTH AND DEVELOPMENT

• Renal → digestive → circulatory → musculoskeletal o childhood
• Brain → CNS → Neurologic Tissue  rapidly grows with in 1 – 2 years o Brain achieves its adult proportion @ 5
years o Rapid growth and development of brain from1 – 2 years o Malnutrition may result to Mild Mental Retardation
• Lymphatic System (Lymph Nodes) o Grows rapidly during infancy and childhood o Provide protection against
infection o TONSIL reach its adult proportion @ 5 years
• Reproductive o Grows rapidly during puberty

RATES OF GROWTH AND DEVELOPMENT

• Fetal and Infancy o Period of most rapid growth and development o Prone to develop anemia
• Toddler o Period of slow growth and development
• Toddler and preschool o Period of alternating rapid and slow growth and development
• School Aged o Slower growth and development o Least to develop anemia
• Adolescent o Period of rapid growth o Secondary prone to anemia
Two Primary Factors Affecting Growth and Development

• Heredity
o Race
o Sex
o Intelligence
o Nationality
• Environment
o Quality of Nutrition o Socio
Economic Status o Health
o Ordinal Position in the family o
Parent – Child Relationship
*Universal Principle: F are born < wt. than M by 1 oz.; F are born < length. than M by 1 in.
THEORIES OF DEVELOPMENT
Developmental Task
• A skill or growth responsibility arising at a particular time in the individual’s life.
• The successful achievement of which will provide a foundation for the accomplishments of the future tasks
SIGMUND FREUD’S PSYCHOSEXUAL THEORY

• 1856 – 1939
• An Austrian Neurologist
• Founder of Psychoanalysis
• 1st to introduce Personality Development
Phase Age Site of Activities Task
Gratificati on
Oral Phase 0 – 18 mos. Mouth • Biting • Provide oral stimulation even if baby is place
• Crying NPO (use pacifier)CBQ
• Sucking • Never discourage thumb sucking

(enjoyment and
release of tension)
Anal 19 mos. – 3 yrs. Anus • Elimination • Help the child achieve bowel and bladder
Phase
(stage
• Retention/ control even if the child is hospitalized
where OC
Defecation of • Principle of holding on and letting go
are develop
Feces • Mother wins or child wins
ed) • Child Wins o Holding on o Child turns to be
hardheaded, antisocial, stubborn, unreliable,
irresponsible
• Mother Wins o Letting go
o Child turns to be kind, obedient,
perfectionist
o Meticulous, OCs, reliable, responsible

Phallic 4 – 6 yrs. Genital • May show • Accept the child fondling his own genetalia as
Phase exhibitionism normal area of
• Have or increase exploration
knowledge of • Divert attention from masturbation
2 sexes
• Answer the child’s question directly
• Human sexuality
Latent 7 – 12 yrs. School aged • Period of • Help the child achieve (+) experiences so that
Phase suppression he’ll be ready to face the conflicts of
• No obvious adolescents
development,
slower growth
• Child’s energy or
Libido is diverted
into more concrete
type of thinking
Genital 12 – 18 yrs Genitalia • Achieve sexual • Give opportunity to relate to opposite sex
Phase maturity and
learn to establish
satisfactory
relationship with
the opposite sex
ERIK ERICKSON’S STAGES OF PSYCHOSOCIAL THEORY

• Former student of Freud
• Stresses the importance of culture and society to the development of one’s personality
• “environment”
1. Trust vs. Mistrust

• 0 – 18 months
• TRUST is the foundation of all psychosocial tasks
• Theme: Give and Receive
• Trust is developed via
o Satisfying needs of infants on time
o Care must be consistent and adequate
o Give experiences that will add security
 Hugs, kisses, touch, eye to eye contact, soft music
2. Autonomy vs. Shame & Doubt
• 18 mos. to 3 years
• Theme: independence and self – government
• Give opportunity for decision making, offer choices
• Encourage the child to make decision rather than judge
• Parents has a moral obligations to set limits
3. Initiative vs. Guilt
• 4 – 6 years old
• Learns how to do BASIC things
• Give opportunity exploring new places and events
• Right time for amusement park and zoos
• Activity recommended: modeling clay and finger painting
• Enhances creativity and imagination and facilitates fine motor development
4. Industry vs. Inferiority
• Learns how to do things well
• Give appropriate short assignments and projects

• Unfinished project will develop inferiority

5. Identity vs. Role Confusion
• 12 – 18 or 20 years old
• Learns who he is or what kind of person he will become by adjusting to new body image and seeking
EMANCIPATION/ freedom from parents
6. Intimacy vs. Isolation
• 18 – 25 or 30 years old
• Career focus
• Looking for a lifetime partner
• Virtue: Love and Commitment
7. Generativity vs. Stagnation
• Middle age adults contribute to the next generation by performing meaningful work as they extend their concern
to the community and the world.
• Encourage them to be active member of the community.
• Virtue: Care
8. Ego Integrity vs. Despair
• 45 years old and above
• Older adults try to make sense of their lives
• Significance: Help them and accept their bodily limitation.
• Virtue: Wisdom
JEAN PIAGET’S STAGES OF COGNITIVE DEVELOPMENT (Sensorimotor, Pre-Operational, Concrete Operational,

Formal Operational)
• Reasoning powers
• Swiss Psychologist
• Genetic Epistemologist
1. Sensorimotor
• Also called Practical Intelligence
o words and symbols are not yet available
o communication through senses
1. Schema 1: Neonatal Reflex

o 1 month
o Early reflexes such as visual tracking of
objects
2. Schema 2: Primary Circular Reaction
o 1 – 4 months
o Activities related to body; repetition of behavior
 Example: thumb sucking
3. Schema 3: Secondary Circular Behavior
o 4 – 8 months
o Activities not related to the body
o Discover person and object’s permanence
o Memory traces are present and anticipate familiar events
4. Schema 4: Coordination of Secondary Reaction
o 8 – 12 months
o Exhibit goal directed behavior
o ↑ sense of permanence and separateness

o Play activities: Throw and retrieve

5. Schema 5: Tertiary Circular Reaction
o 12 – 18 months
o use trial and error to discover characteristic of places and events
o “Invention” of new means
o capable of space and time perception
6. Schema 6: Invention of New Means thru Mental Coordination
o 18 – 24 months
o Symbolic representation
o Transitional phase to the pre-operational thought period
2. Pre-operational Thought
1. Pre – conceptual Thought
o 2 – 4 years old
o Concrete, literal, static thinking
o CBQ EGOCENTRIC – unable to view anothers viewpoint
o CBQ (-) REVERSIBILITY – in every action there is opposite reaction; cause and effect
o Concept of time is only now and concept of distance is only as far as they can see
o CBQ ANIMISM – consider inanimate object as alive
2. Intuitive Thought
o Beginning of causation (4-7 y.o)
3. Concrete Operational
o 7 – 12 years old
o SYSTEMATIC REASONING as solution to problems
o o Concept of (+) reversibility
o Concept of Conservation – constancy despite of transformation
o Activity recommended: Collecting and Classifying
4. Formal Operational
o 12 years old and above
o Period when cognition achieve its final form
o Can solve hypothetical problem with SCIENTIFIC REASONING
o Can deal with past, present and future
o Capable of ABSTRACT, mature thought and formal reasoning
o Activity recommended: talk time; focus on opinions and current events
KOHLBERG’S THEORY OF MORAL DEVELOPMENT

• Recognized the theory of moral development as considered to closely approximate cognitive stages of development
• Stages of Moral Development o Infancy o Premoral o Amoral
o Pre-religious
Age Stage Descritption

PRECONVENTIONAL (Level I)
0 – 3 yrs 1 • PUNISHMENT/ OBEDIENCE/ ORIENTATION

o Heteronomous morality
o Child does right because PARENT tells him to and to avoid punishment

4 – 7 yrs. 2 • INDIVIDUALISM
o Instrumental purpose and exchange
o Carries out action to satisfy own needs rather than society
o Will do something for another if that person does something for the child
CONVENTIONAL (Level II)
4 – 10 yrs. 3 • ORIENTATION TO INTERPERSONAL RELATIONS OF

MUTUALITY
o Child follows rules because of need to be a “good person” in own eyes and eyes of
others
10 – 12 yrs. 4 • MAINTAINANCE OF SOCIAL ORDER, FIXED RULES AND

AUTHORITY
o Child finds following rules satisfying
o Following rules of authority figures as well as parents in an effort to keep the “system”
working
POST – CONVENTIONAL (Level III)
Older than 12 5 • SOCIAL CONTRACT, UTILITARIAN LAW – MAKING

PERSPECTIVE
o Follows standards of society for the good of the people
6 • UNIVERSAL ETHICAL PRINCIPLE ORIENTATION

o Follows internalized standards of conduct
o Only few people achieved this level Only saints and holy
DEVELOPMENTAL MILESTONES
• Major marker of growth and development
• Determines developmental delays
TEETH QUESTIONS
6 mos. Eruption of first temporary teeth 2 LOWER CENTRAL INCISORS
30 mos. Temporary teeth complete
20 decidous teeth
POSTERIOR MOLAR --> last to appear
Time to go to Dentist
Begins to brush teeth
3 years Tooth brushing with minimal supervision

6 years Tooth brushing alone
Temporary teeth begins to fall
1st permanent teeth → 1st MOLAR
Last to appear → WISDOM TOOTH
BOWEL/ BLADDER CONTROL

Bowel Control → 18 months / 1 ½ years
Day Time Bladder Control → 2 years
Night Time Bladder Control → 3 years
MILESTONES
Infancy
• Solitary play o Consider when choosing a play
 Safety
 Age appropriateness

 Hygiene
• Fear: Stranger Anxiety o Begins: 6 – 7 months o Peaks: 8 months
o Diminishes: 9 months
Neonate
• Complete head lag
• Largely reflex visual fixation for human face
• Hands fisted with thumbs in
• Cries without tears because lacrimal glands are not fully developed
1 month
• Dance reflex disappears
• Looks at mobile; follows midline
• Alert to sound, regards face
2 months
• Holds head up when in prone
• Social smile, cries with tears, cooing sound
• Closure of posterior fontanel (2-3 months)
• Head lag when pulled to sitting position
• No longer clinches fist tightly
• Follows object past midline
• Recognizes parents
3 months
• Holds head and chest up when in prone
• Holds hands open at rest
• Hand regard, follows object past midline
• Grasp and tonic neck reflexes are fading
• Reaches for familiar people or object
• Anticipates feeding
4 months
• Head control complete
• Turns front to back; needs space to turn
• Laughs aloud; Babbling sound
• Babinski Reflex disappears
5 months
• Turn both ways (roll over)
• Teething rings, handles rattle well
• Moro reflex disappears (4-5 months)
• Enjoys looking around environment
6 months
• Reaches out in the anticipation of being picked- up
• Sits with support
• Puts feet in mouth in supine position
• Eruption of first temporary teeth ( Lower 2 central incisors)
• Vowel sounds “ah, eh”
• Uses palmar grasp; handless bottle well
• Recognizes strangers

• Sucking reflex disappear
7 months
• Transfer objects from hand to hand (6 – 7 months)
• Likes objects that are good sized for transferring
8 months
• Sits without support
• Peak of stranger anxiety
• Plantar reflex disappear (6-8 months)
9 months
• Creeps or crawls; need space for creeping
• Neat pincer grasp reflex, probes with forefinger
• Finger feeds, combine 2 syllables “mama & dada”
10 months
• Pulls self to stand
• Understand the word no
• Respond to name
• Peek – a – boo, pat a cake, since they can clap
11 months
• Cruising, stand with assistance
• Walking while holding to his crib’s handle
• One word other than mama and dada
12 months
• Stands alone
• Walk with assistance
• Drink from cup, cooperates in dressing
• Says two words other than mama and dada
• Pots & pans, pull toys and nursery rhymes
• Imitates actions, comes when called
• Follows one – step command and gesture
• Uses mature pincer graps, throws objects
Toddlerhood
• Parallel Play – 2 toddlers playing separately
• Provide 2 similar toys for 2 toddlers
• Toys o Squeaky frogs to squeeze o Waddling ducks to pull o Trucks to push o Building blocks o Pounding peg
• Fear: Separation Anxiety o Begins: 9 months o Peaks: 18 months o 3 stages  Protest

