NCM 109

Alteration In Nutrition UNDERNUTRITION

- refers to intake of nutrients insufficient to
NUTRITION
meet daily energy requirements because of
> the sum of all the interactions between an
organism and the food it consume. inadequate food intake or improper digestion and
absorption of food.
NUTRIENTS
> are organic and inorganic substances found Inadequate food intake may be caused by :
➢ Inability to acquire and prepare
in foods that are required for body functioning.
food
FACTORS AFFECTING NUTRITION
➢ Inadequate knowledge about
• Development
essential nutrients and a
• Gender
balanced diet
• Ethnicity and Culture
➢ Discomfort during or after eating
• Beliefs about Food
• Personal Preferences ➢ Dysphagia
➢ Anorexia
• Religious Practices
➢ Nausea
• Lifestyle
➢ Vomiting
• Economics
• Medications and therapy Improper digestion and absorption of nutrients

• Health may be caused by:

 an inadequate production of hormones or
• Alcohol Consumption
enzymes
• Advertising
 medical conditions
• Psychological factors
Inadequate nutrition can be associated with:
Daily Food Guide:
• marked weight loss
Food Pyramid for KIDS
• generalized weakness
• Both inadequate and excessive intakes of nutrients
• altered functional abilities
result in MALNUTRITION.
• Malnutrition is commonly defined as the lack of • delayed wound healing
• increased susceptibility to infection
necessary or appropriate food substances, but in
• decreased immunocompetence
practice includes both undernutrition and
• impaired pulmonary function
overnutrition.
• prolonged length of hospitalization.
OVERNUTRITION
- refers to a caloric intake in excess of daily Protein-calorie malnutrition (PCM)
• significant problem of clients with long-term
energy requirements, resulting in storage of energy in
deficiencies in caloric intake
the form of adipose tissue.
Characteristics of PCM :
• depressed visceral proteins (e.g., albumin)
National Heart, Lung and Blood Institute
- overweight = BMI is between 25 and 29.9 kg/m2 • weight loss

and obese when the BMI is > 30 kg/m2. • visible muscle and fat wasting.
 NURSING MANAGEMENT immunosuppression secondary to insufficient protein
A comprehensive nutritional assessment is often intake.
performed by a nutritionist or a dietitian, and the PLANNING
primary care provider.  Maintain or restore optimal nutritional status.
Components of a Nutritional Assessment :  Promote healthy nutritional practices.
• Anthropometric  Prevent complications associated with
• Biochemical malnutrition.
• Clinical  Decrease weight
• Dietary  Regain specified weight.
NUTRITIONAL SCREENING
- an assessment performed to identify clients ALTERATION IN
at risk for malnutrition or those who are GASTROINTESTINAL SYSTEM
malnourished.
NUTRITION HISTORY
• Age, sex, and activity level
• Difficulty eating
• Condition of the mouth, teeth, and presence of
dentures
• Changes in appetite
• Changes in weight
• Physical disabilities that affect purchasing,
preparing, and eating
• Cultural and religious beliefs that affect food
choices
• Living arrangements (e.g., living alone) and
economic status
• General health status and medical condition
• Medication history.
DIAGNOSING
• Imbalanced Nutrition: Less Than Body
Requirements
• Obesity
COMMON GASTROINTESTINAL
• Overweight
SYMPTOMS OF ILLNESS IN CHILDREN
• Readiness for Enhanced Nutrition
 Vominting
• Activity Intolerance related to inadequate
 Diarrhea (mild, severe)
intake of iron-rich foods resulting in iron deficiency
 Bacterial Infectious Diseases that cause
anemia
diarrhea & vomiting
• Constipation related to inadequate fluid intake and
 Protozoan or Viral Diarrhea
fiber intake
• Chronic Low Self-Esteem related to obesity
• Risk for Infection related to
 COMMON DIORDER OF THE STOMACH COMMON GASTROINTESTINAL SYMPTOMS
AND DUODENUM OF ILLNESS IN CHILDREN
I. Gastroesophageal reflux I. VOMITING
II. Pyloric Stenosis Or throwing up is a forceful discharge of
III. Peptic Ulcer Disease stomach content
IV. Hepatic Disorders: Recurrent vomiting may be caused by
A. Hepatitis underlying medical conditions
> Hepa A, Hepa B, Hepa C,D and E
> Chronic Hepatitis Is Vomiting Harmful?
.> Fulminant Hepatic Failure Some examples of serious conditions that may result
V. Obstruction of the Bile Ducts in nausea or vomiting include:
VI. Nonalcoholic Fatty Liver Disease & Cirrhosis • Concussions
> esophageal varices • Meningitis
VII. Liver Transplantation • Intestinal blockage
• Appendicitis
INTESTINAL DISORDER • Brain tumors
I. Intussusception • Dehydration
II. Volvulus with malrotation
III. Necrotizing enterocolitis ASSESSSMENT
IV. Short Bowel/Short –Gut Syndrome Differentiation between Regurgitation & Vomiting
V. Appendicitis Vomiting is the ejection of contents of the
• Ruptured Appendicitis stomach and upper intestine
VI. Meckel’s Diverticulum Regurgitation is the ejection of small
VII.Celiac Disease (Malabsorption syndrome, amounts of chyme or gastric juice from the mouth
Gluten-Induced Enteropathy, Celiac Sprue) and antecedent nausea.
DIFFERENTIATION BETWEEN
DISORDERS OF THE BOWEL REGURGITATION AND VOMITING
I. CONSTIPATION Characteristic Regurgitation Vomiting

II. INGUINAL HERNIA Timing Occurs w/ feeding Timing unrelated

to feeding
III.HIRSCHPRUNG DISEASE (Aganglionic
Forcefulness Runs out mouth Forceful: often
Megacolon)
w/ little force projected as much
IV. INFLAMMATORY BOWEL DISEASE :
as 4 ft (most often
> Ulcerative Colitis associated with
> Crohn Disease pyloric stenosis)
V. IRRITABLE BOWEL SYNDROME Description Smells barely Extremely sour
VI. CHRONIC RECURRENT ABDOMINAL PAIN sour; only slightly smelling and

DISORDERS caused by FOOD, VITAMIN & curdled curdled, yellow,

green, clear or
MINERAL DEFICIENCIES
watery, or black
I. Kwashiorkor
or blood tinged.
II. Nutritional Marasmus
III. Vitamins and Mineral Deficiencies
Distress Nonpainful; no Possible crying DIFFERENTITATION BETWEEN NORMAL
appearance of just before STOOL AND DIARRHEA STOOL IN AN
distress; may even vomiting as if
INFANT
smile as if abdominal pain is
Diarrheal stool in an infant
sensation is present and after
Characteristic Infant Normal Diarrheal Stool
enjoyable vomiting as if the
force of action is Stool
frightening Frequency 1-3 daily Unlimited number
Duration Occurs once per Continuing until Color Yellow Green
feeding stomach is empty; Effort of Some pushing Effortless; may be
followed by dry
expulsion effort explosive
retching
pH More than 7.0 Less than 7.0
Amount 1-2 teaspoons Full stomach
contents (alkaline) ( acidic)
Odor Odorless Sweet or foul

When to seek immediate medical care? smelling

 Blood in the vomit (bright red or “coffee Occult blood Negative Positive; blood

grounds” in appearance) may be overt

 Severe headache or stiff neck Reducing Negative positive

 Lethargy, confusion or a decreased alertness substances

 Severe abdominal pain

 Diarrhea DIARRHEA may be either:
 Rapid breathing or pulse Short-term (acute)
Long term (chronic)
THERAPEUTIC MANAGEMENT Symptoms :
- water; ORS; IVF; PediaLyte; Fresh Ginger Tea • Cramping
• Belly (abdominal) pain
II. DIARRHEA • Swelling (bloating)
 When stools (bowel movements) are loose and • Upset stomach (nausea)
watery • Urgent need to use the bathroom
 MILD • Fever
 SEVERE • Bloody stools
CAUSES: • Loss of body fluids (dehydration)
 Bacterial infection • Incontinence
 Viral infection Diagnostic Test
 Trouble digesting certain things (food intolerance) •Stool evaluation to check the stool for blood or
 An immune system response to certain foods fat
(food allergy) •Blood tests to rule out certain diseases
 Parasites that enter the body through food or •Imaging tests to rule out structural problems
water •Tests to check for food intolerance or allergies
 Reaction to medicines •Stool culture to check for abnormal bacteria or
 An intestinal disease, such as inflammatory parasites in your child’s digestive tract. A small
bowel disease. stool sample is taken and sent to a lab
Sigmoidoscopy
•Helps to check the child’s large intestine.
•It tell/shows what is causing diarrhea, stomach
pain, constipation, abnormal growths, and
bleeding.
•It uses a short, flexible, lighted tube
(sigmoidoscope). The tube is put into the
intestine through the rectum.
• This tube blows air into the intestine to make
it swell. This makes it easier to see inside.
NURSING DIAGNOSIS:
• Deficient fluid volume related to
loss of fluid through diarrhea.
Related Interventions:
• Promote Hydration and Comfort.
• Record Fluid Intake and Output
III. BACTERIAL INFECTIOUS DISEASES
THAT CAUSE DIARRHEA & VOMITING
• Salmonellosis
• Listeriosis
• Shigellosis (Dysentery)
• Staphylococcal Food Poisoning
IV. PROTOZOAN OR VIRAL
DIARRHEA
Common Disorder of the Stomach and Duodenum
I. GASTROESOPHAGEAL REFLUX
II. PYLORIC STENOSIS
III. PEPTIC ULCER DISEASE
IV. HEPATIC DISORDERS:
A. HEPATITIS
> Hepa A; Hepa B; Hepa C,D and E
> Chronic Hepatitis
➢Fulminant Hepatic Failure
V. OBSTRUCTION OF THE BILE DUCTS
VI. NONALCOHOLIC FATTY LIVER DISEASE &
CIRRHOSIS
> Esophageal Varices
VIII. LIVER TRANSPLANTATION
COMMON DIORDER OF THE STOMACH
AND DUODENUM
I. GASTROESOPHAGEAL REFLUX DISEASE
(GERD)
A digestive disorder that affects the ring of muscle
between the esophagus and stomach.
The ring is called the lower esophageal sphincter
(LES)
GERD occurs when stomach acid frequently flows
back onto the tube connecting the mouth and stomach
(esophagus).
This backwash (acid reflux) can irritate the lining of
the esophagus.
Diagnostic workup may include the ff:
> Upper GI Series
> Ph Probe
> Esophageal Manometry
> Endoscopy
THERAPEUTIC MANAGEMENT
• conservative treatment
• medication
• surgery
•In infants, it is treated by feeding a
thickened formula and keeping the infant
upright after feedings.
•Adolescents are prescribed a proton
pump inhibitor and advised to sleep with
two pillows.
• avoid lying down until 3 hours after a meal
• sleep at night with their upper body elevated on
a foam wedge or extra pillow.
• avoid acidic foods
• Avoiding foods that delay gastric emptying such - Thickening and abnormal enlargement of the
as fatty foods, chocolate, or alcohol pylorus muscles, blocking food from reaching the
• losing some weight if overweight small intestine.
• avoid bending over after meals
• Remove tight belts
RISK FACTORS
 Cerebral palsy
 Down syndrome
 Cystic fibrosis
 Obesity
TYPICAL SYMPTOMS - Pyloric stenosis can lead to forceful vomiting,
 Heartburn that occurs 30 to 60 minutes after a dehydration and weight loss.
meal and regurgitation.
COMMON SYMPTOMS OF GERD includes: - Babies with pyloric stenosis may seem to be hungry
 Burping or belching all the time.
 Not eating - Surgery cures pyloric stenosis.
 Having stomach pain Cause:
 Being fussy around mealtimes Unknown , but genetic and environmental factors
 Vomiting often might play a role.
 Having hiccups Risk Factors:
 Gagging  Sex
 Choking  Race
 Coughing often  Premature birth
 Having coughing fits at night  Family history
THERAPY:  Smoking during pregnancy
- In many cases, GERD can be eased by diet  Early antibiotic use
and lifestyle changes.  Bottle-feeding
Sometimes, medicines, tube feedings, or surgery may Complications:
be needed.  Failure to grow and develop
For babies:  Dehydration
• After feedings, hold the baby in an upright  Stomach irritation
position for 30 minutes.  Jaundice
•If bottle-feeding, keep the nipple filled with
milk. This way the baby won’t swallow too When to see a doctor?
much air while eating. Try different nipples. • Projectile vomits after feeding
Find one that lets the baby's mouth make a • Seems less active or unusually irritable
good seal with the nipple during feeding. • Urinates much less frequently or has
noticeably fewer bowel movements
II. PYLROIC STENOSIS • Isn't gaining weight or is losing weight
- an uncommon condition in infants that blocks food
from entering the small intestine.
 DIAGNOSTIC:
Treatment of Pyloric Stenosis

