Mark Billy L.

Perpetua, MAN RN
Principles of
Growth and
Development
❑Increase in
physical size or a
quantitative
change
❑Increase in the
number and size of
cells
 Most sensitive indicator of growth
DOUBLES – 6 months

TRIPLES – 1 year

QUADRUPLES – 2 and 3 years

*most infants lose 5-10% of birth

weight days after delivery
1 inch/ month – 1st 6 months

1 ½ inch/ month – remainder

of the first year

3 inches/year – 1-7 years

2 inches/year – 8-15 years

9 y/o – MALE = FEMALE

12 y/o – MALE < FEMALE

13 y/o – MALE > MALE

 Reflects brain growth

At birth – 13-14 inches

(33-35.5cm)

FIRST TO ERRUPT: lower

(mandibular) central
incisor – 6-8 months
Age of child in months – 6 = number
of teeth
❑Increase in skill or the
ability to function
(qualitative change)
❑Synonymous with
MATURATION
❑Measured by observing a
child’s ability to perform
tasks
❑Developing instincts or
sensual pleasure
(Freudian theory)

❑Refers to personality
development
(Erikson’s theory)
❑Ability to know right from
wrong and apply these to
real-life situations
(Kohlberg’s theory)

❑Ability to learn and

understand from experience,
acquire and retain knowledge,
and solve problems
(Piaget’s theory)
❑Sensorimotor
development
❑Self awareness
❑Cognitive
❑Moral
❑Creative
❑Therapeutic
❑socialization
Toys should have no:
❑Sharp edges that can cut and
puncture
❑Propelled objects that can
injure the eyes
❑Small parts that can be
swallowed
❑Excessive noise that damage
hearing
Toys should have no:
❑Weak points (brittle/broken
easily)
❑Elements that can burn
❑Electric toys (for 8y/o above)
❑Toxic material (lead →
poisoning)
“ORAL PHASE”

❑Infants are interested in oral

stimulation or pleasure during this
time

❑Infants suck for enjoyment or relief

of tension
“TRUST vs MISTRUST”

❑Learning confidence or learning to

love

❑Infants whose NEEDS are MET

view the world as safe place

❑Infants who receives INADEQUATE

or INCONSISTENT care becomes
fearful and suspicious
❑DEVELOP TRUST
-Arises when one can predict what
is coming next
-Caring should have a rhythm or
consistency

❑PROMOTE SAFETY
Aspiration prevention
-toilet paper roll test
-inspect toys for loose parts
-avoid clothes with buttons
❑PROMOTE SAFETY
Fall Prevention
-lower the crib mattress
-raise side rails (narrow enough to avoid
the child to insert their head)

Car Safety
-place the infant in rear-facing seats in the
back seats (inflating front-seat airbag
could suffocate the infant)

Suffocation
-allow no plastic bags within infant’s reach
-remove contricting clothing at bedtime
(bib from neck)
❑FEEDING DURING THE FIRST YEAR

Birth to 6 months
✓Breastfeeding
-most desirable complete diet for first half
of life

6 to 12 months
✓Solid foods
-due to depleting iron stores (4-6 months)
❑THINGS TO REMEMBER when introducing
solid foods:

✓Solid foods may be started by 5-6 months

✓First foods are strained, pureed, or finely

mashed

✓Finger foods (raw fruit/vegetables) can be

introduced by 6-7 months

✓Avoid foods that have potential for

choking (hotdogs, nuts, grapes,carrots,
popcorn, and hard candies)
❑METHODS of
introduction

✓Introduce one food

at a time

✓Intervals of 5-7
days to identify food
allergies

✓Never introduce
foods by mixing
them with the
formula in the bottle
 Food to introduce Rationale
Cereal (Iron-fortified) ✓Usually introduced FIRST due to
(5-6 months) low allergenic potential
✓Easily digested
✓Aids in preventing iron-deficiency

Vegetables (7 months) ✓Good source of vitamin A

Fruits (8 months) ✓Best source of vitamin C and a

good source of vitamin A

Meat (9 months) ✓Good source of protein, iron, and B

vitamins

Egg yolk (10 months) ✓Good source of iron

❑occurs when the carbohydrate in the
solutions such as formula or glucose
water ferments to organic acids that
demineralize tooth enamel until it decays

❑Propped bottle continuously soaks upper

teeth and lower back teeth that causes
tooth decay
 -period of 1 to 3 years old

“ANAL PHASE”

❑At this age they begin toilet training

❑Children find pleasure in both the

retention of feces and defecation

❑This anal interest is part of toddler’s

self discovery, a way of exerting
INDEPENDECE
“AUTONOMY vs SHAME and DOUBT”

❑Children takes pride in new

accomplishments

❑Parent’s recognition of this trait will

help in the development of autonomy

❑If children are never allowed to do

things they want to do, they will
eventually doubt their ability to do them
PARALLEL PLAY

✓Provide duplicate toys (avoids arguments)

✓Offer toys that the that they can play by

themselves and that requires action

✓Toys that children can manipulate gives a

sense of power, an expression of
AUTONOMY

✓Examples: trucks they can go, waddling

duck they can pull, toy telephone they can
talk into
SEPARATION ANXIETY

Prevented by:

✓Not prolonging goodbye

✓Saying goodbye firmly to

develop trust

✓Saying when you will be back

 ❑NEGATIVISTISM

✓Loves to say “NO!”

