COURSE OUTLINE: PRELIMS ○ Cigarette smoking

○ Age of the mother < 20yrs old

1. Newborn with risks
○ Order of birth (2st pregnancy and >4th
2. Child with Respiratory Disorder
pregnancy
3. Child with Cardiovascular Disorder
○ Closely spaced pregnancies
REFERENCE BOOK ○ Abnormalities of the mother’s reproductive
system
○ Infections
○ Pregnancy complications (PROM)
○ Early induction of labor
MANAGEMENT AND CARE OF ○ Elective CS birth

NEWBORN WITH RISK ● Potential Complications of preterm infants:

○ Anemia of prematurity
○ Acute Bilirubin Encephalopathy
REVIEW OF NORMAL CHARACTERISTICS OF A ○ Persistent Patent Ductus Arteriosus
NEWBORN ○ Periventricular/ Intraventricular
Hemorrhage
VITAL STATISTICS
● Head circumference: 34-35 cm ● Characteristics of a premature Infant:
● Weight: 2.5 - 3.4 kg ○ Very little flexion in the extremities
● Length: 46 - 54 cm ○ With 90 degree angle wrist flexion
● Chest circumference: 32- 33 cm ○ Minimal or absent recoil of extremities
● Term infants: 38-40 wks AOG ○ SCARF SIGN
○ Very little resistance of heel to ear
VITAL SIGNS ○ Few or no creases on the sole of the feet
● Temperature: 36.5C - 37.5C ○ Barely visible nipple or areola
● Pulse: ○ Flat ears
○ Within 1 hr after birth: 120 - 140 bpm ○ Testes are high, few rugae on scrotum
○ HR↓ during sleep (90-110 bpm) (male)
○ HR↑ during crying (up to 180 bpm) ○ Clitoris is very prominent. Labia majora are
○ Slightly irregular heartbeat very small (female)
● Respiration: 30-60 breaths/min
○ Depth: irregular ● Nursing Diagnoses:
○ Rate: irregular ○ Impaired gas exchange r/t immature
○ Rhythm: short period without cyanosis pulmonary functioning
○ Blood Pressure: 80/46 mmHg ○ Risk for deficient fluid volume r/t insensible
○ 10th day: 100/50 mmHg water loss at birth and small stomach
capacity
○ Risk for imbalanced nutrition, less than
NEWBORN PRIORITIES IN THE FIRST DAYS OF body requirements, related to additional
LIFE nutrients needed for maintenance of rapid
1. Initiation and maintenance of respirations growth, possible sucking difficulty, and
2. Establishment of extrauterine circulation small stomach
3. Maintenance of fluid and electrolyte balance ○ Risk for infection related to immature
4. Control of body temperature immune defenses in the preterm infant
5. Intake of adequate nourishment ○ Risk for impaired parenting related to
interference with parent–infant attachment
6. Establishment of waste elimination
resulting from hospitalization of infant at
7. Prevention of infection birth
8. Establishment of an infant–parent/caregiver ○ Deficient diversional activity (lack of
relationship stimulation) related to preterm infant’s rest
9. Institution of developmental care, or care that needs
balances physiologic needs and stimulation for ○ Risk for disorganized infant behavior
best development. related to prematurity and environmental
overstimulation
○ Parental health-seeking behaviors related
THE NEWBORN RISKS BECAUSE OF ALTERED to preterm infant’s needs for health
GESTATIONAL AGE OR BIRTH WEIGHT maintenance

PRETERM INFANTS
● born <38th week of pregnancy POSTTERM INFANTS
a. Late preterm (34-37 weeks) ● born > 41th week of pregnancy; postmature
b. Early preterm (24- 34 weeks) ● Assessment:
● Cause: Unknown ○ With almost similar characteristic with SGA
● Common Factors Associated with Preterm birth infant
○ Low socioeconomic level ○ With grown fingertips
○ Poor nutritional status ○ Polycythemia
○ Lack of prenatal care
○ Multiple pregnancy SMALL FOR GESTATIONAL AGE (SGA)
○ Previous early birth ● <10th percentile of weight for their age
○ Race (nonwhite-higher incidence) ● Causes:

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 ○ Lack of nutrition during pregnancy Respiratory Distress Syndrome
○ intrauterine growth restrictions (IUGR) (hyaline membrane disease)
■ Placental abnormality ● Causes:
○ low level or absence of surfactant
● Assessment:
○ Below average in weight, length, and head ● Assessment:
circumference ○ Low body temperature
○ With overall wasted appearance ○ Nasal flaring
○ Poor skin turgor ○ Sternal and subcostal retractions
○ Large head ○ Tachypnea (more than 60 breaths/min)
○ Small liver ○ Cyanotic mucous membrane
○ Skull sutures may be widely separated ○ fine rales
○ Dull hair and lusterless
○ Sunken abdomen ● Therapeutic Management
○ Dry and stained yellow umbilical cord ○ Surfactant replacement
○ Labs: ○ Oxygen administration
■ High hematocrit level ○ Ventilation
■ Increase RBC ○ Additional therapy
■ Hyperbilirubinemia
■ Decreased glycogen (hypoglycemia) ● Prevention:
○ Magnesium sulfate
LARGE FOR GESTATIONAL AGE (SGA) ○ Betamethasone
● >90th percentile
● Causes: Meconium Aspiration Syndrome
○ Overproduction of nutrients and growth ● Causes:
hormones in utero. ○ it can cause severe RDS
○ Congenital anomalies
● Assessment:
● Important Assessment: ○ difficulty establishing respirations at birth
○ Skin color for ecchymosis, jaundice, and ○ Low APGAR score
erythema ○ Tachypnea
○ Motion of upper extremities - clavicle ○ Retractions
fracture or Erb;s palsy ○ Inflammation of the bronchi
○ Assess asymmetry of the anterior chest ○ Barrel chest
○ Assess eyes for evidence of unresponsive
or dilated pupils; assess of increased ICP ● Therapeutic Management
○ Assess for seizure ○ Amnioinfusion
○ CS birth
● Appearance: ○ O2 admins with ventilation
○ Immature reflexes ○ Antibiotic
○ Extensive bruising or birth injury (broken ○ Chest physiotherapy
clavicle or ERb’- Duchenne paralysis)
○ Caput succedaneum
Apnea
○ Cephalohematoma or molding
● pause in respiration longer than 20 seconds with
● Cardiovascular Dysfunction: accompanying bradycardia (cyanosis also may be
○ Polycythemia present).
○ Signs of hyperbilirubinemia
○ Cyanosis - sign of poor heart function ● High incidence to babies with secondary
stresses:
● Hypoglycemia: ○ infection,
○ Due to poorly controlled DM for the mother ○ hyperbilirubinemia,
○ hypoglycemia, or
● Nursing Diagnoses: ○ hypothermia, (Thilo & Rosenberg, 2012).
○ Ineffective breathing pattern related to
possible birth trauma in the LGA newborn ● Interventions:
○ Risk for imbalanced nutrition, less than ○ Low body temperature
body requirements, related to additional ○ Nasal flaring
nutrients needed to maintain weight and ○ Sternal and subcostal retractions
prevent hypoglycemia ○ Tachypnea (more than 60 breaths/min)
○ Risk for impaired parenting related to ○ Cyanotic mucous membrane
high-risk status of LGA infant ○ fine rales