HISTORY
Epigastric abdominal pain,
postprandial pain, weight loss,
nausea, vomiting, hostry of
NSAID use

For patients <60 Other patients,

without alarm patients >60,
features, in regions patients w/ alarm
with H. Pylori features
Prevalence >20%

Test and treat Endoscopy with

for H. Pylori Ulcer biopsy

III. PEPTIC ULCER DISEASE DRUG THERAPY:

a shallow excavation formed in the mucosal wall of Antacids
the stomach, the pylorus, or the duodenum.  Used as adjunct therapy for peptic ulcer disease
> Includes gastritis  gastric pH by neutralizing acid
(irritation of the lining of the stomach or Anticholinergic drugs
duodenum)  Occasionally ordered for treatment
CAUSES:  Cholinergic stimulation of HCl acid
Helicobacter pylori infection
- Peptic ulcer may lead to bleeding or perforation, Management of Peptic Ulcer
emergency situations The objectives of management are to:
- Bacterial infection of the biliary tract as a result of  relieve pain and discomfort
obstruction (neutralize gastric acid gastric mucosal  accelerate healing
injury)  prevent recurrence and complications
The common signs of a stomach ulcer: Treatment
• A dull burning or gnawing ache in the • If the ulcer is related to H. pylori, the doctor will
stomach prescribe a combination of drugs to eradicate the
• Gas and bloating infection and normalize gastric acid levels so that
• Nausea or vomiting the stomach can heal.
• Loss of appetite • Diet > foods that are easily digested and place little
• Fatigue stress on the stomach.
 Burning; Weight loss Food that PREVENT or HEAL Ulcers
 Fatigue; Dull pain  Avocados
 Heartburn
 Loss of Appetite  Raw honey
 Vomiting  Kale
 Nausea
 Bloating  Cabbage
 Burping  Spinach
 Brussels sprouts HEPA E
 Celery Source: feces
Foods to AVOID with ULCERS Route of Transmission: fecal-oral
 Milk Chronic infection: No
 Alcohol Prevention: ensure safe drinking water
 Bacon Vaccines to hepatitis A and B are available and are
 Buttery pastries
 Mayonnaise
 French fries
 Red meat

IV. HEPATITIS
What is Hepatitis?
“Hepatitis” means the inflammation of the liver
Can be caused by:
 Genetic diseases
 Medications (including OTC) genuinely given to children.
 Alcohol SIGNS and SYMPTOMS of HCV
 Hepatitis viruses (A,B,C,D,E)  When patients develop symptomatic acute HCV
TYPES OF HEPATITIS infection, they most often present with dark
HEPA A urine, and light colored stools, followed by
Source: feces jaundice in which the skin and whites of the
Route of Transmission: fecal-oral eyes appear yellow.
Chronic infection: No  Itching of the skin may be present.
Prevention: pre/post exposure immunization  On average, symptoms appear 6 to 7 weeks after
HEPA B infection
Source: blood/blood-derived body fluids
Route of Transmission: percutaneous permucosal
Chronic infection: Yes
Prevention: pre/post exposure immunization
HEPA C
Source: blood/blood-derived body fluids
Route of Transmission: percutaneous permucosal
Chronic infection: Yes
Prevention: blood donor screening; risk behaviour
modification
HEPA D
CHRONIC HEPATITIS
Source: blood/blood-derived body fluids
- is defined as continuing or relapsing hepatic
Route of Transmission: percutaneous permucosal
disease for more than 6 months, with presence of
Chronic infection: Yes
symptoms and other diagnostic parameters - serology,
Prevention: risk behaviour modification
biochemical and histopathology.
Fulminant Hepatic Failure
- A clinical syndrome resulting from massive
necrosis of hepatocytes or from severe functional
impairment of hepatocytes.
- Synthetic, excretory, and detoxifying functions of
the liver are all severely impaired.

PATTERNS of HEPATITIS:
 Acute hepatitis:
- hepatitis is considered acute if its
manifestation persist for period less than six months VI. NON ALCOHOLIC FATTY LIVER
 Chronic hepatitis: DISORDER
- hepatitis is considered chronic if there is Esophageal Varices
clinical or serological evidence of liver pathology > abnormally enlarged veins in the lower part
persistent for more than six consequent months. of esophageal tube
 Fulminant hepatitis: The main causes of ortal hypertension in children:
- hepatitis is considered fulminant if massive > portal vein thrombosis or cirrhosis
hepatic cell necrosis happened within few Treatment options:
weeks leading to acute hepatic failure > Endoscopic
encephalopathy. > Radiographic
 Carrier state: > Surgical strategies
- is an individual who harbor and can transmit
the virus but has no manifest symptoms.

V. OBSTRUCTION OF THE BILE DUCT

- a biliary obstruction is a blockage of the bile ducts.
Biliary obstruction
The blockage of any duct that carries bile
from the liver to the gallbladder or from the
gallbladder to the small intestine.
This can occur at various levels within the
biliary system.
CIRRHOSIS
The major signs and symptoms of biliary
General signs associated with Liver disease
obstruction result directly from the failure of bile to
 Jaundice
reach its proper destination.
 Clubbing
 Palmar erythema
Possible causes of a blocked bile duct include:
 Spider nevi
Cysts of the common bile duct. Enlarged lymph
 Hepatomegaly
nodes in the portal hepatitis.
 Gynaecomastia
 Testicular atrophy
 Caput medusae
VII. LIVER TRANSPLANTATION
- a surgical procedure that removes a liver that no
longer functions properly (liver failure) and replaces
it with a healthy liver from a deceased donor or a
portion of a healthy liver from a living donor.
Provide discharge teaching:
a. Teach how to reduce risk of infection, and signs of
infection to report.
b. Instruct to recognize and report signs of organ
rejection.
c. Discuss all medications. Stress the importance of
complying with all prescribed medications and
postoperative precautions for the remainder of the
client’s life.
d. Discuss possible changes in body image and
psychologic responses to receiving a transplanted
organ .
Refer to a counselor or support group as indicated.
e. Refer for home health services for continued
assessment and teaching.
f. Stress importance of continued follow-up with
transplant team and primary care provider.
INTESTINAL DISORDER
I. Intussusception
II. Volvulus with malrotation
III. Short Bowel- Gut Syndrome
IV. Appendicitis
V. Celiac Disease

PREOPERATIVE CARE
I. INTUSSUSCEPTION
 complete nursing history and physical
(Intestinal Folding)
examination.
- is defined as the telescoping of a proximal
 Provide routine preoperative care as ordered
segment of the gastrointestinal tract within the lumen
 Discuss preoperative and post operative
of the adjacent segment.
expectations with the client and family
ETIOLOGY
 Once a donor liver is located, check for evidence
Children Adults
of infection; if no infection is present, begin
Spontaneous:(without Spontaneous: (without
preoperative antibiotics as ordered.
anatomical leading point) anatomical leading
POSTOPERATIVE CARE
 routine postoperative care in 90% of cases: point):

 Maintain airway and ventilatory support until  Mucosa edema &  Celiac disease

awake and alert lymphoid  Scleroderma

 Frequently monitor hemodynamic pressures, hyperplasia after  Whipple disease

viral gastroenteritis.
including arterial BP, central venous pressure,
and pulmonary artery pressures. Leading point: Leading point(90%):

 Monitor for signs of active bleeding  Meckel’s  Tumor: usually

diverticulum benign in small
 Polyp intestine &  Slowed growth
 Enterogeneous cyst malignant in large Diagnostic Tests
 Ectopic pancreas intestine  Abdominal UTZ
 Purpura  Polyp  Barium enema
 Ulcer Ladd Procedure
 Foreign body

III. NECROTIZING ENTERO COLITIC (NEC)

 Is a devastating disease that affects mostly the
intestine of premature infants.
II. VOLVULUS with MALROTATION  The wall of the intestine is invaded by bacteria,
Malrotation > occurs when the intestine does not which cause local infection and inflammation
make the turn as it should. that can ultimately destroy the wall of the bowel
Volvulus > is a problem that can occur after birth as (intestine).
a result of intestinal malrotation SYMPTOMS:
Type of Volvulus Stage 1
 Midgut Volvulus  Suspected NEC
 Cecal Volvulus Symptoms:
 Sigmoid Volvulus  bloody stools
Midgut Volvulus (Malrotation)  Diminished activity (lethargy)
 Slow heart rate
 An unstable temperature
 Mild abdominal bloating
 Vomiting
Stage 2
 Definite NEC
Symptoms:
Symptoms:
 vomiting bile (greenish-yellow digestive fluid)
 symptoms of stage 1
 Drawing up the legs
 Slightly reduced blood platelet levels
 Pain in the abdomen (belly)
 Slight excess of lactic acid
 Abdominal distention (swelling)
 No bowel sound
 Rapid heart rate
 Pain when the abdomen is touched
 Rapid breathing
 Reduced or no intestinal movement
 Bloody stools
 Growth of gas-filled spaces in the wall of the
 Malnutrition
intestine.
 Moderate Short Bowel Syndrome
1. Similar to that for mild short bowel syndrome,
with the addition of parenteral nutrition as needed.

