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. 2. 3. By simply observing a child doing specific task. By noting parent’s description of the child’s progress 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. 4. Maturation - synonymous with development “readiness”; [pagiging handa]
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
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 – 1. Patterns of Growth and Development ) 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 ) Reproductive Organ - grows rapidly at puberty
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: 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. Proximo- distal “Centro distal” - progressing form center of body to extremities. Symmetrical - at side of body develop on same direction at same time at same rate. 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. 3
b. c. d.
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. 4
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 a.) Stages of Psychosocial 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. 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
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 1.) Neonate Reflex 2.) Primary Circular 3.) Secondary Circular Reaction Age 1 month 1-4 months 4-8 months Behavior All reflexes - Activity related to body - repetition of behavior ex. thumb sucking - activity not related to body - discover object and person’s permanence - “memory traces are present” - anticipate familiar events. - exhibit goal directed behavior - increase of separateness (will search of lost toy, knows mom) - use trial and error to discover characteristics of places and events -“ invention of new means” - capable of space and time perception (hits fork, spoon on table or drops fork) - transitional phase to the pre operational thought period.
4.) Coordination of Secondary Reaction 5.) Tertiary Circular Reaction
8 - 12 months 12 - 18 months
6. ) Invention of New Means thru mental combination
18 - 24 months
B. Preoperational Thought 2-7 years Schema Preconceptual Age 2-4 years Behavior - thinking basically complete literal and static - 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 Beginning of causation
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 )
Stages of Moral development Infancy – “ pre-moral, pre-religious, amoral stage” AGE Pre-conventional 2 - 3 years 4 – 7 years STAGE Level I 1 2 DESCRIPTION Punishment/ obedience orientation (“heteronomous morality”) Child does right because a parent tells him or her to and to avoid punishment 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. 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. 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. Social contract, utilitarian level making perspectives. Follows standards of society for good of all people Universal ethical Principle orientation. Follows internalized standards of conduct.
Conventional 7 – 10 years 10 – 12 years
Level II 3 4
Post-conventional Above 12 years
Level III 5 6
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 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.
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
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) 10
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 11
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 12
E.4. School Age a. Play - competitive play Example: Tug of war, track and field, basketball, volleyball, softball b. Fear: 1.) 2.) 3.) 4.) school phobia - orienting the child to a new environment displacement from school - teacher and peer of same sex loss of privacy - wants bra 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
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: Iincrease size of breast and genitalia Alert: Menarche - 1st sign sexual maturity in girls Wwidening of hips Aappearance axillary, pubic Alert: (adrenarch) Mmenarche- last sign sexual maturity in Girls BOYS: Aappearance axillary, pubic hair Alert: ( 1st sign sexual maturation) Ddeepening voice Ddevelopment of muscles Iincrease in size of testes and penis Pproduction 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
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
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 16
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
Decrease blood flow
Increase pressure to Left side of heart
Closure of ductus arteriosus
Closure of ductus venosus & AVA
Closure of foramen ovale
What will sustain 1st breath - decreased artery pressure What will initiate lung circulation - lung 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 17
Structure Foramen Ovale Ductus Arteriosus Ductus Venosus Umbilical Arteries Umbilical Vein
Appropriate time of obliteration 1year 1 month 2 months 2 - 3 months 2 - 3 months
Structure remaining Fossa Ovalis Ligamentum Arteriosum Ligamentum venosum 1.) lateral umbilical Ligament 2.) interior iliac artery -ligamentum teres ( round ligament of liver)
Failure to close Atrial Septal Defect (ASD) Patent Ductus Arteriosus (PDA)
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 bulging and tense fontanel increase BP and widening pulse pressure Cushing Triad of ICP Decreased Respiratory Rate, decreased Pulse Rate “hypo-brady-brady” projective vomiting - sure sign of cerebral irritation 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
2.) 3.) 4.) 5.) 6.)
1. 2. 3. 4.
B. PROCESS OF HEAT LOSS evaporation - body to air (TSB) conduction - body to cold solid object (cold compress) convection - body to cooler surrounding air (aircon) 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 Very Economical Always available Facilitates Bonding It facilitates rapid involution Decrease incidence of breast cancer. has antibodies - IgA Breastfed babies have higher IQ than bottle fed babies Has lactobacillius bifidus- interferes with attack of pathogenic bacteria in GastroIntestinalTract Has macrophages – engulfs bacteria Store milk - plastic storage container Store milk – good for 6 months from freezer - put room temperatrure - don’t heat 19
1. 2. 3. 4. 5. 6. 7. 8. 9.
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!