 Despair
 Denial o Prevent:
 Do not prolong goodbye
 Say goodbye firmly
 Say when you’re back
Toddler Characteristic Traits
• Negativistic: says no most of the time
• Saying no – way of developing independence
• Limit questions, offer choices
• Rigid, ritualistic and stereotyped

• Ritualistic – way to gain mastery

• Temper Tantrums o Stomping of feet o Holding breath o Screaming o Head banging o NC: Ignore the behavior
• Scaphoid abdomen – underveloped abdominal muscle

• Physiologic Anorexia  food fad, food jag that last for a short period of time due to the preoccupation to
environment
15 Months
• Plateau stage
• CBQ WALKS ALONE – lateness in walking is a sign of mild mental retardation
• Puts small pellets into small bottle
• Creep upstairs
• 4 – 6 words
• Scribbles voluntarily with pencil, holds spoon well, seat self in a chair
18 Months
• Height of POSSESIVENESS – favorite word MINE
• Bowel control achieved
• No longer rotates a spoon
• Can run and jump in place
• Walks up and downstairs holding on to a person’s hand or railing, typically places both feet on one step before
advancing
• Names one body part
24 months
• TERRIBLE TWOS
• Turns pages one at a time, removes shoes, pants, etc
• Can open doors by turning door knobs, unscrew lids
• 50 – 200 words (2 word sentences), knows 5 body parts
• Walk upstairs alone, still using feet on the same step at same time
• Daytime Bladder Control
• CBQ best time to bring the child to dentist: 2 – 3 years or when temporary teeth is complete
30 months
• Makes simple lines or stroke or crosses with pencil
• Can jump down from chair
• Knows full name, holds up finger to show age
• Copy a circle
• CBQ Temporary teeth complete (posterior molar: last to erupt)
• CBQ 20 deciduous teeth
• CBQ tooth brushing: 2 – 3 years
36 months
• TRUSTING THREES
• Tooth brushing with little supervision
• Unbutton buttons
• Draws a cross, learns how to share
• Knows full name and sex
• Speaks fluently, 200 – 900 words
• NIGHTIME BLADDER CONTROL achieved
• Rides tricycle
Preschoolers
• Cooperative play – playhouse
• Role playing is usual

• Fears:
o Castration/ Body Mutilation o Dark
places and witches o Thunder and
lightning o Ghost
• Curious, creative, imaginative and imitative
Preschooler’s Characteristic Traits

• Telling tall tales
• Imaginary friend  way of relieving tension and anxiety
• Sibling rivalry→ jealousy to a newly delivered baby
• Regression o Signs: bedwetting o Thumbsucking o Baby talk o Fetal position
• Masturbation o Sign of boredom o Divert attention o Offering toy
4 years old
• FURIOUS FOUR
• Noisy, aggressive and stormy
• Buttons button
• Copy square
• Catches ball, jumps, skips
• Alternates feet going downstairs
• CBQ LACES SHOES
• Vocabulary of 1500, knows the basic color
• Says song or poem from memory
5 years old
• FRUSTRATING FIVES
• Jumps over low obstacles
• Spreads with a knife
• Draws 6 part man, copy triangle
• Imaginary playmates
• 2100 words
• Identification with same sex
• Attachment to opposite sex
School – Aged
• Competitive Play: Tug of war
• Fears o School Phobia  orienting child to his new environment o
Displacement from school o Death
• Significant Person o Teacher o Peer of same sex
• Stoppage of height coincide with the eruption of wisdom tooth

• Prone to fracture: Common Green stick
• Mature vision o 20/200 legal blindness
• They’ll Cheat → can’t afford to lose
6 years old
• Temporary teeth begins to fall, permanent teeth begins to appear (1st: First Molar)
• Tooth brushing alone
• A year of continuous motion, clumsy moving
• 1st grade teacher becomes authority figure o nail biting → sign of strict teacher • Beginning interest with God
7 years old

• Age of assimilation
• Copies a diamond
• Enjoys teasing and playing alone
• Quieting down phase
8 years old
• Expansive age
• Smoother movements
• Normal homosexual
• Loves to collexct objects
• Counts backwards
9 years old
• Coordination improves
• Tells time correctly
• Hero worship
• Stealing and lying are common
• Takes care of body needs completely
• Teachers find their group difficult to handle
10 years old
• Age of special talents
• Write legibly
• Ready for competitive games
• More considerate and cooperative
• Joins organizations
• Well mannered with adults and critical with adults
11 – 12 years old
• Pre adolescent
• Full of energy and constantly active
• Secret languages are common
• Share secrets with friends
• Sense of humor is present
• Social and cooperative
School – Aged Characteristic Traits
• Industrious
• Modest
Signs of Sexual Maturity in Female

I ncrease in size of breast and genitalia – telarche – 1st sign W idening of hips
A ppearance of pubic axilliary and pubic hair - adrenarche M enarche – last sign
Signs of Sexual Maturity in Male

A ppearance of axilliary and pubic hair D eepening of
voice
D evelopment of muscle
I ncrease in size of penis and scrotum – 1st sign
P roduction of viable sperm – last sign
Adolescence
• Fear o Acne o Obesity o Homosexuality o Death
o Replacement from friends

• Peer of opposite sex  significant other

• Experiences conflicts between his needs for sexual satisfaction and societal expectations
• Core Concern o Change of body image o Acceptance of the opposite sex
• Nocturnal Emission: Wet dreams o Hallmark of adolescence
• CBQ distinctive odor due to stimulation of apocrine gland

• Testes and scrotum increases until age 17
• Sperm is viable by age 17
• Breast of female and genitalia increases until age 18
• Signs of sexual maturity
• Characteristic traits o Idealistic, rebellious, reformers o Parent child conflict o Very conscious with body image o
Peer pressure
• Problems o Vehicular accident o Smoking o Alcoholism o Drug Addiction o Pre Marital Sex
Concept of Death
6 years old  death is reversible
CBQ 7 – 9 years old  personification of death, permanent loss of the corporal life IMMEDIATE CARE OF THE NEWBORN
8 PRIORITIES OF THE NEWBORN IN THE FIRST DAYS OF LIFE

1. Initiation and maintenance of respiration
2. Establishment of extrauterine circulation
3. Control of body temperature
4. Intake of adequate nutrition
5. Establishment of waste elimination
6. Prevention of infection
7. Establishment of an infant – parent relationship
8. Developmental care that balance rest and stimulation for mental developmental
INITIATION & MAINTENANCE OF RESPIRATION
Alerts!
• Expulsion is @ 2nd stage of labor
• Most neonatal deaths w/in the first 24 hours is due to INABILITY TO INITIATE AIRWAY
• Lung function begins only after birth
How?
• Support head and remove secretion
• Proper suctioning with a catheter o Place baby’s head to side  facilitates drainage
o Suction the mouth first before nose  newborns are nose breathers o Period of 5 – 10 seconds,
should be gentle and quick
 Prolonged suctioning can cause hypoxia, laryngospasm and
bradycardia due to vagal nerve stimulation o Evaluate patency
 Cover 1 nostril, if newborn struggles, additional suctioning needed
• If not effective requires effective LARYNGOSCOPY to open airway. After deep suctioning, and ET tube can be
inserted and O2 administration by (+) Pressure Bag and mask with 100% O2 @ 40 – 60 bpm
Alerts in O2 Administration
• No Smoking  O2 is combustible
• Must be humidified  prevent drying of mucosa
• Cover the nose and mouth only
• Scarring Retina  results Retinopathy (O2 overdose)
• Meconium Stain  never administer O2 with pressure  causes atelactasis
ESTABLISHMENT OF EXTRAUTERINE CIRCULATION

Alerts!
• Circulation id initiated by LUNG EXPANSION and PULMONARY VENTILATION
• Completed by cutting the cord
• Assess characteristics of cry o Normal  strong, vigorous, lusty cry
o Hypoglycemia/ Increased ICP  high pitched, small cry
o Never stimulate crying before all secretion are remove to prevent aspiration
Feto – Placental Circulation

• Placenta → O2 carried by vein → liver → Inferior Vena Cava → Right atrium → 70% goes to Foramen Ovale
→Remaining 30 → tricuspid valve → right ventricle → pulmonary artery → lungs for nutrition → vasoconstriction of
lung tissue pushes the blood to DUCTOS VENOSUS → supply extremities → 2 arteries carry unO2 Blood back →
placenta
Ways to facilitate closure of Foramen Ovale

• Tangential Footslap o Cry → expands lung → ↑ pressure from left to right side of the heart
• Proper positioning of the Baby o Right side lying position → ↑ pressure on left side of heart facilitating closure
Best Position immediately after Birth

• CS → supine, crib – level position
• NSD
Structure Appropriate Time of Complete Closure Structure Remaining Failure to

Obliteration Close
Foramen Ovale 1 year W/in 24 hrs completed Fossa Ovalis Atrial

1 month Septal
Defect
Ductus 1 month W/in 24 hrs completed Ligamentum Arteriosum Patent

Arteriosus 1 month Ductus
Arteriosus
Ductus Venosus 2 2 – 3 months Ligamentum Venosum

Umbilical Arteries 2 – 3 month 2 – 3 months Lateral Umbilical Artery (Intrerior
Iliac Artery)
Umbilical Vein 2 – 3 months 2 –3 months Ligamentum Teres (Round

ligament of the
liver)
Signs of Increased ICP

• Abnormal large head
• Bulged & tensed fontanel
• Projectile Vomiting  surest sign of cerebral irritation
• Cushing Triad of ↑ ICP o ↑ BP o ↓ PR
o ↓ RR
• High pitched, shrill cry
• Dilopia  normal in newborns, sign of ↑ ICP in older children
CONTROL OF BODY TEMPERATURE/ TEMPERATURE REGULATION
Alerts!
• The goal of temperature regulation is to maintain Temperature not less than 97.7 F or 36.7 C
Factors leading to the development of Hypothermia

• Preterm are born POIKILOTHERMIC (easily adapt the temperature of environment due to immaturity of thermo
regulating center of the body HYPOTHALAMUS)
• Inadequate subcutaneous tissues
• Newborn are not yet capable of shivering
• Newborns are wet
Process of Heat Loss

• Evaporation → body to air
• Conduction → body to solid objects (cold compress)
• Convection → body to a cooler surrounding object (fever, aircon)
• Radiation → body to a cold subject not in contact with the body (thermal shift)
Effects of Hypothermia (COLD STRESS)

• ↑ RR → first sign of hypothermia
• Hypoglycemia → due to utilization of glucose o Normal  45 – 55 mg/ dl o Average/ borderline → 40 mg/ dl
• Metabolic Acidosis → due to the catabolism of BROWN FAT (vest-like, best insulators of newborns) leading to the
formation of ketone bodies
• High risk for KERNICTERUS (bilirubin in the brain)
• Additional fatigue added to already stressful heart
Prevention of Cold Stress

• Dry and wrap the newborn
• Mechanical measures ( radiant warmer, acrylic sided incubator)
• Prevent unecesarry exposure→ cover areas not being examined
• In case of no electricity o Cover baby with thin foil
o Skin to skin contact → human blanket/ kangaroo care
ESTABLISHING ADEQUATE NUTRITION
Breastfeeding
Best time
• NSD – ASAP
• CS – after 4 hours
Physiology of Breastmilk Production

↓ Estrogen, ↑ Progesterone → releases PROLACTIN → acts on ACINAR/ ALVEOLI CELLS
→ produces FOREMILK → store in LACTIFEROUS TUBULES/ COLLECTING TUBULES
Sucking → stimulates posterior pituitary gland → release oxytocin → causes Contraction of smooth muscles of Lactiferous
Tubules → milk ejection reflex → let down reflex
Advantages of Breastfeeding
• Economical
• Promotes bonding
• Contains LACTOBACILLUS BIFIDUS → interfere the attack of pathogenic bacteria in the GIT
• Helps in early involution of uterus → oxytocin causes contraction
• Always available
• ↓ Incidence of breast cancer
• Breastfed babies have higher IQ than bottle fed ones
• Antibody → IgA
• Macrophages
Disadvantages of Breastfeeding
• No iron
• Possibility of transfer of Hepa B, HIV, CMV (13 – 39% possibility)