V. APPENDICITIS
- where the appendix becomes swollen, inflamed, and
filled with pus

Treatment:
 Primarily supportive care
- enteral feeds, gastric decompression with
intermittent suction, fluid repletion to correct
electrolyte abnormalities, parenteral nutrition and
prompt antibiotic therapy.
 Monitoring is clinical
 Peak incidence 10-12 yrs
- abdominal roentegenograms should be performed
 Begins as dull, steady pain in periumbilical area
every 6 hours
Progresses over 4-6 hrs & localizes to right lower
 Bowel Perforation
quadrant
- emergency surgery to resect the dead bowel
 Low grade fever
- colostomy, which may be able to be reserved at a
 Nausea
later time
 Anorexia
-short bowel syndrome - malabsorption caused by the
 Sudden pain relief may indicate rupture of
surgical removal of small intestines.
appendix (leads to peritonitis)
Management, Surgical
 Rebound pain or tenderness (RLQ) at
 Early surgical consultation
McBurney’s Point
 Indications for surgery:
*DIAGNOSIS*
 Perforation: 20-30% of cases
 Clinical signs and symptoms
12-48 hrs after onset
 Hi WBC
 Full-thickness necrosis
 Abdominal sonogram
 Deterioration despite aggressive medical
 Exploratory lap
treatment

Appendicitis Symptoms
IV. SHORT BOWEL - GUT SYNDROME
 Sudden pain on the right side of abdomen
Treatment
 Vomiting
Mild short Bowel Syndrome
 Fever
1. Eating small, frequent meals
 Abdominal bloating
2. Driking fluid
 Constipation or diarrhea
3. Taking nutritional supplements
 Loss of appetite
4. Using medications to treat diarrhea
Management ACUTE APPENDICITIES
 Surgery is indicated if appendicitis is diagnosed. Signs
 To correct or prevent fluid and electrolyte  RIF Tenderness in McBurny’s point
imbalance and dehydration, antibiotics and  RIF Rebound Tenderness, Release tenderness or
intravenous fluids are administered until surgery Blumberg’s sign
is performed.  Guarding/ rigidity
 Analgesics can be administered after the  Cope’s Psoas test
diagnosis is made. (Morphine sulphate 10mg/ml)  Cope’s Obturator test
 Rovsing’s sign
 Antibiotics
 Hyperasthesia in Sherren’s Triangle
 Cefotaxime 250mg, 500mg
 Levofloxacin 500 mg
V. MECKEL’s DIVERTICULUM
 Metronidazole 500mg/100ml, 400mg tablet
- most congenital defect of the GIT
Laparoscopic Appendectomy
- an abnormal pouch of tissue on the small intestine
(Appendix Removal)
Clinical Presentation
RUPTURED APPENDICITIS
 Majority of Meckel’s diverticuli are clinically
• A rupture spreads infection throughout the
silent (asymptomatic)
abdomen (peritonitis).
 Symptoms are
• requires immediate surgery to remove the appendix .
a) Severe hemorrhage
b) Intussusception
c) Meckel’s diverticulitis
d) Chronic peptic ulceration
e) Intestinal obstruction

Nursing Management of a Newborn with

Meckel Diverticulum
Signs and symptoms
 Bleeding, anemia, severe colicky abdominal
pain
 Abdominal distention, hypoactive bowel sounds,
guarding , abdominal mass, rebound tenderness.
Management
SYMPTOMS:
 Administer ordered blood products and IV fluids
 Nausea
 Maintain NPO status
 Vomiting
 Perform postoperative care and family education
 Diarrhea
Surgery
 Constipation
 Intestine repaired
 Appetite loss
 Meckel’s diverticulum removed
 Fever
 Swelling in the abdomen
 Pain in the LR abdomen
 VI. CELIAC DISEASE SYMPTOMS OF CELIAC DISEASE
- is a digestive disorder that damages the small (no gluten protein)
intestine, triggered by eating foods containing gluten Skin - brittle nails, acne, eczema
Intestinal - diarrhea, bloating, constipation
In female - infertility, miscarriage, early menopause
Mouth - ulcer and tooth enamel erosion
Joint and muscle - pain and swelling
Stomach - pain and nausea
 Lactose intolerance
 Anemia
 Dizziness
 Migraines
 Depression
 Low vitamin D
 Chronic fatigue

Celiac Disease
- An inherited condition that prevents the small
intestine from absorbing nutrients, causing
malnutrition.
>> Antibodies attack, damage lining of small
intestine
What happens?
- Gluten, a protein found in some grains, stimulates
immune system antibodies.
Symptoms MANAGEMENT:
- Diarrhea, malnutrition, weight loss, skin rash; some • dietary
people have no symptoms • Complete elimination of glutencontaining grain

Microvilli products (including wheat, rye, and barley) .

- Absorb nutrients in food • Children must follow a gluten-free diet for life.

Celiac disease (Endothelial cells, villi, microvilli)

- Damaged by body’s reaction to gluten Benefits of a Gluten-Free Diet
Endothelial cells  Lower the risk of intestinal distress
- Cover surface of villi  Controls the itching connected to dermatitis

Normal intestine villi herpetiformis

- Tiny projections on inside wall of intestine  Can possibly lower death risk when followed
from under the age of two
Gluten-Free Substitutes
Grains- avoid wheat barley and rye
Dairy - good milk products include plain milk
cheese yogurt sour cream and cottage cheese
Beans - enjoy beans!
Vegetables- all vegetables are naturally gluten-free
Fruits - add variety to menu by trying new fruits
Fish - look up processed fish
Meat - most meats are gluten-free
MANAGEMENT:
DISORDERS OF THE LOWER BOWEL  Foods high in fiber
I. Constipation  Non-stimulant laxatives
II. Inguinal hernia  Enemas
III. Hirschprung disease (aganglionic megacolon)  Suppositories
IV. Inflammatory bowel disease:  Biofeedback training
> ulcerative colitis  Prescription medications
>crohn disease  Surgery
V. Irritable bowel syndrome NURSING INTERVENTIONS:
VI. Chronic recurrent abdominal pain  Increase fluid intake
 Laxative fluids e.g. orange juice relives mild
I. CONSTIPATION constipation
Refers to bowel movements that are  Small soapy enema may be given
infrequent or hard to pass. The stool is often hard and  Milk of magnesia may be used as a temporary
dry. measure
ETIOLOGY of CONSTIPATION  Establish or maintain regular bowel action by
Congenital nature means rather than using purgatives.
 Anorectal defects  Psychological support to express his fear and his
 Neurogenic own emotional reactions
 Colonic neuropathies Expected outcome:
 Colonic defects  Infant/child will show no evidence of discomfort
Acquired and passes stool according to his habit
 Functional
 Anal lesions II. INGUINAL HERNIA
 Neurologic conditions - A protrusion of abdominal cavity contents through
 Metabolic the inguinal canal
 Endocrine - Symptoms are present in about 66% of affected
 Drug induced people.
 Low fiber diet SIGNS and SYMPTOMS of HERNIA
 Psychiatric problems - Many hernias present no problem, showing a
painless swelling that gives no symptoms, which may
be worse when standing, straining or lifting heavy
items.
- Immediate medical attention should be sought an Hirschsprung disease
inguinal hernia produces acute abdominal complaints - Congenital agnenesis of ganglion cells of distal
such as: colon
1. Pain Clinical
2. Nausea  Failure to pass meconium
3. Vomiting  Constipation/ intermittent loose stool
4. The swelling in these cases is typically firm and  Bilious, poor PO intake, abdominal distension
tender and cannot usually be reduced.  Enterocolitis (toxic megacolon) complication
5. Hiatal hernia can produce symptoms of acid reflux Diagnosis
- producing heartburn when stomach acid gets into  Rectal biopsy (gold standard)
esophagus.  Contrast enema (presence of transition zone)
Management
MANAGEMENT  Surgical excision of aganglionic segment
 Inguinal hernias should always be repaired  Colostomy with susequent end-to-end
(herniotomy, herniorrhaphy) unless there are anastomosis
specific contraindications. Clinical Manifestations:
 Types of operations:  Failure to pass meconium within 24 hours
- A permanent sutures, as in Shouldice repaire  Constipation during first month of life
(layered suture).  Bile-stained emesis
- A permanent mesh-greater frequency to  Abdominal distension
decrease tension.  Distended abdomen
Inguinal hernia can occur in children. It is  Reluctance to eat
surgically corrected when recognized.  Failure to thrive
 V/D; stool / ribbon-like appearance
III. HIRSCHPRUNG DISEASE DIAGNOSTIC EVALUATION
Also known as congenital aganglionic 1. Rectal exam
megacolon . 2.Barium enema or ultrasound
• Is an absence of ganglionic innervation 3.Biopsy of the affected segment or
to the muscle of a section of the bowel—in most 4.Anorectal manometry
instances, the lower portion of the sigmoid colon just THERAPY
above the anus. • may involve a temporary colostomy followed by
• This results in chronic constipation or ribbonlike surgery in 6 to 12 months to remove the affected
stools. bowel portion.
IV. INFLAMMATORY BOWEL DISEASE (IBD)
> is an umbrella term used to describe disorders that
involve chronic inflammation of the digestive tract.
 V. IRRITABLE BOWEL SYNDROME (IBS)
➢ is a common disorder that affects the large
intestine.
➢ IBS is a chronic condition that need to manage
long term.
Signs and symptoms :
➢cramping, abdominal pain, bloating, gas, and
diarrhea or constipation, or both.
SIGNS & SYMPTOMS
CAUSES of IRRITABLE BOWEL SYNDROME
Ulcerative colitis
(IBS)
 Attack of diarrhea
 Diet
 Rectal bleeding
 Intolerance to food items
 Abdominal cramps
 Mental ailments
Crohn’s Disease
 Infections
 Recurrent diarrhea
 Emotional stress
 Abdominal pain
 GI motor problems
 Anorexia
 Unexplained fever
 Malaise
 Arthritis
 Weight loss
MANAGEMENT
• Mild to moderate symptoms
> oral medication, vitamins and mineral deficiencies
should be corrected.
• Severe cases
> bowel rest, enteral or total parenteral nutrition