✓A way of achieving INDEPENDENCE

Managed by:
✓Limiting questions and offering options
✓If the child’s answer is still a “No”,
parents should make a choice for the child

❑RITUALISM
✓A way of achieving MASTERY
 TEMPER TANTRUMS

✓A way of achieving INDEPENDENCE by

violently objecting to discipline

✓May lie down of the floor, kick their feet,

and scream as loud as possible, others hold
their breath

✓Indication that of child’s inability to

control emotions
Managed by:
✓IGNORING the behavior (if not
injurious to the child)

✓If can result to injury: substitute a

toy or a favorite activity for the
request

✓Continue to be present to provide

feeling of control and security

✓Corporal punishment may further

aggravate the situation

✓Offer options instead of “all or

nothing” and praise positive behavior
 LOVES TOILET TRAINING

FIVE MARKERS OF TOILET TRAINING

READINESS:

1. Bladder readiness
2. Bowel readiness
3. Cognitive reainess
4. Motor readiness
5. Psychologic readiness

*physiologic and psychologic readiness

is not complete until ages 22-30 months,
but preparation should start earlier than 30
months
✓Night time bladder control normally takes
several months to years after daytime
training (sleeps cycle needs to mature)

✓Bowel training is usually accomplished

before bladder training (bowel training has
greater regularity and predictability)

✓*there is no universal right age to begin

toilet training or absolute deadline to
complete training
 -period of 4 to 6 years old

“PHALLIC STAGE”

❑Children’s pleasure zone appears to

shift from the anal to genital area

❑Masturbation is common

❑Children may also shoe exhibitionism

suggesting they hope this will lead to
increased knowledge of the two sexes
“PHALLIC STAGE”

❑Also known as oedipal stage

❑Oedipus complex (son wants to marry

his mother)

❑Electra complex (daughter wants to

marry her father)
❑Penis envy (female)
❑Castration complex (male)

❑Resolved by identification with same-

sex parent
“INITIATIVE vs GUILT”

❑Freedom and opportunity to initiate

motor play reinforces their sense of
INITIATIVE

❑INITIATIVE is also encouraged when

parent’s answer a child’s questions
(intellectual initiative)

❑If they will feel their self-initiated

activities are silly or nuisance, they
may develop GUILT, and may persist in
later life
✓Curious

✓Imaginative

✓Creative

✓Imitative

✓Views DEATH as SLEEPING

 ❑TELLING TALL TALES
✓overimagination

❑IMAGINARY FRIENDS
✓Way of relieving tension and anxiety

✓Educate parents that this is normal

✓Parents can acknowledge the presence of

the imaginary companion but should not be
used by he child to avoid punishment or
responsibility
 ❑SIBLING RIVALRY
✓Due to jealousy

❑REGRESSION
✓Going back to an early developmental stage
✓Bedwetting, baby talk, thumb sucking, fetal
position

❑MASTURBATION
✓If not excessive, it is normal and healthy
✓Part of sexual curiosity and exploration
✓May be an expression of boredom and anxiety

Managed by:
✓Accept and emphasize that it is a private act
✓Divert attention (offer toys)
SEXUAL EDUCATION

❑Questions about procreation

✓If answered by a “tall tale” or “you are

too young to know that” , children will
keep the question with themselves

✓They formulate they own theories to

explain birth
SEXUAL EDUCATION
❑TWO RULES IN ANSWERING

1. Find out what children know and think

-to help children understand why their
explanation is inaccurate
-to avoid giving an “unasked for” answer

2. Be honest
-honesty doesn’t mean imparting every
fact of life or allowing excessive
permissiveness
-one question, one answer
 -period of 7 to 12 years old

“LATENT PHASE”

❑Time in which children’s libido

appears to be diverted into concrete
thinking
“INDUSTRY vs INFERIORITY”

❑Children learn how to do “things well”

❑Sense of INDUSTRY grows when they

are praised and rewarded for their
finish results

❑Parent’s who do not appreciate their

child’s effort may cause the child to
develop INFERIORITY rather than pride
and accomplishment
SIGNIFICANT DEVELOPMENT

✓Boys are prone to fracture

(greenstick)

✓At age 12 (girls are taller than boys)

✓Vision matures (20/20)

✓Industrious

✓Modest

✓Cant’ bear to lose (competitive)

✓Loves to collect things

SIGNS OF SEXUAL MATURITY IN
FEMALES

✓Telarche (1st sign) – increase in the

size of breast and genitalia

✓Widening of hips

✓Adrenarche - Appearnce of pubic and

axillary hair

✓Menarche (last sign)

SIGNS OF SEXUAL MATURITY IN
MALES

✓Increase in the size of penis and

scrotum (1st sign)

✓Appearance of pubic and axillary hair

✓Deepening of the voice

✓Development of muscles

✓Production of viable sperm (last sign)

 -period of 12 to 18 to 21 years old

“GENITAL PHASE”

❑Main events of this period is the

establishment of new sexual aims and
the finding of new love objects
“IDENTITY vs ROLE CONFUSION”

❑Bringing everything they have learned

about themselves and integrate these
different image into a whole that makes
sense

❑Failure to do so leaves them in ROLE

CONFUSION
CLASSIFICATION ACCORDING TO
GESTATIONAL AGE

MARK BILLY L. PERPETUA, MAN RN

▪ Premature (preterm) infant – an infant born
before he completion of 37 weeks of gestation,
regardless of birth weight.

▪ Full-term infant – an infant born between the

beginning of 38 weeks and the completion of
42 weeks of gestation, regardless of birth
weight

▪ Postmature (postterm) infant – an infant born

after 42 weeks of gestational age, regardless
of birth weight
 Preterm vs Full term
PRETERM FULLTERM

POSTURE Lies in RELAXED attitude, More subcutaneous fat and rests

limbs are more extended; in a more flexed attitude
body size is small, head is
somewhat larger in
proportion than the body

EAR Ear cartilages are poorly
developed; may fold easily;
hair is fine and feathery,
lanugo may cover the back
and face
Ear is well formed, hair is more
firm and grows in separates
strands

SOLE Appears more turgid and may Well and deeply creased
only have fine wrinkles

FEMALE Clitoris is prominent, labia Labia majora are fully developed,

GENITALIA majora is poorly developed clitoris not prominent
 Preterm vs Full term
PRETERM FULLTERM

MALE Scrotum isn underdeveloped Scrotum is well-developed,

GENITALIA and not pendulous, MINIMAL pendulous, and rugated and are
RUGAE are present, testes down in the scrotal sac
may be in the inguinal canal
or in the abdomen