● Prevention:
LOW-BIRTH-WEIGHT (LBW)
○ maintain a neutral thermal environment
● > 2,500g at birth ○ use gentle handling to avoid excessive
fatigue
VERY-LOW-BIRTH-WEIGHT (LBW) ○ Always suction gently to minimize
● 1,000-1,500g nasopharyngeal irritation
○ Using indwelling nasogastric tubes rather
ILLNESSES THAT OCCUR IN NEWBORNS than intermittent ones

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 ○ After feeding, observe an infant carefully ● Cause:
because a full stomach can put pressure ○ anoxic episode that interferes with
on the diaphragm and can potentially circulation to a portion of the brain.
compromise respirations Phagocytes and macrophages invade the
○ Careful burping area to clear away necrotic tissue. What is
○ Never take rectal temperatures in infants left is an abnormality in the white matter of
prone to apnea Theophylline or caffeine the brain, which is revealed on a sonogram
sodium benzoate may be prescribed to as a hollow space.
stimulate respirations (Dukhovny, Lorch,
Schmidt, et al., 2011). ● Common:
○ preterm infants
Sudden Infant Death Syndrome
● sudden unexplained death in infancy
● Cause: unknown Hemolytic disease of the Newborn (destruction of
● High incidence: RBC)
○ Infants of adolescent mothers ● Hyperbilirubinemia - elevated bilirubin
○ Infants of closely spaced pregnancies ● Causes:
○ Underweight and preterm infants ○ Rh Incompatibility (mother (Rh-)/ fetal
○ Infants with bronchopulmonary dysplasia blood type (Rh+)
○ Twins ○ ABO Incompatibility
○ Native American infants
○ Alaskan Native infants ● Assessment:
○ Economically disadvantaged black infants ○ Enlarged liver and spleen
○ Infants of narcotic-dependent mothers ○ Hydrops fetalis
○ Jaundice (1st 24hrs)
● Peak of incidence: ■ Release of indirect bilirubin
○ 2-4 months of age (APP, 2011b) glucuronyl transferase indirect
bilirubin
● Contributory factors ■ Normal bilirubin level: 0-3 mg/ 100 dL
○ Sleeping prone rather than supine
○ Viral respiratory or botulism infection ● Disorders caused by severe hyperbilirubinemia:
○ Exposure to secondary smoke ○ Bilirubin-induced neurologic dysfunction
○ Pulmonary edema (BIND)
○ Brain stem abnormalities ○ Hypoglycemia (forced to use stored
○ Neurotransmitter deficiencies glucose due to excessive destruction of
○ Heart rate abnormalities RBC)
○ Distorted familial breathing patterns
○ Decreased arousal responses ● Therapeutic Management
○ Possible lack of surfactant in alveoli ○ Early feeding
○ sleeping in a room without moving air ○ Phototherapy (serum bilirubin 10-12 mg/dl)
currents (the infant rebreathing expired ○ Exchange transfusion
carbon dioxide)
● Warning:
● Recommendations ○ It can cause eye damage
○ Put newborns to sleep on their back;
○ use of a firm sleep surface; ● Elimination:
○ breastfeeding; ○ Stool - bright green, loose
○ Room sharing without bed sharing; ○ Urine -dark colored (urobilirubin formation)
○ routine immunizations; consideration of
using a pacifier; ● Interventions:
○ avoidance of soft bedding, overheating, ○ Monitor axillary body temperature
and exposure to tobacco smoke, ○ Assess skin turgor
alcohol,and illicit drugs (Moon & Fu, 2012) ○ Remove from the light for feeding
○ Explain to parents the rationale for
Apparent Life-Threatening Event phototherapy
● Symptoms:
○ Cyanotic limp ● Exchange Transfusion
○ Survived after mouth-to-mouth ○ small amounts (2 to 10 ml) of the infant’s
resuscitation by parents blood are drawn from the infant’s umbilical
vein and then replaced with equal amounts
● Interventions: of donor blood
○ Apnea monitoring in place (an alarm sound ○ Done under a radiant heat warmer
if HR< 80 bpm, apnea> 20sec) ○ Donor blood must be maintained at room
○ Caution parents to avoid loud noises at temperature
home ○ BT used for transfusion: O Rh(-) if the
infant’s BT is Rh (+)
Periventricular Leukomalacia (PVL)
● is the abnormal for- mation of the white matter of Hemorrhagic Disease of the Newborn
the brain (Horbar, Carpenter, Badger, et al., 2012) ● lack of Vitamin K
● Therapy: none
Twin-to-Twin Transfusion phenomenon

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 ● abnormal arteriovenous shunts occur that direct ○ CS delivery
more blood to one twin than the other ○ Separate the mother and the newborn
(Swiatkowska-Freund, Pankrac, & Preis, 2012).
● Result to anemia (donor twin) and polycytemia HIV Infection
(receiving twin)
○ Management: transfusion (donor twin),
exchange transfusion (receiving twin)