NON-PHARMACOLOGIC THERAPY:
 Avoid anti-diarrheal meds, anticholinergics,
opiates and NSAIDs.
 Address diet case-by-case
 Vit. D and Ca supplementations in all pts. On
VI. CHRONIC RECURRENT ABDOMINAL
steroids.
PAIN
 Surgery case by case
Chronic abdominal pain- defined by pain of at
THERAPY
least three months’ duration, although some
•long term
clinicians consider pain of more than one to two
•If medical therapy is unsuccessful, portions of the
months’ duration to be chronic.
bowel may be surgically removed.
Recurrent abdominal pain - defined as one of the
most common recurrent pain syndromes in childhood.
The classic definition is based upon 4 criteria:
- history of at least 3 episodes of pain
- pain sufficiently severe to affect activities
- episodes occur over a period of three months
- no known organic cause
RECURRENT (Chronic) ABDOMINAL PAIN
 Defined as the occurence of multiple episodes of
abdominal pain over at least 3 months that are
severe enough to cause some limitation of
activity.
 A common problem in children, affecting more
than 10% of children at some time during
childhood.
 The peak incidence occurs between ages 7 and
12 years.
 Although the differential diagnosis of recurrent
abdominal pain is fairly extensive , most children
with this condition are not found to have a
serious (or even identifiable) underlying illness
causing the pain.
DISORDER CAUSED BY FOOD,VITAMIN and
MINERAL DEFICIENCIES
I. PROTEIN ENERGY MALNUTRITION (PEM)
- Marasmus was thought to result primarily from
inadequate energy intake, whereas kwashiorkor was
thought to result primarily from inadequate protein
intake.
- Marasmic kwashiorkor, has features of both
disorders (wasting and edema.)
KWASHIORKOR
- a form of severe protein malnutrition characterized
by edema and an enlarged liver with fatty infiltrates.
- It is caused by sufficient calorie intake.
The symptoms of kwashiorkor include:
• failure to grow or gain weight.
• edema (swelling) of the ankles, feet, and belly.
• damaged immune system, which can lead to more
frequent and severe infections.
• irritability
II. NUTRITIONAL MARASMUS
> Marasmus is a severe form of protein-energy
malnutrition that results when a person does not
consume enough protein and calories.
SIGNS & SYMPTOMS of MARASMUS
 Sunken eyes
 Thin and bony face
 Ribs clearly visible through the skin
 Poor growth

MARASMUS (PEM) KWASHIORKOR

Severe deficiency of all
nutrients and inadequate
caloric intake
Peripheral edema is
absent
Hair changes absent
Skin is dry an wrinkled
but no dermatosis
Severe protein deficiency
but normal caloric intake
Peripheral edema is
present
Hair changes common
(sparse and easily pulled
out)
Dermatosis, flaky paint
appearance of skin
Voracious appetite Poor appetite VITAMIN D
Absent subcutaneous fat Reduced subcutaneous Cause of Deficiency: Lack of sunlight
fat Signs &Symptoms
Fatty liver uncommon Fatty liver common Poor muscle tone, delayed tooth formation
Better prognosis Worse prognosis Rickets (poor bone formation)
Craniotabes (softening of the skull)
III. VITAMIN E MINERAL DEFICIENCIES Swelling at joints, particularly of wrists and cartilage
VITAMIN A of ribs
Cause of Deficiency: A lack of yellow vegetables in Bowed legs, tetany (muscle spasms)
diet
Signs & Symptoms:
Tender tongue, cracks at corners of mouth,
night blindness
Xerophthalmia (dry and lusterless conjunctives)
Keratomalacia (necrosis of the cornea with
perforation, loss of ocular fluid and blindness)

VITAMIN B1
Cause of Deficiency: Most common in children who
eat polished rice as dietary staple because b1 is
contained in hull of rice
Signs & Symptoms:
Beriberi (tingling and numbness of extremities, heart
palpitations exhaustion)
Diarrhea and vomiting
Aphonia (crying without sound)
Anesthesia of feet

NIACIN
Cause of Deficiency: Common in children who eat
corn as dietary staple because corn is low in niacin
Signs & Symptoms
Pellagra (dermatitis, resembles a sunburn), diarrhea,
mental confusion (dementia)

VITAMIN C
Cause of Deficiency: Lack of fresh fresh fruits in
diet
Signs &Symptoms
Scurvy (muscle tenderness, petechiae)
ALTERATIONS IN ENDOCRINE OR METABOLIC
FUNCTION
I. PITUITARY GLAND DISORDERS
1. Growth hormone deficiency
2. Growth hormone excess
3. Diabetes insipidus
What is the function of the pituitary gland?
Anterior Pituitary Gland
 GH
 TSH
 ACTH
 FSH
 LH
 PROLACTIN
Posterior Pituitary Gland
 Oxytocin
 ADH
I.
GH DEFICIENCY
-The cause of the defect is unknown; it may have a
genetic origin.
- A pituitary tumor must be ruled out as the cause of
decreased GH production
- Results in extremely short stature if left untreated
THERAPEUTIC MANAGEMENT
- Administration of intramuscular recombinant human
growth hormone (rhGH)
- Usually given daily at bedtime, the time of day at
which GH normally peaks
II. GH EXCESS
- There is an overgrowth of body tissues
- Usually is caused by a benign tumor of the anterior
pituitary (an adenoma)
III. DIABETES INSPIDUS
- Extreme thirst or appetite may occur
- Therapy is the administration of desmopressin, an
arginine vasopressin.
(Pituitary gland produces insufficient ADH, hence the
kidneys make a lot of urine)
ASSESSMENT:
• Frequent voiding in children most often reflects a
urinary tract infection, but it may be evidence of excessive
urine excretion (polyuria), possibly from pituitary
dysfunction or diabetes mellitus.
• A child’s general appearance may reveal early or late
puberty changes, scaling or dry or darkening skin, drooping
eyelids, protrusion of the eyeballs.
II. THYROID GLAND DISORDERS
1. Congenital hypothyroidism
2. Acquired hypothyroidism (Hashimoto Thyroiditis)
3. Hyperthyroidism (graves disease)
WHAT IS THE FUNCTION OF THYROID GLAND?
THYROXINE
- Control metabolic rate
CALCITONIN
- Lowers blood calcium levels
FUNCTIONS OF THYROID HORMONE
METABOLIC
Increases cellular oxygen consumption and heat production in
part by stimulating Na+/K+ ATPase
CARDIOVASCULAR
Marked positive inotropic and chronotropic effects on heart
SYMPATHETIC
Increases number of alpha and beta-adrenergic receptors in heart
muscle and beta receptors in skeletal muscle, adipose tissue, and
lymphocytes
 RESPIRATORY Caused by overproduction of thyroid hormones. It leads to
Maintains normal hypoxic and hypercapneic drive in medullary jitteriness and tachycardia. Treated by medication to suppress
respiratory center. thyroxine release.

HEMATOPOIETIC EFFECTS Hyperthyroidism in children is caused by an autoimmune

Stimulates secretion of Epo to increase RBC synthesis reaction that results in overproduction of immunoglobin G (IgG)

I. CONGENITAL HYPOTHYROIDISM III. ADRENAL GLAND DISORDER

 Protruding tongue 1. Acute Adrenocortical insufficiency
 Growth retardation 2. Congenital Adrenal Hyperplasia
 Jaundice 3. Cushing Syndrome
 Dry skin Adrenal glands secrete hormones which help regulate stress and
 Slow reflexes metabolism and supplement other glands.
 Hoarse voice
- Occurs as a result of an absent or nonfunctioning thyroid
gland.

- The condition is discovered by a blood spot test at birth

THERAPY: oral administration of synthetic thyroid hormone

- The symptoms of the disorder become apparent during the first

3 months of life in a formula-fed infant and at about 6 months in
a breastfed infant.

- Almost all cases identified through NEONATAL

SCREENING.

CLINICAL

 Constipation
 Hypotonia
 Hoarse cry
 Macroglossia I. ACUTE ADRENOCORTICAL INSUFFICIENCY
DELAYED TREATMENT CAN LEAD TO: An emergency situation in which there is abrupt
nonfunction of the adrenal gland.
 Learning disabilities
 Cognitive deficits ASSESSMENT
 Clumsiness
 BP drops to extremely low levels
 Dimished fine motor skills
 May appears ashen gray, and the pulse will be weak
THEREPEUTIC MANAGEMENT
 Temp. gradually becomes elevated
- Oral administration of synthetic thyroid hormone (sodium  Dehydration and hypoglycemia
levothyroxine) a small dose is given at first, and then the dose is  Seizures may occur.
gradually increased to therapeutic levels.

II. ACQUIRED HYPOTHYROIDISM (HASHIMOTO THERAPEUTIC MANAGEMENT

DISEASE)
- Is an autoimmune phenomenon that interferes with  Immediate replacement of cortisol (with IV
thyroid gland function hydrocortisone sodium succinate) (SoluCortef)
- THERAPY: administration of synthetic thyroid  Administration of deoxycorticosterone acetate (DOCA)
hormone.  IV 5% glucose in normal saline solution solution
Levothyroxine – the most common treatment
Fatigue - the most common symptoms II. CONGENITAL ADRENOGENITAL
Vitamin D – promising new treatment research HYPERPLASIA
A condition that affects the thyroid Abnormalities in specific enzyme of the adrenal gland that cause
Antibodies destroy thyroid tissue severe salt lose, dehydration and abnormally high levels of male
hormones in boys and girls.
SYMPTOMS OF HYPOTHYROIDISM IN CHILDREN THERAPY: administration of hydrocortisone and also
aldosterone if sodium loss is present.
 Short stature or slow growth
 Rough, dry skin
 Cold intolerance
 Fatigue
 Bruising easily
 Delayed puberty
THERAPEUTIC MANAGEMENT

Administration of synthetic thyroid hormone (sodium

levothyroxine)

III. HYPERTHYROIDISM (GRAVES DISEASE)

THERAPEUTIC MANAGEMENT

 Replace the cortisol that is missing, thereby

suppressing ACTH concentration and normalizing
adrenal size and androgen production.
 Corticosteroid agent (as oral hydrocortisone)

III. CUSHING SYNDROME

- Caused by the overproduction of cortisol by the adrenal
gland, which is usually caused by a tumor in the gland.
- Children appear abnormally obese.
- Therapy is the surgical of the tumor

I. TYPE 1 DIABETES MELLITUS

 an autoimmune process that destroys insulin production
islet cells.
 An acute loss in weight is often the first symptom
 Therapy is a combination of insulin, diet, and exercise.

WHAT ELSE CAUSES TYPE 1 DIABETES?

VIRAL INFECTION
Researchers believe that type 1 diabetes can be triggered by a
virus. Such as the common flu or cold. Frequently, type 1
diabetes comes in a weeks following a viral infection.

PANCREAS INJURY
Very rarely, type 1 diabetes can be triggered by trauma to the
pancreas. If the pancreas is surgically removed, the body also
loses the ability to produce insulin, which then causes type 1
diabetes.

THERAPEUTIC MANAGEMENT

THERAPEUTIC MANAGEMENT
- TREATMENT: surgical removal of the causative
tumor
- Prognosis depends on whether the tumor is benign or
malignant because a carcinoma of this type trends to
metastasize rapidly.
- If a major part of the adrenal glands are surgically
removed, the child will need replacement cortisol
therapy indefinitely.
- Insulin administration
- Regulation of nutrition and exercises
- Stress management
- Blood glucose and urine ketone monitoring.
II. TYPE 2 DIABETES
 Sometimes called a “lifestyle” disease.
 May be revealed by being overweight
 Therapy: diet, exercises, and an oral anti glycemic
agent.