SCARF SIGN Infant’s elbow may be easily Infant’s elbow may be brought to
brought across the chest with the midline of the chest, resisting
little or no resistance attempts to bring the elbow past
the midline

GRASP Grasp is weak Grasp is strong

REFLEX

HEEL-TO-EAR Heel is easily brought to ear The maneuver is not possible,

MANEUVER with no resistance there is considerable resistance
a.k.a HYALINE MEMBRANE DISEASE

❑A condition of surfactant deficiency and

physiologic immaturity of the thorax

❑Seen almost exclusively in PRETERM

infant (multifetal pregnancies, infants of
diabtic mother, C/S delivery,etc)
✓Chest indrawing and retractions

✓Tachypnea

✓Labored breathing

✓Substernal retractions

✓Flaring of nares

✓Fine respiratory crackles

✓Central cyanosis (late and serious sign)

✓Pulse oximetry (determines hypoxia)

✓Radiography

✓L/S ratio

✓TDx Fetal Lung Maturity assay

(determines PG level in amniotic fluid or
neonatal tracheal aspirate)
✓Administration of exogenous surfactant

✓Nitric oxide (pulmonary dilation)

✓Oxygen therapy (maintains correct PO2

and pH)

✓IV therapy (hydration and nutrition)

✓Close monitoring

✓Keep oxygen consumption as low as

possible (handle infants as little as
possible)

✓Suction only when necessary (gently but

quickly)

✓Encourage parents to verbalize feelings

❑Relaxation of the anal sphincter and
passage of meconium into amnitic fluid
due to intrauterine stress

❑Occurs primarily in full-term and

postterm infants
✓Stained from meconium stool

✓Tachypneic

✓Expiratory grunting, nasal flaring,

retractions

✓Initially cyanotic

✓Classic Barrel chest

✓Respiratory distress with gasping

✓Laryngoscopy

✓Chest radiographs

✓Pulse oximetry

✓echocardiography
✓Tracheal suctioning (poor respiratory effort,
low heart rate, poor tone)

✓Ventilatory support

✓Exogenous surfactant administration

✓IV fluids

✓Systemic antibiotics

✓Same with other high-risk neonate

❑Common phenomenon in preterm infant

❑Characterized by apneic spells

 TYPES
❑Central apnea
-CNS does not transmit signals to the
respiratory muscles

❑Obstructive apnea
-airflow ceases due to upper airway
obstruction

❑Mixed apnea
-combination of central and obstructive
apnea (*most common)
✓Methylxantines (aminophylline,
theophyline, caffeine)
✓CNS Stimulants to breathing
✓Observe for Sx of toxicity
(tachycardia ar rest, vomiting,
irritability, diuresis)

✓Cafcit (caffeine citrate)

✓Urine output should be closely
monitored (mild diuretic effect)
✓Observation combined with monitoring is the
most effective means of identifying neonatal
apnea

(if apnea begun)

✓Gentle tactile stimulation(rubbing the back or
chest gently)

✓Flow-by oxygen and suctioning

✓Chin is raised gently to open airway

✓Infant is NEVER SHAKEN

✓Record episodes of apnea

❑Sudden death of an infant under 1 year
of age

❑“crib death”

❑Etiology: UNKNOWN
Contributing factors:

✓Prone sleep position

✓Soft bedding

✓Use of pillow

✓Brainstem abnormality

✓Co-sleeping with parents

✓Maternal smoking
Manifestations:
May be seen:
✓Frothy-blood tinged fluid in the
mouth
✓Lying face down in the secretions
✓Hands clutching the sheets

Diagnosis:
✓Autopsy
✓Investigation of the scene
✓Allow the parents to say good-bye

✓Encourage to hold their infant

✓Encourage verbalization of feelings

✓Provide a quiet room with dim

lighting

✓Explain that the death is due to

SIDS and it is not preventable or
predictable
✓Place infants on their back when
sleeping
(plagiocephaly: change head position
periodically)

✓Use firm mattress

✓Avoid exposure to smoke

✓Offer a pacifier for sleep

❑A disorder involving immature retinal
vasculature

❑Formerly know as:

“Retrolental Fibroplasia”

❑Etiology: hyperoxemia, hypoxia,

hypercarbia, hypocarbia, prenatal
complications, exposure to light
✓Strict oxygen management
✓Cryotherapy ablation
✓Laser therapy

✓Decreasing constant bright

environmental light

✓Inform the parents that infant’s

eyelid will be closed and edematous
post operatively
Respiratory System

❑Provides avenue where exchanges of

gases happen from the higher pressure
atmosphere to the lower pressure lungs

❑Responsible for the oxygenation of the

blood and the excretion of carbon dioxide
from the body

❑Helps in the regulation of acid-base

balance in the body
Thoracic Cavity

❑Right lung – 3
lobes

❑Left lung – 2 lobes

❑Mediastinum

❑Smooth parietal
pleura

❑Visceral pleural
sac
Upper Airway

❑Pharynx - passes through the

Waldayer’s ring (ring of tonsils)

❑Larynx
Lower Airway

❑Trachea – provides opening fro the

bronchi

❑Bronchus – smaller airways (right

more vertical than the left)
❑“common cold”

❑Causative agent: rhinoviruses,

Respiratory Syncitial Virus (RSV),
adenovirus, influenza virus,
parainfluenza virus

❑Self-limiting, resolves within 4-10

days
✓Fever

✓Sneezing

✓Muscular aches

✓Chilly sensations

✓irritability
✓No specific treatment

✓Rest

✓Decongestant (infants over 6

months)

✓Cough suppressants (with

dextromethorphan: should not be
administered to young children
continously, due to alcohol content)
✓Elevate the head of the bed/crib

✓Suctioning and vaporization

✓Maintaining adequate fluid

intake (offer favorite fluid)

✓Educate patient and family to

prevent transmission
❑“strep throath”

❑Causative agent: Group A Beta-

hemolytic Streptococcus (GABHS)