• Father can’t bond with the mother and baby → instead, father can sing, cuddle, kiss, put baby to sleep
Alerts!
• Freezer → good for 6 mos./ don’t reheat
• Should be stored in a sterile plastic container
• Pre – Colostrums → 6 weeks
• Colostrums → 3
Stages of Breastmilk
• COLOSTRUM
o Present 2 – 4 days o
Contents  ↓ fats
 ↓ CHO
 ↑ Immunoglobulin
 ↑ protein
 ↑ fat soluble vitamin
 ↑ minerals
• TRANSITIONAL MILK
o Present 4 – 14 days o
Contents  ↑ Lactose
 ↑ minerals
 ↑ water soluble vitamins o Lactose Intolerance → deficiency in enzyme
 Lactase → responsible for digestion of Lactose →sour milk/ smelling of stool
• MATURE MILK
o Present 14 days and above
o Contents
 Linoleic Acid → responsible for the development of brain and integrity of skin
 ↑ CHO (Lactose)
 Protein (lactabulmin)
COWS MILK
• ↑ fats – almost similar to mature milk
• Causes constipation
• Content o ↑ fats o ↓ CHO → add sugar o ↑ CHON → casein → hard to digest
o ↑ Minerals (has traumatic effect to kidneys of babies)
o ↑ PHOSPHORUS ( causes inversely proportional effect of Calcium
• ↑ water to prevent kidney stones
Health Teachings
1. Proper Hygiene
• Hand washing, clean areola with cotton and water or NSS
• Cleanse the area with CAKE COLOSTRUM
2. Position while Breastfeeding
• Upright Sitting (best position)
3. Stimulate and Evaluate Feeding Reflexes
• Rooting Reflexes
o Stimulate by touching the side of the cheek or side of flip then the baby will turn to the stimulus
oo Purpose: to look for food Disappear by 6th weeks
• Sucking Reflexes
o Stimulate the middle part of the lips and the baby will suck o Disappear by 6 months

• Swallowing Reflexes o When the food touches the posterior part of the tongue, the baby will
automatically swallow
o Never disappears
• Extrusion Reflexes o When food touches anterior part of tounge, it will extrude/ protrude o
Purpose: prevent poisoning o Disappears @ 4 moths
4. Criteria for effective sucking
• Baby’s mouth is hiked well – up @ areola
• Mother experiences after pain → sign of releasing oxytocin thereby contracting uterus
• The other nipple is also flowing with milk
5. To prevent from crack nipples and initiate proper production of oxytocin
• Begin initially for 2 – 3 mins/ breast
• ↑ the time 1 min/ breast/ day until it reaches 10 minutes/ breast/ feeding or 20 min/ feeding
6. For proper emptying and continuous milk production per feeding
• Feed the baby at the last breast that you fed him/ her
Problems experience in Breastfeeding

• ENGORGEMENT
o Feeling of fullness and tension in the breast (3rd Day)
o Breastfeeding mother → apply warm compress
o Bottle – Feeding → apply cold compress, wear supportive bra
• SORE NIPPLE/ CRACK NIPPLE

o Crack, red, painful nipple o Causes
 Breastfeeding @ one side only
 Unhealthy sexual practices o Management
 Breastfed using the unaffected side
 Manually express milk @ affected side
 Antibiotic (continue breastfeeding)
• MASTITIS
o Inflammation of breast
o Causative Agent: STAPHYLOCOCCUS AUREUS o Management
 Avoid wearing lined/ wired bra o 4 weeks –
Breast Involution
Contraindications for Breastfeeding

• Maternal Conditions o HIV o Hepa B o CMV
o Coumadin/ Warfarin taking moms → give heparin instead
• Newborn Conditions o Erythroblastocis Fetalis o Inborn errors of metabolism
 Hydrofetalis
 Phenylketonuria
 Galactosemia
 Tay- Sach’s Diseas
ESTABLISHMENT OF WASTE ELIMINATION
GIT Obstructions
• Hirshsprung Disease
• Imperforate Anus
• Meconium Ileus (common with Cystic Fibrosis)
Different Stools
• MECONIUM/ PHYSIOLOGIC STOOL

o Blackish green o Odorless (sterile intestine) o

Normally passed within 24 hours o Tar like o
Sticky
• TRANSITIONAL STOOL
o Present 4 – 14 days o Green o Loose
o Slimy that may appear like diarrhea to the untrained eyes
• BREASTFED STOOL
o Golden yellow
o Occur almost nearly after feeding o With sour milk smell o Mushy o Soft
• BOTTLEFED STOOL
o Pale yellow o Hard → due to casein o Formed
o Typically offensive odor
o Seldom passed 2 – 3 days
INDICATION OF STOOL CHANGES
Light Stool With jaundice
Bright Green Under phototherapy
Mucus –mixed Milk Allergy
Clay Colored Bile Duct Obstruction
Black GIT Hemorrhage
Blood – Flecked Anal Fissure
Curant Jelly Intussuception
Fatty, bulky, foul smelling/ Suspect malabsorption syndrome/
Steatorrhea Cystic Fibrosis/
Celiac Disease
Ribbon – like Hirshsprung disease
ASSESSMENT OF WELL BEING
Apgar Scoring
• Virginia Apgar
Special Consideration
• 1st 1 minute → determines general coneral condition of the baby
• Next 5 Minute → determines the capability of the baby to adjust extrauterinely (most important)
• Next 15 minutes → optional → depndent on the 5 minutes apgar score
Components
A ppearance Color upon birth is slightly cyanotic After first cry baby
will be pink
P ulse Rate Take apical pulse at the lower left nipple

G rimace Determines reflex irritability using tangential foot slap and catheter insertion
A ctivity To determine the degree of muscle tone

R espiration
Newborns will cry within 30 seconds upon expulsion

ASPHYXIA NEONATORUM → failure to cry within 30 seconds because mother received
Demerol
NARCAN → antidote of Demerol

APGAR SCORING
Score
Criteria 0 1 2
Heart Rate Absent < 100 > 100
Respiratory Effort Absent Slow RR/ Weak Good strong cry
Muscle Tone Flaccid Extremities Some reflexes Well Flexed
Reflex Irritability
Catheter No Response No Grimace Grimace Cough or sneeze
Tangential FS Response Cry
Color Blue / Pale Acrocyanosis Pink
• High score means healthy baby
Interpretation
0-3
• Severely depressed
• Needs CPR
• Admission at NICU
4-6
• Moderate depression
• Additional suctioning
7 – 10
• Good and healthy
CARDIOPULMONARY RESUSCITATION
• CPCR → cardiopulmonary and cerebral resuscitation
• 5 minutes of 02 deprivation will cause irreversible brain damage
• Priority: Airway, Breathing, Circulation
AIRWAY
• Clear the airway
• Shake the baby
• If no response, call help
• Immediately do 1 minute CPR before calling for help
• Flat on bed, put a board if the bed is soft
• Head tilt – chin lift maneuver
• No head tilt for suspect of cervical damage
• Overextension may cause occlusion
BREATHING
• Ventilating the lungs
• Check breathlessness
• If breathless → give 2 breaths
• If newborn → mouth and nose
• If child → mouth and pinch the nose
• Force → puff only
• Use one way mask to prevent contact with the secretion
CIRCULATION
• By cardiac compression
• Check if pulseless
• Use brachial pulse → children

• No breath + No pulse → CPR

• Infant → 1 finger breadth below nipple line, 2 finger
• 1 year old → heal of the palm
CPR RATIO
Adult → 2:15
Infant → 1:5
REPIRATORY EVALUATION (SILVERMAN – ANDERSON INDEX)
Score
Criteria 0 1 2
Chest movement Synchronized Long on inspiration See-saw
Intercoastal retraction No retraction Just visible Marked
Xiphoid Retraction No retraction Just visible Marked
Nares dilatation No dilatation Minimal Marked
Expiratory Grunt None Heard by stet only Heard by ear
Low score means Good condition of the baby

Interpretation
0 – 3 → normal, no RDS
4 – 6 → with moderate RDS
7 – 10 → with severe RDS
ASSESSMENT OF GESTATIONAL AGE (Ballard and Dubowitz)

Score
Criteria Less 36 weeks 37 – 38 Weeks 39 weeks and up

Sole creases Anterior transverse only Occasional 2/3 Sole cover with crease
Breast nodule (dm) 2 mm 4 mm (3 – 5 cm) 7 mm (>5cm)

Scalp Hair Fine and fuzzy Fine and fuzzy Course and silky
Ear Lobe Pliable Some Thick
Testes and Scrotom In lower canal, covered Some intermediate Testes pendulous,
testes with scrotum full, extensive
rugae rugae
PRETERM BABIES
• babies delivered after 20 weeks and before 37 weeks
• sign of preterm – less 36 weeks according to Ballatrd and Dubowitz • plus frog legs or lax position
• Hypotonic – prone to repiratory infection
• There is a Scarf Sign → elbow passes midline
• Square window – wrist 90 deg. Angle
• Heal to ear sign
• Anterior traverse crease
• Abundant lanugo
• Prominent labia minora and clitoris
POST TERM BABIES

• Delivered after 42 weeks
• Old mans face – classic sign
• Desquamation – pealing of skin
• Long and brittle fingernails

• Wide and alert eyes
NEONATES IN THE NURSERY
Nursing Responsibilities upon Receiving the Baby

1. Proper identification o Foot print of the baby and the thumb mark of
the mother
2. Take anthropometrics measurement o Length
 19. 5 – 21 inches Ave: 20 inches  47.5 – 53
cm Ave: 50 cm.
o Head Circumference
 13 – 14 inches
 33 – 35 cm Ave: 34 cm
o Chest Circumference
 12 – 13 inches
 31 – 33 cm Ave: 32 cm
o Abdominal Circumference
 12 – 13 inches
 31 – 33 inches Ave: 32 cm
3. Bathing the baby o Give oil Bath
 To cleanse the baby and spread the vernix caseosa
 2 functions of vernix caseosa
• insulator
• bacteriostatic
o Full bath is given when cord falls off
o Babies of HIV + mothers will be given a full bath immediately after the birth to lessen the transmission of
HIV
4. Dressing the Umbilical Cord o Strict asepsis to prevent tetanus
neonatorum that is why mothers are given tetanus toxoid while
pregnant
 CHN – 3 Cleans
• Hand
• Surface
• Cord
o Betadine (Povidone Iodine)
 Check 3 vessels (AVA)
 If only 2 vessels is seen suspect that the baby has a kidney malformation
 1 inch above the base of the cord when cutting
 But if IV infusion or blood transfusion is going to be given to the newborn, leave at least 8 inches
of the umbilical cord
 Umbilical cord is the best site for IV and blood transfusion because it has no nerve and no pain
 OMPHALAGIA → bleeding of the cord for more than 30 cc, suspect hemophilia
 The umbilical cord turns black by the 3rd day and falls of 7 – 10th day
 UMBILICAL GRANULATION → failure of the cord to fall after 2 weeks without foul odor, bring
the baby to the hospital and will be given Silver Nitrate or will be cauterized
 Clean the umbilical cord with saline or 70% alcohol
 It should be dry
 PATENT URACHUS → itf the cord is always moist, suspect a fistula between the bladder and
the umbilicus, do NITRAZINE PAPER TEST
(+ for urine if it turns yellow)
5. Crede’s Prophylaxis o Purpose: to prevent opthalmia neonatorum or gonnorheal conjeunctivitis o If mother has
an untreated gonorrhea and passed the baby vaginally o ERYTHROMYCIN OPTHALMIC OINTMENT → drug of
choice, inner to outer canthus

o Before 1989 – 2 drops of 2% silver nitrate at lower conujunctival sac o It should be washed
immediately after 1 minute to prevent burning
6. Administration of Vitamin K o Purpose: to prevent hemorrhage related o physiologic hypoprothrobinemia o
Other name
 Aquamephyton, Phytomenadone, Konakion
 0.5 – 10.5 mg IM @ vastus lateralis or lateral anterior thigh o Preterm → give
0.5 mg
oo Vit. K is synthesized at the intestineth day, there is ↑ prothrombin

On the 7
7. Weight Taking o Normal Weight
 3000 – 3400 gm
 3 – 3.4 kg
 6.5 – 7.5 lbs o Arbitrary Lowe Limit → 2,500 grams o Low Birth Weight
 < 2,500 g
 it is not the same for gestational age
o Small for Gestational Age  Less than the 10th % rank
o Large for Gestational Age