IV. PANCREATIC DYSFUNCTION

1. Type 1 diabetes mellitus
2. Type 2 diabetes mellitus
3. Cystic fibrosis
LABORATORY STUDIES

-Laboratory studies usually show a random plasma

glucose level greater than 200 mg/dl I.HYPOCALCEMIA
- Normal range, 70 to 110mg/dl fasting; 90 to 180 mg/dl  Lowered blood calcium level, causing tetany to
not fasting and significant glycosuria. develop.
ACCEPTABLE BLOOD GLUCOSE RANGES FOR  Therapy: administration of calcium
CHILDREN WITH TYPE 1 DIABETES
SIGNS AND SYMPTOMS
 BEFORE A MEAL C – onvulsions
= 70-110 mg/dl
 1 HOUR AFTER A MEAL A – arrhythimus
= 90-180 mg/dl
T – etany
 2 HOURS AFTER A MEAL
= 80-150 mg/dl S – tridor and spasms
 BETWEEN 2 AM AND 4 AM
= 70-120 mg/dl CAUSES OF HYPOCALCEMIA
TWO DIAGNOSTIC TESTS USED TO CONFIRM - Vitamin D inadequacy or vitamin D resistance
DIABETES: - Hypoparathyroidism following surgery
Fasting blood glucose test - Hypoparathyroidism owing to autoimmune disease or
Random blood glucose test genetic causes
- Renal disease or end-stage liver disease causing vit. D
inadequacy
- Pseudohypoparathyroidism

II. HYPERCALCEMIA
 Calcium level in the blood is above normal

V. PARATHYROID GLAND DISORDER

1. Hypocalcemia
2. Hypercalcemia
  Cerebral palsy (33 %), behavioral problems

 Often associated with a mousy odor

 Vomiting — prominent early symptoms

 Eczema (20-40%) - mild

 Reduced hair, skin and iris pigmentation

 Reduced growth and microcephaly

 Neurologic impairments (25% epilepsy, 30%

tremors 5% spasticity, 80% EEG abnormalities)

PKU: MANAGEMENT

Dietary Restriction of PHE

Special formulas
Limited protein diets/food
Vitamin supplement

Periodic assessment of plasma PHE levels

Weekly for 2-4 months
Every 2 weeks until 6-12 months
Monthly thereafter

Treatment: Neurodevelopmental assessment

Early intervention (speech therapy, PT, OT)
•If hypercalcemia is mild: Genetic counseling
monitoring of bones and kidneys over time to be sure they
remain healthy.

•Severe hypercalcemia:
medications or treatment of the underlying disease. > Surgery.

Medications:
• Calcitonin - controls calcium levels in the blood

• Calcimimetics - help control overactive parathyroid glands.

• Bisphoshonates - Intravenous osteoporosis drugs, which can

levels, are often used to treat hypercalcemia due to cancer

• Denosumab - used to treat people with cancer-caused

hypercalcemia who don't respond well to bisphosphonates.

• Prednisone - If hypercalcemia is caused by high levels of vit.

TREATMENT:
D, short term use of steroid pills such as prednisone are usually
*Dietary restriction of phenylalanine
helpful.
• Goal: limit dietary intake of phenylalanine in amount
• IV fluids and diuretics - to promptly lower the calcium level
required for normal growth and development but below toxic
to prevent heart rhythm problems or damage to the nervous
level.
system.
• For babies: special milk formula + controlled amount
of breast milk and/or regular milk formula
VI. DISORDERS OF METABOLISM

1. PKU • Typical diet consist of low protein foods, meaning

limited intake of meat, fish, poultry, milk, eggs, cheese,
2. Galactosemia legumes, and regular flour.

3. Tay – Sachs disease • Monitoring of blood phenylalanine level at least

quarterly.
I. PHENYLKETONURIA (PKU)
- A disorder of amino acid metabolism wherein the body
is not able to use phenylalanine leading to its
accumulation.

Classical Phenylketonuria Phenylalanine hydroxylase

deficiency
 Most common outcome is severe mental
retardation (IQ <50)
 II. GALACTOSEMIA
A disorder of carbohydrates metabolism wherein the body
is not able to use galactose leading to its accumulation.

Galactosemia, which means “galactose in the blood,”

refers to a group of inherited disorders that impair the
body’s ability to process and produce energy from a sugar
called galactose.

PROGNOSIS:
 With strict adherence to a galactose-free diet, the
prognosis is good.
 Cataracts are reversible if therapy is started before
3 months.
 There is recovery of the liver abnormalities with
dietary restrictions.
III. TAY-SACHS DISEASE
If galactosemic infant is given milk, unmetabolized milk
sugars build up and damage the liver, eyes, kidneys and Tay-Sachs disease is a rare, inherited disorder. It causes
brain. too much of a fatty substance to build up in tissues and
nerve cells of the brain.
Clinical Manifestations:
•It appear within days of birth or initiation of milk Tay-Sachs disease
feedings  A rare disorder passed from parents to child.
•Signs and symptoms depend on the level of enzymes
deficiency.  Caused by the absence of an enzyme
•Vomiting & jaundice — early signs (gangliosides) that helps break down fatty
•Sepsis — neonatal period substances. > leading to build up toxic levels in
•Failure to thrive the child’s brain and affect the function of the
•Hepatomegaly
nerve cells.
•Cataract — after 3-4 weeks of milk feedings
•MENTAL RETARDATION SIGN AND SYMPTOMS
•Fatal — if milk feedings are continued Is classified in variant forms, based on the time of onset of
neurological symptoms.
Diagnosis: INFANTILE
 Newborn Screening
3 to 10 months
can detect virtually 100% of affected infants JUVENILE
- Requirements: Lactose-containing milk/foods
No blood transfusions Two and 10 years ( extremely rare)
ADULT/LATE ONSET
 Confirmatory Test FREE Repeat DBS (filter
20 and 30 years (usually non-fatal)
card) — Beutler test

Long term treatment and follow- up

 Diet - remove galactose from the diet
 Monitor Gal/Gal-1-P level
 Early intervention for problems of motor, speech
and cognitive development
 All girls should be evaluated for premature
ovarian failure at 10-12 years of age
 Regular ophthalmologic evaluation for those with
cataracts
 Regular evaluation of liver profile
 NURSING PROCESS

ASSESSMENT
 Measure the child’s height and weight to find out
if above or below a typical measurement for that
age.

 To obtain information on activity in the child, take

a day history by asking a parent or child to
describe all the child’s actions on a typical day.

 Assess dietary and elimination habits.

NURSING DIAGNOSIS

• Deficient fluid volume related to constant excessive loss

of fluid through urination.

• Risk for imbalanced nutrition, less than body

requirements, related to an inability to use glucose because
of diabetes mellitus

• Disturbed body image related to abnormal height Health-

seeking behaviors related to the self - administration of
insulin.

• Deficient knowledge related to long-term treatment

needs.

•Fear related to the potential and unknown illness

outcome.

• Anticipatory grieving related to presumed losses

associated with diagnosis of long-term illness.

• Interrupted family processes related to the child's chronic

illness.

•Anxiety related to financial resources required to

maintain optimum family health
NCM 109 Coordination- when action or reaction towards a
TOPIC #3 ALTERATIONS IN PERCEPTION & stimulus is occurring in a purposeful, orderly fashion,
COORDINATION appropriate response to a stimulus

Disturbances in Perception and Coordination NEUROLOGIC EXAMINATION

Six areas to be assessed:
The nervous system is a complex collection of nerves  Cerebral
and specialized cells known as neurons that transmit  Cranial nerve
signals between different parts of the body. It is  Cerebellar
essentially the body's electrical wiring.  Motor
 Sensory
 And reflex function

Role of Nervous System:

1. Reciprocally Interact With The Environment
2. Maintain Homeostasis (WITH THE ENDOCRINE
SYSTEM)

Function:
1. SENSORY-interpret incoming message
2. INTEGRATIVE-analyze, store, make decisions
regarding appropriate behavior
3. MOTOR-initiating muscular or glandular activity;
ongoing and evolving interaction with environment

ALTERED LEVEL OF CONSCIOUSNESS

Perception and Coordination
Consciousness requires:
Perception- conscious recognition and
1. Arousal
interpretation(awareness) of the sensory stimuli.
2. Cognition
Level of Consciousness: o Oculovestibular response (Cold
1. Alert Caloric Testing)
2. Lethargy
3. Obtunded
4. Stuporous
5. Coma

Processes that affect LOC:

 Increased ICP
 Stroke, hematoma, intracranial, hemorrhage
 Tumors
 Infections
 Demyelinating dirsorders

Assessment of Motor System:

 Inspection and palpation of muscles
 Assessment of tones
 Examination of reflexes
 Testing movement and power
 Coordination

Systemic conditions affecting LOC:

 Hypoglycemia
 Fluid and electrolyte imbalance
 Accumulated waste products
 Drugs affecting CNS
 Seizure activity

Client assessment with decreased LOC

 Increased stimulation required
 More difficult to arouse
 Orientation changes
 Continuous stimulation required
 Client has no response
 Loss of normal eye functioning:
o Doll’s eye movement
o Oculocephalic reflex
 CORTICAL SENSATIONS
Stereognosis - Identify familiar object
Two-point discrimination - Can identify 1 or 2
points of a pin
Graphesthesia - Draw a number or letter on palm
and ask to identify the symbol
Point localization/Extinction - Touch client and ask
to identify where touched
Kinesthesia- Move joint and ask client to identify
position

Motor Function
 Assess bilateral symmetry and size of muscles
 Assess for tremors and fasciculation
 Assess muscle tone
 Assess bilateral muscle strength and
Sensory Function Assessments movement
 Assess ability to perceive various sensations
 Touch both sides of various parts of the body Cerebellar Function Assessments
(chest, abdomen, arms, legs)  Assess gait
 Perform Romberg test
SENSORY SENSATION  Assess coordination
Three Types:
1. Superficial: pain, temperature and superficial
touch carried by spinothalamic (lateral)
2. Deep: crude touch, joint position, vibration carried
by dorsal coloumn
3. Cortical sensation: tactile localization, tactile
discrimination, tactile extinction, astereognosis, two-
point discrimination and graphesthesia

GAIT ABNORMALITIES
1. Scissors – stiff; each leg is advanced slowly and
thighs tend to cross forward on each other at each
step; steps are short; appears to be walking through
water (legs flex slightly at the hips and knees, with
each step thighs adduct and knees hit or cross in a
scissors-like movement.

2. Steppage – drag feet or lift high, with knees flexed

and bring them down with a slap onto the floor;
appearing to be walking upstairs, unable to walk on 3. Brachioradialis - Flex arm 45 & rest on
heels (toes scrape the ground during ambulation) examiner’s arm with hand slightly supinated; Strike
tendon directly → pronation of forearm & flexion of
3. Shuffling/Parkinsonian – stooped posture, head elbow
and neck forward, hips and knees slightly flexed;
arms are flexed at elbows and wrists; slow in getting
started, steps are short and shuffling; arm swings are
decreased; turns are stiff.