Necrotizing Enterocolitis (NEC)

● The bowel develops necrotic patches, interfering
with digestion and possibly leading to a paralytic
ileus, perforation, and peritonitis. It occurs because
of anoxia to the bowel and so may result as a
complication of exchange transfusion or an episode CHILD WITH RESPIRATORY
of breathing difficulty. DISORDER
Retinopathy of Prematurity (ROP)
REVIEW OF ANATOMY AND PHYSIOLOGY
● an acquired ocular disease that leads to partial or
total blindness in children
● Caused by vasoconstriction of immature retinal
blood vessels
● Exposure to high oxygen concentration
●
● Result to anemia (donor twin) and polycytemia
(receiving twin)

THE NEWBORN AT RISK BECAUSE OF A

MATERNAL INFECTION OR ILLNESS

ß-Hemolytic, Group B Streptococcal Infection

● Prevention:
○ universal screening from 35-37 wks AOG
○ Ampicillin IV administration during
pregnancy and during labor

● Treatment of Newborn:
○ Penicillin, cefazolin, clindamycin, or
vancomycin

Ophthalmia Neonatorum
● an eye infection that occurs at birth or during the 1st
month of life (Gold, 2011).
● Common Causes:
○ Neisseria gonorrhoeae and
○ Chlamydia trachomatis

● Prevention:
○ Prophylactic instillation of erythromycin
ointment

Hepatitis B Virus (HPV) Infection

● Interventions:
○ infants should be bathed as soon as
possible after birth to remove HBV-infected
blood and secretions.
○ Gentle suctioning is necessary to avoid
trauma to the mucous membrane, which
could allow HBV invasion.
○ The infant is administered serum immune
globulin (HBIG) in addition to the HBV
vaccination.
○ Although the virus is transmitted in breast
milk, once immune globulin has been
administered, women may breastfeed
without risk to an infant.

Generalized Herpesvirus Infection

● Therapeutic management:
○ Acyclovir

4 I NACARIO
 ● Clubbing of the fingers

● Laboratory Tests:
○ Blood Gas Analysis (Arterial Blood Gas) -
O2 vs CO2
■ Pulse Oximetry
■ Nasophyneel culture
■ Sputum analysis
● Diagnostic Procedures:
○ Chest Radiography
○ Bronchography
○ Pulmonary Function Studies

REVIEW OF HEALTH ASSESSMENT

● Components of the Pediatric Health History
○ Biographic data
○ Reason for seeking health care
○ History of present illness THERAPEUTIC THERAPY
○ Present Health Status ● Expectorant Therapy
○ Past Health History ○ Vaporizers
○ Family History ○ Nebulizers
○ Personal and Psychosocial History ○ Coughing
○ Diet and Nutrition ○ Mucus-clearing devices
○ Sleep ○ Chest Physiotherapy
○ Mental Health
○ Sexuality ● Oxygen Administration
○ Development ○ Via nasal catheter with prong
○ Health Promotion Activities ○ Via facemask
● Physical Assessment:
● Pharmacologic therapy
○ Nasal spray
○ Antihistamine
○ Corticosteroids
○ Expectorants
○ Bronchodilators
○ Antibiotics
○ metered -dose inhaler
○ spirometry

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 ○ Cause:
■ Group A ß-hemolytic streptococcus

○ Assessment:
○ Erythematous throat and palate tonsils
○ Enlarged tonsil with white exudate
○ (+) petechiae in palate
○ Fever
○ Sore throat
○ Headache
○ Stomach ache
○ Difficulty swallowing

● Therapeutic Management
○ Antibiotics (penicillin, cephalosporin)
○ Supportive treatment

● Retropharyngeal Abscess
○ Assessment:
○ High fever
○ Refusal to eat
○ Drool
○ Snore
○ Swelling on one side of the neck
DISORDER OF THE UPPER RESPIRATORY TRACT
● Therapeutic Management
CHOANAL ATRESIA ○ IV antibiotic
● -congenita; obstruction of the posterior nares ○ Hospitalization
● Assessed by holding the newborn’s mouth closed ○ tonsillectomy
and then gently compressing first one nostril and
then the other EPISTAXIS (NOSEBLEED)
● (=) - air hunger when mouth is closed ● upright position with their head tilted slightly forward
● Tx: ● Apply pressure to the cartilage for 10 minutes
○ Local piercing of the obstructing membrane ● Discourage putting tissue in the nose or blowing the
○ Surgical removal of the bony growth nose

ACUTE NASOPHARYNGITIS (COMMON COLD) SINUSITIS

● Causes: ● Rarely occur to children <6 yrs (not yet fully
○ rhinovirus, respiratory syncytial virus (RSV), developed)
○ Adenovirus, ● Treatment:
○ parainfluenza viruses, ○ Analgesic for pain
○ And influenza viruses ○ Antibiotic for the specific organism involved
● Assessment: LARYNGITIS
○ Nasal congestion
○ Watery rhinitis ● Complication of pharyngitis or from excessive use
○ Low-grade-fever of voice
○ Posterior rhinitis
○ Cough CONGENITAL LARYNGOMALACIA/
○ Swollen cervical lymph nodes TRACHEOMALACIA
● The infant’s laryngeal structure is weaker than
● Therapeutic Management: normal and collapses more than the usual
○ No specific treatment inspiration(Adil, Rager, & Carr, 2012)
○ Supportive treatment ● Produces laryngeal stridor
○ Nasal spray ● Assessment:
○ Removing nasal mucus via a bulb syringe ○ Retraction
○ Stop sucking during feeding to maintain
PHARYNGITIS adequate ventilation
● Infection and inflammation of the throat
● Either bacterial or viral ● Therapeutic Management
○ No routine therapy
● Viral Pharyngitis ○ Slow feeding
○ Symptoms: ○ Provide rest period
○ Sore throat ○ Health education to parents regarding home
○ Fever care management
○ Rhinorrhea
○ Cough CROUP (LARYNGOTRACHEOBRONCHITIS)
○ General malaise ● Cause: parainfluenza virus
○ Enlarged lymph nodes ● Assessment:
○ Erythema in the back of the pharynx ○ Mildly elevated body temperature
○ Barking cough
● Streptococcal pHaryngitis ○ Inspiratory stridor