 > 90% rank
 Macrosomia – baby delivered 4,000 g or 4 kilos
 Diabetic mother o Appropriate for Gestational Age o Physiologic Weight Loss  5 – 10%
physiologic weight loss 10th days after birth
PHYSICAL EXAMINATION AND DEVIATION FROM THE NORMAL
Important Consideration
• If the client is a newborn, cover areas that is not being examined (prevent hypothermia)
• If the client is an infant, he first vital sign to take is the RR because of fear of stranger will change the normal
respiration. Begin from at least intrusive to the most intrusive procedure.
• If the client is a toddler and preschooler, le them handle the instruments like stethoscope or play syringe. If the
client has security blanket (like stuffed toy) give it to them to lessen anxiety
• If the client is a school age and adolescent, explain the procedure and respect their modesty
Components
• Temperature
o Temperature of the newborn is taken rectally
o Rectal temperature taking is done only once to rule out imperforated anus o Insert thermometer 1
inch inside the anus
o Types of Imperforated Anus

 No Anal Openning
• AtreticAgenetice o These two is the most dangerous because there is
failure to pass meconium after 24 hours
o There is abdominal distention o Foul odor breath
o Vomitus of fecal material which might result in aspiration and casue
respiratory problems
o Management: Surgery with temporary colostomy
 With anal openning
• Stenos
• Membranous

• Cardiac Rate o Newborn → 120 – 160 bpm irregular o Radial pulse of a

newborn is normally absent o If radial pulse is prominent suspect that there is a
PDA
o Femoral pulse is normally palpable, if absent suspect Coarctation of Aorta
CONGENITAL HEART DISEASE

• Common in Boys
o Transposition of the great artery (TOGA) o Truncus
Arteriosus o Tetralogy of Fallot
• Common in Girls o Patent Ductus Arteriosus

o Atrio Septal Defect
• Causes
oo Familial tendency Exposure to rubella/ German measles – 1st month o
Failure of the Heart Structure to progress
Two Major Types

• Acyanotic Heart Defects  shunting from left to right
• Cyanotic Heart Defects  from right to left
Acyanotic Heart Defects with Increase Pulmonary Blood Flow
1. Vetricular Septal Defect

• Opening Between 2 ventricles
• Signs and symptoms
o Systolic murmur at lower border of the sternum and no other significant sign
o Cardiac catheterization reveals increase oxygen saturation at the right side of the heart
o ECG reveals hypertrophy of the right side of the heart o Only 50% of the oxygenated blood
will go to the aorta
• Management
o Open heart surgery
o Placing the client on a long tern antibiotic therapy to prevent the development of sub-acute
bacterial endocarditis
o Protect site of catheterization (right femoral vein) o Avoid flexion of joints
2. Atrial Septal Defect

• Failure of the foramen ovale to close
o Systolic murmur at the upper border of the sternum with no significant sign
o Cardiac catheterization reveals increase oxygen saturation at the right side of the heart
o 50% of the blood goes to the right atrium
• Management
o Open heart surgery
o Placing the client on a long tern antibiotic therapy to prevent the development of sub-acute
bacterial endocarditis
3. Endocardial Cushion Defect

• AV canal affecting both the tricuspid and the mitral valve
o Only confirmed by cardiaccatheterization o Valves are closed

4. Patent Ductus Arteriosus

• Failure of the Ductus Arteriosus to close

o Prominent radial pulse o Continuous machinery like murmur o

ECG reveals hypertrophy of the left ventricle
• Management
o Indomethacine – prostaglandin inhibitor that facilitate closure of
PDA
o Ligation of PDA by 2 – 4 years old
Acyanotic Heart Defects with Decrease Pulmonary Blood Flow
1. Pulmonary Stenosis
• Narrowing of valve of pulmonary artery
o Typical systolic ejection murmur o S2 sound is
widely split
o ECG reveals right ventricular hypertrophy o
Only 50% of the blood goes to the lungs
• Management o Balloon Stenotomy
2. Aortic Stenosis
• Narrowing of valve of aorta
o Typical systolic ejection murmur o Murmur
o ECG reveals right ventricular hypertrophy o Only
50% of the blood goes to the body o Angina like symptoms
may be present when active
• Management
o Balloon stenotomy
3. Duplication of Aortic Arch

• Doubling of arch of the aorta causing compression to the trachea and esophagus
• Signs and symptoms o Dysphagia – due to esophageal compression o Dyspnea – due to tracheal
compression o Left ventricular hypertrophy o Only 50% of the blood goes to the body
• Management
o Close heart surgery
4. Coarctation of Aorta
• Narrowing of ach of aorta
• Outstanding signs o Absent femoral pulse
o BP is higher on the upper extremities and ↓ on the lower extremities
o Epistaxis
Lesser blood goes to the lower extremities
• Management
o Take BP on 4 extremities o Close hear
surgery
Cyanotic Heart Defects with Increase Pulmonary Blood Flow
1. Transposition of Great Arteries

• Aorta is arising from the right ventricle while the pulmonary artery is arising from the left
o

o Cyanosis after 1st cry

o Polycythemia because of increase production of RBC, a compensatory mechanism to the ↓
oxygen supply to the body, the blood become viscous
o Polycythemia will lead to:
 Thrombuis
 Embolus
 Stroke (CVA) o ECG reveals Cardiomegaly
• Management
o Palliative repair – Rash Kind repair o Complete repair
– Mustard repair
2. Total Anomalous Pulmonary Venous Return

• Situation wherein pulmonary vein instead of entering the left atrium enters the right atrium or superior
vena cava
• Signs and symptoms o Open foramen ovale o Mild – moderate cyanosis o Absent spleen
• Management
o Restructuring of the heart
3. Truncus Arteriosus
• Situation in which pulmonary artery and aorta is arising in one common trunk or a single vessel with
ventricular septal defect
 Thrombuis
 Embolus
 Stroke (CVA)
• Management
o Restructuring the heart
4. Hypoplastic Left Heart Syndrome

• Non functioning left ventricle
 Thrombuis
 Embolus
 Stroke (CVA)
• Management
o Heart transplant
Cyanotic Heart Defects with Decrease Pulmonary Blood Flow
1. Tricuspid Atresia
• Failure of the tricuspid valve to open
• Signs and symptoms o Open foramen ovale o Cyanosis


 Thrombuis
 Embolus

Stroke (CVA)
• Management o Fontan Proledum
2. Tetralogy of Fallot
• 4 Anomalies Present (PVOR) o Pulmonary Stenosis o Ventricular Septal
Defect o Overriding of Aorta o Right Ventricular Hypertrophy
• Signs and symptoms o High degree of Cyanosis  outstanding Sign o

Polycythemia because of increase production of RBC, a compensatory
mechanism to the ↓ oxygen supply to the body, the blood become viscous
 Thrombuis
 Embolus
 Stroke (CVA) o Severe dyspnea  relieved by squatting position because it will
prevent venous return and facilitate maximum lung expansion
 Knee chest position in infants There is growth retardation
o TET Spells – blue spells or short episode of hypoxia
o Syncope – faintaing o Mental retardation
o Clubbing in fingernails because of tissue hypoxia – late and last sign
o X – ray reveal a boot shape heart
• Management o Oxygen therapy
o Morphine sulfate – for hypoxic episode o Propanolol (inderal) – decrease heart
spasm o Palliative repair – BLT or Blalock Taussig Shunt Procedure o Complete
repair – Brock Procedure
ACQUIRED HEART DISEASE
Rheumatic Heart Disease

• Inflammatory disease following an infection caused by Group A Beta Hemoilytic Streptococcus
• Affected body parts o Musculoskeletal o Cardiac muscle
o Integumentary system o CNS
• Tonsillitis due to love of sweets with no oral hygiene serving a good medium for bacterial growth causing
inflammation
• Group A Beta Hemolytic Streptococcus will release toxin and enters circulation
• Group A Beta Hemolytic Streptococcus is an anaerobic organism and will stay at the left side of the heart or the
mitral valve as an ASCHOFF BODIES
• ASCHOFF BODIES – round nodules with multi nucleated cell and fibroblast that stays in the miral valve
• Left sided heart failure because of mitral stenosis due to increase in the size of Aschoff Bodies
• Diagnostic Exam: JONE’S CRITERIA
Major Minor
Polyarthritis – multi joint pain Low grade fever
Athralgia – joint pain Diagnostic Exams
CHOREA/ Sydenhamm’s Chorea/ • Antibody
St. Vitous Dance – involuntary, purposeless
movement of the hand and shoulder
• C reactive protein
accompanied by grimacing • ESR
• Anti Streptolysin Titer
Carditis – signs of tachycardia

o

Erythema Marginatum – macular rashes
Subcutaneous nodules
Presence of 2 major or 1 major and 2 minor plus a history of sore throat will confirm diagnosis
• Management o Bed rest

o Avoid contact sports o Throat swab for C & S
o Antibiotics – purpose is to prevent recurrence
o Aspirin Therapy or salicylates – act as an anti-inflammatory agent in RHD o Side effect: Reye’s
Syndrome  encephalopathy accompanied by fatty infiltration of the organs such as the heart and liver
RESPIRATION
• Normal Values = 30 – 60 bpm irregular
• Either abdominal or diaphragmatic breathing with short period of apnea without cyanosis
• Normal apnea in newborn is 15 seconds or less
Age Rate
Newborn 40 – 90
1 year old 20 – 40
2 – 3 years old 20 – 30
5 years old 20 – 25
10 years old 18 – 22
15 and above 12 – 20
Breath Sounds Heard on Auscultation
Vesicular Normal • Soft, low pitched, heard over periphery of lungs, aspiration is longer than expiration
Bronshovesicular • Soft, medium pitched heard over major bronchi, inspiration equals expiration
Normal
Bronchial Normal • Loud, high pitched, heard over the trachea, expiration is longer than inspiration
Ronchi Normal • Snoring sound made by air moving through mucus in bronchi
Rales • Crackles (like Celophane) made by air moving through fluid in alveoli
Abnormal
• Denotes pneumonia, fluid in the lungs or pulmonary edema
Wheezing Abnormal • Whistling on expiration made by air being pushed through narrowed bronchi
• Denotes children with asthma or foreign body airway obstruction
Stridor • Crowing or roster like sound made by air being pulled through a constricted larynx
• Indicative of Respiratory Obstruction
Resonace • Loud, low tone, percussion sound over normal lung tissue
Hyper • Louder, lower sound than resonance, percussion sound over hyperinflated lung tissue
Resonance
1. RESPIRATORY DISTRESS SYNDROME

• Lack of surfactant within 24 hours of life
• Aka Hyalin Membrane Disease

• Common in preterm babies

• The alveoli cannot expand properly • Signs and symptoms
Present within 4 hours of life
oo Using the Silverman Anderson Scoring to determine RDS ↑ RR with retraction (1st sign of
RDS)
o Expiratory Grunting (major sign)

o Xiphoid retraction
o Flaring nasal flares o Cyanosis
o Respiratory acidosis
• Management o Head elevated o Proper suctioning o O2
administration with ↑ humidity o Client placed on
 CPAP Continuous Positive Airway Pressure
 PEEP Positive End Expiratory Pressure
 Purpose id to maintain the alveoli partially open and prevent
alveolar collapse o Monitor for acidosis
o Surfactant replacement
2. LARYNGOTRACHEO BRONCHITIS (LTB)

• Most common form of croup
• Viral infection of the larynx, trachea and bronchi
• Signs and symptoms o BARKING or CROUPY COUGH  outstanding sign o Inspiratory Stridor o
Respiratory acidosis o Cyanosis o Death
• Diagnostic Exams
o Throat swab for c & s o ABG
o Chest and x-ray to ruyle out epiglotitis
• Management o Racemic Epinephrine – bronchodilator
o Humidified Oxygen
3. BRONCHIOLITIS
• Inflammation of the bronchioles characterized by production of tenacious mucus
• FLU – LIKE SYMPTOMS – outstanding sign • ↑ RR
• Causative Agent: Respiratory Syncitial Virus
• Drug: Antiviral – Ribavirin
LTB and Bronchiolitis ends with Epiglotitis
4. EPIGLOTITIS
• Inflammation of the epiglotitis
• Sudden onset
• The child always assume the tripod position