4. Staggering – reeling uncertain gait like an

intoxicated person

5. Spastic – paretic/weak; stiff, foot dragging; walk

with foot drag and toes are scraping the ground

6. Waddling – distinctive duck-like walk (gait of a

child beginning to walk) Deep Tendon Reflexes on Lower Extremity
1. Patellar - Flex client’s knee 90 with lower leg
hanging free; strike patellar tendon → Contraction of
Quadriceps & extension of lower leg

2. Achilles - Knee at 90; ankle in neutral position;

strike the Achilles tendon at level of malleoli →
REFLEX ASSESSMENTS
gastrocnemi us & plantar flexion
Deep Tendon Reflexes of Upper extremity
1. Biceps- Palpate deep tendon in antecubital fossa;
place your thumb over it and strike your thumb →
palpable flexion of elbow

Pathological Reflexes

 Plantar - Stroke sole of foot in “J” pattern;

plantar flexion of toes should occur;
Dorsiflexion = Babinski sign
 Clonus - Test if DTR hyperactive; knee is
flexed and supported with one hand; with
2. Triceps - Flex arm 90 at elbow strike triceps other hand briskly dorsiflex the ankle; should
tendon directly → visible extension of elbow feel no rhythmic oscillating movements

Diagnostic Testing
  Lumbar Puncture 1. Communicating hydrocephalus
 Ventricular Tap 2. Noncommunicating hydrocephalus
 X-Ray Techniques
 Nuclear Medicine Studies (Brain Scan and
Positron Emission Tomography)
Echoencephalography (Ultrasound of Head or
Spinal Cord)
 Electroencephalography

SPECIAL NEUROLOGIC ASSESSMENTS

Signs of Meningitis
 Nuchal rigidity
 Brudzinski
 Kernig

Treatment
 Shunting of CSF
 Small, frequent feedings
 Slow feeding of infants
 Decreased movement during and immediately
after meals
 Possible pre-op and post-op antibiotics
 surgical correction

CRANIAL ABNORMALTIES

1. ENCEPHALOCELE- a congenital anomaly

wherein a saclike portion of the meninges and brain
protrudes through a defective opening in the skull

COMMON HEALTH PROBLEMS OF

NEONATE AND INFANT

2. ANENCEPHALY- a closure defect that occurs at

the cranial end of the neuro axis & results in a
missing part or the entire top of the skull, severely
damaging the brain stem & spinal cord

Types:
SPINAL CORD ABNORMALITIES
1. SPINA BIFIDA- Incomplete closure of one or
more vertebrae

2. MYELOMENINGOCELE- An external sac

containing meninges, cerebrospinal fluid, and a
portion of the spinal cord or nerve roots
Types of Spina Bifida 3. MENINGOCELE- External sac containing
 Spina bifida occulta- incomplete closure of meninges and cerebrospinal fluid
one or more vertebrae without protrusion of
the spinal cord or meninges
 Spina Bifida cystica- incomplete closure of
one or more vertebrae causing protrusion of
spinal contents in an external sac or cystic
lesion

Treatment
 Symptomatic
 Assessment of growth and development
throughout lifespan
 DAT
 PT
 Antibiotics, as indicated
 Surgical closure
 Shunt

COMMON HEALTH PROBLEMS OF CHILD

AND ADOLESCENT

1. CEREBRAL PALSY- Most common crippling

neuromuscular disease in children
- 3 types:
 Spastic (70%)
 Athetoid (20%)
 Ataxic (10%)
 Treatment
 Braces or splints
 Special appliances
 ROM exercises
 Anticonvulsants
 Muscle relaxants
 Antianxiety agents
 Orthopedic surgery
 Neurosurgery
 Eyeglasses, vision correction, hearing aids

2. REYE’S SYNDROME- acute encephalopathy

with fatty degeneration of the liver; a rare but
potentially fatal complication of influenza

Prenatal causes:
- Abnormal placental attachment
- ABO blood type incompatibility
- Anoxia
- Irradiation
- Isoimmunization Manifestations:
- Malnutrition STAGE 1: Sudden onset of persistent vomiting,
- Maternal diabetes fatigue, listlessness
- Maternal infection (esp. rubella in 1st trimester) STAGE 2: personality and behavior changes,
- Rh factor incompatibility disorientation, confusion, hyperreflexia
- Gestational hypertension STAGE 3: coma, decorticate posturing
STAGE 4: deeper coma, decerebrate rigidity
Parturition causes: STAGE 5: seizures, absent deep tendon reflexes,
- Asphyxia from cord wrapping around neck respiratory reflexes, flaccid paralysis
- Depressed maternal vital signs from general or
spinal anesthesia Pathophysiologic changes:
- Multiple births (neonates born last in a multiple  Increased free fatty acid level
birth have an especially high rate of cerebral palsy)  Hyperammonemia
- Prematurity
 Impaired liver function
- Prolonged or unusually rapid labor
 Structural changes of mitochondria in muscle
- Trauma during delivery
and brain tissue
 Significant swelling of the brain
Postnatal causes
- Any condition resulting in cerebral thrombus or
embolus Medical Management:
- Head trauma  Provide initial staging
- Infections, such as meningitis and encephalitis  Supportive treatment
- Poisoning  Treatment take place in PICU

Nursing interventions
 Stage 1: assess hydration status
 Stage 1-5: assess neurologic status
 Stage 2-3: assess respiratory and circulatory
status
 Support child and family
 COMMON HEALTH PROBLEMS ACROSS
LIFESPAN
1. BRAIN TUMOR- growth within the cranium,
including tumors in brain tissue, meninges, the
pituitary gland, or blood vessels
 Offer semi-soft diet (have suction readily
available)
 Reassess function post-operatively
 Perform neurologic checks
 Reorientation
 Monitor patients with seizures
 Check motor function at intervals
 Assess sensory disturbances
 Evaluate speech
 Assess eye movement, pupil size and reaction

II. CRANIOCEREBRAL TRAUMA (traumatic

MANIFESTATIONS:
brain injury)
Frontal Lobe tumor:
 Inappropriate behavior Any injury of the scalp, skull (cranium or facial
 Personality changes bones), or brain
 Inability to concentrate
 Impaired judgment Classification:
 Recent memory loss  Penetrating (open) head injury
 Headache
 Expressive aphasia
 Motor dysfunction

Parietal Lobe tumor:

 Sensory deficits (paresthesia, loss of two-
point discrimination, visual deficits
 Closed head injury
Temporal Lobe tumor:
 Psychomotor seizures

Occipital Lobe tumor:

 Visual disturbances

Cerebellum tumors:
 Disturbances in coordination and equilibrium

Pituitary Tumors: Causes:

 Endocrine dysfunction  falls
 Visual deficits  motor vehicle crashes
 Headache  Assaults
 firearm use
DIAGNOSIS:  sports injuries
 History of illness  occupational injuries
 CT scan or MRI
 Arteriography Mechanisms of head injury
 EEG  Acceleration injury
 Endocrine studies  Deceleration injury
 Acceleration-deceleration injury
Medical Management:  Deformation injuries
 Chemotherapeutic agents
 Radiation therapy Types:
 Corticosteroid  Skull injury
 Bone marrow transplantation  Brain injury
 Intracranial hemorrhage
Nursing Management
 Evaluate gag reflex and ability to swallow
preoperatively
 Teach patient to direct foods and fluids
towards the unaffected side
 Assist to an upright position to eat
 3. Subdural hematoma
4. Intracerebral hematoma

V. DIFFUSE BRAIN INJURY- Affects the entire

brain caused a shaking motion, with twisting
movement as the primary mechanism of injury.
Categories:
1. Mild concussion
2. Classic Cerebral Concussion
3. Diffuse Axonal Injury
Surgery:
*evacuation of clot
*craniotomy

Nursing Interventions
III. SKULL FRACTURE- break in the continuity of  Monitor for:
the skull o ICP
Classification: o Changes in VS
 Open o Fluid status, I and O
 Closed o NVS
o Respiratory pattern
 Maintain head and neck in neutral alignment
 Clear nose and mouth of mucus and blood
 Suction PRN
 Prepare O2 administration
 Prepare for cranial surgery

VI. SPINAL CORD INJURY

 Occurs commonly in young adult males
between ages 15-25
 Common traumatic causes: motor vehicle
accidents, diving in shallow water, falls,
industrial accidents, sports injuries, gunshot
or stab wounds
4 Categories:  Nontraumatic causes: tumors, hematomas,
1. Linear Fractures aneurysms, congenital defects (spina bifida)
2. Comminuted Classification:
3. Depressed  Extent of injury: vertebral column, anterior
4. Basilar Fractures and posterior ligaments, spinal cord
 Level of Injury: cervical, thoracic, lumbar
Management:  Mechanisms of Injury •
 Simple linear: bed rest and observation for o Hyperflexion
underlying injury or hematoma o Hyperextension
 Depresses skull: wound debridement, removal o Axial loading
of the bone fragments o Penetrating wounds
 Regular neurologic assessments Assessment Findings
 Antibiotic prophylaxis  Spinal shock
 Symptoms depend on level and extent of
Nursing Intervention injury:
 Monitor otorrhea and rhinorrhea o Level of injury
 Test drainage  Quadriplegia
 Observe blood tinged fluid for “halo” sign  Paraplegia
 Keep nasopharynx and external ear clean o Extent of injury
 Instruct not to blow nose, cough or inhibit  Complete cord transection
sneeze  Incomplete lesions
 Use aseptic technique at all times Medical management
 Horizontal turning frames
IV. FOCAL BRAIN INJURY  Skeletal traction
Categories: o Cervical tongs
1. Contusion o Halo traction
2. Epidural hematoma
  Surgery: decompression, laminectomy, spinal
fusion

CNS INFECTIONS
1. Meningitis- inflammation of the pia mater,
arachnoid, and subarachnoid space