6 I NACARIO
 ○ Marked retractions from inflammation of the
larynx and major bronchi.

● Therapeutic Management
○ Cool moist air combined with corticosteroid

EPIGLOTTITIS
● Viral: Haemophilus influenzae B, Echovirus, RSV
● Bacterial: pneumococci, steptoccoci, or
staphylococci
● Prevention: H. Influenzae B vaccine

● Assessment:
○ After 1 0r 3 days, Severe inspiratory stridor
○ Fever
○ Hoarseness
○ Sore throat
○ Difficulty swallowing

● Therapeutic Management
○ Oxygen for cyanosis or respiratory distress
○ IV fluids
○ Antibiotic,
○ Establishing endotracheal airway

CROUP (LARYNGOTRACHEOBRONCHITIS)
● Management
○ Hard forceful blow at the back
○ Encourage to cough
○ Abdominal thrusts

BRONCHIAL OBSTRUCTION
● Assessment:
○ Violent cough
○ Dyspneic
○ Localized wheezing

● Therapeutic Management
○ Remove the foreign body in the OR
○ VS monitoring
○ NPO for an hour

DISORDER OF THE LOWER RESPIRATORY TRACT

INFLUENZA
● Causes:
○ orthomyxovirus influenza type A, B, or C.

● Symptoms:
○ Cough
○ Fever
○ Fatigue
○ Body aches
○ Sore throat
○ GI symptoms (vomiting, diarrhea)

● Prevention:
○ yearly Flu vaccine

BRONCHITIS
● Cause: influenza viruses, adenovirus, and
Mycoplasma pneumoniae, among others.

● Assessment:
○ Fever
○ Dry, hacking cough, mildly productive
○ Rhonchi
○ Coarse cracked
○ Diffuse alveolar hyperinflation
○ Markings at the hilus of the lung

7 I NACARIO
 ● Therapeutic Management ○ Mechanical ventilation
○ supportive treatment
PNEUMONIA
BRONCHIOLITIS ● infection and inflammation of alveoli
● Cause: RSV ● Causes:
○ Pneumocystis carinii
● Assessment:
○ Congestion ● Pneumococcal Pneumonia
○ Rhinorrhea ○ Onset:
○ Fever ■ abrupt followed by URTI
○ Cough
○ Wheezing ○ In infants:
○ retraction ■ bronchopneumonia

● Therapeutic Management ○ Older children:

○ Antipyretics ■ localizes pneumonia
○ Adequate hydration
○ Nasal suctioning ○ Assessment:
○ Nasal saline ■ Acutely ill
○ Avoidance of tobacco exposure home ■ High fever
monitoring ■ Tachycardia
○ Hospitalization (for children with severe ■ Chest or abdominal pain
illness) ■ Chills
○ Infection control (hand hygiene ■ Signs of respiratory distress
○ Palicizumab ■ Diiminished breath sounds
■ Crackles (rales)
ASTHMA ■ Dullness on percussion
● “greek word “panting” ■ (+) consolidation
● severity depends on risk factors: ■ (+) leukocytosis
○ Genetics
○ Environmental exposures (allergens, stress, ○ Therapeutic management:
pollutant) ■ IV therapy
■ Antibiotics
● Allergens: ■ Antipyretics
○ Mice and cockroaches ■ Assess O2 sat frequently
○ Pollens ■ Humidified oxygen
○ Grasses ■ repositioning
○ pollution
● Chlamydial Pneumonia ( Chlamydia trachomatis
● Assessment: pneumonia)
○ Dry cough ○ Seen in newborn up to 12weeks of age
○ Difficulty exhaling ○ Contact after vaginal birth
○ Dyspnea ○ elevated levels of IgG and IgM antibodies,
○ wheezing peripheral eosinophilia
○ antibiotic treatment
● Therapeutic Management
○ Inhaled short-acting B-agonist (albuterol) ● Viral Pneumonia
○ Learn the possible triggers through ○ caused by viral infection of the URT
environmental control
○ Learn to use metered-dose inhaler or ○ Symptoms:
nebulizer ■ URTI
■ Diminished breath sounds
STATUS ASTHMATICUS ■ Fine rales on auscultation
● Severe and prolonged asthma attack that is not
○ Treatment:
responsive to asthma therapy.
■ Rest
■ Antipyretics
● Assessment:
■ fatigue
○ Acute respiratory distress
○ Elevated HR and RR
● Mycoplasma Pneumonia
○ Altered alertness and responsiveness
○ Symptoms:
○ Anxious
■ Fever
○ Low O2 sat and PO2
■ Cough
○ Elevated PCO2 resulting to accumulating
■ Cervical lymphadenopathy
CO2
■ rhinitis
● Therapeutic Management
○ Treatment:
○ Continuous nebulization with an inhaled B2
■ Erythromycin
agonist and IV corticosteroids
■ tetracycline
○ Oral or IV steroids
○ Smooth muscle relaxers
○ Endotracheal intubation

8 I NACARIO
 PNEUMOTHORAX
● Is the presence of atmospheric air in the pleural
space, causing atelectasis

● Causes:
○ Puncture wounds

● Symptoms:
○ (-) or decreased breath sounds on the
affected side
○ Hyperresonant
○ A shift of the apical pulse away from the site
of pneumothorax.
○ Darker-area of the air-filled pleural space