• Less than 18 months cannot cough – must be placed on mist tent or “Croup tie” – make sure that the edges are
tucked in o Provide washable plastic toys or materials o Avoid toys that crate friction o Avoid toys that are hairy
or furry
Blood Pressure
• Newborn – 80 – 46 mmHg
• After 10 days – 100/ 50 mmHg
• BP taking begins by 3 years old
SKIN
• If cyanotic after the first cry suspect Transposition of the Great Arteries
1. Acrocyanosis → body is pink, extremities are blue

2. Generalized Mottling due to the immaturity of the circulatory system
3. Birthmarks
a. Mongolian Spots
• Slate grya or bluish discoloration/ patches commonly seen across the sacrum or buttock
• Related to ↑ melanocyte which is common in Asian newborn
• Usually disappear by 1 – 5 years old (preschool)
b. Milia
• Plugged or unopened sebaceous glands usually seen as a white pinpoint patches at the nose,
chin and cheeks and will disappear by 2
– 4 weeks
c. Lanugu
• Fine downy hair which is common in preterm
d. Desquamation
• Peeling of the newborn’s skin within 24 hours characterized by extreme dryness that begin in the
sole and palm, common in post term babies
e. Stork Bites (Talengeiclasis Nevi)
• Pink patches at the nape, never disappears
f. Erythema Toxicum (Flea Bite Rash)
• First self limiting rash to appear sporadically and unpredictably as to time and place
g. Harlequin Sign
• Dependent part is pink, independent part is blue because of the immaturity of circulation, the RBC
settles down
h. Cutis Memorata
• Transitory motlling of the neonates skin when exposed to cold
i. Hemangiomas
• Vascular tumors of the skin
• Types:
o Nevus Flammeus/ Port Wine Stain
 Macular purple or dark red lesions usually seen on the face or thigh,
disappears and be removed surgically o Nevus Vasculosus/ Strawberry
Hemangioma
 Dilated capillary in the entire dermal or subdermal area continuing to
enlarge but disappear after 10 years old
o Cavenous Hemangiomas
 Consist of communicating network of venules in the subcutaneous
tissue that never disappear with age
j. Vernix Caseosa
• White cream cheese – like substance that serves as skin lubricant
SKIN COLOR AND THEIR SIGNIFICANCE

1. Blue  cyanosis , hypoxia
2. White  edema
3. Gray  infection

4. Yellow  jaundice or carotinemia

5. Pale  anemia
Burn Trauma
• Injury to body tissues caused by excessive heat
Characteristic
1st Degree Involves only the superficial epidermis characterized by erethema, dryness and pain
Partial Thickness Ex: Sunburn – heals by regeneration in 1 – 10 weeks
2nd Degree Involves the entire epidermis, and portion of the dermis, characterized by erythema,
Partial Thickness blistered and moist from exudates which is extremely painful Ex: Scalds
3rd Degree Involves skin layers, epidermis and dermis, may involve adipose tissue, fascia, muscle and
Full Thickness bone. It appears to be leathery, white or black, not sensitive to pain since nerve ending had
been destroyed Ex: Lava Burn
Management:
• First Aid o Put out the flames by rolling the child on a blanket o Immerse the burned part on cold water o Removed
burned clothing (sterile material) o Cover burned part with sterile dressing
• Maintainance of patent airway o Suction PRN
o O2 administration with ↑ humidity o
Endotracheal Intubation o Tracheostomy
• Prevention of shock and flued and electrolyte imbalances o Colloids to expand blood volume o Isotonic saline to
replace electrolyte
o Dextrose in water to provide calories
• Booster dose of Tetanus Toxoid

• Relief pain such as IV analgesic (morphine sulfate) • Prevention of wound infection o Cleaning and debriding the
wound o Open or close method of wound care o Whirl pool therapy
• Skin grafting o 3rd degree burn o get skin from buttocks or pig skin (xenograft) or from frozen cadaver
• Diet  ↑ CHON and calories
Atopic Dermatitis
• Skin disease characterized by papulo-vesicular eruthematous lesions with weeping and crusting • Usually caused by
food allergen o Milk o Eggs o Citrus Juice o Tomatoes o Wheat
o Extremely pruritus – outstanding sign o Linear excoriation o Crusty o
Lichenification  dry and shinny, scaly white skin
• Management
o Avoid allergens
o Prosobes/ Isomil – hypoallergenic milk
o Prevent infection by proper handwashing, cut the fingernails o Hydrate with a burrows solution
o Topical steroid – 1% hydrocortisone cream
Impetigo
• Skin disease caused by Group A Beta Hemolytic Sreptococcuscharacterized by papulovesicular lesions surrounded
by localized erythema becoming purulent and ooze forming honey colored crust
• Before the development, the baby should always been exposed to Pediculosis Capitis (kuto)
• Management o Proper handwashing o Treated with antibiotic • Complication: AGN

Acne
• Self limiting inflammatory disease involving sebaceous gland, common in adolescents
• Comadones – composed o sebum that is mainly causing white heads • Sebum – composed of lipids
• Management
o Proper handwashing wild mild soap (sulfur soap) and water, leave for 5 – 10 minutes or use tretenoin or Retin
A – anti acne
Anemia/ Pallor
• Caused by o Early cutting of the cord
o Bleeding disorders/ blood dyscarias
BLEEDING DISORDERS/ BLOOD DYSCARIAS
Hemophilia
• Sex – linked (X) Recessive disorders
• The mother is the carrier
• The son is affected
• The father transmits to daughter
• Deficiency in clotting factor o Hemophilia A  factor 8  classic hemophilia o Hemophilia B  Factor 9 
Christmas disease o Hemophilia C  Factor 11
• OMPHALAGIA  earliest sign o >300 cc loss of blood during cutting of the cord
• the maternal clotting factor is present in the new born that is why there is a delayed diagnosis of hemophilia
• in toddlers  sudden bruising
• HEMARTHROSIS  major sign repeated bleeding, bleeding of the synovial membrane
• Diagnostic exam: PTT
• Nursing Diagnosis: High Risk for Injury
• Goal: Prevention of injury • Health Teaching o Avoid contact sports
o Determine the case before doing any invasive procedure
 In immunization  change the needle into a smaller one
o In case of fracture/ injury
 Immobilize and elevate
o Cold compress o Gentle pressure
o Blood transfusion of cryoprecipitate
Leukemia
• Group of malignant disease characterized by rapid proliferation of immature RBC
• Ratio is 500 RBC : 1 WBC
• The client is immunocompromised
• Classification of Leukemia o Lympho – affects the lymphatic system o Myelo – affects the bone marrow o Acute/
Blastic – affects the immature cells o Chronic/ cystic – affects the mature cells
Acute Lymphocytic Leukemia

• Most common in children
• Increase immature WBC
• Signs and Symptoms
a. Infection
i. Fever
ii. Poor wound healing
b. Bone weakness and causes fractures
c. Signs of bleeding

i. Blood in the urine

ii. Emesis
iii. Petechiae
iv. Epistaxis
d. Signs of anemia
i.Pallor
ii. Body malaise
iii. constipation
e. Invasion of the organs
i. Hepatomegaly  abdominal pain
ii. Spleenomegaly
2. Diagnostic examinations
a. Peripheral Blood Smear  reveals immature WBC
b. CBC  reveals anemia and thrombocytopenia; neutropenia
c. Lumbar Puncture
i. To determine CNS involvement
ii. Fetal position without flexion of the neck because it will cause airway obstruction
iii. C position or shrimp position
d. Bone Marrow Aspiration
i. Determines the presence of blast cells
ii. Site of bone marrow aspiration  iliac Crest  post op : prevent hemorrhage
iii. Lie on affected site
e. Bone Scan  determines the degree of bone involvement
f. CT Scan  determine the degree of organ involvement
3. Management Triad
a. Surgery
b. Irradiation
c. Chemotherapy
d. Bone marrow transplant
4. 4 Levels of Chemotherapy
a. Induction
i. To achieve remission
ii. Drugs
 IV – Vincristine
 L – Asparagine  Oral Prednisone
b. Sanctuary
i. To treat the leukemic cells that has invaded the testes and CNS
ii. Drugs
 intrathecal methotrexate – via spine
 cytocine
 arabinase  steroids
 irradiation
c. Maintainance
i. To continue remission
ii. Drugs
 oral methotrexate
 oral 6-mecaptopurine
 cytarabine
d. Reinduction
i. Give anti-gout agent To
ii. To treat leukemic cells after relapse occurse
iii.Treat hyperurecemic neuropathy
 Alopurinol or zylo[rene
5. Nursing Management

a. Assess for common side effects of chemotherapy – nausea and vomiting

b. Assess for stomatitis ulceration and abcess of oral mucosa
i. Oral care
ii. Alcohol free mouthwash
iii. Cotton piedgets
c. Diet – give food acoording to child’s preference
d. Alopecia – temporary side effect of chemotherapy
HEMOLYTIC DISORDERS
Rh Incompatibility
• Rh = monkey  foreign body
• Mother (-) – no antigen; no protein factor
• Fetus (+), Father (+) – has antigen and protein factor
• 4th baby is severely affected
• Erythroblastocis Fetalis o hemolysis/ destruction of RBC leading to ↓ O2 carrying capacity leading to IUGR with
pathologic jaundice w/in 24 hours
• ALERT! Baby is small and yellowish • Management o RHOGAM
 Vaccine given to Rh(-) mothers within the first 24 hours or within 72 hours  Given once
 If pregnancy was aborted and the mother udergo D & C, RHOGAM must be given w/in 24 hours, if not
given within 24 hours, mother will produce antibody
 Action: destroys RBC preventing antibody formation
• Diagnostic Test  Coomb’s Test
ABO Incompatibility
• Mother – Type O; Fetus – Type A  most common
• Mother – Type O; Fetus – Type B  most severe
• Hydrops Fetalis
o Common in abo incompatibility
o Newborn is edematous, on lethal state, accompanied by pathologic jaundice w/in 24 hours
• Difference from Rh Incompatibility o First pregnancy is affected o NB is yellow and edematous
• Management
o Initiation of breastfeeding, then temporary suspension of breastfeeding after 4 days ( breastfeeding realeses
prenanediole causing kernicterus)
o Pregnanediole  delays actions of Glucoonyl transferase ( liver enzyme that converts indirect bilirubin into
direct bilirubin)
 Indirect bilirubin
 Fat soluble
 Can’t be excreted by kidneys
 Causes hyperbilirubenemia causing jaundice
 Direct Bilirubin
 Water soluble
 Can be excreted by the kidneys
o Use phototherapy
o Exchange transfusion for Rh and ABO affectations that tend to casue a continuous decrease in hemoglobin
during the first 6 months because the bone marrow fails to produce erythrocytes in reponse to the
continuous hemolysis
Hyperbilirubenemia
• More than 12mg of indirect bilirubin among full terms
• Normal Indirect Bilirubin Level: 0 – 3 mg/dl
Kernicterus/ Bilirubin Encephalopathy

• Irreversible brain damage

• > 20 mg/dl of indirect bilirubin among full terms
• > 12 mg/ dl of indirect bilirubin among preterm because of immaturity
Physiologic Jaundice Pathologic Jaundice Breastfeeding Jaundice

Normal Within 24 hours Within 6th – 7th day Due to
Within 48 – 72 hours Mx: Yellow upon birth glucoronyl transferase
Expose to early morning sunlight
Possible Rh/ ABO incompatibility
Assessment of Jaundice
• blanching of forehead, nose and sternum
• yellow skin, sclera
• light stool
• dark urine
Management
• Phototherapy/ Photooxygenation o Nursing Responsibilities
 Cover the eyes – prevents retinal damage
 Height of light from baby – 18 – 20 inches  Increase Fluid intake
 Cover genetalia – prevent priapism ( painful continuous erection
 Change position
 Avoid lotion and oils
 Monitor I&O – best way is to weigh the baby
 Monitor VS
Bronze Baby Syndrome

