1.

A Growth and Development

Growth - increase in physical size of a structure or whole.
- quantitative change.
Two parameters of Growth
1. Weight - most sensitive measure of growth, especially low birth rate.
Weight doubles - 6 months
Triples - 1 year
Quadruples - 2 - 2 ½ years
2. Height - increase by 1inch per month during 1st 6 months
- half inch per month by 7 months
- average increase in height - 1st year = 50%
- increase in height coincide with eruption of wisdom tooth.
Development - increase skills or capability to function
- qualitative
How to measure development
1. By simply observing a child doing specific task.
2. By noting parent’s description of the child’s progress
3. By DDST- Denver Development Screening Test.
MMDST (Phil) Metro Manila Developmental Screening Test.
DDST measures mental
4 main rated categories of DDST
1. Language communication
2. personal social - interaction
3. fine motor adaptive - ability to use hand movement; pre Hensile activity
4. gross motor skills - large body movement

3. Maturation - synonymous with development “readiness”; [pagiging handa]

4. Cognitive development – ability to learn and understand from experience
- to acquire and retain knowledge
- to respond to a new situation and to solve problems.
Learning – change of behavior
IQ test - test to determine cognitive development
Mental age x 100 = IQ
Chronological age
Average IQ – 90-100
Gifted child - > 130 IQ
Genius - Over 140

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 1.B Basic Divisions of Life
Stages:
I. Prenatal stage
( from conception to birth )
II. Period of infancy
1. Neonatal - 1st 28 days of life or 1st 4 weeks of life
2. Formal infancy - 29th day – 1 year
III. Early childhood
1. Toddler – 1-3 years
2. Pre school 4 - 6 years
IV. Middle childhood
1. School age- 7 – 12 yrs

V. Late childhood (Adolescent Period)

1. Pre adolescent 11 – 13 years
2. Adolescent ( 12 - 18 – 21 ) overlapping of age
1.C Principles of Growth and Development
1. Growth and Development is a continuous process
- begins from conception - ends in death
- womb to tomb principles
2. Not all parts of the body grow at the same time or at same rate.
- asynchronism or asynchronous growth –

Patterns of Growth and Development

1. ) renal
digestive grows sparely smoothly during childhood
circulatory
musculoskeletal
2. ) Neuromuscular tissue (CNS, brain, Spinal cord)
- grow rapidly 1 - 2 years of life
- brain achieved its adult proportion by 5 years.
Significance: Food for the brain “POTATO”
3. ) Lymphatic system - lymph nodes
- spleen grows rapidly
- infancy and childhood to provide protection
- infection
- tonsil achieve its adult proportion by 5 years
4. ) Reproductive Organ - grows rapidly at puberty

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 Rates of Growth and Development
1. Fetal and infancy – most rapid Growth and Development
2. Adolescent - rapid Growth and Development
3. Toddler - slow Growth period
4. Toddler and preschool - alternating rapid and slow
5. School age - slower growth
fetal and infancy - prone to develop anemia
3. Each child is unique
2 primary factors affecting Growth and Development
A. Heredity - R – race
I – intelligence
S – sex
N - nationality

Females are born less in weight than males by 1 oz.

Females are born less in length than males by 1 inch
B. Environment
Q – quality of nutrition
S – socio economic status
H – health
O – ordinal position in family
P – parent - child relationship

Eldest - skillful in language and social skills

Younger - toilet trained self
4. Growth and Development occurs in a regular direction reflecting a definitive and
predictable patterns or trends.
A. Directional trends - occur in a regular direction reflecting the development of
neuromuscular function: these apply to physical, mental, social and emotional
developments and includes:
a. Cephalo - caudal “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.
b. Proximo- distal “Centro distal”
- progressing form center of body to extremities.
c. Symmetrical - at side of body develop on same direction at same time
at same rate.
d. Mass specific “differentiation”
In which the child learns form simple operations before complex
functions or move from a broad general pattern of behavior to a
more refined pattern.

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 B. Sequential - involves a predictable sequence of Growth and Development to
which the child normally passes.
a. Locomotion - example: creep then crawls, sit then stand, walk
then run
b. Socio and language skills - example: solitary games, parallel games
C. Secular – refers to the worldwide trend of maturing earlier and growing larger
as compared to succeeding generations.

5. Behavioral is the most compressive indicator of developmental status:

“Act at your age”
6. Universal language of child - play
7. Great deal of skill and behavior is learned by practice. Practice makes perfect.
8. There is an optimum time for initiation of experience or learning
9. Neonatal reflexes us must be lost before one can proceed.
- rooting reflex – disappear by 6 weeks
- plantar reflex - disappear before baby can walk: 8 – 9 months
- moro reflex - disappear before baby can roll : 4 – 5 months
- protect himself from the attacker
- persistent primitive infantile reflexes – suspect case of cerebral palsy
1.D Theories of Growth and Development
Developmental tasks - different form chronological age
- skills or growth responsibility arising at a particular time
in the individuals life.
Theorists
1. Sigmund Freud 1856 - 1939 Austrian neurologists. Founder and Father
of psychoanalysis
- offered personality development
Psychosexual theory
a.) Oral Phase 0 - 18 months
- mouths site of gratification
- activity of infant- biting, sucking crying.
- why do babies suck?- enjoyment and release of tension.
- provide oral stimulation even if baby was placed on NPO.
Significance: Offer pacifier - never discourage thumb sucking.
b.) ANAL - 18 months - 3 years
- site of gratification- anus Obsessive Compulsive -anal phase
- activity: elimination, retention or defecation of feces may occur
* toilet training *
- principle of holding on or letting go enters
- mother wins or child wins
- child wins - stubborn, hardheaded anti social.
(“anak pupu na”, child holds “pupu”,child wins)
Impacted stools – Letting Hold
- mother wins - obedient, kind, perfectionist, meticulous – Letting GO
Significance: help child achieve bowel and bladder control even if child
is hospitalized.

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 c.) Phallic – 4 - 6 years
- site of gratification - genitals
- activity - may show exhibitionism
- increase knowledge of a sexes
- accept child fondling his/her own genitalia as normal exploration
- answer Childs question directly.
Right age to introduce sexuality – preschool
d.) Latent – 7 - 12 years
- period of suppression - no obvious development (slower growth)
- Childs libido or energy is diverted to more concrete type of thinking
Significance: helps child achieve (+) experience so ready to face conflict
of adolescence
e.) Genital – 12 - 18 years opposite sex
- site of gratification - genitals
- achieve sexual maturity and satisfactory
- learns to establish relationships with opposite sex.
Significance: give an opportunity to relate to opposite sex.
2. ERIC ERICKSON - trained in psychoanalysis theory
- stresses important of culture and society to the
development of ones personality
Importance
a. environment
b. culture
Stages of Psychosocial
a.) Trust vs. Mistrust – 0 - 18 months.
Alert!
- foundations of all psychosocial task
- to give and receive is the psychosocial theme
To know to develop trust on baby
1. satisfy needs on time - breastfeed
2. care must be consistent and adequate - both parents - 1st 1 year of life
3. give an experience that will add to security- touch, hugs and kisses, eye to eye
contact, soft music.
b.) Autonomy vs. Shame and Doubt 18 months - 3 years
- independence / self government
To develop autonomy on toddler
1. give an opportunity of decision making like offer choices.
2. encourage to make decision rather then judge.
3. set limits – moral obligations of the parent

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 c.) Initiative vs. Guilt – 4 - 6 years
- learns how to do basic things well
To develop:
- give opportunities to explore new places and events
Activities recommended:
- modeling clay, finger painting will enhance imagination
and creativity and further enhances fine motor development
d.) Industry vs. Inferiority 7 - 12 yrs
- child learns how to do things well
To develop:
- give opportunity on short assignments and projects
e.) Identity vs role confusion or diffusion 12 - 18 yrs
- learns who he/she is or what kind of person he/ she will become by adjusting
to new body image and seeking emancipation or freedom from parents
f.) Intimacy vs. Isolation 20 – 40 years up to 45 years old
- looking for a lifetime partner and career focus
g.) Generatively vs. Stagnation 40 – 45 – 60 – 65 years old
h.) Ego Integrity vs. Despair 60 – 65 years old and above
3. JEAN PIAGET – a Swiss psychologists ; cognitive
- develop reasoning power
STAGES OF COGNITIVE DEVELOPMENT
A. Sensory Motor 0 - 2 years
- “practical intelligence”- words and symbols not yet available
- baby communicates through senses and reflexes.
(sub divided)
Schema Age Behavior
1.) Neonate Reflex 1 month All reflexes
2.) Primary Circular 1-4 - Activity related to body
months - repetition of behavior
ex. thumb sucking
3.) Secondary Circular Reaction 4-8 - activity not related to body
months - discover object and person’s
permanence
- “memory traces are present”
- anticipate familiar events.
4.) Coordination of Secondary 8 - 12 - exhibit goal directed behavior
Reaction months - increase of separateness (will
search of lost toy, knows mom)
5.) Tertiary Circular Reaction 12 - 18 - use trial and error to discover
months characteristics of places and events
-“ invention of new means”
- capable of space and time perception
(hits fork, spoon on table or drops fork)
6. ) Invention of New Means 18 - 24 - transitional phase to the pre operational
thru mental combination months thought period.

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B. Preoperational Thought 2-7 years
Schema Age Behavior
Preconceptual 2-4 - thinking basically complete literal and static
years - egocentric - unable to view on others view point
- concept of TIME is only now
- concept of distance is only as far as they can see.
- concept of animism inanimate object is alive
(animism is the main reason why they are afraid in the dark
places)
-not aware of concept of reversibility - in every action there is
an opposite reaction or cause and effect
Initiative 4-7 Beginning of causation
years
C. Concrete Operational Thought 7 - 12 years
1. able to find solution to everyday problems with systematic reasoning.
2. have concept of reversibility- cause and effect ( in every action there is an
opposite reaction )
3. have concept of conservation – constancy despite of transformation.
Activity Recommended:
- collecting and classifying Such as in collection of stamps, stationeries,
dolls, rubber band markers.
D. Formal Operational thought 12 and up.
1. Cognition achieved its final form
2. can deal with past present and future
3. have abstract and mature thoughts.
4. can find solutions to hypothetical problems with scientific reasoning.
Activity: will sort out opinions and current events.
4. KOHLBERG - recognized the theory of moral development as considered to
closely approximate cognitive stages of development
(“ sabay” with cognitive development )

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 Stages of Moral development
Infancy – “ pre-moral, pre-religious, amoral stage”
AGE STAGE DESCRIPTION
Pre-conventional Level I
2 - 3 years 1 Punishment/ obedience orientation (“heteronomous
morality”) Child does right because a parent tells him
or her to and to avoid punishment
4 – 7 years 2 Individualism. Instrumental purpose and exchange.
Carries out action to satisfy own needs rather than
society. Will do something for another if that person
does something for the child.
Conventional Level II
7 – 10 years 3 Orientation to interpersonal relations of mutuality.
Child follows rules because of a need to be a “good”
person in own eyes and eyes of others.
10 – 12 years 4 Maintenance of social order fixed rules and authority.
Child finds following rules satisfying. Follows rules of
Authority figures as well as parents in an effort to keep
the “system” working.
Post-conventional Level III
Above 12 years 5 Social contract, utilitarian level making perspectives.
Follows standards of society for good of all people
6 Universal ethical Principle orientation. Follows
internalized standards of conduct.
1.E DEV’T MILESTONES – means major markers of growth and development
E. 1. Period of infancy - universal language of child - play
a.) Play - Infancy- solitary plays
- solo, non interactive example: rattles, mobiles, teeters, music box
- facilitate motor and sensory development
Note: In choosing toys: safety - important age appropriate
b.) Fear of Infancy - stranger anxiety begin
Alert: begins at 6 - 7 months; peak - 8 months ; diminishes - 9 months
c.) Milestone
Neonate – largely reflex; complete head lag; hands fisted; cry without tears; visual
fixation for human face
1 month - dance reflex disappears looks at mobile
2 months - holds head up when in prone,
- social smile,
- baby coos “doing sound”
- cry with tears
- closure of posterior fontanel 2 - 3 months
- head lag when pulled to sitting position.