● Therapy:
ATELECTASIS ○ oxygen therapy
● Collapse of lung alveoli ○ Thoracotomy catheter or needle may be
placed through the chest wall
● Primary Atelectasis
○ seen in preterm newborns with limited BRONCHOPULMONARY DYSPLASIA
surfactant and poor respiratory strength or ● Frequently found in preterm infants who received
mucus or meconium plugs in the trachea mechanical ventilation for respiratory distress at
(Dargaville, 2012) birth.
○ Symptoms: ● Symptoms:
■ Nasal flaring ○ Tachpnea
■ Apnea ○ Retractions
■ grunting ○ Nasal flaring
○ Tachycardia
○ Treatment: ○ Oxygen-dependence
■ Crying ○ Decreased air movement
■ O2 administration ○ CXR - areas of overinflation, inflammation,
● Secondary Atelectasis and atelectasis
○ occurs from a respiratory tract obstruction
that prevents air from entering a portion of ● Therapeutic Management
the alveoli (Federico, Kirby, Deterding, et al., ○ Oxygen
2011) ○ Chronic tracheostomy
○ Causes: ○ Mechanical ventilation during the first year of
■ Mucus plugs life
■ Foreign object aspiration ○ Corticosteroids
■ Pressure on lung tissue from outside ○ Bronchodilators
forces such as compression from ○ Nutrition and fluid intake
diaphragmatic hernia, scoliosis, or
enlarged thoracic lymph nodes. TUBERCULOSIS
○ Sings of secondary atelectasis: ● Causes:
■ Asymmetry of the chest ○ Mycobacterium tuberculosis
■ Diminished breath sound
■ tachypnea ● Mode of Transmission:
■ Cyanosis ○ Inhalation of infected droplets
■ Collapsed alveoli ○ Incubation period: 2-10 weeks

○ Therapeutic management: ● Assessment:

■ bronchoscopy ○ Tuberculin test
○ Mantoux test - “Purified protein derivative
(PPD)
○ Sputum analysis

● Therapeutic management
○ Isoniazid
○ Rifampicin

9 I NACARIO
 ○ Pyrazinamide HEALTH HISTORY
○ Ethambutol ● Birth history with maternal and newborn issues
○ Up-to-date vaccination ● Pregnancy history (infections, medications, drugs
○ High-protein diet and calcium used)
● Family history
CYSTIC FIBROSIS ● Child’s current health status( medical, surgical,
● An inherited disease of the secretory glands hospitalization, current medication)
● Characterized by thick mucus secretions, ● Height, Weight, BMI, VS, O2 sat
particularly in the pancreas and the lungs,
electrolyte abnormalities in sweat gland secretions. GENERAL APPEARANCE
● Visual Assessment
● Assessment: ○ Comfortable?
○ Screening test ○ Lethargic?
○ Chromosomal abnormality ○ Distress?
○ Abnormal chloride concentration in ○ Color of the extremities?
perspiration ○ Capillary refill time?
○ (-) pancreatic enzymes in the duodenum
○ (+) immunoreactive trpsinogen in the blood PHYSICAL EXAMINATION
2dary to pancreatic obstruction, and ● Place hand on the left-side of the chest to evaluate
pulmonary involvement for the:
○ Apical impulse- Apical point of maximal
● Diagnostic tests: impulse (PMI) - is normally located at the
○ Sweat testing 4th or 5th intercostal space, midclavicular
○ Duodenal Analysis line; deviation- indication of enlarged heart
○ Stool Analysis ○ Thrills- vibration felt 2ndary to significant
○ Pulmonary testing cardiac murmurs
○ Lifts- is a forceful cardiac contraction that
EXAMPLES OF NURSING DIAGNOSES causes the hand to move up
● Activity intolerance related to insufficient ○ Heaves- is a very forceful cardiac
oxygenation contraction that actually causes the hand
● Fatigue related to impaired gas exchange to move up and laterally
● Fear related to inability to breathe without effort
● Impaired gas exchange related to excessive mucus ● Auscultation:
production ○ S1 - contraction - “systole”
● Impaired social interaction related to difficulty in ○ S2 - relaxation - “diastole”
keeping up with physical activities of peers ○ S3 - normal sound in children
● Ineffective breathing pattern related to decreased ○ S4 - pathologic; associated with decreased
energy and fatigue ventricular compliance
● Deficient knowledge related to the need for ○ Murmurs - turbulent flow through an
continued treatment abnormal valve, vessel, or chamber.
(either innocent or pathologic)
○ Innocent murmur - intracardiac disease
CHILD WITH CARDIOVASCULAR ○ Pathologic murmur- cardiac anomaly
DISORDER
BLOOD FLOW PATHWAY THROUGH THE HEART

● Assessing Innocent murmur:

○ I - Intensity (loudness)
○ L- Location (point of max. intensity)
○ P - Position in the cardiac cycle (Systole,
diastole, continuous)
○ P - Pitch (high or low)

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 ○ Q - Quality (harsh, soft, blowing) CONGESTIVE HEART FAILURE (CHF)
○ R- Radiation (do you hear it elsewhere?) ● is defined as the inability of the heart to supply
○ R - Response of the murmur to exercise or adequate oxygenated blood to meet the metabolic
change in position demands of the body.
○ T- Thrill ● Cardiac Output = Heart Rate x Stroke Volume
○ It is the blood pumped by the ventricles
each minute
● Stroke Volume is affected by the following
factors:
○ Preload- the volume of blood in the
ventricles at the point just before
contraction; it is an indicator of circulating
blood volume
○ Contractility - ability to modulate the rate
and force of fiber shortening
○ After load - amount of resistance met by
the ventricles upon ejection
○ Compliance - the ability of the ventricles to
stretch and fill
DIAGNOSTIC TEST
● CXR ● Causes of CHF in children:
○ Heart’s size and orientation, pulmonary ○ Congenital heart defects - most common
blood flow, associated lung disorders ○ Cardiomyopathies- due to metabolic
disorders
● Laboratory Testing ○ Infectious diseases
○ Chemistry ○ Drugs
■ K, Ca, Na - electrolyte ○ Kawasaki disease
imbalances ○ Myocardial dysfunction after heart surgery

○ Hematology
■ Hgb, Hct - need for blood
transfusion

○ Prothrombin Time (PT) and Partial

Thromboplastin Time (PTT)
■ Coagulation studies

○ International normalized ratio (INR)

■ Imperative before and after
surgery to prevent unnecessary
bleeding

○ Creatinine-kinase (CK-MB)
■ Enzyme specific for myocardial
damage

○ C-reactive protein (CRP)

■ Indicator of an active infectious
process

○ Erythrocyte sedimentation rate (ESR)

■ Indicator of an inflammation

○ B-Type natriuretic peptide (BNP)

■ A substance secreted from the
ventricles in response to changes
in pressure that occur when heart
failure develops and worsen.