• Transient bronze discoloration of the skin
• Minor side effect of phototherapy
HEAD
• ¼ of its legth • Structures o sutures o fontanels
 anterior/ bregma – 3 x 4 – 12 – 18 mos
 posterior/ lambda - 1 x 1 – 2 – 3 mos
• Noticeable structures of the Head o Craniotabes
 Localized softening of the cranial bone common to first bone chiold due to early lightening
 If present in older children; sign of rickets or Vit. D deficiency o Seborrheic dermatitis/ Cradle
Cap
 Scaling, greasing, appearing salmon – colored patches
 Usually seen at the scalp, behind ears and umbilicus
 Usually caused by improper hygiene
 Management
• Application of baby oil the night before shampooing the child
o Caput Succedaneum
 Edema of the scalp due to prolonged pressure at birth  Present at birth
 Crosses the suture line
 Disappears 2 – 3 days
 Disappears without treatment o Cephalhematoma
 Collection of blood due to rupture of capillaries of poriosteal capillaries
 Present after 24 hours

 Does not cross the suture line

 Disappears after 4 – 6 weeks
 Disappears without treatment o Hydrocephalus
 Excessive accumulation of CSF
 Types
• Communicating/ extraventricula hydrocephalus
•
No-communication/ intraventricular hydrocephalus/ obstructive hydrocephalus – caused
by tumor
 Signs and symproms
• Signs of increased ICP o Diplopia – eye deviation @ 6th mos and above o
Management
 Low semi – fowlers (30 degrees) best position
• Frontal bossing 9 prominent forehead)
• Sunset eyes
•
Prominent scalp vein
 Therapeutic management
• Osmotic Diuretic o Mannitol o Diamox /
acetazolamide • Seizure precautions
• Surgery – Shunting o AV Shunt -
atrioventricular
o VP shunt – ventriculoperitonial – most common
 Best time to shave the head – just before the surgery – prevent infection
 Post VP Shunt management
• Position – sidelying on non-operated side ( applicable to all eyes and head
surgeries)
• Sign of good shunting – sunken fontanel
• Sign of blocked shunting – bulging fontanel
• Catheter is changed as the child is growing
• Child with BP shunt is prone to infection
SENSES
Sense of Sight
• Sclera o Normal – light blue o Later Color – dirty white
• Pupils o Normal – round and adult size

o Coloboma – key hole pupils part of the iris is missing o Congenital N Cataract – whiteness/
opacity of the lens
• Cornea o Normal – round and adult size
o Congenital Glaucoma – larger than normal
Test for Blindness

Age Common Test
Newborn General appearance
Can see @ a distance of 10 – Check ability to follow object pass midline
12 inches with visual acuity of DOLL’S EYE TEST – done at approximately 10th day
20/200 to 20/ 800 GLADELLAR TEST – test for blink reflex, not blinking is a sign of blindness
Infant and children ALLEN’S CARD – test for visual acuity

- familiar pictures are flashed 20 ft away from the
child

ISHIARA PLATE – test for color blindness
3 years old School age Cover testing test – for strabismus

School age – adult Snellen’s test
RETINOBLASTOMA
• malignant tumor of the eye
• signs and symptoms
o cat’s eye reflex (whitish glow of pupil) o red, painful eye usually
accompanied by glaucoma
• Management
o Surgery  innucleation - removal of the eyeball o Irradiation o
Therapy
SENSE OF SMELL
• Normal nasal membrane - pinkish
• Check for sense of smell
• Check for nasal flaring
Sign of Cocaine User

• Ulceration and abscess of nasal mucosa
• Absence of hair
Epistaxis
• Nose bleeding
• Management
o Position, upright, sitting, head trilted, slightly forward o Gentle pressure o
Cold compress o Epinephrine – last resort
SENSE OF HEARING
• Normal should be aligned with the outer canthus of the eye
• Low Set Ears is a sign of o Kidney malformation
• Renal agenesis
• Absence of kidney
o Chromosomal Abnormalities
• Due to advance maternal age - >35y/o
• Types o Nondisjunction (uneven divison)
• Trisomy 21
• Down Syndrome
• Most common type
• Extra chromosome 21
• 47xx + 21/ 47xy + 21
• can be related to advance paternal age
• signs and symptoms o broad nose o protruding tongue o low- set ears o puppy’s neck o
hypotonia prone to URTI
o simian crease single traverse line in palm o mental retardation –
ranging from educable to institutionalization
• Trisomy 18

• Has 3 numbers of 18 chromosomes

• Severely cognitively impaire SGA
• Low set ears, small jaw, CHD, index finger crosses over the other fingers, rounded
soles of feet
• Trisomy 13
• Patau’s syndrome
• Extra chromosome 13
• Severely cognitively impaired
• Signs and symptoms o Microcephaly o Micropthalmia o Cleft-lip and palate o Low-set
ears o VSD
o Do not survive
• Turners
• Gonadal Dysgenesia
• One functional x chromosome
• Short in stature
• Neck appear to be webbed and short
• COA and kidney problems
• Only 1 streak (nonfunctional) gonads
• Secondary sex characteristic does not develop except for pubic hair
• Lack ovarian function – sterility
• Cognitively challenged but mostly normal intelligence
• Klinefelter’s syndrome
• Males with a XXY chromosome pattern
• @ puberty child has poorly developed secondary characteristics and small testes that
produces ineffective sperm
• boys tend to develop Gynecomastia
o Deletion Abnormalities
• Cri – du – chat Syndrome
• Result of a short arm on chromosome 5
• Cat’s cry
• Small head, wide set eyes, downward slant to the palbepral fissure of the eyes
• Severe cognitive impairment
• Fragile X Syndrome
• X linked pattern
• One arm of x chromosome is weakened
• Most common cause of cognitive impairment in boys
• Before puberty, boys typically have maladaptive behavior like hyperactivity and autism
•Large head, long face with high forehead, prominent lower jaw, large protruding ears
o Translocation abnormalities
• Balance translocation Carrier

• Unbalanced Translocation Syndrome
o Others
• Mosaicism
• A situation wherein the nondisjunction of chromosome occurs during mitotic cell division after
fertilization resulting to different cells contains different numbers of chromosome
• Isochromosomes
• A situation wherein the chromosome instead of dividing vertically it divides horizontally resulting to
chromosomal mismatch
Otitis Media
• Inflammation of the middle ear

• Common to children due to wider and shorter Eustachian tube

• Predisposing factors o Bottle propping o Cleft lip/ palate
 Signs and symptoms o During otoscopic exam, reveals bulging tympanic membrane o Observe for passage of
purulent, foul – smeeling odor discharge
 Management
o Positioning – sidelying on the affected side o
Supportive care
 Medical management
o Massive dosage of antibiotics o Mucolytics o Ear
drops
 < 3 y/o – down and back
 >3 y/o – up and back
o Surgery
 Myringectomy – slight incision of tympanic membrane to prevent hearing loss
 Side effect – bacterial meningitis
MOUTH AND TONGUE

• Check for symmetry
Bell’s palsy/ Facial Nerve Paralysis

• 7th CN injury
• usually related to forceps delivery
• risk for URTI
o Continuous drooling of saliva o Inability to open one eye and close the other
• Management
o Artificial tear o Self limiting
o Refer to PT for rehabilitation
TEF/ TEA
• No connection between esophagus and stomach
• There is a blind pouch
• Hydramnios – earliest sign intrauterine
• Signs and symptoms o Coughing o Chocking o Cyanosis o Continuous drooling
• Management o Emergency surgery
Epstein Pearls
• White glistening cyst
• Usually seen on palate, gum
• Related to hypercalcemia
Natal Tooth
• Tooth at the moment of birth
• Related to hypervitaminosis
• Management
o Manual extraction if rootless
Neonatal Tooth
• Appearance of tooth within 28 days of life
Oral Thrush

• White cheese-like, curd like patches

• Usually seen in mouth and on toingue
• Causative agent  C. Albicans – fungi
• Management o Do not remove – can cause wound o Wash with cold, bottled water
o Medical – Mycostatin/ Nystatin
Kawasaki Disease
• Discovered in Korea
• Strawberry tongue
• Common in asian countries
• Criteria for diagnosis o Fever lasting for more than 5 days o Bilateral conjunctivitis o Changes in lips and oral
cavity
 Dry red fissure lips
 Strawberry tongue
Diffuse erythema of mucos membrane
o Changes in the peripheral extremities
 Erythema on the palms and soles
 Erythema on the hands and feet
Membranous desquamation from fingertips
o Polymorphous rash (primarily at trunk)
o Acute non purulent sweeling of the cervical lymph nodes to > 1.5 cm in diameter
• Drug of Choice : ASPIRIN
Cleft Lip
• Failure of the median maxillary nasal process to fuse
• Common to boys
• Surgery – cheiloplasty o Done w/in 1 – 3 months o To save sucking reflex

o Evident at birth o Milk from nostrils spills o Cold is common o Frequent URTI and otitis media
• Post cheilo – sidelying
• Nutrition – use rubber tip syringe
Cleft Palate
• Failure of the palate to fuse
• Common to girls
• Surgery – Uranoplasty o Done w/in 4 – 6 months o To save speech

o Evident at birth o Milk from nostrils spills o Cold is common o Frequent URTI and otitis media • Post cheilo
– prone
• Nutrition – use paper cup/ plastic cup/ soup spoon
Condition to consider for suspension of operation

• If child has a cold/ nasopharyngitis – may lead to general septicemia
General management
• Maintainance of patent airway • Proper nutrition o NPO 4 hours post op o Clear liquid
 Popsicle except red and brown in color
 Flavore gelatin
 No ice cream • Observe for bleeding o Frequent swallowing

• Protect suture lines specially LOGAN BAR o Clean using hydrogen peroxide, bubbles traps microorganism, more
bubbles more microorganism trapped
o Prevent crying by attending to needs
Therapeutic Management
• Emotional support
• Proper Nutrition
• Cleft lip nipple (long tip, made by silicon) • Prevent Colic o Burp frequently
o One at the middle of the feeding o Another at the end of the feeding
o Upright sitting position o Pat at the back – lower to upper o Prone position
o Right – sidelying position – facilitates gastric emptying
• Educate parents
• Apply elbow restraints so the baby can easily adjust post –op
NECK
• Check for symmetry
Congenital Torticollis/ Wry neck

• Birth injury of sternocleidomastoid due to excessive traction during cephalic delivery
• A case of incompetence to the one giving birth
• Management
o Passive stretching o Exercise daily o Surgery • Complication o Scoliosis
Congenital Critinism/ Congenital Hypothyroidism

• Absence or non – functioning thyroid gland • Causes o Due to delayed diagnosis, thyroid is covered by
sternocleidomastoid muscle
o Hypothyroidism
o Thyroid dysgenesis (absence of thyroid) o Baby receive maternal thyroxine
• Earliest Signs and Symptoms o Change in sucking o Change in crying
o Excessive sleeping (16-20 hours/ day) o Constipation o Edema – moon faced baby o Mental retardation –
late sign
• Diagnostic Test o Radioimmunoassay Test o Protein bounbd iodine
• Treatment o Synthroid / sodium levothyroxine for life
CHEST
Witch Milk
• Transparent
• Liquid coming out from newborns breast related to hormonal changes
ABDOMEN
Abdominal Assessment
• Inspection
• Ausculation
• Percussion
• Palpation
Diaphragmatic Hernia
• Protrusion of stomach contents through a defect in diaphragm due to failure of pleuroperitoneal canal to close

• Signs and Symptoms o Sunken abdomen o Signs of RDS o Right to left Shunting
• Treatment – diaphragmatic repair w/in 24 hours
Omphalocele
• Protrusion of stomach content between the the junction of abdominal wall and umbilicus
• If small – surgery
• If large – suspend surgery
• Apply wet dressing
GASTROINTESTINAL SYSTEM
• Functions o Assist in maintaining fluid and electrolytes and acid and base balance o Processes and absorbs
nutrients to maintain and support growth and development
o Excrete wasted products from the digestive process
Supplementary Feeding
• Begin 4 – 6 months
• As early as 4 months
• Usually at 6 months
• Principles o Solid food are often according to the following sequence
 Cereals  rich in iron
 Fruits
 Vegetables  Meat
o Begin with small quantities o Finger food are offered @ 6 months o Soft table food is offered @ 1 year o
Diluted citrus/ fruit juices @ 6 months
o Offer new food one at a time with an interval of 4 – 7 days or 1 week o Never offer half cooked egg  may
lead to gastroenteritis/ salmoneliosis
Major Concepts of Fluid and Electrolyte Balance

• Distribution of Body Fluids o Fluids are greater in ECF in infant and children o Newborns are candidate for
dehydration
o Total Body fluid is 65 – 85% of their body weight in infants and children
Acid – Base Imbalance