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3 months - holds head and chest up when prone
- follows object past midline
- grasp and tonic neck reflex fading
- hand regard (looks at hand)
4 months – turns form front to back
- head control complete
- needs space to turn
- Laugh aloud, bubbling sounds
5 months - turn both ways “roll over”
- teething rings
- handles rattle well
- moro reflex disappears ( 4 - 5 months)
6 months - reaches out in anticipation of being picked up
- sits with support
- uses palmar grasp
- eruption of 1st temp teeth 6-8 months 2 lower central incisors
- say vowel sounds “ah”, “oh”, “eh”
- handles bottle well
7 months – beginning fear of strangers (6 – 7 months)
- transfer object hand to hand
- likes object that are good size
8 months - sits without support
- peak of stranger anxiety
- plantar reflex disappears 8 - 9 months in preparation for walking
9 months - creeps or crawls
- neat finger grasp reflex
- combine 2 syllables “mama” and “dada”
- needs space for creeping
10 months – pull self to stand
- understands the word “no”
- responds to own name
- peak a boo, pat a cake since they can clap
11 months - cruises
- stand with assistance
12 months - stand alone take 1st step
- walk with assistance
- drink from cup, cooperate in dressing
- says 2 words mama and dada
- pots and pans, pull toy, nursery rhymes

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E.2. Toddler - parallel play - 2 toddlers playing separately
a. Play - provide with similar toys
Examples:
- squeaky frog to squeeze
- waddling duck to pull
- trucks to push- push pull toy ( best parallel toy )
- building blocks, pounding peg
- toys to ride on
b. Fear - separation anxiety
begin 9 months
peak 18 months
3 phases of separation anxiety (in order)
1. P- protect
2. D - despair
3. D- denial
How to prevent separation anxiety:
- don’t prolong goodbye
- say goodbye firmly to develop trust
- say when you will be back
c. Milestones
15 months – plateau stage
walks alone
Alert: lateness in walking- mild mental retardation
- puts small pellets into small bowl
- holds spoon well
- seats self on chair
- creep up stairs
- 4 - 6 words
- scribbles voluntarily with pencil
18 months - height of possessiveness
- favorite word- “mine”
- bowel control achieved (bowel contro1st before bladder control)
- no longer rotates spoon
- can run and jump in place
- walks up and down stairs holding on to persons hand or railing
- 7 - 20 words
- name, body part
- typically places both feet on 1 step before advancing.
24 months - also known as the terrible two
- can open doors by turning door knob or unscrew lids
- can walk upstairs alone, still using both feet on same step
at same time
- 50 - 200 words ( 2 words sentences)
- daytime bladder control achieved
(daytime 1st- next nighttime bladder control)
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30 months or 2 ½ years – makes simple lines or stroke or crosses with a pencil
- can jump down from chairs
- knows full name
- copy a circle
- holds up finger to show age
- temp teeth complete
( last temporary teeth to appear posterior molars )
( 20 deciduous teeth )
- beginning of toothbrush – 2 – 2 ½ years
- tooth brushing with little assistance 3 years
- tooth brushing alone – 6 yrs
- right time to bring to dentist- when temp teeth complete
( 2 – 2 1/2 years old )
36 months or 3 years – trusting 3
- unbutton buttons (unbutton before learn to button)
- draw a +
- learns how to share
- knows full name and sex (gender identity)
- speaks fluently
- nighttime bladder control achieved
- 300 - 900 words
- ride a tricycle
d. Character Traits of toddler
1.) Negativistic - “NO!” - way to search for independence
– limit questions; offer options
– modify questions to a statement
2.) Rigid, Ritualistic and Stereotype
ritualism - for mastering
3.) Temper tantrums- head banging, screaming, stamping feet, holds breath
What to do: ignore behavior
• Slightly protruding - scaffold abdominal - due to
underdeveloped/immaturity of the abdominal muscles
• physiologic anorexia- due to preoccupation with environment- food jag
that last for short period of time
• loves rough and tumbling play
• steady gait
• love to stay with daddy
• loves toilet training
• failure of toilet training - unreadiness
Clues of toilet readiness:
1.) can stand, squat walk alone
2.) can communicate toilet needs
3.) can maintain dry for an interval of 2 hours

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E.3. Pre schoolers - associative or cooperative play
a. Play : “bahay-bahayan” – play house
* role playing
b. Fear - body mutilation or castration
- fear of dark places witches
- fear of thunder and lightning
- fear of ghosts
c. Milestones
4years old - furious for they are noisy, aggressive, stormy
- can button buttons
- copy a square 2 – 2 1/2 years
- jumps and skips
- laces shoes 3 years
- vocabulary 1,500
- knows four basic colors
5 years old - frustrating
- copy a triangle 4 years
- draw a 6 part man
- imaginary playmates
- 2,100 words 5 years
d. Character Traits of Pre-schooler:
1.) Curious
2.) Creative
3.) Imaginative
4.) Imitative
5.) 2 favorite words – “why” and “how”
6.) complexes- word identification to parent of same sex and attachment to
parent of opposite sex
example: Oedipal complex- boy to mom
Electra complex- girl to dad
Cause of incest: marital discord
7.) Death-sleep only
Behavior problems Preschool
1. telling tall tales - over imagination
2. imaginary friend – way to release tension and anxieties
3. sibling rivalry - jealousy to newly delivered baby.
4. regression - going back to early stage
Signs of Regression:
- thumb sucking (should be oral stage only)
- baby talk
- bed wetting
- fetal position
5. masturbation- sign of boredom
What to do: - Accept and do it in private place
- Divert attention
- Offer a toy

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E.4. School Age
a. Play - competitive play
Example: Tug of war, track and field, basketball, volleyball, softball
b. Fear: 1.) school phobia - orienting the child to a new environment
2.) displacement from school - teacher and peer of same sex
3.) loss of privacy - wants bra
4.) fear of death - 7 – 9 years death is personified
- death - permanent loss of life
Preschooler - death is sleep
c. Significant Development
a. boys - prone to bone fracture - age 9 – have the same height
age 12 – girls are taller than boys
* greenstick fracture
b. mature vision 20/20
d. Milestone
6 years - temporary teeth begin to fall
- permanent teeth appear - 1st molar
* 1st temporary teeth - 5 months
* 1st permanent teeth - 6 years (1st molar)
- year of constant motion
- clumsy movement
- recognize all shapes
- 1st grade teacher becomes authority figure
- nail biting
- begin interest in God.

7 years- assimilation age

- copy a diamond
- enjoys teasing and playing alone
- quieting down period
8 years- expansive age
- smoother mouth
- loves to collect objects
- count backwards
* homosexual - normal
9 years – coordination improves
- tells time correctly
- hero worship
- stealing and lying are common
- takes care of body needs completely
- teacher finds this group difficult to handle

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10 years - age of special talent
- writes legibly
- ready for competitive games
- more considerate and cooperative
- joins organizations: girl scouts/boy scouts
- well mannered with adult
- critical of adults
11 - 12 years – pre adolescents
- full of energy and constantly active
- secret language are common
- share with friends secrets
- sense of humor present
- social and cooperative
e. Character Traits School Age
1. industrious
2. modest
3. can’t bear to lose - they will cheat
4. love collections - stamps
Signs of sexual maturity
GIRLS:
I- increase size of breast and genitalia
Alert: Menarche - 1st sign sexual maturity in girls
W- widening of hips
A- appearance axillary, pubic
Alert: (adrenarch)
M- menarche- last sign sexual maturity in Girls
BOYS:
A- appearance axillary, pubic hair
Alert: ( 1st sign sexual maturation)
D- deepening voice
D- development of muscles
I- increase in size of testes and penis
P- production of viable sperm
Alert: ( last sign sexual maturity)
E.5 Adolescent Period – significant others and peers
a. Fear
1. obesity
2. acne
3. homosexuality
4. death
5. replacement from friends

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 b. Significant Person – opposite sex
c. Significant Development
1. Experiences conflict between his needs for sexual satisfaction and societies
expectation
2. They change of body image and acceptance of opposite sex
3. Nocturnal emission – wet dreams; hallmark of adolescent
4. Distinctive odor- due to stimulation apocrine glands
5. sperm is viable by age 17 years
Alert: . testes & scrotum increase until age 17
breast and female genitalia increase until age 18
d. Personality Traits Adolescents
idealistic
rebellious
reformers
conscious with body image
adventuresome
e. Problems:
1. vehicular accident
Due to peer pressure:
2. smoking
3. alcoholism
4. drug addiction
5. pre marital sex
II. IMMEDIATE CARE OF NEWBORN
1st days of life
A. The 8 Priorities of the Newborn in the first days of life:
1. Initiation and maintenance of respiration
2. Establishment of extra uterine circulation
3. Control of body temperature
4. Intake of adequate nourishment
5. Establishment of waste elimination
6. Prevention of infection
7. Establishment of an infant-parent relationship
8. Developmental care that balances rest and stimulation for Mental
Development
1.) Initiation and maintenance of respiration
Alert: 1. 2nd stage of labor- initial airway
2. Initiation of airway is a crucial adjustment among the newborn
3. Most neonatal deaths with in the first 24 hours is primarily caused
by inability to initiate airway
4. Lung function begins only after birth

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 How to initiate airway:
A. Remove secretions bulb syringe
B. Proper Suctioning with a Catheter
1.) place head to side to facilitate drainage of secretion
2,) suction mouth 1st before nose
- neonates are nasal breathers / obligatory nasal breather
3.) period of time
- 5 - 10 seconds suctioning, gentle and quick
prolonged and deep suctioning can lead to:
a. hypoxia
b. laryngo spasm
c. bradycardia due to stimulation vagal nerve – located near the
esophagus and anus
4.) evaluate for patency
- cover one nostril and when the baby struggles there’s a need for
q additional suctioning
C. If not effective, requires effective laryngoscopy to open airway.
After deep suctioning an endotracheal tube can be inserted and oxygen
can be administered by an (+) pressure bag and mask with 100% oxygen
at 40 – 60 bpm.
Nursing Alert:
1. No smoking for it can facilitate combustion
2. Always humidify to prevent drying of mucosa (Mask should cover the
nose/mouth not including the eyes)
3. Over dosage of oxygen can lead to scarring of retina leading to
blindness ( retro lentalfibroplasia or ROP - retinopathy of prematurity)
4. When mecomium stained (greenish) never administer oxygen with
pressure ( O2 pressure will push mecomium inside) to prevent
atelectasis
2.) Establishing extra uterine circulation
Nursing Alert: circulation is initiated by lung expansion or pulmonary ventilation
and
completed by cutting of cord.
FETO PLACENTAL CIRCULATION
Placenta (simple diffusion) → oxygenated blood is carried by the umbilical vein →
passes liver → ductus venousus → Inferior Vena Cava → Right Atrium 70% blood
is shunted to → Foramen Ovale → Left Atrium → Mitral Valve →Left Ventricle
→ Aorta → Lower Extremities. The remaining 30% → Tricuspid Valve → Right
Ventricle → Pulmonary Arteries → Lungs (for nutrition) → vasoconstriction of
lungs pushes blood to the → ductus arteriousus to the → aorta → to supply upper
extremities. The two arteries carry the unoxygenated blood back to the placenta for
oxygenation.
Alerts: Increase Pressure to the left side → closure of foramen ovale

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 SHUNTS - shortcuts
Ductus Venosus - shunts from liver to Inferior Vena Cava
Foramen Ovale - shunts between 2 atrias
Ductus Arteriosus - from pulmonary artery to aorta

Decrease PO2, increase PCO2 acidosis

Will cause 1st breath /cry of baby

Decrease pulmonary artery pressure

Increase PO2 Decrease blood Increase pressure to

flow Left side of heart

Closure of Closure of
Closure of foramen
ductus ductus venosus
ovale
arteriosus & AVA

st
What will
What will initiate
sustain 1lungbreath - decreased
circulation - lungartery pressure
expansion
What will complete circulation - cutting of cord
A. 2 way to facilitate closure - of foramen ovale
a.) Tangential Foot slap - slap foot of baby to make the baby cry
Alert: - never stimulate the baby to cry if secretions not fully drained to prevent
aspiration
- check characteristic of cry
normal cry- strong, vigorous and lusty cry “UHA”
cri-du-chat syndrome-chromosomal obliteration / cat like cry or meow
like cry
b.) Proper Positioning - right side lying position
- will increase pressure on left and foramen ovale will close
Foramen Ovale and Ductus arteriosus will begin to close within 24 hours
Obliteration - means complete closure

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 Structure Appropriate time of Structure remaining Failure to close
obliteration
Foramen 1year Fossa Ovalis Atrial Septal Defect
Ovale (ASD)
Ductus 1 month Ligamentum Arteriosum Patent Ductus
Arteriosus Arteriosus (PDA)
Ductus 2 months Ligamentum venosum
Venosus
Umbilical 2 - 3 months 1.) lateral umbilical
Arteries Ligament
2.) interior iliac artery
Umbilical 2 - 3 months -ligamentum teres ( round
Vein ligament of liver)

Position of infant immediately after birth:

NSD – trendelenberg / T position for drainage
contraindication of trendelenberg position - increase ICP
CS - supine or crib level position
Signs of increased ICP
1.) abnormally large head
2.) bulging and tense fontanel
3.) increase BP and widening pulse pressure Cushing Triad of ICP
4.) Decreased Respiratory Rate, decreased Pulse Rate “hypo-brady-brady”
5.) projective vomiting - sure sign of cerebral irritation
6.) high deviation – diplopia – sign of ICP older child
4 - 6 months - normal eye deviation
> 6 months - lazy eyes or indication of ICP
7.) High pitch shrill cry - late sign of ICP or hypoglycemia
3.) Temperature Regulation
Alerts:
- goal in temperature regulation is to maintain it not less than
97.7%° F (36.5° C)
- maintenance of temperature is crucial on preterm and SGA (small for
gestational age) - babies prone to hypothermia or cold stress
A. Factors Leading to the development of HYPOTHERMIA
1. preterms are born per kilo thermic - means cold blooded
- babies easily adapt to temperature of environment due to immaturity of
thermo regulating system of body → Hypothalamus
2. inadequate Sub cutaneous tissue
3. new born is not capable of shivering
4. babies are born wet

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 B. PROCESS OF HEAT LOSS
1. evaporation - body to air (TSB)
2. conduction - body to cold solid object (cold compress)
3. convection - body to cooler surrounding air (aircon)
4. radiation - body to cold object not in contact with the body
earliest sign of hypothermia - increase in Respiratory Rate
C. Effects of Hypothermia ( Cold stress)
1.) Hypoglycemia - 45 - 55 mg/dl normal
40 - borderline
2.) metabolic acidosis – catabolism (breaking down) of brown fats (best insulator of
newborns body) leading to formation of ketones
3.) high risk for kermicterus body - bilirubin in brain leading to irreversible brain
damage such as cerebral palsy
4.) additional fatigue to a stressful heart
D. Prevent Hypothermia
1. dry and wrap baby
2. mechanical pressure – radiant warmer
i. pre-heated first isolette (or square acrylic sided incubator)
3. prevent an necessary exposure – cover the areas that is not being examine
4. cover baby with tin foil or plastic
5. embrace the baby - known as kangaroo care
4. Establish Adequate Nutritional Intake
CS- breastfeeding after 4 hours Board
NSD- breastfeeding as soon as possible Question
Alerts:
A. Physiology breast milk production
As you deliver baby, decrease Estrogen, decrease Progesterone- -Anterior
Posterior Gland (APG) releases prolactin – acts on acinar cells (or alveoli) –
produce foremilk – stored in lactiferous tubules ( or collecting tubules of the
breast ) where breast milk is produced – alveoli posterior pituitary gland
Sucking → PPE → oxytocin → contraction of smooth muscles of lactiferous
tubules → milk ejection reflex → let down reflex.
B. Advantages of Breastfeeding
1. Very Economical
2. Always available
3. Facilitates Bonding
4. It facilitates rapid involution
5. Decrease incidence of breast cancer.
6. has antibodies - IgA
7. Breastfed babies have higher IQ than bottle fed babies
8. Has lactobacillius bifidus- interferes with attack of pathogenic bacteria
in GastroIntestinalTract
9. Has macrophages – engulfs bacteria
Store milk - plastic storage container
Store milk – good for 6 months from freezer
- put room temperatrure
- don’t heat
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 Disadvantages:
1. Possibility of transfer HEP B, HIV, cytomegalo virus(CMV)
2. No iron
3. Father can’t feed & bond as well
C. Stages of Breastmilk:
1. Colostrum – 2 - 4 days present
content: decrease fats
increase IgA
decrease CHO
increase CHON
increase minerals
increase fat soluble vitamins
2. Transitional milk - 4 – 14 days
content: increase lactose
increase water soluble vitamins
increase minerals
3. Mature milk - 14 days & up
content: Increase Fats (linoleic acid) – cause for higher IQ
( responsible for the development of the brain &
integrity of skin )
Increase CHO - lactose – easily digested, that is
why the baby not constipated ( responsible for
sour milk smelling odor of stool )

Lactose intolerance - deficiency of enzyme LACTASE that digest

LACTOSE protein - lactoallbumin
D. Cows milk – increase fats
Contents: Decrease CHO – that is why we need to add a little sugar
Increase CHON – casein has curd that’s hard to digest –
that is why baby is constipated.
Increase Minerals – traumatic effect on kidneys of babies.
Can trigger stone formation in the kidney
Increase Phosphorus – reverse proportion in Calcium
E. Health Teachings:
1. Proper hygiene - proper hand washing
Care of breast - cotton balls with lukewarm water – “inner to outer”
Caked colostrums - dry colostrums on breast
2. Best position in breastfeeding – upright sitting - avoid tension!