○ Arterial blood gas (ABG)

■ Provides information regarding
the child’s arterial acid-base ● Therapeutic Management:
balance, CO2, O2, bicarbonate ○ Symptomatic
○ Tx of underlying cause
● Electrocardiogram (ECG)
● Holter/ Event Monitor ● Goal of tx:
● Transthoracic Echocardiogram ○ Symptomatic
● Computed Tomography (CT)/ Magnetic Resonance ○ Tx of underlying cause
Imaging (MRI)
● Exercise Stress Testing ● Goal of Care:
● Cardiac Catheterization ○ Comfortable and participate in ADLs

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 ● Focus of Interventions: → Most common
○ Helping support heart function → Located in the center of the atrial
○ Helping parents deal with this crisis until septum
the child is stabilized and the underlying
condition can be treated, if possible ○ Primum defect
→ Found low in the martial septum near
CONGENITAL HEART DEFECTS the IVC
● Newborn - 8% → Associated with atrioventricular
● Preterm infants - 9-10% septal defects (AVSD)
● Neonates:
○ 25|% have other congenital anomalies ○ Sinus venosis defects
○ 85% are expected to survive to adulthood → Allow communication of one or more
of the pulmonary veins with the right
● Classification of Congenital Heart Defects: atrium
○ Embryological formation
○ Structure ● Assessment:
○ physiology ○ If the defect is small, it may go undetected
○ If noted, may cause no clinical concern
● Classification of Defects: and require no intervention
○ Increasing pulmonary blood flow ○ If the defect is large enough, a child may
○ Decreasing pulmonary pulmonary blood show symptoms of pulmonary
flow or Obstruction to systemic blood flow overcirculation:
○ Single-ventricle defects ■ Rales
■ Congestion
■ Tiring with activity
“Right-to-left-shunt” - cyanotic heart disease ■ Poor weight gain
“Left-to-right-shunt” - acyanotic heart disease ■ Overtime, tie right heart may also
dilate

DEFECTS THAT INCREASE PULMONARY BLOOD ● Management:

FLOW ■ Based on the size of the defect and
age of the child
PATENT DUCTUS ARTERIOSUS (PDA) ■ Diuretics
● When the fetal shunt fails to close after several ■ defects>5mm - referred for closure
days of life ■ Surgical closure
● Frequent to premature infant (20%-60%) ■ Cardiopulmonary bypass
● Acyanotic defect

● Assessment:
○ Systolic murmur early in life
○ Continuous murmur as the child ages
○ Murmurs are noted on the 2nd intercostal
space, left upper sternal, or out to the left
clavicular area
○ If the defect is large enough (rales,
congestion, ↑ work of breathing, difficulty
feeding, or failure to thrive.
○ over time, the left heart can become dilated

● Management:
○ Addressing the symptoms
○ Diuretics (Furosemide)
○ PDA closure/ surgical closure via left-sided
thoracotomy incision
○ If noted at birth:
VENTRICULAR SEPTAL DEFECT (VSD)
■ Indomethacin and prostaglandin ● Most common defects found in children, either in
inhibitor - to facilitate closure isolation or combined with other defects.
○ Cardiac catheterization for older children. ● Occurs when a portion of the ventricular septum
does not completely close
● May be single or multiple

● Assessment:
○ ↑ pulmonary blood flow and ultimately ↑
the volume of blood returning to the left
heart, causing the heart dilation over time
○ Murmur
ATRIAL SEPTAL DEFECT (ASD) ○ Symptoms: similar to ASD and PDA
○ Confirmed by echocardiogram
● Is created when a portion of the atrial septal tissue
does not completely form.
● Management:
○ Diuretic (furosemide)
● Types:
○ Increase calorie need
○ Secundum defect

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 ○ Surgical closure: median sternotomy ○ a band surgically placed around the
pulmonary artery that constricts it to increase
the resistance within the pulmonary artery
■ Surgical repairs:
○ Closing atrial and VSDs
○ Repairing the mitral and tricuspid valves
○ With risk of heart block after surgery

TRANSPOSITION OF THE GREAT ARTERIES

● 2nd most common congenital defect
● Reversal of the great arteries
● 50% with VSDs of infants
● Anatomy:
○ Aorta - coming off the RV
○ Pulmonary artery - arising from LV
● 2 separate blood circulations:
○ oxygenated blood returns from the lungs
to the left atrium, to the left ventricle, and
then proceeds back through the pulmonary
artery and to the lungs again
○ deoxygenated blood returns from the
ATRIOVENTRICULAR SEPTAL DEFECT (AVSD) body to the right atrium, the right ventricle,
● Comprises several defects: and proceeds back out the aorta,
○ A primum ASD supplying deoxygenated blood to the
○ A high VSD systemic circulation (Fig. 41.8). The
○ Failure of the tricuspid and mitral valves to coronary arteries are positioned on the
develop and attached correctly aorta coming off the right ventricle
● 20% of children with trisomy 21 (Down syndrome)