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
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
APGAR Scoring Chart: Heart Rate Respiratory effort 0 - absent - absent 1 < 100 - slow, irregular, weak - some flexion - grimace - grimace - acrocyanosis ( body- pink extremities-blue ) 2 > 100 - good strong cry - well flexed - cough, sneeze - cry - pinkish
Muscle tone - flaccid extremities Reflex irritability Catheter - no response Tangential Foot slap No Reaction Color - blue / pale
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
Silvermann Anderson Index
B. Respiration Evaluation – lowest score – best Criteria 0 1 Chest movement synchronized Lag on respiration Intercostal retraction No retraction Just visible Xiphoid retraction None Just visible Nares dilatation None Minimal Expiratory grunt None Heard on stet only
2 See - saw Marked Marked Marked 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 (Preterm) Sole creases Anterior transverse Occasional creases crease only 2/3 inch Breast nodules 2 mm 4 mm or 3.5 mm Scalp hair Fine & fuzzy Fine & fuzzy Ear lobe Pliable Some cartilage Testes and testes in lower canal Some intermediate Scrotum Scrotum – small few 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
39 and up Sole covered with creases > 5 or 7 mm Coarse & silky Thick cartilage Testes pendulus Scrotum full extensive rugae
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
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
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
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 1. 2. Signs and Symptoms: systolic murmur @ upper border of sternum result of cardiac catheterization & ECG same with Ventricular Septal Defect Management: open heart surgery
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 1.) 2.) Management: Pulmonary Stenosis & Aortic Stenosis balloon stenostomy surgery – recurrent so the “least” important
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 * 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 Right to Left
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 1. polyarthritis – multi joint pain 2. chorea – sydenhamms chores or st. vetaus dance - purposeless involuntary hand and movements of shoulder accompanied by grimacing 3. carditis – tachycardia 4. erythema marginatum - macular rashes SQ nodules Minor 1. arthralgia – joint pain 2. low grade fever 3. all lab results = elevated increase antibody “ 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 – 1 year 2 – 3 years 5 years 10 years 15 years & above 40 20 20 20 17 12 – – – – – – 90 40 30 25 22 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
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 •
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 ANTERIOR POSTERIOR Head 9.5 9.5 Neck 1 1 Upper arm 2 2 Lower arm 1.5 1.5 Hand 13 1.25 Trunk 13 Back 13 Genital 1 @ buttocks 2.5@ Thigh 2.75 2.75 Leg 2.5 2.5 foot 1.75 1.75 5 - 9 years old Anterior Posterior 6.5 6.5 1 1 2 2 1.5 1.5 1.25 1.25 13 13 1 2.5 @ 4 4 3 3 1.75 1.75
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 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.
* 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 pallor 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
PROTOPORPHYRIN - Direct Bilirubin WATER SOLUBLE Can be excreted by kidneys
Indirect Bilirubin FAT SOLUBLE
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 43
crosses suture lines 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”
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”
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
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”
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
NECK1.) 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 51
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 52
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
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
a. b. c.
B. Diarrhea – exaggerated excretion of intestinal contents Types: 1. Acute diarrhea are associated with the following: related to gastroenteritis, salmoneliosis dietary indiscretions 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
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.
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
1.) 2.) 3.)
1.) 2.) 9.
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: persistent paroxysmal abd pain vomiting currant jelly stool - due to bleeding & inflammation palpate sausage shaped mass Diagnostic Test: 1.) X ray with barium enema which reveal “ staircase signs” Management: Hydrostatic reduction with barium enema Surgery
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 lysine phenylalanine tryptophase trioonine thyroxine 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
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 CHON & CHO (muscle wasting) peripheral edema & malnutrition Vitamin D calcium Iron folic acid
Inadequate blood coagulation Osteomalasia
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: beginning sx of lethargy impulsiveness and learning difficulties 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
1. 2. 3.
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
Renal Disoreder NEPHROTIC SYNDROME
Symptoms 1. Anasarcageneralized body edema 2. massive protenuria 3. microscopic 4. no hematuria 5. serum CHON decreased 6. serum lipid increased 7. fatigue 8. normal or decreased BP 1. (PPP) primary peripheral periobital edema 2. moderate protenuria 3. gross hematuria ( smokey urine) 4. serum K increased 5. fatigue 6. increase BP Complication : 1. hypersensitive encephalopath y 2. anemia
Treatment Prednisone ; Diuretic Lasix Furosamide
Nuursing Care Focus of care: monitor edema weigh daily Diet: Increase CHON Increase KOrange Juice, beef broth, banana Decrease Na cantaloupe 1. weigh daily 2. monitor BP & neurologiuc status 3. Diet: decrease K, decrease Na
AGN ( acute Glomerulo Nephritis) 3A’s; AGN, autoimmune, Group A
Autoimmune Group A beta hemolytic streptococcus
1. anti HPN drug - hydralazine or apresoline 2. iron
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
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: 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
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: Advance right crutch Advance left foot Advance left crutch 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 weightbearing and flexion To Stand Up 1. Move forward to the edge of the chair with the strong leg slightly under the seat Place both crutches in the hand on the side of the affected extremity. Push down on the hand piece while raising the body to a standing position To Go 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
a. b. c. d.