❑Complications: rheumatic fever and

acute glomerulonephritis
✓Pharyngitis

✓Headache

✓Fever

✓Anterior cervical lymphadenopathy

✓Throat culture

✓Antistreptolysin O titer (retrospective Dx)

✓Oral penicillin
✓IM Penicillin G benzanthine
✓If allergic to Pen G: Erythromycin

✓Obtain throat swab for culture

✓Administer medications
✓Cold or warm compress to the neck
✓Offer cool liquids or ice chips
✓Teach on the prevention of
transmission
❑Tonsils (masses of lymphoid tissue)
that protect the respiratory and
alimentary tract

❑Causative agent: viral or bacterial

✓Dysphagia/odynophagia

✓Mouth breathing (dry and

irritated mucous membrane)

✓Cough is also common

✓Self-limiting

✓Treatment is symptomatic

✓Surgical Tx:
✓Tonsillectomy and Adenoidectomy
✓Should not be done for children
under 3 y/o
Hans Christian F. Vitug RN, MAN 2/7/2021 8:25 PM 101
✓Give cool-mist vaporizer
✓Give warm saltwater gargle, throath
lozenges
✓Administer acetaminophen
Post-op:
✓Until fully awake: place on the abdomen
or side (drain secretion)
✓Careful suctioning
✓Give cool water, crushed ice, ice pops
✓Avoid red or brown-colored food
✓Discourage coughing frequently, clearing
the throat, blowing the nose
✓Monitor for hemorrhage: most obvious
sign is frequent swallowing
❑General term applied to complex
symptoms

❑Characterized by:
✓Hoarseness
✓Resonant (barky/brassy/croupy)
cough
✓Inspiratory stridor
✓Respiratory distress
❑“acute supraglotitis”

❑The condition requires immediate

attention

✓Fever and drolling

✓Dysphagia and odynophagia

✓Child insists a TRIPOD position

✓Antibiotic (bacterial)

✓Corticosteriod

✓Intubation or tracheostomy

✓Allow the child to assume tripod position

✓Continuous monitoring

✓*Never attempt to check the throat with

tongue depressor if suspecting epiglottitis:
refer immediately
❑Common in older children and
adolescents

❑Causative agent: viruses

✓Hoarseness
✓Nasal congestion
✓Sore throat
✓Fever
✓coryza
✓Symptomatic
✓Fluid and humidified air
❑Most common type of croup

❑Causative agent: viruses

✓Low-grade fever
✓Child is awoke with barky, brassy cough
✓Inspiratory stridor
✓Cough
✓hoarseness
 ✓Maintenance of airway
✓Humidity/cool air vaporizer
✓Cool temp therapy
✓Nebulized epinephrine (racemic
epinephrine)
✓Corticosteriod (IM Dexamethasone)

✓Assessment and monitoring

✓Available intubation/tracheostomy set

should be available at bedside
❑“midnight croup”

❑Paroxysmal attacks of laryngeal

obstruction that occur most often at night

✓No fever
✓Metallic cough
✓Hoarseness
✓Noisy inspiration
✓restlessness
✓Warm mist
✓Self limiting :
supportive therapy
❑Infection of the muscosa of the upper
trachea

❑obstruction→ respiratory alert

✓Crooping cough
✓Stridor unaffected by position
✓Similar to LTB (no responsive to LTB
treatment)
✓Antibiotics

✓Humidified oxygen

✓Antipyretics

✓Tracheal suctioning

✓Endotracheal intubation
❑A.k.a “tracheobronchitis”

❑Inflammation of the large airways

❑Causative agent: viruses

✓Dry, hacking, non-productive cough that is

worse at night, that becomes productive in
2-3 days
✓Self-limiting: symptomatic tx
❑Causative agent: RSV and paramyxovirus

✓Rhinorrhea and intermittent fever

✓Pharyngitis
✓Coughing and sneezing
✓Dyspnea
✓Tachypnea (plaring of nares and retractions)
✓wheezing

✓RSV antigen
✓Immunofluorescent antibody
✓ELISA
✓Humidified Oxygen
✓Adequate fluid intake
✓Maintenance of airway
✓Bronchodilators
✓Rivabirin (aerosol)
✓Use goggles/mask) – can cause
dryness of eyes and oral mucosa

✓Assess respirations
✓Oxygen therapy
✓hydration
❑A chronic inflammatory disorder of
the airways in which many cells play
a role such as:
❑Mast cells
❑Eosinophils
❑T-Lymphocytes

❑Most common chronic disease of

childhood
✓Dyspnea and wheezing

✓Cough (classic manifestation) in the

absence of infection occurs at night

✓Shortness of breath

✓Younger children: tripod position

✓Older children: sitting with

shoulders hunched over
✓Based on signs and symptoms,
History, and Physical examination

✓Spirometry

✓Chest radiograph

✓Skin testing (for hpersensitivity)

✓Allergen control
✓CPT
✓Pharmacotherapy
✓Corticosteroids
✓Cromolyn (NSAID)
✓Beta-adrenergic agonists
(albuterol, terbutaline)
✓Anticholinergic
✓Methylxanthines
✓Place the child in a semi fowlers position
✓IV fluids (if cannot tolerate oral)
✓Reassure the parents

✓Health teaching
✓Avoidance of allergens
✓Maintenance of health and prevention
of complications
✓Promotion of normal activities
✓Self-care (hallmark of asthma mngt)
✓Play techniques (breathing exercises)
✓Blowing cotton balls/ping pong balls
(increases expiratory time and
pressure)
❑Inherited, autosomal recessive trait\

❑Etiology: mutated gene of

Chromosone 7 (cystic fibrosis
transmembrane regulator)

❑Common in Caucasians
✓Quantitative Sweat Chloride Test
(Pilocarpine iatrophoresis)
-stimulates sweat production