● Assessment:
● Assessment:
○ With early symptoms similar to CHF
○ The development of increased pulmonary
resistance has been noted to occur more
rapidly in children with Down syndrome,
necessitating earlier repair in these children.
○ Confirmed with echocardiography
○ ●
● Management:
○ Medication
○ Furosemide
○ Digoxin
○ ACE inhibitor (captopril, enalapril)
■ Concentrated feed to help maintain
weight
■ Surgical correction at 3 months (Down
syndrome)
■ 5 or 6 months (without Down syndrome)
■ Pulmonary artery band
○ Temporary measure to delay surgery
○ A cyanotic defect noted immediately after birth
○ Tachypneic
○ Noted with murmur
○ Started immediately with prostaglandin E1
(PGE 1) infusion to maintain patency of the
ductus arteriosus and encourage mixing of
blood
○ Side effects:
■ Apnea (10%- 20% for wt <2kg)
■ Hypotension
○ Confirmed by echocardiogram
Management:
○ Surgical correction within the first 14 days of
life
○ Arterial switch or Jatene procedure
○ Requires cardiopulmonary bypass
○ With potential complications
○ Remain in ICU setting from birth until they
undergo their corrective surgery
○ Nursing Interventions before surgery:
■ ensuring their oxygen saturation
remains normal for this defect, which
is 75% to 85%;
■ monitoring for signs of increased
pulmonary blood flow; and

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 ■ supporting the family as they wait for ● Equally among males and females
their newborn to undergo heart ● 4 components:
surgery. ○ Pulmonary artery stenosis
○ VSD
ANOMALOUS PULMONARY VENOUS RETURN ○ Overriding aorta
● Result of failure of the pulmonary venous ○ Right ventricular hypertrophy
connections to unite with the left atrium in utero.
● Instead, they return to another vessel
● (left innominate, portal, or coronary sinus vein) or
directly to the right atrium, and the oxygenated
pulmonary blood return drains back into the right
side of the heart.
● Requires urgent surgical intervention.

● Assessment:
○ Systolic murmur at the left upper sternal
border
○ Spasm on area below the pulmonary valve
○ Right-to-left shunt across the VSD
○ Hyercyanotic spell “tet-spell)
○ Etiology: unclear
TRUNCUS ARTERIOSUS ○ During spell:
● is characterized by a single arterial vessel that ■ Distress
originates from the heart, overrides the ventricular ■ Irritable
septum, and supplies all of the systemic, coronary, ■ Period of lower saturations
and pulmonary blood flow (Fig. 41.10)
● The branch pulmonary arteries arise at some point ● Management:
along this large vessel. ○ Knee-chest position
● It occurs as a result of the great artery ○ Surgery - approx. 3-6 months of age
● failing to divide in utero into two vessels, the ■ Closure of the SVD
pulmonary artery and the aorta. ■ Repair of the stenotic pulmonary valve
● Requires urgent surgical intervention. and any associated right ventricular
outflow tract anomalies
○ Blalock-Taussig (BT)
■ Palliative procedure if the right
ventricular tract narrowing was
extremely severe at birth
■ Placement of conduit (synthetic tube)
between the subclavian artery and the
pulmonary artery (Fig.41.12)

DEFECTS THAT INCREASE PULMONARY BLOOD

FLOW

TETRALOGY OF FALLOT (TOF)

● USA - 4%-5%/ 10,000 births
● Accounts to 7%-10% of cases of congenital heart
disease DEFECTS WITH OBSTRUCTION TO SYSTEMIC
● Is one of the most congenital heart lesions requiring BLOOD FLOW
interventions in the first year of life

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COARCTATION OF THE AORTA (CoAo)
● typically located at the level of the ductus arteriosus
insertion;
● The mechanism is thought to be migration or
extension of ductal tissue into the wall of the fetal
thoracic aorta, causing the tissue to constrict (Fig.
41.13).
● Aortic narrowing occurs across a spectrum that
encompasses discrete thoracic lesions,
ong-segmental defects, tubular hypoplasia, and,
rarely, coarctation in the abdominal aorta.
● Coarctation accounts for 4% to 6% of all congenital
heart defects, with a reported prevalence of about 4
per 10,000 live births. It occurs more commonly in
males than in females.

● Assessment:
○ Discrete narrowing of the aorta
○ As they grow, they are hypertensive
○ Elevated BP in the Right arm ● Assessment:
○ Murmur along the left sternal border and the ○ Heart murmur at the right 2nd intercostal
left midscapular area space, but the child may be asymptomatic
○ you must assess the patient for the presence ○ If obstruction is severe, the child may
of pulse equality in the upper and lower experience chest pain with exercise
extremities. While a child is lying supine, the ○ Aortic regurgitation
right radial and femoral pulses are palpated ○ Echocardiography- used to determine the
concurrently. The pulses in both areas should exact location and severity of the narrowing
be felt simultaneously without delay. There
should be no absence or weakness in the
femoral pulses compared with the radial or
brachial pulse. ● Management:
○ Obtain blood pressures in the right arm and ○ Beta-blocker or calcium-channel blocker - to
either leg. The pressures should be fairly reduce or prevent further ventricular
equal, with the systolic pressure in the lower hypertrophy
extremity reading slightly higher than that in ○ Routine echocardiograms
the upper extremity. If the systolic pressure ○ Possible cardiac catheterization
reading in the right upper extremity is 10 ○ Balloon dilation
mmHg higher than that in the lower extremity,
this is an indicator of potential CoAo and SINGLE VENTRICLE DEFECTS
requires further evaluation.
HYPOPLASTIC LEFT HEART SYNDROME (HLHS)
● Management:
● is a rare disorder,
○ Balloon angioplasty
● accounting for only 1% to 3% of congenital heart
○ Surgical repair through a left thoracotomy
disease, and is detectable on prenatal ultrasound.
incision
● HLHS results when there is poor or no flow to the
left ventricle, typically secondary to mitral or aortic
AORTIC STENOSIS stenosis or atresia.
● The narrowing prevents blood from passing freely ● Infants are typically male, rarely premature, and
from the left ventricle of the heart into the aorta have no other associated cardiac anomalies.
● Aortic stenosis accounts for about 10% of
congenital cardiac abnormalities (Darst et al.,
2012).
● Valvar aortic stenosis - the most common location
for obstruction

