NURSING CARE OF THE CHILD

BORN WITH A PHYSICAL OR

DEVELOPMENTAL CHALLENGE

Learning Outcomes
1 Describe common physical and developmental
disorders that occur in newborns.
2 Assess an infant who is born physically or
developmentally challenged.
3 Utilize knowledge of congenital physical or
developmental challenges to promote quality maternal
and child health nursing care.
CLEFT LIP AND CLEFT PALATE
Cleft Lip
It is a failure of the maxillary & median nasal processes to
fuse that range from small notch in the upper lip to total
separation of lip & facial structure up into floor of the nose,
with even upper teeth and gingiva absent.

This condition can be unilateral or bilateral. More common in

Course Outline boys, high incidence in Asian population, and lower incidence
in African-American population. The cause can be hereditary,
Physical and Developmental Disorders of the transmission of multiple genes, or teratogenic factors such as
Gastrointestinal System viral infection or folic acid deficiency.
□ Ankyloglossia
□ Cleft Lip and Cleft Palate This condition can be detected through ultrasound and can
be readily evident on inspection upon birth.
□ Tracheosophageal atresia and fistula
□ Omphalocele and Gastroschisis Management:
□ Intestinal Obstruction
□ In uterus: fetal surgery
□ Diaphragmatic Hernia
□ 2-10WOF: surgical repair
□ Imperforate Anus
Physical and Developmental Disorders of the Nervous □ Nasal mold apparatus to shape better nostril.
System □ Revision of original repair if needed.
□ Hydrocephalus
Cleft Palate
□ Neural Tube Disorders
Physical and Developmental Disorders of the Skeletal It is a palate opening that usually on the midline & involves
System anterior hard palate, posterior soft palate, or both. The
□ Developmental Hip Dysplasia palate process closes at 9th-12th WOIL. It usually occurs in
conjunction with cleft lip. In assessing, direct visualization of
□ Absent or Malformed Extremities
palate by using tongue depressor. Child with cleft palate must
□ Finger and Toe Conditions be assess for other congenital anomalies.
□ Chest Deviations
Management
□ Craniosynostosis
□ Achondroplasia □ Early repair -> second repair
□ Talipes disorders □ Soft palate: 3-6mos old repair
□ Hard palate: 15-18mos old old
PHYSICAL & DEVELOPMENTAL DISORDERS OF
THE GI SYSTEM

ANKYLOGLOSSIA
Also known as “tongue tied”. The abnormal restriction of
tongue by abnormally tight frenulum. The only management
is surgery.

@NurseMD_
 TRACHEOSOPHAGEAL ATR ESIA AND FISTULA OMPHALOCELE AND GASTROSCHISIS
ATRESIA: orifice/passage in body that is closed or absent. Omphalocele

FISTULA: abnormal/surgically made passage beween hollow Abdominal contents protruding through wall of abdomen at
or tubular organd & body surface, between 2 hollow, or the junction of UC and abdomen. Intestines are usually
tubular organs. herniated but sometimes it included stomach and liver.

ESOPHAGEAL ATRESIA: obstruction of esophagus. This usally converted & contained by thin amnion & chorion
layer with UC protruding from exposed sac. Defect < 4cm
usually there is hernia of umbilical cord while >10cm true
omphalocele exist.

A. The esophagus ends in a blind pouch; there is a

tracheoesophageal fistula between the distal part of the
esophagus and the trachea.
B. The esophagus ends in a blind pouch; there is no
connection to the trachea.
C. A fistula is present between an otherwise normal
Gastroschisis
esophagus and trachea.
D. The esophagus ends in a blind pouch. A fistula connects Almost similar to omphalocele however the abdominal
the blind pouch of the proximal esophagus to the trachea. organs spill freely from abdomen and no membrane.
E. There is a blind end portion of the esophagus. Fistulas are
present between both widely spaced segments of the This condition is diagnose during prenatal sonogram and if
esophagus and the trachea. the maternal serum alphafetoprotein. If not, inspection is
vital and make sure to document general appearance & its
This condition must be ruled out in infant born with size in cm upon birth.
hydramnios. Every hydramniotic patient should examine the
infant for other congenital anomalies as VACTERYCYL
syndrome. During first feeding WOF infant cough that can
progress into cyanosis and DOB. Superabundance of mucus of
newborns appears to be blowing bubbles.

To assure tracheoesophageal atresia & fistula, when inserting

a catheter, it cannot be pass to infant’s upper GI and aspirate
stomach contents. Another assessment for confirmation is
Barium swallow and esophageal endoscopy.