 Bacterial Meningitis
o Causative agents:
 Neisseria meningitis
 Meningococcus
 Streptococcus pneumoniae
 Haemophilus influenzae
 Escherichia coli
Nursing Interventions o Risk factors:
EMERGENCY CARE
 Head trauma
1. Assess ABC
 Otitis media
2. Perform quick head to toe assessment
 Mastoiditis
3. Immobilize
 Sinusitis
 Neurosurgery
 Systematic sepsis
 Immunocompromise
o Manifestations:
 Restlessness, agitation,
irritability
 Severe headache
 n/v
 Signs of meningeal
irritation
 Chills and high fever
 Confusion, altered LOC
 Photophobia, diplopia
 Seizures
Acute Care  IICP
 Maintain optimum respiratory function  Petechial rash
 Maintain optimal cardiovascular function o Complications:
 Maintain immobilization and spinal alignment  Arthritis
 Prevent complications of immobility  Cranial nerve damange
 Hydrocephalus
 Maintain urinary and bowel elimination
 Viral Meningitis (Aseptic Meningitis)
 Check temp
o Causes:
 Observe for and prevent infection
 Herpes simplex
 Observe for and prevent stress ulcers  Herpes zoster
 Epstein-barr virus
  Cytomegalovirus
o Manifestaions:
 Similar to bacterial but
usually milder
 Mild fluke illness prior to
onset
II. ENCEPHALITIS- an acute inflammation of the
parenchyma of the spinal cord
Causes:
 virus (almost always): arbovirus, enterovirus,
herpes simplex type 1 virus)
 bacteria
 fungi
 protozoa
 lead or arsenic ingestion
 carbon monoxide inhalation
a. Viral Encephalitis
 Manifestations:
o Similar to meningitis
o Disoriented, agitated, restless,
lethargic and drowsy
o Coma
b. Arbovirus Encephalitis
 Manifestations:
o Fever, malaise, sore throat, n/v, stiff
neck, tremors, paralysis of extremities,
exaggerated DTR, seizures altered
LOC
Diagnostic Test: Lumbar Puncture
- Introduction of needle into spinal
subarachnoid space(L3-L4), (L4-L5), (L5-S1)
to assess CSF pressure and obtain sample
(MS, Increased ICP from meningitis,
subarachnoid hemorrhage, brain tumor, brain
abscess, encephalitis, viral infections)
Normal CSF values:
 Pressure: 60-180mmH2O or 5-10mmHg
 Glucose: 50-80 mg/dl
 Protein: 20-50mg/dl
 Ensure signed consent
 Let client empty bladder before the procedure
 Help client assume lateral recumbent position
near side of bed. Client should assume fetal
position
Post LP Nursing Care
 Take and record vital signs
 Monitor neurologic status
 Monitor puncture site
 Ensure that the client voids 8 hours after the
procedure
 Encouraged increased OFI
 Administer analgesics for pain
III. BRAIN ABSCESS- Infection with a collection
of purulent material within the brain tissue
Causes:
 Open trauma and neurosurgery
 Infections
 Metastatic spread
Pathogenic causes:
 Streptococci, staphylococci, bacteroids, yeast
and fungi
Manifestations:
 Chills, fever, malaise, anorexia
 Seizures, altered LOC, manifestations of IICP
MEDICAL MANAGEMENT:
Bacterial Meningitis
 Antibiotics
 Corticosteroids (Dexamethasone)
 Strict respiratory precaution
 Universal precaution on CSF and blood
Viral Meningitis
 Antipyretic
 Analgesics
 Antiviral: Acyclovir (Zovirax); Vidarabine
(Vira-A)

Fungal Meningitis
 Antifungal agents: Amphotericin B;
Fluconazole

Brain Abscess
 Antibiotics
 Tx of symptoms
 I and D
 Other med:
o Anticonvulsants: Phenytoin

NURSING CARE
 Health promotion
 Monitor LOC, NVS, VS
 Monitor IICP
 Administer prescribed meds and maintain
prescribed fluid restriction
Preparation  Institute seizure precautions
  MIO greatly from mild impairment to irreversible failure
(Al-Khafaji 2020).
 Daily body weights
 Monitor skin turgor, condition of mucus ● Organs most commonly affected by MODS include
membrane, urine amount, color and odor the heart, lungs, liver and kidneys (Gu et al. 2018).

● associated with significant mortality and morbidity,

estimated to affect around 15% of ICU patients and
contributing to about 50% of deaths in ICU (Nickson
2019; Osterbur et al. 2014).

A. ASSESSMENT

1. Subjective Data - Health History

2. Objective Data - Physical Assessment / Diagnostic and
Laboratory Tests

1. SUBJECTIVE DATA

History
- Basic Information
- Chief Complaint
- History of present illness
- Past History
a. Pregnancy and delivery
TRANS TOPIC : Nursing care of a Child with Life b. Neonatal History
Threatening Conditions/ Acutely Ill/ Multi organ Problems/ c. Surgical History
High Acuity and Emergency Situations d. Medical History
(Acute and Chronic) e. Developmental History
- Allergies
LIFE THREATENING DISEASES - Immunization
- Medications
● are chronic - Sexual History of adolescents
● usually incurable diseases, which have the effect of - Family History
considerably limiting a person's life expectancy - Social History
- Review of systems

Table I. Basics of the ABCDE approach 2. OBJECTIVE DATA

____________________________________________
Physical Assessment
- General appearance
Letter Life-Threatening Condition - Skin
- Vital Signs
A - AIRWAY Airway blockage, cervical spine - Head, eyes, ears, nose, mouth and throat
injury - Neck
- Chest
B - BREATHING Tension pneumothorax, pulmonary
- Cardiovascular
edema, bronchospasm
- Abdominal examination
- Genitalia
C - CIRCULATION Shock (hypovolaemic, obstructive ,
- Extremities
distributive, cardiogenic)
- Neurologic
D - DISABILITY Seizure, hypoglycemia, meningitis,
Ill Child Assessment – begins with an interview of the child
intracranial haemorrhage or
and parents to identify ways they think the illness will change
infarction , intoxication
their lives
E - EXPOSURE Hypothermia or Hyperthermia ,
critical conditions such a fasciitis or How to Assess for Multiple Organ Dysfunction Syndrome
urticaria
● Undertake a systems approach assessment (head-to-toe
assessment).
Multiple Organ Dysfunction Syndrome (MODS)
● Document and analyze data from the patient’s vital
● the progressive physiological dysfunction of two or signs, taking into account any trends.
more organ systems where homeostasis cannot be
maintained without intervention (Osterbur et al. 2014; ● A SOFA (quick Sepsis Related Organ Failure
Nickson 2019). Assessment) score can be used in line with other
assessment tools.
Multiple Organ Dysfunction Syndrome: Overview | Ausmed
● Children with long-term illnesses need continual
● generally initiated by illness, injury or infection, reassessment because, like all children, their needs
causing a state of immunodepression and change as they grow older.
hypometabolism (Nickson 2019).
DIAGNOSTIC TEST / LABORATORY TESTS
● Rather than a single event, MODS is considered a
continuum where the extent of dysfunction can vary
 - For a child who needs diagnostic or therapeutic ● Anticipatory grieving related to chronicity of the
procedures child’s illness

ASSESSMENT ● Risk for delayed growth and development due to

- carefully evaluate a child’s age and developmental
stage as well as any special needs child may have.
- assess a child’s level of anxiety associated with a
procedure as well as the child’s knowledge concerning
a technique.
decreased mobility because of disability
Some examples of nursing diagnoses when a terminal illness is
present include:
● Hopelessness related to steady progression of the
child’s disease

SAMPLE NURSING DIAGNOSES ● Anticipatory grieving related to the child’s terminal

- vary greatly depending on the extent of a child's illness,
the care needed, and the age of the child.
● Fear related to new and strange surroundings of the
procedure room.
 Deficient diversional activity related to hospitalization
and lengthy procedures
 Imbalanced nutrition, less than body requirements,
related to need for food restriction pre procedure and
post procedure
illness
● Powerlessness related to inability to change the course
of the child’s illness
● Decisional conflict related to treatment options and
choice of setting for the child’s final care.
C. PLANNING AND IMPLEMENTATION OF CARE
Focusing on hopeful but realistic outcomes.
Referrals

● Risk for injury related to need for invasive procedures.
When performing or assisting with procedures on children,
remember to maintain safety and legal responsibilities for care
such as:
- Accompany a child to a treatment room.
- Coordinate and collaborate.
- Provide support during the procedure
- Ensure adherence to standard infection precautions.
- Assess a child’s response to the procedure.
- Provide care to a child and specimens obtained once
the procedure is completed.
- Document
Laboratory screening tests be accomplished for pediatric
patients.
● Helps parents recognize their child’s capabilities and
arrange appropriate activities for the child.
● Helping parents develop coping strategies
● Maintain quality care despite the burdens of care
● Maintain a balanced life that includes self-care are
other important measures.
Health Promotion/Risk Management Health/ Restoration
and Maintenance Therapies
National Center for Chronic Disease Prevention and Health
Promotion
● Reducing obesity risk for children in ECE facilities.

1. Newborn metabolic screening ● Improving healthy food options and nutrition education
2. Hemoglobin or hematocrit levels in school
3. Urinalyses
4. Lead screening ● Improving physical education and physical activity
5. Cholesterol screening opportunities in school.
6. Sexually transmitted disease screening
● Preventing use of all tobacco products.
IMAGING PROCEDURES
● Helping children and adolescents manage their chronic
1. Plain radiographs health conditions in school.
2. Ultrasonography
3. Computer tomography (CT) ● Promoting the use of dental sealants to prevent cavities.
4. Magnetic Resonance
5. Nuclear Scan ● Promoting adequate sleep.

LONG TERM ILLNESS:

B. NURSING DIAGNOSIS
- Help children with a long-term disorder to as much
Nursing diagnoses when a long-term illness is present include: care for themselves as possible within the limits of
their illness. Self-care empowers them to be as
● INterrupted family processes related to recent diagnosis independent as possible.
of chronic illness in the child
- A child and parents can be expected to move through
● Compromised family coping related to the child’s stages of grief on learning about a potentially fatal
disability diagnosis.