20
 3. Stimulate & evaluate feeding reflexes
a.) Rooting reflex - by touching the side of lips/cheeks then baby will turn
to stimulus. Disappear by 6 weeks- by 6 weeks baby
can focus. Reflex will be gone
Purpose rooting: to look for food.
b.) Sucking Reflex – when you touch middle of lips then baby will suck
- Disappears by 6 months
- When not stimulated easily disappear
Purpose: to take food
c.) Swallowing - when food touches posterior of tongue then it will be
automatically swallowed
d.) Extrusion/ Protrusion reflex - when food touches anterior portion of
tongue then food will be automatically
extruded or protruded
Purpose: to prevent from poisoning
Disappear by 4 months & baby can already spit out by 4 months.
Extrusion – “no force”
Spitting Up – “with force”
4. Criteria Effective Sucking
a.) Baby’s mouth is hike up well to areola
b.) That Mom experiences after pain.
c.) Other nipple is also flowing with milk.
5. To prevent from crack nipples & initiate proper production of oxytocin.
- begin 2 - 3 minutes at each breast ( 5 – 7 minutes other authors )
to initiate production of oxytocin
- increase 1 minute / day – until reaching 10 minutes at each breast or
20 minutes / feeding.
6. For proper emptying & continuous milk production / feeding
- feed baby on last breast that you feed her with alternately
( if not emptied - mastitis)
Problems experienced in Breastfeeding :
Changes in breast post partum:
a.) Engorgement - feeling of fullness & tension in the breast.
- sometimes accompanied by fever known as MILK FEVER.
Management: Warm compress - for breastfeeding mom
Cold compress – for bottle feeding & wear snug
supportive bra.
When is involution of breast? - 4 weeks

21
 b.) Sore nipple – cracked, wet and painful nipple
Management:: 1.) exposure to air – remove bra & wear dress
2.) expose to 20 Watt bulb
3.) avoid wearing plastic liner bra – prevent air to
enter
- will create moisture, cotton only
c.) Mastitis- inflammation of breast, cause by staphylococcus aureus
Factors:
1. Improper breast emptying
2. Unhealthy sexual practices
- contraindicated for breast feeding
- manually express inflamed breast
- feed on unaffected breast
- give antibiotics – can still feed on unaffected breast
Contra Indications in Breast Feeding:
Maternal Conditions:
HIV
CMV
Hepatitis B
Coumadin
Newborn Condition - Inborn errors of metabolism
1. Erythrobastosis Fetalis – Rh incompatibility
2. Hydrops Fetalis
3. Phenylketonuria (PKU)
4. Galactosemia
5. Tay Sachs disease

5. Establish of waste – elimination

A. Different Stools
A.1. Meconium - physiologic stool
- black green, sticky, tar like, odorless because of Sterile intestine
- will pass with in 24 – 36 hours
failure to pass mecomium after 24 hour - GastroIntestinalTract obstruction
example: 1. Hirschsprungs disease
2. Imperforate anus
3. Mecomium ileus – due to Cystic Fibrosis
A.2. Transitional stool -
- green loose & slimy that may appear to be like diarrhea
to the untrained eye
A.3. Breastfed stool - golden yellow, soft, mushy with sour milk smelling odor
frequently passed
- recurring almost nearly every feeding

22
 A.4. Bottlefed stool –
- pale yellow, formed hard with typical offensive odor
- seldom passed, 2 – 3 times a day
- with food added
- brown & odorous
B. Indication of Stool Changes
Jaundice baby – light stool
Undergoing phototherapy – bright green
Mucus mixed with stool - milk allergy
Clay colored stool – obstruction to bile duct
Chalk clay stool – after barium enema
Black stool – GIT bleeding (melena)
Blood flecked stool - anal fissure.
Currant jelly stool – intussusceptions
Ribbon like stool – hirschsprung disease
Steatorrhea stool – fatty, bulky foul smelling odor stool
Malabasorption Syndrome
1. celiac disease or
2. cystic fibrosis
Cult blood – stool exam
III Assessment for Well – being
A. APGAR SCORE – Dr. Virginia Apgar
Special Considerations:
1st 1 minute – determine general condition of baby
Next 5 minute - determine baby’s capabilities to adjust extra uterinely
(most important )
Next 15 minute – dependent on the 5 minute
Newly Born Baby:
A- appearance - color – slightly cyanotic after 1st cry baby becomes pink.
P- pulse rate – apical pulse – left lower nipple
G- grimace – reflex irritability
Subcomponents: tangential foot slap, catheter insertion
A – activity – degree of flexion or muscle tone
R – respiration
New Delivered Baby:
Baby cry – within 30 seconds
Failure to cry after 30 seconds – asphyxia near the neotorium
Respiratory Depression – due mom given Demerol. Administer Naloxone

23
APGAR Scoring Chart:

0 1 2
Heart Rate - absent < 100 > 100
Respiratory effort - absent - slow, irregular, - good strong cry
weak
Muscle tone - flaccid extremities - some flexion - well flexed
Reflex irritability
Catheter - no response - grimace - cough, sneeze
Tangential Foot slap No Reaction - grimace - cry
Color - blue / pale - acrocyanosis - pinkish
( body- pink
extremities-blue )
APGAR result
0 – 3 = severely depressed, need CPR, admission NICU
4 – 6 = moderately depressed, needs additional suctioning & Oxygen Administration
7 - 10 = good / healthy
Cardio Pulmonary-Resuscitation
Cardio pulmonary resuscitation or CPR other name
Cardio pulmonary cerebral resuscitation (CPCR)
Basic Life Support ( BLS )
Airway ( Clear Airway)
5 minutes “no” Oxygen – irreversible brain damage
1. Shake, no respiration, call for help
2. Flat on head
3. Head tilt chin lift maneuver [except spinal cord injury] over extension may
occlude airway
Breathing ( ventilating the lungs )
4. Check for breathlessness
5. If breathless, give/administer 2 breaths- ambu bag – use one mask
* infant – mouth and nose
> 1 year old- mouth to mouth, pinch nose
< 1 year – mouth to nose
force – different between baby & child
infant – puff
Circulation ( by cardiac compression )
6. Check for pulslessness :carotid- adult
Brachial – infants up to 1 year old
CPR – breathless/pulseless
Compression – infant – 1 finger breath below nipple line or 2 finger breaths or thumb

CPR infant 1 : 5
Adults 2 : 15
7. Assessment tool determines respiration of baby
24
 Tool Use: Silvermann Anderson Index

B. Respiration Evaluation – lowest score – best

Criteria 0 1 2
Chest movement synchronized Lag on respiration See - saw
Intercostal retraction No retraction Just visible Marked
Xiphoid retraction None Just visible Marked
Nares dilatation None Minimal Marked
Expiratory grunt None Heard on stet only Heard on naked ear
Interpretation result:
0 - 3 – normal, no Respiratory Distress Syndrome
4 – 6 – moderate Respiratory Distress Syndrome
7 – 10 – severe Respiratory Distress Syndrome
C. Assessment of Gestational Age
Tool Used: Ballards & Dobouitz
Findings Less 36 weeks 37 - 38 39 and up
(Preterm)
Sole creases Anterior transverse Occasional creases Sole covered with
crease only 2/3 inch creases
Breast nodules 2 mm 4 mm or 3.5 mm > 5 or 7 mm
Scalp hair Fine & fuzzy Fine & fuzzy Coarse & silky
Ear lobe Pliable Some cartilage Thick cartilage
Testes and testes in lower canal Some intermediate Testes pendulus
Scrotum Scrotum – small few Scrotum full
rugae extensive rugae
Signs of Preterm Babies
Born after 20 weeks, after 37 weeks
- frog leg or laxed positon
- hypotonic muscle tone- prone to respiratory problem
- scarf sign – elbow passes midline
- square window wrist – 90 degrees angle of wrist
- heel to ear sign
- abundant lanugo
Signs of Post term babies:
> 42 weeks
- classic sign – old man’s face
- desquamation – peeling of neonate skin
- long brittle finger nails
- wide & alert eyes
IV. Neonate in Nursery
* Special and Immediate Interventions:
1. Upon receiving baby
- proper identification
- foot printing, affixing mother thumb print

25
 2. Take anthropometric measurement
Normal Length - 19.5 – 21 inches or 47.5 – 53.75 cm
Average = 20 inches Average = 50 cm
Head Circumference 33- 35 cm or 13 – 14 inches
Average = 34 cm
Hydrocephalus - >14 inches
Chest : 31 – 33 cm or 12 – 13 inches
Abdomen 31 – 33 cm or 12 – 13 inches
Note: Head is bigger than the chest/abdomen
3. Bathing
- oil bath – initial
- to cleanse baby & spread vernix caseosa
Function of vernix caseosa
1. insulator – “brown fats”
2. bacterio - static
Alert: 1. Babies of HIV + mom – immediately give full bath; to lessen
transmission of HIV ; 13 – 39 % possibly of transmission of HIV
2. Full Bath - safely given when cord falls
4. Dressing the Umbilical Cord
* follow strict asepsis to prevent tetanus neonatorium by giving
tetanous toxoid
three cleans in community:
1. Clean hand
2. Clean cord
3. Clean surface
Note: Betadine or Povidone Iodine - used for cleaning the cord
Umbilical Granulation – after 2 weeks, umbilical cord does not fall.
* Check for three vessels
Alert: 1. If 2 vessel cord – suspect kidney malformation
2. Leave about 1 inch of cord
* If Blood Transfusion or IV infusion
– leave 8 inches of cord best access
– no nerve
* Check cord every 15 minutes for 1st 6 hours – bleeding
> 30 cc. of blood – “hemorrhage” to the new born
* Bleeding of cord with pus – Omphalitis – suspect
hemophilia/blood dyscrasia
* Best access for IV transfusion – Umbilical cord
* Cord turns black on 3rd day & fall 7 – 10 days
* Faiture to fall after 2 weeks- Umbilical granulation
Management: silver nitrate or catheterization
- clean with normal saline solution not alcohol
- don’t use “bigkis” – air
- persistent moisture-urine, suspect patent uracus – fistula between
the bladder and normal umbilicus
Diagnostic Examination: Nitrazine paper test – yellow – urine
Management: Surgery
26
 5. Credes Prophylaxis – Dr. Crede
- prevent opthalmia neonatorum or gonorrheal conjunctivitis
- how transmitted – mom with gonorrhea/ chlamydia
Drug: Erythromycin Ophthalmic Ointment- inner to outer
silver nitrate (used before) – 2 drops lower conjunctiva (not used due to staining)
6. Vitamin K – to prevent hemorrhage Related To physiologic
hypoprothrombinemia
- Aquamephyton, phytomenadione or konakion
- .5 – 1.5 ml IM, vastus lateralis or lateral anterior thigh
- 5 ml preterm baby
Vitamin K – synthesized by normal flora of intestine
Vitamin K – medication is synthetic due intestine is sterile
7. Weight - Taking:
Normal weight: 3.000 – 3400 grams ;
3 – 3.4 kg
6.5 - 7.5 lbs
Arbitrary lower limit 2500 grams
Low birth weight baby delivered < 2500g
Small for gestational age (SGA) < 10th % rank or born small
Large for gestational age > 90th % rank or macrosomia > 4000 g
Appropriate for Gestational Age – within 2 standard deviation of mean
Physiologic weight loss – 5 – 10% wt loss few days after birth
Small Gestational Age < (less) 10
Large Gestational Age > (more) 90
V. Physical Exam and Deviations from Normal
A. Important Considerations:
1. if client is new born, cover areas not being examined
2. if client is infant – the 1st yr of life - the first vital sign to take
* from the least intrusive to the most intrusive area
– take Respiratory Rate 1st
3. if client is a toddler and preschool, let them handle an instrument like:
- play syringe or stethoscope, security blanket – favorite article.
Let baby hold it.
3. if the client is school age and adolescent, explain procedure and respect their
modesty