• Depending upon the following o Chemical buffers
o Renal and respiratory system involvement o Dilution of strong acids and bases in blood
• Imbalance of Acid o Respiratory Acidosis
 Carbonic acid excess
 LTB – RDS
 Hypoventilation – COPD o Respiratory Alkalosis  Carbonic acid deficit
 Hyperventilation
 Fever, encephalitis o Metabolic Acidosis
 Base bicarbonate deficit
 Diarrhea
 Severe malnutrition and dehydration
 celiac o Metabolic Alkalosis
 Base bicarbonate excess due to uncontrolled vomiting

o
o
NGT aspiration
Gastric lavage
 Pyloric stenosis
Conditions that Produce Fluids and Electrolyte Imbalance
Vomiting
• Forceful expulsion of stomach content
• Signs and symptoms o Nausea o Abdominal crumping o Flushing of face o Watery eyes • Assessment o
Frequency o Forces
 Projectile – increase ICP/ Pyloric stenosis
 Non – projectile
• Alerts o Vomiting is an initial symptom of GI Obstruction o Vomitus of upper GI can be blood tinged but bot bile
streaked o Vomitus of lower GI is bilous
o Projectile vomiting is ewither a sign of increased ICP or GI Obstruction o Abdominal distention is the major
symptom of lower GIT obstruction
• Management o Banana o Rice cereal o Apple sauce
o Toast
Diarrhea
• Exaggerated excretion of intestinal contents
• Acute diarrhea is associated with the following o Gastroenteritis/ salmonelliasis o Antibiotic use – penicillin,
tetracycline o Dietary indigestion
• Chronic non specific diarrhea o Food intolerance o CHO/ CHON malabsorption o Excessive fluid intake
• Assessment o Frequemcy
o Consistency (best criteria) o Appearance of green colored stool • Complications o Mild dehydration – 5%
weight loss o Moderate dehydration – 10% weight loss o Severe dehydration – 15% weight loss
• Signs of dehydration o Tachycardia – earliest sign Tachypnea
Hypontension
o Increase temp o Sunken fontanel o Sunken eyeball o Poor skin turgor o Absence of tears o Scanty urine
o Oliguria – severe dehy=dration o Weight loss
o Prolonged capillary refill time
• Management o NPO
o IV infusion
o KCl – given by doctors
 Assess child for ability to void before giving KCl – may lead to hyperkalemnia
 Normal K Value – 3.5 – 5.5
o Order Na Bicarbonate, administer slowly to prevent cardiac overload
Gastric Motility Disorders
Hirschprung’s Disease/ Congenital Aganglionic Megacolon

• Absence of ganglion cells needed for peristalsis
• Assessment o Neonatal Period
 Abdominal distention
 Failure to pass meconium within 24 hours o Early childhood
 Ribbon like stool
 Constipation



 Foul smelling stool
 Diarrhea
 Vomitus of fecal materials
• Diagnostic Procedures o Barium enema – reveals narrowed portion of the bowel o Rectal biopsy – reveals
absence of ganglion cells o Abdominal x- ray – reveals dilated loops on intestines o Rectal manometry – reveals
failure of intestinal sphincter to relax
• Therapeutic Management o NGT Feeding

 NGT Measurement
• Infant – nose-ears – middle of xiphoid process and umbilicus
• Adult – nose – ears – xiphoid process
o Surgery
 Temporary colostomy
 Anastomosis and pull through procedure o Diet
 Increase CHON
 Increase Calorie
↓ residue diet – pasta foods no raisin/
prunes
Gastroesophageal Reflux
• presence of stomach content on esophagus
• Assessment
o chronic vomiting
o failure to thrive syndrome – organic
o esophageal bleeding manifested by melena and hematemesis
• Complications o esophagitis o aspiration pneumonia o esophageal cancer

• Diagnostic Procedure o barium esophogram
o esophageal manometry – reveals lower esophageal pressure o intraesophageal pH content – reveals pH
of distal esophagus
• Medications o anticholinergics
 bathanechol/ urecholine
• ↑ esophageal tone and peristaltic activity  Methachlopromide (Reglan)
• ↓ esophageal pressure by relaxing pyloric and duodenal segments
• ↑ peristalsis without stimulating secretions
 H2 Blocker/ histamine Receptor Antagonist
• ↓ gastric acidity and pepsin secretion
 Maalox/ Cimetidine (Tagamet)/ Ranitidine (Zantac)
• Neutralizes gastric acid between feedings
• Surgery: Nissen Fundoplication
• Diet o Thickened feeding with rice cereal  prevents vomiting o Feed slowly o Burp often every 1 oz o Positioning
 < 9 mos – infant sit/ infant supine
 > 9 mos – prone with head on mattres slightly elevated on a 30° angle
Obstructive Disorders
Pyloric Stenosis
• hypertrophy of the muscle of pylorus causing narrowing and obstruction
• Assessment
o Projectile vomiting o Failure to gain weight o Metabolic alkalosis

o
o
o Peristaltic wave visible from left to right across epigastrum o Palpation of olived shaped mass
• Diagnostic Procedure o ABG
Serum Electrolyte - ↑ Na and K, ↓ Cl
Ultrasound o X-ray of upper abdomen with barium swallow
• Management
o Pyloromyotomy/ Fredet – Ramstedt Operation
Intussusception
• Telescoping or invagination of one portion of the bowel into the other
• Peritonitis – danger of intussusception
• Emergency for URT – epiglotitis
• Emergency for GIT – peritonitis
• Signs and symptoms o Acute paroxysmal abdominal pain
o Currant jelly stool caused by inflammation and bleeding o Sausage shaped mass
• Non congenital
• Caused by fast eating and positioning
• Management
o Hydrostatic reduction with barium enema
o Surgery – Anastomosis
Inborn Errors of Digestion
Phenylketonuria/ PKU
• Deficiency of the liver in Phenyalanine Hydroxylase Transferase (PHT)
• PHT is a liver enzyme that coverts protein into amino acid
• 9 Essential Amino Acids o Tyrosine / phenylalanine o Histidine o Isoleucine o Leucine o Lysine o Methionine/
cysteine o Threonine o Tryptophan o Valine
• Tyrosine or Phenylalanine – responsible for the melanin production
• Signs and Symptoms o Fair complexion o Blond hair o Blue eyes o Infantile eczema o Mousy/ musty odor urine
o Seizure – due to Phenyl Pyruvic Acid goes to brain o Mental retardation
• Guthrie Test o Specimen – Blood o Preparation – Increase Fluid Intake
• Management o Diet
↓ phenylalanine diet indefinitely
Chicken, meat, peanuts, milk, legumes, cheese – contraindicated  Lofenalac – special
formula
Celiac Disease/ Malabsorption Syndrome; Gluten Induced Enteropathy

• Sensitivity or immunologic response to protein
• Assessment
o Early signs
 Diarrhea, failure to regain weight following diarrheal episode
 Constipation
 Vomiting
 Abdominal pain
 Steatorhea o Late signs
 Behavioral changes: irritability and apathy
 Muscle wasting and loss of subcutaneous fats o Celiac Crisis



 Development of infection by a child having a celiac disease
 Acute vomiting and diarrhea
• Diagnostic Procedure o Stool analysis
o Serum antiglandin and antireticulin antibodies o Sweat test
• Therapeutic management o Vitamin supplements o Mineral supplements o Steroid
Poisoning
• Common accident in toddlers – poisoning
• Common accident in infants – falls
• Principles o Determine the substance taken and assess LOC
o Unless poisoning was corrosive, caustic (strong alkali, such as lye) or hydrocarbon, vomiting is the most
effective way to remove the poison from the body
 Strong acid poisoning – give weak acid to neutralize strong acid o Syrup of ipecac –
oral antiemetic to cause vomiting after drug overdose or poisoning
 15 ml – adolescent, school age and preschool
 10 ml – infant o Universal Antidote
 Activated charcoal
 Milk of magnesia
 Burned toast
• Charcoal absorbs toxic substance
o Never administer the charcoal before ipecac because giving charcoal first will absorb the effect of ipecac
Antidote for acetaminophen poisoning : Acetylcysteine (mucomyst)
Kerosine/ Gasoline poisoning: Give mineral oil to coat the intestine and prevent poison absorption
• Tracheostomy set will be at bed side
Lead Poisoning
• Pencil, paint, crayon Lead
↓
Destruction of RBC Functioning
↓
hyupochromic Microcytic Anemia
↓
Destroys Kidney Function
↓
Accumulation of ammonia
↓
Leading to Encephalitis (Late stage)
↓
Severe mental retardation
• Assessment
o Beginning symptoms of lethargy o Impulsiveness and learning difficulty
o As lead ↑, severe encephalopathy with seizure and permanent mental
retardation
• Diagnostic procedure o Blood smear o Abdominal x-ray o Lone bone
• Management
o Chelation – binds with the lead and excreted via kidneys o Ca EDTA/ BAL/
Dimercapro
 Nephrotoxic
ANOGENITAL
Female

o
o
• Pseudomenstruation
o Slight vaginal bleeding related to hormonal changes
• Rape/ Child Abuse

o If the client came with a laceration and bleeding at the perineum o Report rape within 48
hours
o Preschool are proneto rape because of their innocence o CBQ Report rape cases to
barangay chairman first or bantay bata
Male
• Cryptochirdism o Undecended testes or empty scrotum or ectopic testes
 Common in preterm babies
 Testes is palpable at lower quadrant  Surgery: Orchioprexy

The Royal Pentagon Review Specialist Inc. Pediatric
Nursing
•
• Preop – warm the room and hands
Epispadias o Urinary meatus is located at the dorsal or above the glans penis
• Hypospadias
o Urinary meatus is located at the ventral or below the glans penis o Hypospadias is usually accompanied
by Chordee ( A fibrous band causing penis to curved downward)
o Both are manage by surgery
• Phimosis
o Tight foreskin o This will cause infection o
Circumcision as management
• Hydrocele
o Fluid filled scrotum
o Flashlight/ transillumination test to determine
• Varicocele o Enlarged vein opf the epididymis
RENAL DISORDERS
Renal Causes Assessment Findings Treatment Nursing Care

Disorder
Nephrotic Infection Anasarca Prednisone Skin Care

Syndrome Massive proteinuria Weigh the client saily with the
Microscopic or no hematuria same clothing
↓ serum CHON ↑ CHON(Normal Diet)
↑ serum lipid ↓ Na
Normal or ↓ BP ↑K
Fatigue
Acute Autoimmun Primary pheripheral AntiHPN Monitor weight

Glomerul e perioprbital edema Moderate Hydralazine Skin Care Monitor BP
onephritis Group A beta Proteinuria Apresoline and neurologic status
Goss hematuria
hemolytic ↓K
streptyococ cus (smokey urine) Complication
↑ serum K Hypertensive ↑ Fe
Fatigue Encephalopat hy ↓ Na
HPN
BACK
• Check for flatness and symmetry of the back
Spina Bifida Occulta

• Failure of the posterior lamina or vertebral to fuse
• Sampling of the lower back
• Abnormal tufts of hair
Spina Bifida Cystica

With Sac

•
•
Types o Meningocele – protrusion of CSF and Meninges o Myelomeningocele –
CSF, Meninges and Spinal cord o Ecephacele
 cranial meningocele - CSF and meninges
 Myelomeningocele - brain, CSF , meninges
• Common Complication
o Infection o Rupture of
Sac
• Treatment
o Surgery to prevent infection: post op – prone position
Scoliosis
• Lateral curvature of the spine, common in school age because of heavy bags
• Uneven hemline
• Tell the child to bend forward, one hip higher than athe other and one shoulder is most prominent
• Types
o Structural o
Postural
• Management o Conserbvative  Exercise
 Avoid obesity o Preventive
 Milwaukee Braces worn 23 hours a
day o Corrective: Surgery
EXTREMITIES
• Count the number of digits
Digits
• Syndactyl – webbing of the digits (foot – ginger –like foot)
• Polydactyl – extra digits
• Olidactyl – lacks digits
Erb – Duchennse Paralysis/ Brachial Plexus Injury

• Birth injury of breech delivery
• Signs
o Inabiluity to abduct the arm fronm the shoulder, rotate the arm extremely and supinate the forearm
o Assymetrical oor absence of moro reflex
• Management
o Abduct the arm from the shoulder with the elbow flexed
Congenital Hip Dislocation