✓Chest radiography

✓Stool fat or enzyme analysis

✓Newborn Screening for CF

✓Prevent or minimize pulmonary
complications
✓CPT (cornerstone of pulmonary
therapy), exercise, deep breathing
and coughing
✓Bronchodilators and anti-
inflammatory
✓Flutter mucus device- removal of
mucus
✓Huffing “forced expiration”
✓Antibiotics and oxygen
✓Lung transplantation
✓For other organ involvement:
✓PANCREAS: obstruction of duct
✓Inadequate/no release of
enzyme
✓Malabsorption of fats, protein,
and fat-soluble vitamins
✓Steatorrhea
✓High-protein high caloric diet
✓SKIN: high amount of Na and Cl in
sweat
✓Skin care
✓Add salt to all meals (summer)
✓Digestion and absorption of
nutrients

✓Perform excretory function

✓Provide detoxification

✓Participate in maintaining fluid

and electrolyte balance

✓Serve a lymphoid function by

providing a barrier for pathogens
❑Congenital anomaly that results in
mechanical obstruction from
inadequate motility of part of the
intestine
✓Failure to pass meconium within the
first 48 hours

✓Ribbon-like fouls smelling stools

✓Abdominal distention
✓Vomiting
✓constipation
✓Basing on history and physical
examination

✓Barium enema

✓Anorectal manometry (measures

reflex pressure)

✓Rectal biopsy (confirmatory)

✓Surgery (two stages)

✓1st : temporary ostomy to relieve

the obstruction
✓2nd : complete corrective surgery
Soave endorectal pull-thorugh

✓Anorectal myomectomy (very

short-segment disease)
✓Observation of the passage of
meconium (early diagnosis)

✓Helping the parents adjust to the

congenital disorder

✓Preparing the parents for the

medical-surgical procedure
❑“spastic colon”

❑Functional gastrointestinal disorder

❑No known cause

❑May appear post-infection or due to

food intolerance (lactose.etc)
✓Alternating diarrhea and
constipation

✓Flatulence

✓Bloating

✓Abdominal distention

✓Lower abdominal pain

✓Environmental modifications
✓Stress management
✓Psychosocial intervention
✓Antispasmodics
✓antidiarrhea;l
✓Simethicone

✓Diet
✓High fiber (soluble)
✓Psyllium supplements
✓Family support and education
✓Collaborate with the family with
dietary modifications:
✓Eating slowly
✓Avoiding carbonated beverages
✓Adding fiber to diet
✓Relieving environmental
stressors
❑Inflammation of the vermiform
appendix
✓First symptom: colicky, cramping,
abdominal pain in the periumbilical
area
✓Nausea, vomiting, anorexia

✓Blumberg sign: rebound tenderness

✓Rovsing sign: RLQ tenderness upon
palpation of other quadrans
✓Psoas sign
✓Obturator sign
✓Basing on history and physical
examination

✓CBC: high WBC

✓Ultrasonography

✓CT Scan
✓Surgery: APPENDECTOMY
✓Assist in establishing diagnosis
✓Instruct the child to pint a finger
on the painful region
✓Light palpation will satisfactorily
elicit pain

✓Pre-op care
✓Post-op care
❑Remnant of the fetal
omphalomesenteric duct, that
connects the yolk sac with the
primitive midgut during fetal life

❑Normally the structure obliterates

by 7th – 8th of gestation

❑Mechanisms that causes

obstruction: intussusception,
incarceration by hernia, volvulus
✓Painless, rectal bleeding (due to
ulceration) – most common

✓Based on history and physical

examination
✓Radiographic study
✓Radionuclide Scintigraphy (Meckel
Scan) – confirmatory

✓Lab studies – severity of anemia

✓Severe hemorrhage: correct
hypovolemic shock (IVF and
Oxygen)

✓Surgery

✓Diverticulitis
✓antibiotics
PRE-OP
✓Frequent monitoring of VS and
blood pressure
✓Keep the child on bed rest
✓Recording the approximate
amount of blood lost in stool
POST-OP
✓Maintain IVF
✓NGT for decompression
✓Psychological support
 ❑Occurs when the circumferential
muscle of the pyloric sphincter
becomes thickened that produces
outlet obstruction and compensatory
dilation
✓Nonbilous projectile vomiting

✓Dehydration

✓Weight loss

✓Failure to thrive

✓Palpable olive-shaped mass in

epigastrium
✓Basing on history and physical
examination

✓Ultrasonography

✓Upper GI radiography
✓Surgery:
✓Pyloromyotomy or Fredet-
Ramstedt procedure (standard
procedure)
✓Careful regulation of fluid therapy

✓Reestablishment of normal
feeding patterns

✓Encourage the parents to become

involved in caring for the child
 ❑Telescoping or invagination of the
proximal segment to a more distal
segment that results in lymphatic and
venous obstruction
✓Sudden onset of crampy abdominal
pain
✓Inconsolable crying
✓Drawing up of knees on the chest
✓Bilous vomiting
✓Palpable sausage-shaped mass in
the abdomen
✓Currant jelly-like stool
Hans Christian F. Vitug RN, MAN 2/7/2021 8:25 PM 178
✓Based on subjective finding

✓Barium enema

✓Abdominal radiograph

✓Rectal exam (mucus and blood)

✓Non-surgical hydrostatic
reduction (using enema or air
pressure)
✓Not recommended if there are
signs of perforation
✓Surgery: resection of non-viable
portion
✓NG decompression
✓IVF
✓Antibiotic therapy
✓Assist in establishing diagnosis

✓Explain the basic defect to the

parents and how it is corrected
❑“Gluten-sensitive/gluten-induced
enteropathy”

❑Permanent intestinal intolerance to

dietary wheat gliadin and related
protein that produces mucosal
lesions in genetically susceptible
individuals

❑Also caused by immunological-

mediated enteropathy
✓Failure to thrive

✓Chronic diarrhea

✓Abdominal distention

✓Muscle wasting

✓Anorexia

✓irritability
✓Presence of antigliadin and
antiendomysial immunoglobulin and
their disappearance when gluten is
removed from the diet

✓Villous atrophy and hyperplasia in

children who eat a diet with gluten

✓Remission of symptoms upon gluten

withdrawal
✓Dietary Management:
✓Gluten-free diet
✓Avoid: B-R-O-W
✓B-arley
✓R-ye
✓O-at
✓W-heat