27
B. Components:
1. Vital Signs:
* Temperature
rectal - newborn – to rule out imperforate anus
- take it once only, 1 inch insertion
Imperforate anus
1. atretic – no anal opening
2. agenetic – no anal opening
3. stenos – has opening
4. membranous – has opening
Earliest sign:
1. no mecomium
2. abdominal distention
3. foul odor breath
4. vomitous of fecal matter
5. can aspirate – respiratory problem
Management:
Surgery with temporary colostomy
* Cardiac rate: 120 – 160 beats per minute newborn
Apical pulse – left lower nipple
Alert:
Radial pulse – normally absent. If palpable present PDA
( Patent Ductus Arteriosus )
Femoral pulse – normal present. If absent- COA
( Coartation of Aorta )
* Congenital Heart Disease
* Common in girls :
1. PDA (Patent Ductus Arteriousu)
2. ASD (atrial septal defect)
* Common in boys:
1. TOGA ( transportation of great arteries)
2. TA – ( tricuspid atresia)
3. TOF – (tetralogy of fallot)
Causes:
1. familial
2. exposure to rubella (german measles) – 1st month
3. failure of structure to progress
Two Major Types:
1. acyanotic Left to Right
2. cyanotic Right to Left

28
Two Major Types:
A. Acyanotic heart defects Left to Right Shunting
* with increase Pulmonary Blood Flow
1. Ventricular Septal Defect - opening between 2 ventricles
Signs & Symptoms:
1. systolic murmurs at lower border of sternum and no other significant signs
2. cardiac catheterization reveals increased oxygen saturation at the Right side
of the heart
3. ECG reveals hypertrophy of the right ventricle or Right side of the heart
50% - goes to the Upper/Lower extremities
50% - right side of the heart – causing hypertrophy of the right ventricle
Nursing Care:
Cardiac catheterization: common site – Right femoral vein
1. NPO 6 hours before procedure
2. protect site of catheterization.
PROTECTION OF Femoral Vein:
a. Avoid flexion of joints proximal to site.
b. Observe for the signs and symptoms of complications
3. assess for complication
1. infection
2. thrombus formation – possible embolism
4. check pedal pulse ( dorsalis pedis)
Management:
1.) self limiting
2.) open heart surgery
2. Atrial Septal Defect – failure of foramen ovale to close within 24 hours
(closure)
Position: right side lying position
Signs and Symptoms:
1. systolic murmur @ upper border of sternum
2. result of cardiac catheterization & ECG same with
Ventricular Septal Defect
Management: open heart surgery

29
 3. Endocardial Cushion Defects – also known as atrium ventricular (AV )
– canal between the atria and ventricles ; affects both tricuspid
and mitral valve

Signs and Symptoms:

confirmed by cardiac catheterization
Management: open heart surgery
4. PDA – Patent Ductus Arteriosus
- failure of ductus arteriosus to close
- should close within 24 hours - complete close – 1 month
Signs and Symptoms:
1. continuous machinery like murmurs
2. prominent/ presence radial pulse
3. ECG- hypertrophy Left ventricle
Management:
1. Endomethazine – prostaglandin inhibitor - facilitate closing of PDA
2. Ligation of PDA by 3 - 4 years old
3. thoracotomy procedure- nakadapa child
* with decrease Pulmonary Blood Flow
1. Pulmonary Stenosis
- narrowing of valve of pulmonary artery
Signs &Symptoms:
1. typical systolic ejection murmur
2. S2 sound widely split
3. ECG - Right ventricular hypertrophy
2. Aortic Stenosis
– narrowing of valve of aorta
Signs and Symptoms:
1. inactive, symptoms same with angina
2. typical murmur
3. rough systolic sound and thrill
4. ECG- Left ventricular hypertrophy
* If active – the child may exhibit signs of Angina
Management: Pulmonary Stenosis & Aortic Stenosis
1.) balloon stenostomy
2.) surgery – recurrent so the “least” important

30
 3. Duplication of Aortic Arch
- doubling of arch of aorta causing compression to trachea and esophagus

Signs &Symptoms:
1. dysphagia
2. dyspnea
3. left ventricular hypertrophy – ECG
Management: close heart surgery
4. Coartation of Aorta
– narrowing/ congestion of arch of aorta
Outstanding Symptom : absent femoral pulse
* Blood Pressure higher on upper extremities and decreased on
lower extremities
* ECG – hypertrophy Left ventricle
Management: close heart surgery
B. CYANOTIC HEART DEFECTS Right to Left

* with increase Pulmonary Blood Flow

1. Transportation of Great Arteries (TOGA)
- a situation wherein aorta arising from Right ventricle
pulmonary artery arising form Left ventricle

Outstanding Symptoms:
1. cyanosis after the 1st cry (due to no oxygenation)
Mechanism to decrease
polycythemia – increased RBC = compensatory mechanism to decrease
Oxygen supply = viscous blood causing =thrombus = embolus = stroke
(complications)
2. ECG – cardiomegaly
Management:
Palliative repair – rashkind procedure
Complete repair – mustard repair
2. Total Anomalous Pulmonary
venous return – pulmonary vein instead of entering Left atrium, enters Right
atrium or Superior Vena Cava
• Increased pressure on Right so blood goes to Left (open foramen Ovale)
• Right to Left Shunting supplying the body mixture with blood
Outstanding Sx: Open foramen ovale
Mild to moderate cyanosis
Polycythemia = thrombus = embolus = stroke
31
 Asplenia - absent spleen
Management: Restructuring of heart

3.) Truncus Arteriousus - aorta & pulmonary artery is arising from 1 single vessel or
common trunk with VSD
Signs & Symptoms: 1. cyanosis
2. polycythemia – thrombus = embolus = stroke
Management: Restructuring of Heart
4.) Hypoplastic Left heart syndrome – non-functioning Left ventricle
* Function of the left ventricle is to pump oxygenated blood to aorta
Signs and Symptoms:
1. cynosis
2. polycythemia – thrombus = embolus = stroke
Management: heart transplant
5.) Tricuspid atresia – failure of tricuspid valve to open
Signs and Symptoms: 1. open foramen ovale
(R to L shunting – goes to Lt atrium)
2. cynosis
3. polycythemia
Management: Fontan procedure – open tricuspid valve
6.) Tetralogy of Fallot
Four Anomalies Present:
P – pulmonary stenosis
V – ventricular Septal Defect
O – overriding or dextroposition of aorta
R – Right ventricular hypertrophy
Signs & Symptoms:
1. Right ventricular hypertrophy
2. high degree of cyanosis
3. polycythemia
4. severe dyspnea – only relieve by squatting position – inhibit venous return
- facilitate lung expansion.
5. growth retardation – due no O2
6. Tet Spell or blue spells - short episodes of hypoxia
7. syncope or fainting
8. clubbing of fingernails – due to chronic tissue hypoxia
9. mental retardation – due decreased O2 in brain
Management:
1. Oxygen
2. no valsalva maneuver , fiber diet laxative
3. morphine – hypoxia
4. propranolol (Inderal) – decrease heart spasms
5. palliative repair –
BLT blalock taussig procedure
Brock procedure – complete repair

32
ACQUIRED HEART DISEASE
1. RHD Rheumatic Heart Disease
- inflammatory disease followed by an infection acquired/caused by group A
Beta hemolytic strepto coccus
Affected body parts :
1. cardiac muscles and valves
2. musculoskeletal
3. CNS
4. Integumentary
* From initial Sorethroat before RHD
Tonsillitis (children because they love sweets)
* Aschoff Bodies – rounded nodules with multinucleated cells and fibroblasts that stays
and occludes mitral valve.
Signs and Symptoms:
Jones Criteria
Major Minor
1. polyarthritis – multi joint pain 1. arthralgia – joint pain
2. chorea – sydenhamms chores or 2. low grade fever
st. vetaus dance - purposeless involuntary hand and
movements of shoulder accompanied by grimacing
3. carditis – tachycardia 3. all lab results = elevated
4. erythema marginatum - macular rashes increase antibody
SQ nodules “ C reactive protein
“ erythrocyte
sedimentation rate
“ anti- streptolysin
O titer (ASO)
Criteria:
Presence of 2 major signs, or 1 major and 2 minors + history of sore throat will
confirm the diagnosis
Diagnostic Tests:
1. Antibody
2. C-reactive protein
3. Erythrocyte Sedimentation Rate
4. Anti – Streptolysin O titer (ASO).
Nursing Care:
1. Complete Bed Rest
2. Avoid contact sports
3. throat swab – prepare culture and sensitivity
4. antibiotic management – to prevent recurrence
5. aspirin – anti-inflammatory. Low grade fever – don’t give aspirin.
Side Effects of aspirin:
* Reyes syndrome – “encephalopathy” – accompanied by fatty infiltration of
organs such as liver and brain
33
Respiration
Newborn respiration: 30 - 60 breaths per minute, irregular abdominal or diaphragmatic
with short period of apnea (absence of breathing) without cyanosis
< 15 seconds – normal apnea – newborn

Respiratory Check:
Newborn – 40 – 90
1 year - 20 – 40
2 – 3 years - 20 – 30
5 years - 20 – 25
10 years - 17 – 22
15 years & above 12 – 20
BREATH SOUNDS HEARD DURING ASCULTATION:
1.) VESICULAR – soft, low pitched, heard over periphery of lungs, inspiration longer
than expiration. Normal
2.) BRONCHOVESICULAR - soft, medium-pitched, heard over major bronchi,
inspiration equals expiration. Normal
3.) BRONCHIAL SOUNDS - loud high pitched, heard over trachea, expiration longer
than inspiration. Normal

4.) RHONCHI – snoring sound made by air moving through mucus in bronchi. Normal
5.) RALES - or crackles ( like cellophane ) made by air moving through fluid in alveoli.
Abnormal : denotes pneumonia or pulmonary edema which is fluid in
alveoli
6.) WHEEZING - whistling on expiration made by air being pushed through narrowed
bronchi .Abnormal: seen in children with asthma or foreign-body
obstruction.
7.) STRIDOR - crowing or rooster like sound made by air being pulled through a
constricted larynx. Abnormal : seen in children with respiratory
obstruction
8.) R ESONANCE – Loud , low tone, percussion sound over normal lung tissue
9.) HYPERRESONANCE – Louder. lower sound than resonance, a percussion sound
over normal lung tissue
Asthma - pathognomonic sign – expiratory wheezing
Pet – fish. Sport – swimming
Drugs – Amynophylline
Monitor blood pressure, may lead to hypotension
RDS (respiratory distress syndrome or hyaline membrane disease)
Cause: lack of surfactant ( Lecithin) – for lung expansion
34
 Hypotonia, Post surgery, Common to preterm

Fibrine hyaline
Symptoms:
1. definite with in 1st 4 hours of life
2. RETRACTION: EARLIEST SIGN
Increase RR with retraction
3. Inspiratory grunting – pathognomonic
7 – 10 severe RDS (silvermenn Anderson index)
cyanosis due to atelectasis
4. flaring alaenacy
Management:
1. surfactant replacement and rescue
2. position: head elevated
3. proper suctioning – 5 – 10 seconds
4. oxygen with increase humidity - to prevent drying of mucosa
5. monitor Vital Signs, skin color , ABG
6. CPAP- continuous positive airway pressure
7. PEEP - positive end expiratory pressure
Purpose of # 6-7 - to maintain alveoli partially open and alveoli collapse
LARYNGOTRACHEOBRONCHITIS
LTB – most common Croup – refers to the viral infection of larynx (inflamed),
trachea & bronchi
outstanding symptoms: croupy cough or barking
pathognomonic - stridor = signs of carbon dioxide retention ( Respiratory Acidosis)
- labored respiration
- respiratory acidosis
- end stage – death
Laboratory:
1. ABG
2. throat culture
3. diagnosis - neck
4. Chest x-ray to rule out epiglotitis
Nursing Management:
1. bronchodilators ( Racemic Epinephrine )
2. increase oxygen with humidity
3. prepare tracheostomy set
Laryngo Tracheo Bronchitis LTB
- inspiratory stridor – pathognomonic sign

BRONCHOLITIS - Inflammation of bronchioles – tenacious mucus

Causative agent – RSV – Respiratory sincytial viruses
Symptoms: flu like symptoms/cold like symptoms
Increased Respiratory Rate
Drug: Antiviral – Ribavirin
End stage – epiglotitis

35
EPIGLOTITIS - inflammation of epiglottis
- emergency condition of Upper Respiratory Tract Infection
Symptoms: sudden onset
Tripod position – leaning forward with tongue protrusion
Management: Avoid/never use tongue depressor
prepare tracheotomy set
< 5 years old – unable to cough out, put on mist tent (humidifier o2)
or croupette
Nursing Care: check edges tucked on mist tent
Provide washable plastic material toys for mist tent
No toys with friction due Oxygen
No hairy toys – due moist environment medium for bacterial growth
Drug of Choice: RIBAVIRIN

• Blood Pressure Cuff should cover 2/3 or 50 – 75% of the upper arm
• More than 2/3 = low Blood Pressure
• Below 2/3 = False high blood pressure
* Blood Pressure – 80/46 mmHg newborn
* Blood Pressure after 10 days - 100/50
* Blood Pressure taking begins by 3 years old
COA coartation of aorta – take Blood Pressure on 4 extremities

2. SKIN:
Acrocyanosis – Body : pink
- Extremities: blue
BIRTHMARKS:
1. Mongolian spots – stale gray or bluish discoloration patches commonly seen
across the sacrum or buttocks due to accumulation of
melanocytes. Disappear by 1 year old . Common in Asian
new borne
2. Milla – plugged or unopened sebaceous gland . white pin point patches on nose,
chin or cheek. Disappear without treatment by 2 -4 weeks
3. Lanugo – fine, downy hair – common preterm
4. Desquamation – peeling of newborn skin within 24 weeks – post term
- extreme dryness that begin sole and palm.
5. Stork bites (Talengeictasi nevi) – pink patches at the nape of the neck
 hair will grow as child grows old
6. Erythema Toxicum – (flea bite rash) - 1st self limiting rash appear sporadically &
unpredictably any time & place.
7. Harlequin sign – dependent part is pink, independent part is blue
(side lying – bottom part is dependent pink)
8. Cutis Marmorato – transitory mottling of neonates skin when exposed to cold.
9. Hemangiomas – vascular tumors of the skin

36
 3 types Hemangiomas
a.) Nevus Flammeus – port wine stain – macular purple or dark red lesions
usually seen on the face or thigh. NEVER disappear but
as the child grows it can be removed surgically
b.) Strawberry hemangiomas – nevus vasculosus – dilated capillaries in the
entire dermal or subdermal area continuing to enlarge
but disappears after 10 years old.
c.) Cavernous hemangiomas – consists of communicating network of venules
in subcutaneous tissue that never disappear with age.
MOST DANGERIOUS – internal hemorrhage
10. Vernix Caseosa – white cheese like for :
1. lubrication
2. insulator Significance
3. bacterio static
Skin color and their significance:
blue – cyanosis or hypoxia
Pale skin - anemia
White/Shining – edema
Grey – infection
Yellow – jaundice , carotenimia - ↑ carotene in the skin
* BURN TRAUMA – is an injury to body tissue caused by excessive heat.