Management:
Management:
□ “E” surgery
□ Surgery within 24 after birth
□ Antibiotics
□ Small
□ Gastrostomy
□ Large
□ Close monitoring until suture dissolves
□ Silastic pouch/ “silo”
The prognosis really depends on repair, child’s condition at □ TPN
the time of surgery, and (+) or (-) of other anomalies. High
mortality rate d/t congenital anomalies association, LBW
tracheal abnormality association,
@NurseMD_
INTESTINAL OBSTRUCTI ON
STENOSIS = narrowing
For this condition, anticipate the pt had hydramnios
throughout pregnancy. The findings for newborn is < 30mL
gastric contents can be aspirated, distended abdomen and
tender to palpate. When the infant vomit, it is not sour
smelling and the appearance may be green or black. The pain
can be manifest by hard, forceful, distressful crying, and legs
pulling up against abdomen. Tachypnea as diaphragm is
pushed up. The abdominal flat-plate radiograph or sonogram
reveals absence of air at the level of obstruction. Barium
enema/swallow for confirmation because this aids greater
visualization of point of obstruction.
Management:
□ NPO
□ OGT/NGT unsertion
□ IV for fluid & electrolytes replacement
IMPERFORATE ANUS
Anal stricture is narrowing the end of tube that takes stool
out of the boy. The other term is “anal stenosis”. This
condition may be detected by prenatal sonogram and
inspection at birth. Sometimes, membrane is filled with
meconium and protrudes from anus.
Upon assessment, wink reflex is absent, no stool will be
passed, distended abdomen. Radiogram or sonogram is
needed.
Management:
□ NPO until surgery is done
□ IVT
□ Temporary colostomy until repair, if possible.
PHYSICAL & DEVELOPMENT DISORDERS OF THE
NERVOUS SYSTEM
HYDROCEPHALUS

□ Surgery Unusual CSF accumulation in the ventricles or subarachnoid

spaces. If the fluid can reach the spinal cord, it can be
communicating hydrocephalus or extra ventricular
DIAPHRAGMATIC HERNIA
hydrocephalus. This condition can be classify as congenital or
Abdominal organ, usually the stomach or intestine, protrudes
acquired. Excess CSF can result from fluid production by
through defect in diaphragm in chest cavity. This usually
choroid plexus, the passage of fluid is blocked, or there is
detected through sonogram while the infant is still in utero.
something that interferes CSF absorption.
Bowel removal can be done via fetoscopy.
In the first week, fontanelles are tensed and widen, separated
Upon assessment after birth, dyspnea occurs d/t lung is
sutured lines, and the diameter of head became enlarged.
compressed by an abdominal organ. Abdomen looks
When the fluid still accumulates, shiny scalp is evident upon
generally sunken, affected has absent breath sounds, and the
inspection. The scalp veins are prominent, bulging of brows
infant looks cyanotic. There is retraction in the intercoastal or
forward and sunset eyes.
subcoastal retractions, shunting of right-to-left by foramen
ovale and may cause patency of ductus arteriosus.

Management:

□ Surgical emergency repair

□ Semi fowler’s position?
□ NPO
□ NGT/ gastrostomy insertion

@NurseMD_
Cushing triad is the most common manifestation, reflexes are NEURAL TUBE DISORDERS
hyperactive, strabismus, optic atrophy, feeling of thrive,
lethargic & failure to thrive, and typical shrill. For assessing
this kind of condition, ultrasound, CT scan, and
transillumination test in order to identify abnormalities in the
body.

SPINA BIFIDA is a latin word which means “divided spine”.

This happens when the fusion of posterior laminae of
vertebrae fails. Poor perfusion is noticeable when dimpling,
abnormal tufts of hair or any discoloration of skin. Spina
bifida occulta is a benign disorder that does not need
immediate intervention.

MENINGOCELE is when the meninges herniate through

unformed vertebrae. Protruding mass appears and usually
have same size of an orange at the center of back. Layer of
skin or just clear dura mater covers the protrusion.
Management:
MYELOMENINGOCELE is the spinal cord & meninges
□ Still depends on cause and extent
protruding the vertebrae same with meningocele. There is an
□ Acetazolamide [diuretic] absent of motor & sensory function at the end of spinal cords
□ Ventricular endoscopy -> lower motor neuron damage. The child can feel flaccidity,
□ Tumor removal inadequate sensation of LE, and uncontrolled bladder and
bowel. The higher the myelomeningocele, the higher the
□ Laser surgery
chance hydrocephalus accompany it. CT scan/Ultrasound/MRI
□ VP shunt differentiates diagnosis of meningocele to
□ Flat or 30 degrees head position after shunt myelomeningocele.
□ Increased ICP monitoring

Management:

□ Elevated MSAFP
□ Prenatal ultrasound, fetoscopy
□ Fetoscopic surgery
□ CS birth
□ Lower extremities cobservation
@NurseMD_
 □ Voiding and nature of micturation & defecating
assessment
□ Immediate surgery
□ Health teaching: Lower extremities paralysis and
bowel and bladder dysfunction after surgery.
ANENCEPHALY, the absence of cerebral hemispheres. The
mother may experience difficult in labor, most of this
condition present as breech. If the medulla is intact, the
infant may survive several days but without it, the patient
cannot survive longer.
Microcephaly is a slow growth of brain that falls more than 3x
below normal on growth charts. This can be caused by
infection, severe malnutrition or anoxia in early infancy. The
patient is cognitively challenge because of functioning brain
tissue.
PHYSICAL & DEVELOPMENT DISORDERS OF THE
SKELETAL SYSTEM
DEVELOPMENTAL HIP DY SPLASIA
Hip underdevelopment or imperfect hip can affect the head,
acetabulum, or both. The femur head don’t lie deep enough
within acetabulum & slips out in movement. This occurs in
females seven times more often than males.
1 Acetabular dysplasia – mildest form; femoral head
remains in acetabulum.
2 Subluxation – most common form; femoral head
partially displaced.
3 Dislocation – femoral head not in contact with
acetabulum; displaced posteriorly and superiorly.
Affected leg is has limitation in abduction, the folds of
gluteus, popliteal, and thigh is asymmetric, Ortolani’s sign,
and Galeazzi’s sign. When the child starts to walk, the patient
is lordotic and have waddling gait. The limb is shorter on the
affected side and the hip is restricted in abducting on affected
side.
Management:
□ Surgical intervention
□ Directed towards enlarging and deepening the
acetabulum by placing the head of the femur within
the acetabulum and applying constant pressure.
□ Positioning with legs slightly flexed and abducted:
Pavlik harness; spica cast from the waist to below
the knees; brace
Considerations
Respiratory problems: hypostatic pneumonia
□ Frequent change position, raise head of mattress
□ Teach: postural drainage & exercise
□ When to seek immediate care
Infection or excoriation of skin
□ Observe peripheral perfusion and pulsation
□ Don’t let child put small toys or food inside cast
□ Teach: Signs of infection
□ Protection of cast edges
□ Use of diapers & plastic lining
Constipation
□ Teach: child straining on defecation & constipation
□ Fluids and fiber
Nutrition
□ Small and frequent meals
□ Caloric intake adjustment
Transportation & Positioning
□ Protection from falling
□ Two people should provide adequate body support
□ Don’t pick child by bar between the leg of cast
@NurseMD_
ABSENT OR MALFORMED EXTREMITIES
This condition can be result from ingestion of maternal drug,
viral invasion, and amniotic band formation. Prostheses of
lower extremity are fitted as early as 6 mos while upper
extremity are fitted this early so infant can handle and
explore objects readily. Early introduction of prosthesis
prevents child from adjusting to missing extremity.
FINGER AND TOE CONDITIONS
POLYDACTYLY is a presence of one or additional fingers or
toes. These are usually amputated off early. SYNDACTYLY is
when two fingers or toes are fuse.
Weebing [separation of digits can be done]
Bones are fused [cannot be fully reconstructed]
CHEST DEVIATIONS
PECTUS EXCAVATUM is the indention of lower portion of
sternum. There’s can be decreased lung volume, heart is
displaced to the left.
PECTUS CARINATUM is when the sternum is displaced
anteriorly, increasing AP diameter of the chest.
CRANIOSYNOSTOSIS
The sutures of the skull is closing prematurely and may occur
in utero or early infancy. This condition needs to be detected
early because sealed skull will compromise brain growth. It
can be caused by inherited trait, rickets, irregularities of
calcium, or phosphate metabolism.
Assessment
Sagittal suture
□ The head tends to grow anteriorly or posteriorly
□ Observation
Coronal suture
□ Orbits become misshapen
□ Exopthalmos, nystagmus, papilledema, strabismus,
atrophy of optic nerve with consequent loss of vision
□ Syndactyly association
□ Syndactyly: head circumference observation
□ Surgical intervention
Children age 2 y/o below needs head circumference
measurement and this condition is diagnosed via radiograph
or ultrasound.
@NurseMD_
ACHONDROPLASIA Management:

It is when the bone fails to grow and inherited as a dominant □ Cast application
trait. This causes disorder cartilage production in intrauterine
□ Frequent changing of diapers
life. Upon assessment, head appears larger, can be diagnosed
□ Health teaching: inspecting infant’s toes and
in utero or at birth via comparison of the length of capillary refill test
extremities to the normal. Radiography is the standard
□ Change cast q1-2wks
diagnostic that can see the characteristic of abnormal flaring
□ Approx 6wks, cast is already removed
epiphyseal plate.
□ Passive foot exercise
□ Denis Browne splints

TALIPES DISORDERS
Comes from the Latin “talus” which means ankle and “pes”
which means foot. This condition is also known as clubfoot.
Pseudo-talipes d/o d/t intrauterine position; may be
corrected via manipulation.

1 PLANTARFLEXION – equinus or “horsefoot”

position
2 DORSIFLEXION – anterior foot is flexed towards
anterior leg
3 VARUS DEVIATION – foot turns in
4 VALGUS DEVIATION – foot turns out

The earlier it is recognized, the better for correction.

Straightening newborn feet to midline is part of the initial
assessment to detect this condition.
@NurseMD_