✓Substitutes: rice and corn

✓Helping the child adhere to
dietary regimen

✓Advise parents the necessity of

reading all label ingrediants
✓HIDDEN SOURCES OF GLUTEN:
✓Bread, cake, cookies, crackers,
donuts, pies, spaghetti, pizza,
hotdog, luncheon meat, hamburger
✓Due to inflamed bowel the child
must avoid high fiber foods:

✓Nuts, raisins, raw vegetable, raw

fruits with skin, until inflammation
subside
❑CL results from incomplete fusion of
the embryonic structures sorrounding
the primitive oral cavity

❑CP occurs when the primary and

secondary plates fail to fuse during
embryonic development
❑ETIOLOGY:
❑Teratogens

❑Inheritance

❑Drugs (phenytoin, valproic acid,

thalidomide, pesticide dioxin)

❑Folic acid deficiency

❑Maternal smoking and alcohol

ingestion
✓Apparent at birth

✓CL diagnosed in utero through

ultrasound (14th – 16th weeks)

✓Palpation of the palate

✓Surgey:

✓Cleft lip (cheiloplasty)

✓Cleft palate (palatoplasty)

✓Maximize speech production
and growth of midface
✓Feeding:
✓Best accomplished with the infants
head in an upright position
✓Special bottles for feeding

✓Post-op:
✓Cleft lip: avoid prone position
✓Cleft palate: prone position
✓Elbow restrains (remove at regular
intervals)
✓Avoid use of suction, tongue
depressor, thermometers, spoons, and
straws
 Anatomy and physiology

▪ Metabolic waste excretion

 Urine production
▪ Erythropoietin production
▪ BP regulation
 Renin release
▪ Acid-Base Regulation
▪ Vitamin D activation
❑A reaction that occurs as a by-
product of an antecedent
streptococcal infection with certain
strains of the Group-A Beta-hemolytic
Streptococci

❑Most common of the non infectious

renal diseases in children
Hans Christian F. Vitug RN, MAN 2/7/2021 8:25 PM 202
✓Puffiness of the face (periorbital
edema)
✓Hematuria (cloudy and smoky
brown)
✓Mild to moderate hypertension
✓Pallor, irritability, anorexia,
deccreased urine output, and dysuria

✓Complications:
✓Hypertensive encephalopathy
✓Cardiac decompensation
✓Acute Renal Failure
✓Urinalysis:
✓Hematuria
✓Proteinuria
✓Increased specific gravity

✓Serologic test
✓Antistreptolysin O titer
✓250 todds unit or higher
✓Increased BUN and Creatinine
✓Dietary Management
✓Moderate sodium restriction
✓Protein restriction (if with
azotemia)
✓Potassium restriction (severe
oliguria)

✓Antibiotics (streptococcal
infection)
✓Antihypertensive
✓Diuretics
✓Monitor vital signs

✓Daily weight

✓Measure I and O

✓Emphasize the diet modifications

❑Most common presentation of
glomerular injury in children

❑Increased glomerular permeability

to plasma protein results in massive
urinary protein loss

❑Pathogenesis is poorly understood

✓Puffiness of the face (periorbital
edema)

✓Abdominal swelling from ascites

✓Labial or scrotal ascites

✓Muehrcke lines

✓Oliguria (Frothy urine)

✓Waxy pallor
Hans Christian F. Vitug RN, MAN 2/7/2021 8:25 PM 210
✓On the basis of history and clinical
manifestations

✓Hypoalbuminemia
✓Hypercholesterolemia
✓High urine specific gravity

✓Renal biopsy (glomerular status)

✓Dietary Management
✓sodium restriction
✓Moderate protein
(contraindicated with azotemia)

✓Corticosteroid
✓Prednisone (steroid of choice)
✓Side effect: immunosuppression, growth
retardation

✓Immunosuppressant therapy
✓Monitor vital signs

✓Daily weight

✓Measure I and O and abdominal

girth

✓Emphasize the diet modifications

❑“Nephroblastoma”

❑Most common intraabdominal and

kidney tumor of childhood
✓Swelling or mass within the
abdomen
✓Firm, non-tender, confined

✓Secondary anemia
✓Weight loss
✓hypertension
✓On the basis of history and clinical
manifestations

✓Radiographic studies
✓Abdominal ultrasound
✓CT scan
✓MRI

✓Hematologic studies (polycythemia)

✓Surgery
✓Nephrectomy

✓Radiation therapy

✓Chemotherapy
✓Actinomycin D
✓Vincristine
✓PREVENT/AVOID PALPATION OF
THE ABDOMEN
✓“DO NOT PALPATE” sign on
bedside

✓Prepare the child and family for

the operation

✓Post-op:
✓Advise to avoid high-risk
activities, prevent UTI, report and
GU signs and symptoms
❑Urethral opening on the dorsal
surface of the penis
❑Urethral opening on the ventral
surface of the penis
✓Chordee
✓cryptorchidism
✓Surgery
✓Correction
✓Glans Approximation Procedure
✓Meatal advancement and
Granuloplasty Procedure
✓Meatotomy (urethra extended to
normal function)
✓Testostenone (pre-op)
✓Urethral urinary drainage (post-op)
✓Health teaching on the care on
catheter

✓Advise the family to encourage

the child to increase OFI

✓Avoid rough activities (swimming,

straddle toys, etc.)
Blood – a specialized organ in a
fluid state

❖Fluid portion: (55%)

✓Plasma (proteins: albumin, globulin,
fibrinogen)
(electrolytes, waste products, nutrients)
❖Cellular component: (40-45%)
Three primary cell type:
✓Erythrocytes (red blood cells)
✓Leukocytes (white blood cells)
✓Thrombocytes (platelets)
✓Complex process of the formation and
maturation of blood cells