INFANT 5 - 9 years old

ANTERIOR POSTERIOR Anterior Posterior
Head 9.5 9.5 6.5 6.5
Neck 1 1 1 1
Upper arm 2 2 2 2
Lower arm 1.5 1.5 1.5 1.5
Hand 13 1.25 1.25 1.25
Trunk 13 13
Back 13 13
Genital 1 1
@ buttocks 2.5@ 2.5 @
Thigh 2.75 2.75 4 4
Leg 2.5 2.5 3 3
foot 1.75 1.75 1.75 1.75

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 Assessment:
1. DEPTH
1st degree – (partial thickness) – involves only the superficial epidermis
characterized by erythema, dryness and PAIN
example: sunburn, heals by regeneration from 1 – 10 days
2nd degree – (partial thickness) – involves the entire epidermis & portion of
dermis, characterized by erythema, blisters, moist from exudates
which is extremely painful
example: scalds
3rd degree – (full thickness) – involves both skin layers, epidermis and dermis/
may involve adipose tissue, fascia, muscle & bone. It is leathery,
white or black and not sensitive to pain since nerve endings had been
destroyed.
Example: lava burns; flames
Management:
1.) 1st aid a.) put out flames by rolling child on a blanket
b.) immerse burned part on cold water
c.) remove burned clothing of with sterile material
d.) cover burn with sterile dressing
2.) Maintenance of a patent airway
a.) suction if necessary (PRN)
b.) administration of oxygen with increased humidity
c.) endotracheal intubation
d.) tracheostomy
3.) Prevention of shock & Fluid and Electrolyte imbalance
a. colloids to expand blood volume
b. isotonic saline to replace electrolytes
c. dextrose & H2o to provide calories
4.) A booster dose of Tetanus toxoid
5.) Relief of pain such as IV analgesic
MORPHINE SO4 – needed for 2nd degree – very painful
6.) prevention of wound infection
1st defense of body – intact skin
a.) cleaning & debriding of wound
b.) open or close method of wound care
c.) whirlpool therapy – drum with solution
7.) skin grafting – 3rd degree – thigh or buttocks (autograft)
(common in children) pigs/ animals – xenograft
frozen cadaver – hallow graft
8,) diet – increase/high CHON, increase calories.

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* ATOPIC DERMATITIS - infantile eczema (“hika ng balat”)
Papulo vesicular erythematus lesions with weeping & crusting
Cause – food allergies: milk, citrus juice, eggs, tomatoes, wheat
Symptoms: extreme pruritus, linear excoriation, weeping and crusting; scaly
shiny white – lechenification
Goal of care: decrease pruritus – avoid food allergens
Diet: Isomil or Nutramigen
Hydrate skin with a borow solution topical steroid such as
1% hydrocortisone cream
Prevent infection – proper handwashing, trim nails: cut it short
* IMPETIGO - skin disease.
Causative agent – cause by group A beta Hemolytic streptococcus characterized by
Papulo-vesicular surrounded by localized erythema – becoming
purulent and oozes forming a honey colored crust
Pediculosiscapitis –“KUTO”
Management: proper hygiene – wash soap and water
Sequelae: oral penicillin – bactroban ointment
Can lead to acute glomerulonephritis AGN
* ACNE - adolescent problem (common)
- self limiting inflammatory disease that involves sebaceous gland
- comedones – sebum causing white heads
- sebum - composed of lipids/cholesterol causing acne bulgaris
Management: proper hygiene- mild soap or sulfur soap
Body Acne - antibacterial Retin A or Tretinol
* ANEMIA - pallor
Possible Causes:
1.) early cutting of cord – preterm – cut umbilical cord ASAP
fullterm – cut umbilical cord when pulsation stops
2.) Bleeding disorders – blood dyscrasias
* HEMOPHILIA – deficiency of clotting factor.
- X linked recessive – inheritance
* If mom – carrier, son – affected
* If father carrier - transmitted to daughter

Hemophilia A – deficiency of coagulation component factor 8 (Classic)

Hemophilia B – or Christmas Disease, deficiency of clotting factor 9
Hemophilia C – deficiency of clotting factor 11
Assessment:
- umphalagia – earliest sign ( excessive bleeding of the cord or after
circumcision
- newborn receive maternal clotting factor (no bleeding)

39
 - newborn growing – easy bruising on bump area – “marks” earliest sign
- continuous bleeding – hematrosis – damage or bleeding synovial membrane

Diagnostic test :
PTT. Partial thromboplastin time – reveals deficiency in clotting factor
Long Term Goal- prevention of injury
Nursing Diagnosis: increase risk of injury
Health Teaching:
1. avoid contact sport, swimming only
2. don’t stop immunization – just change gauge of needle
“Falls” – immobilized , elevate affected part, apply gentle pressure
- not more then 10 minutes
- cold compress
3. determine case before doing invasive procedure
Alert: NO ASPIRIN
* LEUKEMIA - group of malignant disease characterized by rapid proliferation of
immature White Blood Cell (5,000 – 10,000 cucmm3 )
• WBC – protection from infection, soldiers of body
Classification :
1. Lympho – affects lymphatic system
2. acute / blastic- affects immature cell Acute Lymphocytic
3. Myelo – affects bone marrow Leukemia
4. chronic/ cystic- affects mature cells (Most common Cancer)
Signs & Symptoms:
1. from invasion of bone marrow
signs of infection
a.) fever
b.) poor wound healing
c.) bone weakened & causes fracture
signs of bleeding
a.) petechiae - small, round, flat, dark red spot
b.) epistaxis – nose bleeding
c.) hematuria - blood in urine/ emesis – blood in vomiting
signs of anemia
a.) pallor
b.) easy fatigability
2. from invasion of body organ - hepato spenomegaly – abdominal pain , CNS
affectation, increase ICP
Diagnostic Tests:
1. PBS - peripheral blood smear – determine immature RBC
2. CBC – determine anemia, leukocytosis, thrombocytopenia, neutropenia
3. lumbar puncture (LP) – determine CNS involvement.
* Before Lumbar Puncture , fetal position - avoid flexion of neck – will cause airway
obstruction.“C” position or shrimp position only.
4. bone marrow aspiration – determine blast cells,
- common site - iliac crest
- post BMA: side effect – bleeding
- apply pressure. Put patient on affected side to prevent hemorrhage
40
5. Bone scan – determine bone involvement
6. CT scan – determine organ involvement

Therapeutic Management:
TRIAD: for CANCER
1. surgery
2. irradiation
3. chemotherapy
Focus Nursing Care: prevent infection
4 LEVELS OF CHEMOTHERAPHY
1. For Induction – goal of treatment: to achieve remission
Medications: IV vincristine
L- agpariginase
Oral prednisone
2. For Sanctuary - treat leukemic cells that invaded testes & CNS
Give: 1. Methotrixate - administer intrathecally via CNS or spine
2. Cytocine
3. Arabinoside, steroids with irradiation
3. For maintenance - to continue remission
Give: oral methotrisate – check WBC
- administration of methotrisate
– do weekly White Blood Cell check-up
oral 6 Mercaptopurine; Cytarabine
4. For Reinduction – reduce leukemic cells after relapse occurs.
Medications: same as induction
5. Antigout Agents: allopurinol or Zyloprim
- treat or prevent hyperurecemic nephropathy.
Nursing Management:
1. Assess the common side effects of chemotherapy
Outstanding nursing diagnosis: alteration in nutrition less body requirement.
Based on Maslow’s hierarchy “ Physiologic” – always the first priority
Side Effect of Chemotherapy:
1. Nausea and Vomiting – administer antiemetic drugs 30 minutes before
chemotherapy and continue until 1 day after chemotherapy
2. Ulcerations / stomatitis / abscess of oral mucosa- (alteration nutrition less than
body requirement)
oral care: 1. alcohol free mouthwash
2. betadine mouthwash
3. don’t brush
4. use cotton pledgets
5. topical xylocaine before meals
diet: soft, bland diet according to child’s preference
Temporary Side Effects of chemotherapy:
a. Alopecia – altered body image
b. Hirsutism – hair
Health Teaching:
41
 - give emotional support to parents

3. Hemolytic Disorders: destruction of RBC

a. Rh Incompatibility – Rhesus – Monkey
↓
Foreign Body CHON
Mother (-) = no antigen (no protein factor)
Father (+) = has antigen (protein factor)
Erythroblastosis Fetalis – Hemolysis - ↓oxygen carrying → IUGR with pathological
jaundice within 24 hours
Rhogan – a vaccine given to Rh (-) given to mother within 72 hours to destroy fetal RBC
hence preventing Rh sensitization after 72 hours – should not be given

Destroyed RBC

HEME GLOBULIN

IRON PROTOPORPHYRIN

Indirect Bilirubin FAT SOLUBLE - Direct Bilirubin WATER SOLUBLE

Can be excreted by kidneys

ABO incompatibility –
Most common incompatibility – ( mom) O – ( fetus) A,B,AB
Most severe incompatibility (Mom) O– (Fetus) B
st
Can affect 1 pregnancy
“O” – universal donor ; AB – universal recipient
Hydrops (h20) Fetalis – edematous on lethal state with pathologic jaundice
Within 24 hours ( most common ABO incompatibility)
Management:
1. initiate feeding
2. Temporary suspension of breastfeeding
• glucoronil transferase content breast milk pregnanedioles – that delays
action of glucoronil transferase
• glucoronil transferase – is a liver enzymes converts “indirect bilirubin”
(fat soluble ) to become direct bilirubin (water soluble)
* Life span of RBC – 20 days
3. Use of phototherapy

42
 4. Exchange transfusion for Rh or ABO affectations that tend to cause continuous
decrease in hemoglobin during the first 6 months because the bone marrow fails
to produce erythrocytes in response to continuing hemolysis.

Yellow – Jaundice
Hyperbilirubinemia - > 12 mg/dL of indirect bilirubin among full term
Normal – 0 - 3 mg/dL (indirect bilirubin)
- bilirubin encephalopathy
- Kemicterus - > 20 mg/dL among full term &
>12 mg /dl of indirect – preterm
= can lead to cerebral palsy
Physiologic jaundice – jaundice within 48 -72 hours (2-3 days) expose morning sunlight
- also known as Icterus Neonatorium ( Yellow Baby)
Pathologic Jaundice – within 24 hours. Jaundice during delivery.
Icterus Gravisneonatorium ( Baby Yellow “na”)
Breastfeeding jaundice – caused by pregnanediole – delayed reaction of glucoronil
transferase; present 6 -7 days
Assessment of Jaundice :
1. Blanching neonates forehead, nose or sternum – ( normal cyanotic )
2. yellow skin & sclera
3. color of stool – light stool
4. color of urine – dark urine
Management: Phototherapy – photo oxygenation
Nursing Responsibilities:
1. cover eyes – prevent retinal damage
2. cover genitals – prevent priapism – painful continuous erection
3. change position regularly – even expose to light
4. increase fluid intake – due prone to dehydration
5. monitor Input & Output – weigh baby
weigh diaper 1gm = 1cc
6. monitor Vital Signs – avoid use of oil or lotion , due to heat at phototherapy
side effects: bronze baby syndrome - transient Side Effect of phototherapy
18 inches – 20 inches = height of phototherapy light

3. Head – largest part of baby ; ¼ of its length

Craniostenosis or craniosinustosis – premature closing of anterior fontanel
Hydrocephalus – ant fontanel open after 18 months
Microcephaly – small growing brain - due to alcohol & HIV positive mom
withdrawal syndrome
Anencepahly – absence of cerebral hemisphere
Noticeable Structures of the Head:
1. Craniotabes – localized softening cranial bone. Common to the 1st born child
- due to early lightening (2 weeks prior to EDD)
Rickets of Vitamin B deficiency – soft craniotabes in older children
2. Caput Succedaneum – edema of scalp due prolonged pressure at birth
Characteristics:
1. present at birth
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 2. crosses suture lines
3. disappear after 2 - 3 days

3. Cephalhematoma - collection of blood due to rapture of periosteal capillaries

Characteristics :
1. present after 24 hours
2. never cross suture line
3. disappear after 4 - 6 weeks
4. Seborrheic Dermatitis – ‘craddle cap”
Scaling, greasy appearing salmon colored patches usually seen on scalp
the behind ears and umbilicus
Cause: - improper hygiene
Management:
1. proper hygiene
2. application of baby oil before shampooing the child
5. Hydrocephalus – excessive accumulation of CerebroSpinalFluid
1. communicating – extra ventricular hydrocephalus
2. non-communicating- intraventricular hydrocephalus or obstructive
hydrocephalus mainly due to tumor obstruction
Symptoms: ↑ ICP – abnormally large head, bulging fontanel
- cushings triad : ↑ Blood Pressure ; ↑ Respiratory Rate with
widening ; high pitched cry
“older children” – diplopia – eye deviation
- projectile vomiting
- fontanel bossing – prominent forehead
- prominent skull vein
- sunset eyes
Management:
Position to lessen ICP – low semi-fowlers 30 degrees angle
Administer - osmotic diuretic: Mannitol/ Osmitrol , Diamex- Azetam
To decrease CSF production
“Surgery” Shunting – AV shunt or VP shunt (ventriculoperitoneal shunt)
Shave hair just before the surgery – in OR – to prevent growth
of micro organism
Nursing Care:
1.) post VP shunt – side lying on non operated site - to prevent increase ICP or
increase IOP
monitor for good drainage - sign – sunken fontanel
bulging fontanel – blocked shunt
4. SENSES
A. Sense of Sight (EYES):
Assessment
1. check for symmetry
2. sclera – normal color – light blue then become dirty white
3. pupils – round- adult size
coloboma- part of iris is missing
sign: key hole pupil