• Congenital hip dysplacia
When the head of the femus is outside the scetabulum
2 types o subluxated – most common o
dislocated
• Signs and Symptoms
o Shortening of the affected leg o Assymetrical gluteal fold o Limited
movement – earliest sign
o + ortolanis sign – abnormal clicking of during abduction o when
able to walk the child limps (Trendelenburg sign) – late sign

•
•
• Management – facilitate abduction o Triple the diaper o Carry the baby o Frejka Splint o Pavlik Harness o Hip
Spica Cast
Talipes
• Club foot
• 4 types o Equinos – plantar rotation/ horse foot (most common)
o Calcenuous – dorsiflexion/ the heel is held lower than the foot/ the
anterior portion of the foot is flexed towards the anterior leg
o Varus – foot turns in o Valgus – foot turns out
• Assessment
o Make a habit of straightening the legs and flying it to the midline position
• Management
o Corrective shoes : Dennis Brown Shoes o Spica Cast
 For immobilization
 Maintain bone alignment
 Prevent muscle spasm
 If there is a blood mark on the cast – mark a pen to determine whether there is a hemorrhage
 Neurobvascular check
• Circulation
• Motion
• Sensation
CRUTCHES
• Wait is on the palm not the axilla
• Exercise – squeeze ball
Different Crutches and Gait
Swing Through
• Advance both crutches
• Lift both feet/ swing forward/ land feet in front of crutches
Advance both crutches
Lift both feet/ swing forward/ land feet in front of crutches
Swing To
• Advance both crutches
• Lift both feet/ swing forward/ land feet next to crutches • Advance both crutches
• Lift both feet/ swing forward/ land feet next to crutches
Three point gait

• Advance left foot and both crutches • Advance right foot
• Advance left foot and both crutches
• Advance right foot
Four Point Gait

• Advance right crutch
• Advance left foot
• Advance left crutch
• Advance right crutch

•
•
Two Point Gait
• Advance left foot and right crutch
• Advance right foot and left crutch
• Advance left foot and right crutch
• Advance right foot and left crutch
Other Crutch – Maneuvering Technique
To Sit Down
• Grasp the crutches at the hand pieces for control
• Bend forward slightly while assuming a sitting position
• Place the affected leg forward to prevent weight bearing and flexion
To Stand Up
• Move forward to the edge of the chair with the strog leg slightly under the seat
• Place both crutches in the hand on the side of the affected extremity
• Push down on the hand piece while raising the body to a standing position
To Go Downstairs
• Walk forward as far as possible to the step
• Advance the crutches to the lower step. The weaker leg is advanced first and then the stronger leg. In this way, the
stronger extremity shares the work of raising and lowering the patient’s body weight with the arms
To Go Upstairs
• Advance the stronger leg first up to the next step
• Then advance the crutches and the weaker extremity ( strong legs goes up first and comes down last.)

•
A memory device for the patient is “UP WITH THE GOOD, DOWN WITH THE BAD”
WALKER
• A walker provides more support than cane andf crutches
• The patient is taught to ambulate with a walker as follows o Patient must hold the walker on the hand grips for
stability o Lift the walker, placing it in front of you while leaning your body slightly forward
o Walk into the walker, supporting your body weight on your hands while advancing the weaker leg,
permitting partial weight bearing or non weight bearing leg as prescribed
o Balance yourself on your feet
o Lift the walker and place it in front of you again and continue the pattern of walking.
CANE
• Used to help patient walk with greater balance and support and to relieve the pressure on the weight bearing joints
by redistributing the weight.
• Quad Cane (four – footed cane) is hold on the hand of affected extremity.
METHODS OF TRANSFERRING A PATIENT FROM THE BED TO A WHEELCHAIR

• Weight bearing transfe4r from bed to chair. The patient stands up, pivots his back is opposite the new seat and sits
down.
• (Left) Non weight bearing transfer from chair to bed. (Right) With legs braced.
• (Left) Non weight bearing transfer combined method. (Right) Non weight bearing transfer, pull up method.
THERAPEUTIC EXERCISE
Exercise Description Purpose Action
Passive carried out by the therapist or To retain as much joint range Stabiolize the proximal
the nurse without assistance of motion joinyt, and support the distal
from the patient as possible To part. Move the joint
maintain smoothly, slowly and gently
circulation through its full rang of
motion Avoid producing
pain.
Active Assistance Carried out by the patient To encourage normal muscle Support the distal part and
with the assistance of the function encourage the patient to take
therapist or the nurse the joint actively through its
ROM.

Give no more assistance than

is necessary to accomplish
the action. Short periods of
activity should be followed by
adequate rest periods.
Active Accomplished by the patient To increase muscle strength When possible, active
without assistance, activities exercise should be performed
include turning from side to against gravity. The joint is
side and from back to moved through full ROM
abdomen and moving up and without assistance. (make
down in bed sure that the patient does not
substitute another joint
movement for the one
intended)
Resistive An ective exercise carried out To provide resistance to The patient moves the joint
by the patient working against increase muscle through its ROM while the
the resistance produced by power therapist resist slightly at first
either manual or mechanical and the progressively
means increasing resistance.
Sandbagws and weights can
be used and are applied at
the distal point of the joint
involved. The movement
should be performed
smoothly.
Isometric/ Muscle Setting Alternately contracting and To maintain strength when a Contract or tighten the
relaxing a muscle while joint is immobilized muscle as much as possible
keeping the part in fixed without moving the joint. Hold
position; performed by the for several seconds, and
patient then let go and relax.
Breath deeply.
TRACTION
• Use to reduce dislocation Principles of Traction
• The client should be in dorsal or supine position

• For every traction, there is always a counter traction

• Line of pull should be in line with deformity
• For traction to be effective it must be continuous
• Weight must be freely hanging
Types of Traction
• Straight traction – weight of the body serves as counter pull
• Skin traction – applied directly to the skin o Bryant’s Traction
 use to immobilize for < 2 years old at a 90 ° angle with buttocks off the bed o Buck’s
extension
 For > 2 years old
• Halo traction – immobilize the spine
• Skeletal traction o Nursing responsibilities
 Assess for circulatory and neurology impairment
 It can lead to HPN
 Be careful to carry out nursing functions by not moving the weights
AUTOIMMUNE SYSTEM
• Types of Immunity o Passive Natural
 Developed via exposure to a disease o Active Natural
 Transplacental transfer, IgA from breastmilk o Passive
Artificial
 Vaccination o Active Artificial
 Anti Rabies Serum
NEUROMUSCULAR SYSTEM
Reflexes
Blink reflex
• Rapid eye closure when strong light is shown to protect the eyes; never disappears
Palmar Grasp Reflex
• When a solid object is placed on the palm then the baby will grasp the object
• To cling to the mother for safety
• Disappears at 3 months
Step – in/ Walk – in Place Reflex/ Dance Reflex
• Neonate placed on a vertical position with their feet touching on hard surface will take a few quick alternating steps
• Placing reflex  almost the same with the dance reflex except that is when you are touching the anterior surface of
newborns leg
Plantar Grasp Reflex
• When an object touches the sole of the newborn’s foot at the base of his toes, the toes grasp in the same manner as
the fingers do
• Disappears @ 8 – 9 months in preparation for walking
Tonic Neck Reflex/ Fencing/ Boxing reflex
• When the newborn lies on its bact, their heads usually turns to one side, the arm and the leg on the side to which the
head turns extend to the opposite arm and legs contract
Moro Reflex/ Startle Reflex
• With a loud voice or by a jarring the base of the crib, the baby will assume a c position
• Test for neurologic integrity
Magnet Reflex
• When there is pressure at the sole of the foot, the baby pushes back against the pressure
Crossed extension Reflex

• While supine and the sole of the foot is stimulated by a sharp object, it causes the foot to raise and the other foot to
extend
• Test for spinal nerve integrity
Trunk Incurvation Reflex/ Galant Reflex
• While in prone position and the parabvertebral area is stimulated, it causes flexion of the trunk and swing his pelvis
towards the touch
Landau reflex
• While the infant is placed on a vertical position with the hand underneath supporting the trunk the baby exhibit some
muscle tone
• Present at 3 months
• Test for muscle tone
Parachute Reflex
• When the infant is placed on a vertical suspension with the change in equilibrium, it causes the extension of the
hands and legs
• Present at 6 – 9 months
Babinski Reflex
• When the sole of the foot is stimulated by inverted j, it causes fanning of the toes
• Disappears by 2 months but may persist till 2 years old

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GROWTH AND DEVELOPMENT

Growing  complex phenomenon of a structure or whole

• Increase in physical size of a structure or whole

2x = 5 – 6 mos. Weight gain:

LEARNING  change of behavior

Jomar Anthony D. Maxion, BSN, RN PLM BSN 2006

GIFTED CHILD  > 130 IQ level

BASIC DIVISIONS OF LIFE

oo Neonatal Formal Infancy  first 28 days  29th – 1 year

• Early Childhood o Toddler  1 – 3 y/o o Preschool  4 – 6 y/o

• Middle Childhood o School Age  7 – 12 y/o

• Late Childhood o Pre – adolescent  11 – 13 y/o o Adolescent – 12 – 13 y/o to 21

PRINCIPLES OF GROWTH AND DEVELOPMENT

 Creeps → Stands → Walks → Run

• BEHAVIOR → most comprehensive indicator of developmental stages o act @ your age

• PLAY → universal language

PATTERNS OF GROWTH AND DEVELOPMENT

• Reproductive o Grows rapidly during puberty

Jomar Anthony D. Maxion, BSN, RN PLM BSN 2006

RATES OF GROWTH AND DEVELOPMENT

• Toddler o Period of slow growth and development

• School Aged o Slower growth and development o Least to develop anemia

• Adolescent o Period of rapid growth o Secondary prone to anemia

Two Primary Factors Affecting Growth and Development

SIGMUND FREUD’S PSYCHOSEXUAL THEORY

• Sucking • Never discourage thumb sucking

Jomar Anthony D. Maxion, BSN, RN PLM BSN 2006

ERIK ERICKSON’S STAGES OF PSYCHOSOCIAL THEORY

1. Trust vs. Mistrust

Jomar Anthony D. Maxion, BSN, RN PLM BSN 2006

• Unfinished project will develop inferiority

JEAN PIAGET’S STAGES OF COGNITIVE DEVELOPMENT (Sensorimotor, Pre-Operational, Concrete Operational,

1. Schema 1: Neonatal Reflex

Jomar Anthony D. Maxion, BSN, RN PLM BSN 2006

o Play activities: Throw and retrieve

KOHLBERG’S THEORY OF MORAL DEVELOPMENT

Age Stage Descritption

0 – 3 yrs 1 • PUNISHMENT/ OBEDIENCE/ ORIENTATION

Jomar Anthony D. Maxion, BSN, RN PLM BSN 2006

CONVENTIONAL (Level II)

4 – 10 yrs. 3 • ORIENTATION TO INTERPERSONAL RELATIONS OF

10 – 12 yrs. 4 • MAINTAINANCE OF SOCIAL ORDER, FIXED RULES AND

POST – CONVENTIONAL (Level III)

Older than 12 5 • SOCIAL CONTRACT, UTILITARIAN LAW – MAKING

6 • UNIVERSAL ETHICAL PRINCIPLE ORIENTATION

3 years Tooth brushing with minimal supervision

BOWEL/ BLADDER CONTROL

Jomar Anthony D. Maxion, BSN, RN PLM BSN 2006

Jomar Anthony D. Maxion, BSN, RN PLM BSN 2006

• Sucking reflex disappear

• Fear: Separation Anxiety o Begins: 9 months o Peaks: 18 months o 3 stages  Protest

Jomar Anthony D. Maxion, BSN, RN PLM BSN 2006

• Ritualistic – way to gain mastery

• Scaphoid abdomen – underveloped abdominal muscle

Jomar Anthony D. Maxion, BSN, RN PLM BSN 2006

Preschooler’s Characteristic Traits

• Significant Person o Teacher o Peer of same sex

• Stoppage of height coincide with the eruption of wisdom tooth

• They’ll Cheat → can’t afford to lose

Jomar Anthony D. Maxion, BSN, RN PLM BSN 2006

Signs of Sexual Maturity in Female

Signs of Sexual Maturity in Male