✓Site of hematopoiesis
✓Adult: pelvis, ribs, vertebrae, and sternum
✓Embryonic: Liver and Spleen
✓Biconcave
✓Very thin membrane that allows diffusion
✓Consist primarily of hemoglobin
✓Lifespan 120 days

Detects low levels of oxygen (anemia, high

altitudes)

Stimulates differentiation of the primitive

myeloid stem cell into an erythroblast
✓Primarily protect the body against
infection and tissue injury

- Presence of granules in the - Granule-free cytoplasm

cytoplasm
✓MONOCYTES:
✓NEUTROPHILS: Phagocytosis
Bacterial infections ✓LYMHOCYTES:
✓EOSINIPHILS: Parasitic produces
infections and antibodies and
hypersensitivity identification of
reactions other cells and
✓BASOPHILS: organisms as
hypersensitivity foreign
reactions
✓ Plays an essential role in the control of bleeding

Injury
Release of
endothelin
vasoconstriction

Stimulation of Von Wille

Brand factor
Attracts platelets
Clot formation
Temporary plug
Clotting cascade
❑Reduction in the number of RBCs
and/or hemoglobin concentration
compared with normal values for age
❑Iron is needed in the production of
hemoglobin
❑Main causes:
❑Inadequate production
(hypoproliferative)
❑Increased destruction of RBC
(hemolytic)
❑Excessive loss (hemorrhage)
❑Inadequate supply or loss of iron

❑At birth a fullterm has:

❑300mg iron (5-6 months)

❑Lack of dietary source → Anemia

✓Pallor
✓Fatigue
✓Dizziness
✓Glossitis
✓Angular stomatitis
✓Koilonychia (spoon-shaped nail)
✓tachycardia
✓RBC – small
(microcytic/hypochromic)

✓Mean Corpuscular Volume (MCV)

decreased
✓Dietary Management
✓Iron-fortified food/milk
substitute for breast milk
✓Importance of correct
complementary feeding

✓Ferrous iron
✓More readily absorbed than Ferric Iron
✓Oral/liquid/parenteral

✓Blood transfusion – severe anemia

✓Packed RBC not Whole blood (to avoid
circulatory overload)
SPECIAL CONSIDERATIONS:

(Oral form)

✓Given before meals, can be given after

meals but the potency is reduced by 50%

✓Take with vitamin C-rich juice (enhances

absorption by reducing to its most soluble
form)

✓Do not give antacid and dairy products

(diminishes absorpton)
(Liquid form)

✓Administer with straw (teeth-staining)

✓Oral care before and after

✓Instruct that dark-colored stool is

normal

✓Increase fluid intake to avoid

constipation
(Parenteral form)

✓Use Z-track method in administering IM

injection to avoid leak and staining the
skin, avoid massaging the injection site

✓Provide health teaching (diet,

medications)
✓Bed rest, oral care, and skin care
❑Inadequate supply or inability to
absorb vitamin B12

❑Lack of Intrinsic factor (common

cause)

❑Previous gastric surgery, crohn’s

disease,autoimmune gastric mucosal
atrophy, anorexia nervosa, etc
✓RED BEEFY TONGUE*

✓Pallor

✓Anorexia

✓irritability
✓Schilling’s Test (most definitive)
✓Intrinsic factor antibody test
*Small dose of RADIOACTIVE vit. B12 followed by a
larger dose of NON-RADIOACTIVE vit. B12

If absorbed; 8% If no radioactivity is present in

of the radioactive the urine; vit.B12 stays in the GIT
dose will be
excreted in the Problem: Malabsorption
urine
Patient will receive vit.B12 plus
Problem: not ileal intrinsic factor
disease or
pernicious If absorbed: Pernicious
anemia anemia is diagnosed
✓Monthly vitamin B12 injection (IM –
lifelong)

✓Identify patients at risk

✓Assist with ADLs
✓Provide health teachings (diet)
✓Rest periods in between meals
✓Provide understanding of the
necessity of lifelong therapy
❑Presence of abnormally shaped
elongated RBC

❑Inheritance of the sickle hemoglobin

gene which causes the hemoglobin
molecule to be defective

❑Exposure to low oxygen tension,

dehydration, and temperature elevation by
this sickle hemoglobin (HbS) causes it to
become crystal-like and lose its original
round, biconcave, and pliable structure
✓S/sx of anemia
✓Jaundice*
✓Enlargement of the bones
(face and skull)
✓Tachycardia
✓Cardiac murmurs
✓Cardiomegaly
✓Dysrhythmias
✓Spleenomegaly*
✓Blood Smear – sickled RBC

✓Sickle Turbidity Test – (blood mixed

with special solution)
✓Positive – turbid or cloudy
✓Negative – clear

✓Hemoglobin electrophoresis
 ✓Periods of exacerbation

✓Vasoocclusive crisis – “painful

episode” most common type of non-
life threatening crisis
✓Abdomnal pain
✓Priapism
✓arthralgia
✓Sequestration crisis – pooling of
large quantities of blood usually in
the spleen
✓Aplastic crisis – diminished RBC
production, usually triggered by
infection (parvovirus)

✓Hyperhemolytic crisis –
accelerated rate of RBC destruction
✓Jaundice
✓reticulocytosis
✓Prevent sickling crisis
✓Hydroxyurea - (increases
concentration of HgbF)
✓Hematopoetic Stem Cell
Transplantation – ( the only potential
for cure)
✓Bed rest
✓Hydration
✓Electrolytes replacement
✓Analgesia
✓Blood replacement
✓Antibiotics and vaccine
✓Minimize tissue deoxygenation

✓Promote hydration

✓Minimize crises

✓Promote supportive therapy

❑Rare type

❑Bone marrow hypoplasia/aplasia

resulting in pancytopenia

❑Decrease or damage to marrow

stem cell , damage in the
maicroenvironment within the
marrow, replacement of the marrow
with fat
ETIOLOGY:

✓Idiopathic
✓Congenital or acquired
✓Exposures to chemicals
(benzene)
✓Viral infections
✓Certain drugs
 ✓Signs and symptoms of infection
✓Anemia (fatigue, pallor, dyspnea)
✓Purpura (bruising)
✓Bleeding tendencies