44
 whiteness & opacity of lens “congenital cataract”
cornea – round & adult size
larger – “congenital glaucoma”

45
 Test for blindness common tests
1. newborn – general appearance
- can only see 10 inches – 12 inches
- visual acuity 20 /200 to 20/ 800
1.1. Doll’s eyes test - test for blindness
- done 10th day
- pupil goes opposite to direction when head is moved
1.2. Globellars test – test for blink reflex.
Points near nose – baby should blink
(-) blink - - blind
2. Infant & children
- general appearance
- ability to follow object past midline
3. 3 years – school age
- general appearance
Allen cards – test for visual acuity. Show picture 20 feet away
Ishiharas plates – test for color blindness
Prechool E chart - test for stereoptist of depth perception
Cover testing test – cover 1 eye for 10 – 15 min. Then remove.
Test for strabismus
4. School age – adult
- general appearance
- snellens test
Retinobastoma – malignant tumor of retina
Outstanding sign : oat’s eye reflex-whitish glow of pupil
- red painful eye usually accompanied with glaucoma
- blindness
surgery – Enucleation – removal of eyeball put artificial aye
Normal – 4 – 6 months –eye deviation
> 6 months – lazy eye: eye patch for covering the eyes
B. Sense of Smell (NOSE):
1. flaring alenase – case of RDS
2. cyanosis at rest – choanal atresia - post nares obstructed with bone
or membrane
Symptoms:
1. resistance during catheter insertion
Management: emergency Surgery within 24 hours
* normal color nasal membrane – pinkish
* chronic rhinitis – presence of creases & pale
* check sense of smell – blindfold – smell
* inflammation/infection – red membrane
* Hair in nose – cilia
Adolescent no hair with ulceration of nasal mucosa suspect “cocaine user”

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 Epistasis – nosebleed
- sit upright, head slightly forward to facilitate drainage
- cold compress , apply gentle pressure, epinephrine administration based on
constriction
* most developed sense of newborn – sense of touch
* 1st sense to develop & last to disappear – hearing
C. Sense of Hearing (EARS):
1. Kidney Malformations :
Properly aligned with outer cantus of eyes
low set ear – kidney malformation/ chromosomal aberrations
example: Renal aginesis – absence of kidney
• unilateral – one kidney
• Bilateral – two kidneys
sign in uterus : oligohydramnios
sign in newborn: 2 vessel cord
failure to void within 24 hours (suspect renal aginesis)
Management: kidney transplant
2. Chromosomal aberrations : related to advance maternal age
A. Nondisjunction – uneven division
Classifications:
1.1. Trisomy 21 - down syndrome - extra chromosome
47xx + 21 - related to advance paternal age
47xy + 21
Symptoms:
Mongolian slant eyes; low set ears
Broad flat nose
Protruding tongue
Puppy’s neck
Simean crease (Hands) – single transverse line on palm.
Mental Retardation
Trisomy 18 – “edward syndrome” – sole of foot is rounded called
“Rockers Bottom Foot”
1.3. Trisomy 13 - patau syndrome - microptamia
1.4. Turners – Monosomy of X syndrome
- 45 x 0
- affected girls
- signs , evident during puberty
- has poorly developed secondary sexual characteristics
- Sterile
1.5. Klinefilters Syndrome - has male genitalia - 47 XXY
- poorly development secondary sexual characteristics
- no deepening of voice
- characteristics: small testes and penis – sterile
* Klinefelter – Calvin Kline – male
* Turner – Tina Turner – female

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 B. Deletion Abnormalities
1. Cri-du-chat Syndrome - chromosomal obliteration / cat like cry or meow
like cry
2. Fragile X Syndrome

C. Translocation Abnormalities
1. Balanced Translocation Carrier
2. Unbalanced Translocation Syndrome
D. Others
1. Mosaicism – a situation wherein the nondisjunction of chromosomes
occurs during the mitotic cell division after fertilization resulting to
different cells contains different numbers of chromosomes.
2. Isochromosomes – a situation wherein the chromosome instead of
dividing vertically it divides horizontally resulting to chromosomal
mismatch.

*** Otitis Media – inflammation of middle ear. Common children due to wider &
shorter Eustachian tube
Causes
1.) bottle propping
2.) Cleft lip/ cleft palate
Symptoms: Otitis
1. bulging tympanic membrane, color – pearly gray
2. absence light reflex
3. observe for passage of milky, purulent foul smelling odor discharge
4. observe for URTI
Nursing Care:
1. position side lying on affected aside – to facilitate drainage
2. supportive care- bed rest, increase fluid intake
Medications :
1. Massive dosage antibiotic
Complication – bacterial meningitis
2. Apply ear ointment
* < 3 years old - down-back (small child)
* > 3 years old - up-back (school age)
Small child – down & back ( no age)
< 3 years old – down & back
>3 years old – up & back
School age – up and down
Surgery (to prevent permanent hearing loss)– otitis media – myringotmy with
tympanostomy tube ↓
post surgery – position affected side for drainage slight incision of
both – put ear plug tympanic membrane
if tympanous tube falls – healed “na”

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5. Mouth and Tongue
a. Bells Palsy - facial nerve; #7 cranial nerve injury or paralysis R/T forcep
delivery
Symptoms.
1. Continuous drooling of saliva
2. inability to open one eye & close the other eye
Management:
Refer to Physical Therapist
b. TEF (Tracheoesophageal Fistula) – self limiting
TEA (Tracheoesopageal Atresia ) - there is a pouch; no connection
between the esophagus and stomach
Outstanding Symptom:
Coughing
Choking Newborn
Continuous drooling 4 C’s
Cyanosis
Management:
Emergency surgery
c. Epstein pearl – white glistening cyst usually seen at/on palate & gums
related to hypercalcemia
* Hypervitaminosis
d. Natal tooth – tooth at birth. Move with gauze
e. Neonatal tooth – tooth within 28days of life
f. Oral Moniliasis – oral candidiasis ; oral thrush
- white cheese like, curd like patches that coats the mouth and the tongue
Nursing Care: don’t remove, wash with cold boiled water
Medications: nystatin / Mysnastatin – antifungal
* Kawasaki Disease -- strawberry tongue - originated in Korea
- Dr. Kawasaki discovered it
- common in Japan
- “mucocutaneous Lymphnode Syndrome”
Criteria for diagnosis of Kawasaki Disease:
1. persistent fever lasting more than 5 days
2. Bilateral Conjunctivitis
3. Changes of lips and oral cavity
a. dry, red fissure lips
b. strawberry tongue
c. diffuse erythema of mucous membrane
4. Changes of peripheral extremities
a. erythema of the palm & sole
b. indurative edema of the hands and feet
c. membranous desquamation from fingertips
5. Polymorphous rash ( primarily on trunk)

49
 6. Acute nonpurulent swelling of cervical lymph node to > 1.5 cm in
diameter
* lymph adenopathy > 1,5 cm
* Drug: aspirin ; administration of gamma globulin
* May lead to MI
LIPS- symmetrical
Cleft lip – failure of median maxillary nasal process to fuse by 5 - 8 weeks of
pregnancy
- common to boys
- unilateral
Cleft Palate - Failure of the palate to fuse by 9 – 12 weeks of pregnancy
- common to girls
- unilateral or bilateral
By means of ULTRASOUND – can be detected at once
Symptoms:
1. evident at birth
2. milk escapes to the nostril during feeding
3. frequent colic
4. otitis media
5. URTI
Management:
1. Surgery
cleft lip repair – Cheiloplasty = done 1 - 3 months to save sucking reflex
(lost in 6 months )
Cleft Palate - uranoplasty = done 4 - 6 months to save speech
(palatoplasty)
Pre operation care:
1. emotional support for the parents especially to mom
2. proper nutrition - if unable to suck – use medicine dropper
- use cleft lip nipple
3. prevent colic
feed – upright seating or prone position
burp frequently 2 times at middle and after feeding - lower to upper tap
Bootle feeding : every 3 -5 minutes
Position: Right side lying position – to facilitate gastric motility
Post Operative Care:
1. orient parents to type of feeding
rubber tipped syringe – cheiloplasty (cleft lip)
paper cup/ soup spoon/ plastic cup – urano plasty (tonsillectomy)
Position: Prone Position
2.. apply restraints – elbow restraints (apply pre-operatve)
so baby can adjust post operation
Position: Prone Position

50
 Condition that warrants suspension of operation
- Check for the presence of colds & nasopharyngitis
= can lead to generalized infection – septicemia
Post Operative Nursing Care :
(Priority) 1. airway – positon for post cheilopasty – side lying for drainage
post uranoplasty (tonsillectomy) - prone
2. assess for RDS symptoms : bleeding
3. assess for bleeding – frequent swallowing, 6 - 7 days after surgery
– bleeding
4. proper nutrition
- clear liquids- (gelatin except red or brown color due may mask
bleeding)
- ( popsicle - not ice cream)
full liquid
soft diet
regular diet
5. Maintain integrity of suture line such as:
Logan bar – wash ½ strength Hydrogen Peroxide & Saline
Solution - Bubbling effect traps microorganism
- prevent baby from crying for pain - analgesic
* “gutom” hungry
* wet diaper
NECK-
1.) check symmetry
Congenital torticolis - “ wryneck”- burn injury of sternocleidomastoid muscle
during delivery – due to excessive traction at cephalic delivery
( case of incompetence )
Management: passive stretching exercise
Last Management: Surgery
Complication: Scoliosis
THYROID gland – for basal metabolism
Congenial cretinism – absence or non functioning thyroid glands
(Hypothyroidism) Thyroidismgenesis
Reasons for Delaying Diagnosis:
1. Thyroid glands covered by sternocleidomastoid muscles in newborn
2. baby received maternal thyroxine
3. baby sleeps 16 – 20 hours a day
Earliest sign:
1. change in crying
2. change in sucking
3. sleep excessively
4. constipation
5. edema – moon face
Late sign
1. mental retardation

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Diagnostic Test:
1. PPI - protein purine iodine
2. radioimmunoassay test
3. radioactive iodine uptake
Treatment:
Synthroid – sodium Levothyrosine - synthetic thyroid given lifetime
- check pulse rate before giving synthroid
- tachycardia – Symptoms of hyperthyroidism
CHEST
1. check for symmetry
2. breast - transparent (witch milk)fluid coming out from newborn related to
hormonal changes: * enlargement of the left breast is a suspect of Cardiomegaly
* enlargement of the chest is a suspect of Atlectasis
3. chest has retroactive – RDS ( respiratory distress syndrome)
4. sternum sunken – pectus excavatism
ABDOMEN (in order)
1. inspection I
2. Auscultation A
3. percussion P
4. Palpation P = Will change bowel sounds, so do last
Normal contour of abdomen – slightly protruding
A. Diaphragmatic Hernia - Sunken abdomen ; protrusion of stomach content
through a defective diaphragm due to failure of pleuroperitoneal
canal to close.
Symptoms:
1. sunken abdomen
2. enlargement of right and left chest
3. Symptoms of RDS
4. Right to Left shunting
Management:
Emergency surgery within 24 hours
CPAP – continuous positive airway pressure
CPPB – continuous positive pressure breathing
ECMO – extra corporeal membranous oxygenation
B. Omphalocele – protrusion of stomach contents in between junction of
abdominal wall and umbilicus.
Management: If very small - surgery
If large – suspension surgery
Silver sulfadioxine ointment
Nursing Management:
protect sac- sterile wet dressing

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 C. Gastrochisis – absence of abdominal wall
Nursing Management: sterile wet dressing
Gastrointestinal System
1. Functions:
1. Assists in maintaining Fluids & Electrolytes & acid/ base balance
2. Processes & absorbs nutrients to maintain metabolism & support Growth &
Development
3. Excrete waste products from digestive process
2. Recommended Daily Allowance
Calories : 120 cal / Kilo body weight per day
360 – 380 cal / day
CHON - 2.2 g / Kbw / day
3. Supplementary Feeding
Principles in Supplementary Feeding :
Supplementary Feeding usually – 6 months
Supplementary feeding can begiven as early as – 4 months ( 4 – 6 months)
Proper Weaning: done 6 – 9 months when shortening the nursing time
Principles: Never wean the child if the baby is in crisis condition
a.) Solid food offered according to the following sequence:
1. cereals – rich in iron
2. fruits
3. vegetables
4. meat
b.) begin/ start with small quantities
c,) finger foods – offered 6 months
d.) soft table food – “modified family menu” is offered by 1 year
BQ-- e.) dilute fruit juices – 6 months 1:4 – fresh fruits - 1 oz of fruits to 4 oz of water
f.) never give half cooked eggs – usually causes of salmoneliosis or gastroenteritis
g.) never/don’t give honey – infant botulism – food poisoning
BQ-- h.) offered new food one at a time – interval of 4 – 7days or 1 week to determine
food allergens
4. Major Concepts of fluid and electrolyte Balance:
Total Body Fluids - comprises 65 - 85% of body weight among infants &
children
Where fluids are greater in infants
Extracellular fuild – prone to develop dehydration
5. Acid Base Balance - dependent on the following:
a. chemical buffers
b, renal & respiratory system involvement
b. dilution of strong acids and bases in blood