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- weightbearing transfer, pull – up method C. Therapeutic Exercises Exercise Passive Description An exercise carried out by the therapist or the nurse without assistance from the patient Purposes * To retain as much joint range of motion as possible. * To maintain circulation To encourage normal muscle function Action Stabilize the proximal joint and support the distal part. Move the joint smoothly, slowly, and gently through its full range of motion. Avoid producing pain. Support the distal part, and encourage the patient to take the joint actively through its full range of motion. Give no more assistance than is 67
Active An exercise carried out by Assistance the patient with the assistance of the therapist or the nurse
Isometric or Muscle Setting
necessary to accomplish the action. Short period of activity should be followed by adequate rest periods An exercise accompanied by To increase muscle When possible, active the patient without strength exercise should be assistance, activities include performed against turning from side to side and gravity. The joint is from back to abdomen and moved through full moving up and down in bed range of motion without assistance. (Make sure that the patient does not substitute another joint movement for the one intended.) An active exercise carried * To provide The patient moves the out by the patient working resistance joint through its range against resistance produced * To increase of motion while the by either manual or muscle power therapist resists mechanical means 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. Alternately contracting and To maintain Contract or tighten the relaxing a muscle while strength when a muscle as much as keeping the part in a fixed joint is immobilized possible without position; this exercise is moving the joint, hold performed by the patient for several seconds, then let go and relax. Breathe deeply
Traction - use to reduce dislocation and immobilize fractures 1. 2. 3. 4. 5. Principles of Traction: The client should be in dorsal or supine position For every traction there is always a counter traction Line of pull should be in line with deformity For traction to be effective, it must be continuous Weight must be 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 1. 2. 3. Nursing Responsibility: Assess for circulatory and neurologic impairment It can lead to hypertension 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 Neuromuscular System Reflexes: Blink Reflex – rapid eyelid closure when strong light is shown Purpose: To protect the eyes 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” 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 12.
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.
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” 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 Magnet Reflex – when there is pressure at the sloe of the foot, he pushes back against the pressure. Test for spinal nerve integrity 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. 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 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. 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 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.
G. H. I. J. K. L.
AGE 2 mos.
HANDS / SKILLS
STAND Head up when in prone
GAMES Infancy-solitary play Mobile, teeter, music box, rattle Freud- Oral – 0-18 mos Erikson-Trust vs mistrust Piaget-Sensory motor 0-2 years
3 mos. Hand regard 4 mos.
Head & chest up when in prone Turn front to back
Laugh aloud, bubbling sound Say vowel sounds 1st temp teeth- 2 Rattle, soft toys, bright “ah” “oh” lower incisors colors
5 mos. Moro reflex disappears both ways Turn 4-5mos 6 mos. Palmar grasp Sits with support Holds bottle well 7 mos. Can transfer object from hand to hand 8 mos. Sits without support Plantar reflex disappear 9 mos. Neat finger grasp Creeps reflex 10 mos. Can clap Pull self to stand Understands “no” Responds to own name 11mos Stands with assistance Cruisse 12 mos Stand alone Walk with assistance
2 syllablesmama,papa Peek-a-boo Pat-a-cake
2 words-mama, papa
Toddler-parallel play Similar toys, squeaky frog Pull toy, building blocks, pounding peg, toys to ride on, pots & pans, -nursery rhymes
18 mos Achieve bowel control (bowel 1st before bladder)
24 mos Daytime bladder control (daytime 1st before nighttime)
Can run & jump in place. Walks up/down stairs holding railing or hand. Puts both feet on 1 step before advancing. Can open doors by turning knobs. Can unscrew lids. Can walk up stairs alone. Can jump down from chair. Copy a circle. Holds up finger to show age
Favorite word-“Mine” Can name body part. 1-20 words
Freud- Anal - 18mos3yrs E-Autonomy vs Shame & Doubt.
50-200 words 2 words sentences.
PiagetPreoperational2-7 years old Kohlberg- 2-7 years oldPreconventional Temp teeth complete. Posterior molar last temp teeth to appear. Deciduous/temp teeth-20 total Tricycles, coloring, puzzles, books, videos F- Phallic- 3-6 yrs Pre-school 4-6 yrs Associative/cooperative play. Playhouse, role playing. Imaginary playmate.
Knows full name
36mos Unbotton buttons Draw a + 3years Nighttime bladder Ride a tricycle control Learns to share 4 years Can button Copy a Jumps,
300-900 words Speaks fluently Knows full name & gender. 1500 words
skips Lace shoes, knows 4 basic colors Copy a triangle 2100 words Draw a 6-part man
Recognize all shapes Nail biting Interest in God
-perm teeth appear- 1st molar -temp teeth fall.
School Age-7-12 yrs Tug of war, track and field, basket ball
Copy a diamond Enjoys teasing and playing alone
F-Latent 7-12 yrs E-Industry vs Inferiority P-Concrete operational K-Conventional
Expansive age Smoother mouth Loves to collect objects Count backwards 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 Age of special talent Writes legibly Ready for competitive games More considerate and cooperative Joins orgs. Well mannered with adult Critical of adults Full of energy and constantly active Secret language are common Share with friends secrets Sense of humor present Social and cooperative Pre-adolescents