✓Bone Marrow Aspiration and Biopsy –

(visible fatty marrow and few or no cells)
✓Bone Marrow Transplant – younger
than 60y/o, healthy, compatible
donor can be CURED
✓Peripheral Stem Cell
Transplantation
✓Immunosupressive therapy
✓BT PRN
✓Assess carefully for signs of
bleeding and infection
✓Encourage frequent rest periods
✓Reverse or protective isolation
✓Good personal hygiene
✓Monitor VS especially temperature
Minimize bleeding:
✓Soft bristled toothbrush
✓Electric razor
✓Nails are cut short
✓Avoid injections
✓Stool softener
✓Control bleeding (apply pressure
and ice packs)
❑An x-linked recessive inherited bleeding
disorder classified into Hemophilia A and
Hemophilia B
❑Hemophilia A; clotting factor VIII
deficiency (classic hemophilia)

❑Hemophilia B; clotting factor IX

deficiency (christmas disease)

❑Carried by women expressed in male

patients
✓Factor VIII and IX assay
✓Partial thromboplastin Time
✓DNA testing

✓Replacement of clotting factor

concentrates
✓Vasopressin (rise in factor VIII)
✓Corticosteroids
✓Aminocaproic acid (prevents clot
destruction)
✓Hemorrhages
✓Hemarthroses (complication:
ankylosis - fusion of bones)
✓Hematoma
✓Hamaturia
✓GIT bleeding
✓Intracranial hemorrhage (Promtly
evaluate head trauma)
✓Regular exercise and physical
therapy
✓Active rather than Passive ROM

✓Prevent bleeding
✓Advise not to engage in contact
sports
✓Dental hygiene (soft-bristled
toothbrush)
✓Electric shaver
✓Advise to wear identification
bracelet
✓Avoid aspirin (acetaminophen –
substitute)
✓Bleeding – (R.I.C.E)
✓Prevent crippling effects of bleeding
✓Active ROM
✓Family support
❑An acute or chronic bleeding disorder
that results from immune destruction of
platelets by antiplatelets antibody
✓Petichiae
✓Bruising
✓Bleeding (mucus membrane)

✓CBC
✓Platelet count (reduced to
<20,000 mm3
✓Self-limited (supportive)
✓Activity restriction
✓Infusion of Anti-D antibody
(increases platelet count 48hrs post
infusion)
✓IV immunoglobulin
✓Prednisone
✓Spleenectomy (pneumococcal,
meningococcal, H. Influenza vaccine
pre-op)
✓Advise not to engage in contact
sports

✓Avoid aspirin (acetaminophen –

substitute)

✓Thrombocytopenic precautions
❑Midline defects involving failure of
the osseous (bony) spine to close

❑Most common defect of the CNS

❑Major precipitating factor: Folic

acid deficiency during pregnancy
TYPES:
❑Spina bifida occulta (not visible
externally) – skin depression or dimples
and dark tuffs of hair

❑Spina cystica (visible defect with an

external sac-like protrusion)
❑Meningocele (encases meninges and
spinal fluid, but no neural elements)
❑Myelomeningocele (contains
meninges,spinal fluid, and nerves)
✓MRI – most sensitive tool for
evaluating the defect

✓CT scan

✓Ultrasound (prenatal)

✓Amniocentesis (Increased AFP)

✓ Spina bifida occulta – needs no
immediate surgical correction

✓ Meningocele and
Myelomeningocele – immediate
surgery
✓ Done 24-72 hours (most favorable outcome)
✓ Child with myelomeningocele will
continue to have paralysis and loss of
bladder bowel function
✓Care of the myelomeningocele sac:
✓Kept from drying
✓Application of moist, non-adherent
dressing
✓Dressing changed every 2-4 hours

✓Pre-op: prone position

✓Diapering (contraindicated)
✓Gentle ROM (prevents contractures)

✓Post-op: prone position

✓Monitor VS, I&O, singns of infection
✓Measure head circumference
❑Excess of Cerebrospinal Fluid (CSF)
in the ventricles or the subarachnoid
space

❑Three main reasons:

❑Overproduction

❑Obstruction

❑Interference with absorption

✓Head enlargement
✓Bulging fontanels
✓Dilated scalp veins
✓Macewen sign (crackd-pot sound)
✓Due to separation of sutures, elicited by
percussion
✓Frontal “bossing”
✓Sunset eyes
✓Transillumination
✓Shrill, brief, high-pitched-cry
✓Fetal ultrasonography – 14 wks AOG

✓CT Scan

✓MRI

✓Skull X-ray

✓Transillumination
✓Acetazolamide
✓Furosemide

✓Surgical treatment:
✓Plexectomy

✓Shunt systems
✓Venticuloperitoneal shunt
✓Ventriculoatrial shunt
Compilcations: Obstruction, infection,
perforstion of abdominal organs, subdural
hematoma
✓Endoscopic Third venticulostomy
(bypassing the aqueduct of Sylvius)
✓Daily head circumference
measurement
✓Assessment of child’s LOC
✓Preparing the child for Dx
examinations
✓Post-op:
✓Observe for signs of increasing
ICP
✓Pupil dilation
✓Abdominal distension
✓Shunt care
❑Metabolic encephalopathy
associated with other characteristic
organ involvement

❑Characterized by:
❑Fever
❑Profoundly impaired
consciousness (cerebral edema)
❑Disordered hepatic function (fatty
changes in liver)
❑Elevated ammonia level
❑Cause:
❑Not well understood
❑Most cases follow a common viral
illness (influenza or varicella)
❑Associated with aspirin use in
varicella infection
❑Salicylates – offending
ingredient in aspirin (also
present in Pepto-Bismol)
❑Diagnostic evaluation:
❑Liver biopsy
❑Bleeding time
❑Therapeutic/Nursing Management:
❑Early diagnosis and aggressive
therapy
❑Monitor ICP and level of
consciousness
❑Monitor I/O