53
Respiratory Acidosis – carbonic acid excess
- hypoventilation
- RDS
- COPD
- Laryngotracheobronchitis (LTB)
Respiratory Alkalosis – carbonic acid deficit
- hyperventilation
- fever
- encephalopathy
Metabolic Acidosis – base HCO3 deficit
- diarrhea
- severe dehydration
- malnutrition
- ciliac crisis
Metabolic Alkalosis – base HCO3 excess
- uncontrolled vomiting
- NGT aspiration
- Gastric lavage

• Waist Above – Acidosis

• Waist Below – Bases Alkalosis
6. Conditions that produces fluids and electrolytes imbalance
A. Vomiting – forceful expulsion of stomach content
Symptoms:
1. nausea; headache
2. dizziness
3. facial flushing
4. abdominal cramping
Assessment:
* assess for the amount, frequency, force, color
* projectile vomiting = increase ICP or pyloric stenosis
Management:
B – banana
R - rice/cereal
A - apple sauce
T - toast

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 B. Diarrhea – exaggerated excretion of intestinal contents
Types:
1. Acute diarrhea are associated with the following:
a. related to gastroenteritis, salmoneliosis
b. dietary indiscretions
c. antibiotic use – Ampicillin and Tetracycline
2. Chronic non specific diarrhea (CNSD) : Dietary Indiscretion:
Causes:
1. food intolerance
2. excessive fluid intake
3. CHO, CHON malabsorption
Assessment:
• assess for the frequency, consistency, appearance of green
colored stool.
• Best criteria to determine diarrhea : consistency
Complications: = dehydration
Mild dehydration 5% weight loss
Moderate dehydration 10% weight loss
Severe dehydration 15 % weight loss
Earliest symptoms of dehydration
First sign:
tachycardia increase temp weight loss
tachypnea sunken fontanel & eyeballs scanty urine
hypotension absence of tears poor skin turgor – dry skin and mucous
“hypotachytachy” membrane
Severe dehydration:
Oliguria , Prolonged capillary refill time
Sign: weight loss
Management:
Acute – NPO ( rest the bowel )
- with fluid replacement – IV
- electrolyte loss is Poatssium (K)
- prone to Hypokalemia – give K chloride
Before administering of K chloride – check if baby can void,
if cant void – hypokalemia
Drug: Na HCO3 – adminster slowly to prevent cardiac overload

55
7. Gastric Motility Disorder:
A. HIRSCHPRUNGS DISEASE – (congenital aganglionic megacolon)
Aganglionic – absence of ganglion cells needed for peristalis
Earliest sign
1. failure to pass mecomium after 24 hours
2. abdominal distention
3. vomitus of fecal material
early childhood – ribbon like stool
foul smelling odor stool
constipations
diarrhea
Diagnostic Procedure:
1. Barium enema – reveals narrowed portion of bowel
2. Rectal Biopsy – reveals absence of ganglionic cells
3. abdominal x-ray – reveals dilated loops on intestine
4. rectal manometry – revels failure of intestine sphincter to relax
Therapeutic Management/Nursing Care
1. NGT feeding – measure tube from the nose to ear to midline of xyphoid
& umbilicus
2. surgery
a.) temporary colostomy - temporary; close 2 – 3 months after the procedure
b.) anastomosis & pull through procedure
Diet:
High CHON, high calories , low residue – pasta , spaghetti and chicken
B. GER - Gastroesophageal Reflux
Chalasia – presence of stomach contents in the esophagus will lead to:
1. esophagitis complication
2. aspiration pneumonia
3. esophageal carcinoma or cancer
Esophageal cancer
Assessment :
1. chronic vomiting
2. faiture to thrive syndrome
3. organic – organ affected
OFTT ( Organic Failure To Thrive Syndrome)
4. melena or hematemesis – esophageal bleeding
Diagnostic Procedure:
1. barium esophogram – reveals reflux
2. esophageal manometry – reveals lower esophageal sphincter pressure
3. intra esophageal pH content – reveals pH of distal esophagus.

56
 A. Medications:
1. Cholinergic
a.) Betanicol ( urecholine) – to increase esophageal tone & peristaltic
activity
b.) Metachloporomide (Reglam) – to decrease esophageal pressure by
relaxing pyloric & duodenal segments
- increasing peristalsis without stimulating
secretions
c.) H2 Histamine Receptor Antagonist – to decrease gastric acidity &
pepsin secretion
- Zimetidine, Ranitidine (Zantac)
- take 30 minutes before meals
d.) antacid – to neutralizes gastric acid between feedings - Maalox
Surgery: Nissen funduplication :
Chronic vomiting –
- thickened feeding with baby cereals - effective if without vomiting
- feed slowly, burp often every 1 ounce
- positioning
< 9 months – infant sit with infant supine
> 9 months – prone with head of mattress slightly elevated on a 30
degree angle
8. OBSTRUCTIVE DISORDERS
A. PYLORIC STENOSIS – hypertrophy of muscles of pylorus causing
narrowing & obstruction.
1.) outstanding Symptoms: projectile vomiting
Alerts:
- vomiting is an initial symptoms of upper GI obstruction
- vomitus of upper GI can be blood tinged not bile streaked. (with blood)
- vomitus of lower GI is bilous ( with pupu)
Outstanding signs: projectile vomiting – increase ICP or GI obstruction
- abdominal distention – major symptom of lower GIT obstruction
2.) metabolic alkalosis
3.) failure to gain weight
4.) peristaltic wave visible from left to right across epigastrium
5.) olive shaped mass – on palpation of the abdomen
Diagnostic Procedures:
1.) ABG
2.)serum electrolyte – increase Na & K, decrease chloride
3.) ultrasound
4.) x ray of upper abdomen with barium swallow, reveal “string sign”
Therapeutic Management:
1. Pyloromyotomy
2. Fredet Ramstedt procedure

57
 B. INSTUSSUSCEPTION- invagination or telescoping of portion of bowel
to another
Common site – ilio-cecal junction
Prone to person who eat fast
Complication – peritonitis – emergency
Symptoms:
1.) persistent paroxysmal abd pain
2.) vomiting
3.) currant jelly stool - due to bleeding & inflammation
- palpate sausage shaped mass
Diagnostic Test:
1.) X ray with barium enema which reveal “ staircase signs”
Management:
1.) Hydrostatic reduction with barium enema
2.) Surgery
9. Inborn Errors of Metabolism- deficient liver enzymes autosomal
recessive Inheritance
A. PHENYLKETONURIA (PKU) – Both parents are carrier
- deficiency of liver enzymes (PHT)
Phenylalaninehydroxylase Transferase – liver enzyme that converts CHON to amino acid
9 amino acids:
valine isolensine tryptophase thyroxine
lysine phenylalanine trioonine thyroxine

Thyronine – decrease malanine production

1.) fair complexion
2.) blond hair
3.) blue eyes
Thyroxine – decrease basal metabolism
- accumulation of Phenyl Pyruvic acid
4.) Atopic dermatitis / infantile eczema
5.) musty / mousy odor urine
6.) seizure – mental retardation
Diagnostic Test – GUTHRIE TEST – specimen – blood
Done: 3 – 4 days after breast or bottle feeding
- preparation increase CHON intake
- test if CHON will convert to amino acid
- specimen and urine
mixed with pheric chloride, presence of green spots at diaper a sign of PKU
DIET: Low phenylalanine diet- food contraindicated- meats, chicken, milk, legumes,
cheese, peanuts
Give: Lofenalac - milk with synthetic protein , special formula for a child with PKU

58
 Galactosemia – deficiency of liver enzyme
- GUPT – Galactose Urovil Phosphatetranferase
- Converts galactose to phosphate tranferace glucose
Galactose – will destroy brain cells if untreated – death within 3 days
Diagnostic Test:
Beutler test – get blood -done after 1st feeding
presence of glucose in blood – sign of galactosemia
galactose free diet lifetime
neutramigen – milk formula

B. CELIAC DISEASE – gluten enteropathy

Common gluten food:
Intolerance to food with brow
B- barley
R- rye not rice example: cakes, pastries, bread
O- oat
W- wheat

Gluten – glutenine( normal absorption)

Gliadin ( toxic to epithelial cells of

villi of intestines, causes
malabsorption syndrome)

Malabsorption

Fats CHON & CHO Vitamin D Vit K Iron folic

(muscle wasting) calcium acid
peripheral edema &
malnutrition Inadequate blood
coagulation

Steatorrhea Osteomalasia Bleeding anemia

Early Symptoms:
1. diarrhea – failure to gain wt ff diarrheal episodes
2. constipation
3. vomiting
4. abdominal pain – protruberant abdomen even if with muscle wasting
Celiac Crisis- exaggerated vomiting with bowel inflammation

59
 Diagnostic Test:
1. lab studies – stool analysis
2. serum antigliadin and antireticulin antibpdies – presence indicates disorder
3. Sweat Test – rule out cystic fibrosis
gluten free diet – lifetime
all BROW – not allowed
ok – rice & corn
Management:
1. vitamin supplements
2. mineral supplements
3. steroids – to treat BOWEL inflammation
10. POISONING- common in toddlers. (falls- common to infant)
Principles:
1. Determine substance taken, assess LOC
2. Unless poison is corrosive, caustic (strong alkali such as LYE) or a hydrocarbon,
vomiting is the most effective way to remove poison.
3. Give syrup 1 pecac to induce vomiting
Ipecac – oral emetic
* 15 ml – adolescent, school age & pre school
* 10 ml to infant
4. UNIVERSAL ANTIDOTE- charcoal, milk of magnesia & burned toast
5. Never adm charcoal before ipecac
6. Antidote for Acetaminophen poisoning – Acetylsysterine ( Mucomyst)
7. For caustic poisoning ( muriatic acid ) neutralize acid by giving vinegar . Don’t
vomit prepare tracheostomy set
8. Gas - mineral oil will coat intestine
Lead poisoning
Lead = Destroy RBC functioning = Hypochormic Microcytic Anemia
= Destroy kidney functioning
Accumulation of anomia = Encepalopathy
Symptoms:
1. beginning sx of lethargy
2. impulsiveness and learning difficulties
3. as lead increases, severe encepalopathy with seizure and permanent mental retardation
Diagnostic Test:
1. Blood smear
2. abdominal x ray
3. long bones
Management:
1. remove child from source
2. if > 20 ug/dL – need chelation therapy = binds with lead & excreted by kidney
= nephrotoxic

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 8. Amogenital
Female:
Pseudomenstration slight bleeding on vagina related to hormonal changes
Tearing of fourchette with blood – rape/ child abuse
• Proper recording
• No erasures
• Rape- Report within 48 hours to
• BARABGGAY CAPTAIN
• Bantay bata 163
Shape pubic hair in inverted triangle ( female)
Male:
Undescended testes – cyrptorchidism - common to preterm
surgery – orchidopexy
assess scrotum- warm room & hands
Ectopic Testes
baby – pee within 24 hours
- check for arch of urination
Epispadias - urinary meatus located dorsal or above glans penis
Hypospadias - urinary meauts loc ventral or below glans penis
Hypospadias with “chordee” - fibrous band causing penis to curve downward
Management:
Surgery
UROTHOPLASTY; MEATOBLASTY
Phimosis - tight foreskin
Balanitis - infection of glands penis – due smegma (“kupal”)
Management: Circumcision

Hydroseal – fluid filled scrotum

Test of Diagnosis:
Transillumination with use of flashlight - glowing sign

Varicoseal – enlarged vein of epididimis ( boys)

( girls ) - vulvular varicosities

61
 Renal Cause Symptoms Treatment Nuursing
Disoreder Care
NEPHROTIC infectious 1. Anasarca- Prednisone ; Focus of
SYNDROME generalized Diuretic care: monitor
body edema Lasix edema
2. massive Furosamide weigh daily
protenuria Diet:
3. microscopic Increase
4. no hematuria CHON
5. serum CHON Increase K-
decreased Orange
6. serum lipid Juice, beef
increased broth,
7. fatigue banana
8. normal or Decrease Na
decreased BP cantaloupe
AGN ( acute Autoimmune 1. (PPP) primary 1. anti HPN drug 1. weigh
Glomerulo Group A beta peripheral - hydralazine or daily
Nephritis) hemolytic periobital apresoline 2. monitor
streptococcus edema 2. iron BP &
3A’s; 2. moderate neurologiuc
AGN, protenuria status
autoimmune, 3. gross 3. Diet:
Group A hematuria decrease K,
( smokey decrease Na
urine)
4. serum K
increased
5. fatigue
6. increase BP
Complication :
1. hypersensitive
encephalopath
y
2. anemia

9. BACK - check for flatness & symmetry

Open Neural Tube Defec - decreased Folic Acid intake
a. SPINA BIFIDA OCCULTA - failure of post laminae of vertebrae to fuse
Symptoms: 1. dimpling of back
2. Abnormal tufts of hair
b. SPINA BIFIDA CYSTICA - failure of post laminae of vertebrae to fuse
with a sac

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Types:
1. Meningocele – protrusion of CSF & Meninges
2. Myelomeningocele – (Cranial Meningocele) protrusion of CSF &
Meninges & spinal cord ( most dangerous)
3. Encephalocele ( CNS complication – hydrocephalus) – cranial meningocele
or myelomeningocele
Most common problem
- rupture of sac
- prone pos
- sterile wet dressing
Most common complication - infection
Myelomeningocele – genitourinary complication- urinary & fecal incontinence
Nursing care: always check diaper
Orthopedic complication – paralysis of lower extremities
Management:
1. Surgery to prevent infection CNS complication: Hydrocephalus
2. Post operative position – prone position
SCOLIOSIS- lateral curvature of the spine
2 types:
1. structural – rye neck
2. postural – improper posture
Diagnosis:
1. uneven hemline
2. bend forward- 1 hip higher
1 shoulder blade more prominent
Nursing care:
1. conservative – avoid obesity, exercise
2. preventive – Milwaukee brace - worn 23 h a day
3. corrective surgery – insert Harrington rod
post operative - how to move
log rolling - move client as 1 unit

10. EXTREMITIES:
I. check # of Digits = 20
1. syndactyly – webbing of digits (ginger like foot)
2. polydactyly – extra digits
3. olidactyly – lack of digits
4. Amelia – total absence of digits
5. pocoamelia- absence of distal part of extremities
II. Erb- duchennse – paralysis- brachial plexus injury or brachial palsy
- birth injury caused by lateral & excessive traction during
a breech injury
Symptoms:
1. unable to abduct arms from shoulders, rotate arm externally or
supinate forearm
2. absence or asymetrical moro reflex
63
 Management:
1. Rotate arm from shoulders with elbow flex.