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● Pre-operative care:
○ A child must be healthy before cardiac
surgery.
○ They must exhibit no signs of an upper
respiratory tract infection or have a fever. Vital
signs (blood pressure, temperature, pulse,
respirations, and oxygen saturation) will be
noted to establish baseline values.
○ An accurate height and weight are also
recorded. Weight must be documented in
kilograms
○ as all medication calculations in children are
based on this unit of measure.
○ Laboratory values must be checked,
specifically chemistry, hematology, and
coagulation values.
○ Blood products must also be typed and
cross-matched.
○ Pregnancy testing, either urine or serum, must
be performed for any girl who has begun
menstruating.
○ It is also important to ensure that consents for
surgery and anesthesia have been signed by
the family and the appropriate provider.
○ It is important to include the child in
developmentally appropriate discussions
regarding the planned surgical procedure and
postoperative course.
○ By speaking with both the child and parents,
the parents will be able to reinforce your
teaching. This also demonstrates to children
that their parents approve and feel secure with
these surgery plans. Because many children
scheduled for cardiac surgery have already
had a cardiac catheterization, talking to them
about their previous hospitalization experience
can be helpful to reveal things they are
worrying about. Any misconceptions they
have can then be discussed and clarified.
○ Be certain to explain that anesthesia is a
“special sleep” from which they will have no
difficulty waking.
○ After the child is fully prepared, ask parents
whether they need additional time to discuss
the surgical procedure
● NURSING DIAGNOSES:
○ Risk for ineffective cardiopulmonary tissue
perfusion related to depressed myocardial
function after surgery
○ Risk for excess or deficient fluid volume
related to fluid shifts accompanying cardiac
surgery
○ Impaired gas exchange related to atelectasis
and/or collection of fluid in the chest cavity
(pleural effusions)
○ Risk for ineffective peripheral tissue perfusion
related to dysrhythmias.
○ Risk for infection related to surgical incision
○ Parental anxiety related to lack of knowledge
of postoperative routine and exercises
● NURSING INTERVENTIONS:
○ Accurate V/S
○ Continuous cardiac monitoring
○ Hemodynamics monitoring
○ I/O monitoring
○ Monitor laboratory results
○ Endotracheal suctioning assist with chest
physiotherapy
○ Monitor cardiac activities
○ Watch out for infection and fluid and
electrolyte imbalances
○ Antibiotic therapy is continued for 24-48 hrs
after chest closure
○ Monitor temp
○ Assess surgical incision site
○ Wear shirts and bibs when feeding to prevent
formula from dropping on the incision site
○ Encourage parents to participate in their
child’s care
○ Caution parents not to pick up an infant under
the arms to move or hold the child because
this pulls on the chest incision, Show them
how to lift an infant.
○ Teach parents to help an older child out of bed
by wrapping their arms around the child’s
chest. To prevent pain, they should not pull on
the child’s arms.
○ Despite the sternal wound, all children should
use seat belts or car seats as directed to
ensure safety.
○ Infants should not be placed prone for “tummy
time” for approximately 2 to 3 weeks after
surgery.
● DISCHARGING A CHILD AFTER CARDIAC
SURGERY
○ Avoid any active contacts while they are
recuperating at home
○ Good hand washing techniques used by all
visitors
○ Children who have undergone a median
sternotomy must be restricted from physical
activity, including physical education class and
any sports activities, for 6 weeks from the time
of sternal closure.
○ They should be assigned a helper in school
because these restrictions include lifting
heavy backpacks or other heavy items.
○ They should also not drive a car during this
time to allow for healing of the sternum. They
must be cleared by the cardiologist or surgeon
before they can return to these activities.
○ Assist in wound dressing and bathing
○ Advise parents to follow through with
neurologic and behavioral specialists
ACQUIRED HEART DISEASE
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KAWASAKI DISEASE (mucocutneous lymph node
syndrome)
● Is defined as an acute febrile syndrome associated
with generalized vasculitis affecting all blood
vessels throughout the body.
● Cause: unknown
● With genetic predisposition
● Strong suggestion of infectious precursor
● It occurs commonly in winter and spring, with males
affected more than females
● Criteria for diagnosis:
○ Prolonged fever (>100.4°F [39°C]) of 5 or
more days
○ Four or more of the following symptoms:
○ Changes in hands and feet (erythema,
edema, peeling)
○ Polymorphous exanthema (diffuse
maculopapular rash of the trunk and
extremities)
○ Bilateral conjunctivitis without exudates
○ Changes in lips and mouth (erythema,
strawberry tongue, dry, cracked lips)
○ Cervical lymphadenopathy (>1.5 cm diameter,
usually unilateral)
● Laboratory results:
○ Thrombocytosis
RHEUMATIC FEVER
○ Leukocytosis ● is an autoimmune disease that occurs as a reaction
○ Elevated ESR and CRP, liver enzymes to a group A β-hemolytic streptococcal infection,
○ Mild anemia specifically, a pharyngitis.
● It occurs most often in children 6 to 15 years of age,
● Symptoms: with a peak incidence at 8 years
○ Very irritable and uncomfortable from the fever ● Therapeutic Management:
○ Joint pain ○ Penicillin therapy (10 day course)
○ Skin desquamates (plam and soles) ○ Oral NSAIDs
○ Platelet count rises ○ Phenobarbital and diazepam (Valium) - for
severe carditis valve damage; effective in
● Therapeutic Management: purposeless movements of chorea
○ Supportive measures 7-10 days- high dose of ○ Surgical intervention later in life- valve
IV immunoglobulin and high-dose aspirin replacement
therapy

● NURSING DIAGNOSES:
○ Parental anxiety related to a lack of
knowledge regarding Kawasaki disease
○ Discomfort related to swelling of lymph nodes
and inflammation of joints

● NURSING INTERVENTIONS:
○ Antipyretic drugs administration
○ Provide comfort measures
○ Try to protect the edematous areas from
pressure
○ Make sure that clothing is not constricting and
irritating areas of rash
○ Applying lip balm
○ Offer extra fluid
○ Carefully monitor and record the child’s intake
and output to be certain intake is adequate.
○ Encourage the child to continue brushing his
or her teeth (use a soft toothbrush or a
commercial swab), even though the oral
mucous membrane is tender, to prevent tooth
decay or ulcer formation.
○ Soft, non irritating foods such as gelatin may
be better tolerated than foods that require
chewing or acidic fluids, such as orange juice,
which might sting.

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