III. CONGENITAL HIP DISLOCATION – head of femur is outside

acetabulum
Types;
1. subluxated – most common type
2. dislocated
Symptoms:
1. shortening of affected leg
2. asymmetrical gluteal fold
3. limited movement – earliest sx
4. (+) ortolanis sign – abnormal clicking sound
5. when able to walk – child limps
– late symptoms: trendelenburg sign
Goal of Management:
Facilitate abduction
Management:
1. triple diaper
2. carry baby astride
3. Frejka splint
4. Pavlik harness
5. Hip Spica Cast

IV. TALIPES – “clubfoot”

Types:
a.) Equinos – plantar flexion – horsefoot
b.) Calcaneous – dorsiflexion – heal lower than the foot
- anterior portion of foot flexed towards anterior leg
c.) Varus - foot turns in
d.) Valgus - foot turns out
Equino varus - most common
Assessment:
1. Make a habit of Straightening legs & flexing them at
midline position
Management:
1. Corrective shoe: 1. Dennis brown shoe
2. spica cast

CAST
Function of cast – “Purposes”
1. to immobilize
2. to maintain bone alignment
3. to prevent muscle spasm
lead pencil – mark area to be amputated
cold H20 – hasten setting process
hot H20 - slow setting process

64
 After cast application – how to move patient:
• use open palm not fingers - fingers will cause indention
- support the cast with pillow
Signs:
Blueness or coldness
Lack of peripheral pulse
Edema not corrected by elevation
Pain on the casted extremities
• Tingling Sensation – notify the doctor
* sign of nerve impairment
• dry cast – natural air not blower : White
Resonant Sound
Shinny
Cold to touch
• priority check : neurovascular check
C- circulation
M- motion
S- sensation
Cast – with bleeding
- mask with ball pen edge of blood to know if bleeding is on going
do petalling – making rough surface of cast smooth

CRUTCHES
FUNCTIONS: - To maintain balance
- To support weakened leg
Principles in crutches
- weight of body on palm!
- Brachial pulsing – if wt of body in axila
- Do palm exercise- squeeze ball
Different crutch Gaits:
1. Swing Through
Procedure:
a. Advance both crutches
b. Lift both feet / swing forward / land feet in front of crutches
c. Advance both crutches
d. Lift both feet / swing forward / land feet in front of crutches
2. Swing to
- no weight bearing are allowed into lower extremities
Procedure:
a. Advance both crutches
b. Lift both feet / swing forward / land feet next to crutches
65
 c. Advance both crutches
d. Lift both feet / swing forward / land feet next to crutches

3. Three point Gait

- weight bearing is allowed in 1 extremities
Procedure:
a. Advance left foot and both crutches
b. Advance right foot
c. Advance left foot and both crutches
d. Advance right foot
4. Four point gait
- weight bearing allowed in both extremities
Procedure:
a. Advance right crutch
b. Advance left foot
c. Advance left crutch
d. Advance right foot
5. Two point Gait
- weight bearing allowed in 2 lower extremities
Procedure:
a. Advance left foot and right crutch
b. Advance right foot and left crutch
c. Advance left foot and right crutch
d. Advance right foot and left crutch

Other Crutch-Maneuvering Techniques

To Sit Down
Grasp the crutches at the hand pieces for control
2. Bend forward slightly while assuming a sitting
position
3. Place the affected leg forward to prevent weight-
bearing and flexion
To Stand Up
1. Move forward to the edge of the chair with the strong leg slightly under the seat
2. Place both crutches in the hand on the side of the affected extremity.
3. Push down on the hand piece while raising the body to a standing position
To Go Down Stairs
1. Walk forward as far as possible on the step
2. Advance crutches to the lower step. The weaker leg is advanced first and then the
stronger one. In this way, the stronger the extremity shares the work of raising
and lowering the body weight with the patient’s arms.
To Go Up Stairs
1. Advance the stronger leg first up to the next step

66
 2. Then advance the crutches and the weaker extremity. (Strong leg goes up first
and comes down last.) A memory device for the patient’s “Up with the good;
Down with the bad”.

Walker – a walker provides more support than a cane or crutches.

The patient is taught to ambulate with a walker as follows:
1. Patient must hold the walker on the hand grips for stability
2. Lift the walker, placing it in front of you while leaning your body
slightly forward
3. Walk into the walker, supporting your body weight on your hands
when advancing your weaker leg, permitting partial weight-bearing
or non-weight-bearing leg , as prescribed.
4. Balance yourself on your feet
5. Lift the walker and place in front of you again. Continue this
pattern of walking
Cane – a cane is used to help the patient walk with greater balance and support and to
relieve the pressure on weight-bearing joints by redistributing the weight. Quad canes
(four-footed canes) The cane is held in the hand opposite to the affected extremity.

Methods of Transferring the Patient from the bed to a wheelchair.

a. Weight-bearing transfer from bed to chair. The patient stands up, pivots his
back is opposite the new seat, and sits down.
b. (Left) Non-weight-bearing transfer from chair to bed. (Right) with legs
braced.
c. (Left) Non-weight-bearing transfer, combined method. (Right) Non- weight-
bearing transfer, pull – up method

C. Therapeutic Exercises

Exercise Description Purposes Action

Passive An exercise carried out by
the therapist or the nurse
without assistance from the
patient
Active An exercise carried out by
Assistance the patient with the
assistance of the therapist or
the nurse
* To retain as Stabilize the proximal
much joint range of joint and support the
motion as possible. distal part. Move the
* To maintain joint smoothly, slowly,
circulation and gently through its
full range of motion.
Avoid producing pain.
To encourage Support the distal part,
normal muscle and encourage the
function patient to take the joint
actively through its
full range of motion.
Give no more
assistance than is
67

Active An exercise accompanied by To increase muscle When possible, active
the patient without
assistance, activities include
turning from side to side and
from back to abdomen and
moving up and down in bed
Resistive An active exercise carried
out by the patient working
against resistance produced * To increase
by either manual or
mechanical means
Isometric Alternately contracting and
or Muscle relaxing a muscle while
Setting keeping the part in a fixed
position; this exercise is
performed by the patient
necessary to
accomplish the action.
Short period of activity
should be followed by
adequate rest periods
strength exercise should be
performed against
gravity. The joint is
moved through full
range of motion
without assistance.
(Make sure that the
patient does not
substitute another joint
movement for the one
intended.)
* To provide The patient moves the
resistance joint through its range
of motion while the
muscle power therapist resists
slightly at first and
then with
progressively
increasing resistance.
Sandbags and weights
can be used and are
applied at the distal
point of the involved
joint. The movements
should be performed
smoothly.
To maintain Contract or tighten the
strength when a muscle as much as
joint is immobilized possible without
moving the joint, hold
for several seconds,
then let go and relax.
Breathe deeply

Traction - use to reduce dislocation and immobilize fractures

Principles of Traction:
1. The client should be in dorsal or supine position
2. For every traction there is always a counter traction
3. Line of pull should be in line with deformity
4. For traction to be effective, it must be continuous
5. Weight must be hanging freely
Types:
68
 Straight Traction
Weight of the body serves as a counter pull
Skin Traction
Apply directly to the skin

Bryant’s Traction
Use immobilized fracture for less than 2 years old; 90° angle with
buttocks off the bed
Buck’s Traction
For more than 2 years old
Skeletal Traction
Apply directly to the bone
Halo Traction
Use to immobilized the spine
Nursing Responsibility:
1. Assess for circulatory and neurologic impairment
2. It can lead to hypertension
3. Be careful in carrying out nursing functions by not moving the weights

11. Autoimmune System

• Newborn has immunity to diphtheria; pertusis; tetanus; measles, polio but
they don’t have immunity for chicken pox.
• This immunity last up to 9 – 12 months
Types of Immunity:
a. Passive Natural - receive maternal antibodies thru placenta and breast
milk
b. Active Natural – contract a disease and produce memory cells
c. Passive Artificial – receive anti serum with antibodies from another host
d. Active Artificial – receive a vaccine and produce memory cells
12. Neuromuscular System
Reflexes:
A. Blink Reflex – rapid eyelid closure when strong light is shown
Purpose: To protect the eyes
B. Palmar Grasp Reflex – when a solid object is placed on palm, then the baby will grasp
the object.
Purpose: To cling to their mother for safety
“nawawala - - - 6 weeks – 3 months”
C. Step in/ Walk-in Place Reflex – neonate placed on a vertical position with their feet
touching a hard surface will take few quick , alternating step. “ Dancing Reflex”
• Placing Reflex – almost the same with the step – in place reflex only that
you are touching the anterior surface of a NEWBORN’S LEG

69
D. Plantar Grasp Reflex – when an object touches the sole of a newborn’s foot at the base
of the toes, the toes grasp in the same manner as the finger do. “ Disappear: 8 – 9 months
in preparation for walking.

E. Tonic-Neck-Reflex – when newborns lie on their back, their head usually turn to one
side or the other. The arm and the leg on the side to which the head turns extend, and the
opposite arm and leg contract. “ Fencing Reflex”
F. Moro Reflex – start reflex; “Bigla” reflex – with a loud voice or jarring the base of the
crib, the baby assumed a letter “C”, position; Test for neurological Integrity; Disappear 3
– 4 months
G. Magnet Reflex – when there is pressure at the sloe of the foot, he pushes back against the
pressure. Test for spinal nerve integrity
H. Crossed Extension Reflex – when the sloe of foot is stimulated by a sharp object, it
causes the foot to rise and the other foot extend.
I. Trunk Incurvation Reflex - while in prone position and the paravertical area is
stimulated, it causes flexion of the trunk and swing his pelvis towards the touch
J. Landau Reflex – while prone position and the trunk is being supported, the baby exhibit
some muscle tone. Test for muscle tone and present by 3 months.
K. Parachute Reaction – while on a ventral suspension, with the sudden change of
equilibrium, it causes extension of the hands and legs. Present by 6 – 9 months
L. Babinski Reflex – when the sole of foot is stimulated by an inverted “J”, it causes
fanning of toes. Disappear by 2 months and may persist for 2 years.

70
AGE HANDS / STAND WORDS TEETH GAMES
SKILLS
2 mos. Head up when in Infancy-solitary play
prone Mobile, teeter, music
box, rattle

Freud- Oral – 0-18 mos

Erikson-Trust vs
mistrust
Piaget-Sensory motor
0-2 years
3 mos. Hand regard Head & chest up
when in prone
4 mos. Turn front to back Laugh aloud,
bubbling sound
5 mos. Moro reflex disappears
Turn both ways
4-5mos
6 mos. Palmar grasp Sits with support Say vowel sounds 1st temp teeth- 2 Rattle, soft toys, bright
Holds bottle well “ah” “oh” lower incisors colors
7 mos. Can transfer
object from hand
to hand
8 mos. Sits without support
Plantar reflex
disappear
9 mos. Neat finger grasp Creeps 2 syllables-
reflex mama,papa
10 mos. Can clap Pull self to stand Peek-a-boo
Understands “no” Pat-a-cake
Responds to own
name
11mos Stands with
assistance
Cruisse
12 mos Stand alone 2 words-mama, Toddler-parallel play
Walk with papa Similar toys, squeaky
assistance frog
Pull toy, building blocks,
pounding peg, toys to
ride on, pots & pans,
-nursery rhymes

71
18 mos Achieve bowel Can run & jump in Favorite Freud- Anal - 18mos-
control place. word-“Mine” 3yrs
(bowel 1st before Walks up/down Can name body E-Autonomy vs Shame
bladder) stairs holding railing part. & Doubt.
or hand. 1-20 words
Puts both feet on 1
step before
advancing.
24 mos Daytime bladder Can open doors by 50-200 words Piaget-
control (daytime turning knobs. 2 words Preoperational-
1st before Can unscrew lids. sentences. 2-7 years old
nighttime) Can walk up stairs Kohlberg- 2-7 years
alone. old-
Pre-
conventional
30 mos Can jump down Knows full name Temp teeth
from chair. complete.
Copy a circle. Posterior molar
Holds up finger to last temp teeth
show age to appear.
Deciduous/temp
teeth-20 total

36mos Unbotton buttons Draw a + 300-900 words Tricycles, coloring,

3years Nighttime bladder Ride a tricycle Speaks fluently puzzles, books, videos
control Knows full name
Learns to share & gender. F- Phallic- 3-6 yrs

4 years Can button Copy a 1500 words Pre-school 4-6 yrs

Jumps, Associative/cooperative
skips play.
Lace shoes, knows 4 Playhouse, role
basic colors playing.
5 years Copy a triangle 2100 words Imaginary playmate.
Draw a 6-part man

6 years Recognize all -perm teeth School Age-7-12 yrs

shapes appear- 1st Tug of war, track and
Nail biting molar field, basket ball
Interest in God -temp teeth
fall.

72
7 years Copy a diamond F-Latent 7-12 yrs
Enjoys teasing and E-Industry vs
playing alone Inferiority
P-Concrete operational
K-Conventional
8 years Expansive age
Smoother mouth
Loves to collect
objects
Count backwards

9 years Coordination
improves
Tells time
correctly
-Hero worship
stealing and lying
are common
-Takes care of
body needs
completely
-Teacher finds this
group difficult to
handle

10 Age of special
years talent
Writes legibly
Ready for
competitive games
More considerate
and cooperative
Joins orgs.
Well mannered
with adult
Critical of adults

11-12 Full of energy and Pre-adolescents

years constantly active
Secret language are
common
Share with friends
secrets
Sense of humor
present
Social and
cooperative

73