● Disabling family coping related to the parents’ inability - Children and parents are apt to need help to face a
to accept the child’s long-term illness terminal diagnosis in a child
 - Urge the parents and the child to ask for help to see
them through this very difficult time in their lives.
Treatment and Management of Multiple Organ Dysfunction
Syndrome
- MODS is difficult to treat, escalates quickly and is
often fatal
- Therefore, early detection is crucial in preventing its
progression (Wang et al. 2017)
- Positive patient outcomes rely on immediate
recognition, ICU admission and invasive organ support
(Gourd & Nikitas 2019). Management and treatment
may include:
- Identifying and treating the underlying causes,
comorbidities or complication;
- Fluid resuscitation to increase perfusion; and
- Support care and monitoring:
o Multi-organ support
o Mechanical or non-invasive
ventilation
o Maintaining fluid homeostasis
o Renal replacement therapy
Pharmacological Therapeutics
The principles of safe medicine administration for adults also
apply to children.
Pediatrics | Pharmacotherapy: A Pathophysiologic Approach,
10e | AccessPharmacy | McGraw-Hill Medical (mhmedical.com)
● Children are not just “little adults”, and lack of data on
important pharmacokinetic and pharmacodynamic
differences has led to several disastrous situations in
pediatric care.
● Variations in absorption of medications from the
gastrointestinal tract, intramuscular injection sites, and
skin are important in pediatric patients, especially in
premature and other newborn infants.
● The rate and extent of organ function development and
the distribution, metabolism, and elimination of drugs
differ nit only between pediatric versus adult patients
but also among pediatric age groups.
● The effectiveness and safety of drugs may vary among
age groups and from one drug to another in pediatric
age groups.
● Concomitant diseases may influence dosage
requirements to achieve a targeted effect for a specific
disease in children.
● Use of weight-based dosing of medications for obese
children may result in suboptimal drug therapy.
● The myth that neonates and young infants do not
experience pain has led to inadequate pain
management in this pediatric population.
● Special methods of drug administration are needed for
infant and young children
● Many medicines needed for pediatric patients are not
available in appropriate dosage forms; thus, the dosage
forms of drugs marketed for adults may require
modification for use in infants and children,
necessitating assurance of potency and safety of drug
use.
● The pediatric medication-use process is complex and
error prone because of the multiple steps required in
calculating, verifying, preparing, and administering
doses.
BASIC CARDIAC LIFE SUPPORT (BC LS) &
ADVANCE CARDIAC LIFE SUPPORT iN NEONATE &
CHILD
Cardiopulmonary Resuscitation (CPR) In Children (webmd.com
1. Check to see if the child is conscious
● Make sure you and the child are in safe surroundings.
● Tap the child gently.
● Shout, “Are you OK?”
● Look quickly to see if the child has any injuries,
bleeding, or medical problems.
2. Check breathing
● Place your ear near the child’s mouth and nose
● Is there breath on your cheek?
● Is the child’s chest moving?
3. Begin chest compressions
If the child doesn’t respond and isn’t breathing:
● Carefully place the child on their back.
● For a baby, be careful not to tilt the head back too far.
If you suspect a neck or head injury, roll the baby over,
moving their entire body at once.
Chest compressions
● For a baby, place two fingers on the breastbone.
● For a baby, press down about 1 1/2 inches, about 1/3 to
1/2 the depth of the chest. Make sure not to press on
the end of the breastbone.
● Do 30 chest compressions, at the rate of 100 per minute.
Let the chest rise completely between pushes.
● Check to see if the child has started breathing.
● Continue CPR until emergency help arrives
For a baby
● place two fingers on breastbone
 ● press downabout11/2inches,about1/3to1/2the depth of
chest.
● Do 30 chest compressions, at the rate of 100 per
minute.
Chest compressions ...
● For a child, place the heel of one hand on the center of
chest at the nipple line. You also can push with one
hand on top of the other.
● For a child, press down about 2 inches. Make sure not
to press on ribs, as they are fragile and prone to fracture.
For a child, place the heel of one hand on the center of chest at
the nipple line.
● You also can push with one hand on top of the other.
● Press down about 2 inches
4. Do rescue breathing
To open the airway,
● Lift the child’s chin up with one hand. At the same
time, tilt the head back by pushing down on the
forehead with the other hand.
● Do not tilt the head back if the child is suspected of
having neck or head injury
● For a child, cover their mouth tightly with yours.
Pinch the nose closed and give breaths
•For a baby, cover the mouth and nose with your mouth and
give breaths.
•Give the child two breaths, watching for the chest to rise each
time. Each breath should take one second
5. Repeat compressions and rescue breathing if the child is
still not breathing
● Two breaths can be given after every 30 chest
compressions. If someone else is helping you, you
should give 15 compressions, then 2 breaths.
● Continue this cycle of 30 compressions and 2 breaths
until the child starts breathing or emergency help
arrives.
● If you are alone with the child and have done 2 minutes
of CPR (about 5 cycles of compressions and breathing),
call 911 and find an AED.
6. Use an AED as soon as one is available
● For children age 9 and under, use a pediatric
automated external defibrillator (AED), if available.
● If a pediatric AED is not available, or for children age
1 and older, use a standard AED.
● Turn on the AED
● Wipe the chest dry and attach the pads.
● The AED will give you step-by-step instructions.
● Continue compressions and follow AED prompts until
emergency help arrives or the child starts breathing.
ASPIRATION
- Inhalation if a foreign object into the airway immediate
reaction is:
o CHOKING , HARD FORCEFUL
COUGHING
- If the airway becomes obstructed:
o A series of back blows or subdiaphragmatic
abdominal thrusts may be used,
- Abdominal thrust is an emergency technique to help
clear someone’s airway.
- The procedure is done on someone who is choking
and also conscious.
- Most experts do not recommend thrusts for infants less
than 1 year old.
- You can also perform the maneuver yourself.
- First ask, "Are you choking? Can you speak?" DO
NOT perform first aid if the person is coughing
forcefully and is able to speak. A strong cough can
often dislodge the object.
If the person is choking, perform abdominal thrusts as
follows:
- If the person is sitting or standing, position yourself
behind the person and reach your arms around his or
her waist. For a child, you may have to kneel.
- Place your fist, thumb side in, just above the person's
navel (belly button).
- Grasp the fist tightly with your other hand.
- Make quick, upward thrusts with your fist.
If the person is lying on his or her back,
- straddle the person facing the head
- Push your grasped fist upward and inward in a
movement similar to the one above.
You may need to repeat the procedure several times before
the object is dislodged. If repeated attempts do not free the
airway, call 911.
● If the person loses consciousness, start CPR.
● If you are not comfortable performing abdominal
thrusts, you can perform back blows instead on a
person who is choking
Surgical Interventions
The decision for a child to undergo surgery will be based on
careful evaluation of the child's medical history and medical
tests, such as blood tests, X- rays, MRI, CT scan,
electrocardiogram, or other laboratory work performed to
determine the exact diagnosis.
What are the different types of surgery?
Surgery can be classified as major or minor, depending on:
● The seriousness of the illness
● The parts of the body affected
● The complexity of the operation
● Then expected recovery time.
Nutrition and Diet Therapies
● Maintaining optimal nutritional status in the face of an
illness or therapy that interferes with adequate intake
● Correcting nutritional deficiencies or otherwise aiding
children and families to follow the nutritional care plan
devised by the healthcare team.
● Educating a child and family regarding specific
nutritional needs as well as overall sound nutritional
health
● Promoting nutrition such as measuring fluid intake and
output and providing enteral feedings, gastronomy tube
feedings, and total parenteral nutrition.
Complementary and Alternative Therapies
● Complementary and alternative medicine practices
such as massage, acupuncture, tai chi and drinking
green tea.
● Complementary and alternative medicine (CAM) is
the term for medical products and practices that are not
part of standard medical care.
CAM therapies may work in a variety of ways:
- may help to control symptoms and ease pain
- enhance feelings of well being and quality of life
- may possibly boost the immune system.
When considering any therapy, it is important to weigh the
risk and benefits.
D. CLIENT EDUCATION
- Long-term illness in a child is often most difficult for
parents to accept at times when the child would have
been achieving specific milestones of development.
- Extra support for both the parents and the child may be
necessary
- Help children with a long-term disorder to do as much
for themselves as possible within the limits of their
illness. Self-care empowers them to be as independent
as possible.
- Children are about 9 years old before they are able
to understand the meaning of death and that it is
permanent. A child and parents can be expected to
move through the stages of grief on learning about a
potentially fatal diagnosis.
- Children and parents are apt to need help to face a
terminal diagnosis in a child. Urge the parents and the
child to ask for help to see them through this very
difficult time in their lives.
E. EVALUATION OF CARE
Some examples suggesting achievement of outcomes include:
- Parents state realistic plans for their child regarding
school placement.
 Parents state they have been able to deal with their
grief over their child’s diagnosis to maintain near-
normal family functioning.
- Parents state they are able to cope with present
stressors and can specify coping strategies they utilize.
 The child states he is aware his illness is chronic (long
term) but thinks of himself as a person who will be able
to accomplish many things in life.
 F. DOCUMENTATION - Refer women and their families to online
resources for further information when
- the written and legal recording of the interventions that
concern the patient and it includes a sequence of appropriate.
processes.
- “NOT DOCUMENTED, NOT DONE”
IMPLEMENTATION
Long-lasting therapies which are provided from the health
organizations, usually include two types of care:
- Focus on teaching her new or additional
● specialized and intermediate care measures to maintain health (e.g. during
pregnancy)
Recording Systems of the Nursing Care

1.The recording focused on the source

2. The recording focused on the problem OUTCOME EVALUATION
3. The recording model problem-intervention evaluation (ΡΙΕ)
4. The focused recording - Make evaluation ongoing to ensure that you
5. Charting by exception know whether interventions are successful
6. Recording to the computer
7. Case Management

NURSING CARE OF AT-RISK AND SICK

TRANS TOPIC WEEK 4: Nursing Care of At-
CHILD APPLYING INTEGRATED
Risk/Sick Mother
MANAGEMENT OF CHILDHOOD ILLNESS
(IMCI)
Women’s Health Nurse Practitioner
___________________________________________
● A women’s health nurse practitioner is a
nurse with advanced study in the promotion
INTEGRATED MANAGEMENT OF
of health and prevention of illness in women.
CHILDHOOD ILLNESS
● They plays a vital role in educating women
about their bodies and sharing with them
● Aims to reduce death, illness and disability
methods to prevent illness; in addition, they
and to promote improved growth and
care for women with illnesses such as
development among children under five
sexually transmitted infections, offering
years of age..
information and counseling them about
reproductive life planning.
OBJECTIVES OF IMCI
● They play a large role in helping women
remain well so that they can enter a
1. Reduce deaths and the frequency and severity
pregnancy in good health and maintain their
of illness and disability;
health throughout life
2. Contribute to improved growth and
CARE OF A WOMAN WITH A PREEXISTING
development
OR NEWLY ACQUIRED ILLNESS
___________________________________________
Computerized Tool for IMCI Training

- IMCI Computerized Adaptation and Training

ASSESSMENT
Tool (ICATT)
- is a computerized, adaptable tool for training
- Objective measures establishing baseline vital
in the Integrated Management of Childhood
signs as well as subjective factors (such as the
Illness (IMCI).
level of exhaustion a woman is experiencing.
- A joint project of WHO and the Novartis
Foundation for Sustainable Development.
- It is also important to teach a woman how to
- The ICATT provides the opportunity for an
assess her own health in relation to objective
innovative, flexible and modern approach to
parameters.
teaching and learning but it is not a stand-
alone training program.
OUTCOME IDENTIFICATION AND PLANNING
Components of IMCI Training
- Be certain that expected outcomes are
1. computer training
realistic.
2. clinical practice
- Outcomes should relate to the entire family’s
3. classroom activities
health
- Allowing a woman to choose among
alternatives
 5. Give Extra Fluid for Diarrhea and Continue
Feeding

Plan A : Treat for Diarrhea at Home

Plan B : Treat for Some Dehydration with ORS
Plan C: Treat for Severe Dehydration Quickly

SICK CHILD AGE 2 MONTS UP TO 5 YEARS

___________________________________________
6. Give Follow-up Care
ASSESS AND CLASSIFY THE SICK CHILD
Assess, Classify and Identify Treatment Pneumonia
Check for General Danger Signs Wheeze (first episode)
Diarrhea still present after 5 days
Dysentery
Then Ask About Main Symptoms: Persistent Diarrhea
● Does the child have a cough or difficult Malaria
breathing? Fever-other cause
● Does the child have diarrhea? Ear infection
● Does the child have fever? Anemia
● Classify malaria Not growing well
● Does the child have an ear problem? Feeding Problem
● Then Check for Malnutrition and Anemia
● Then Check the Child’s Immunization Status Symptomatic HIV:
● Assess Other Problems 1st follow-up
● Check for symptomatic HIV infection Repeat follow-up
Palliative Care

TREAT THE CHILD COUNSEL THE MOTHER

1. Teach the mother to give oral drugs at home: ● Assess the Child’s Feeding
● Feeding Recommendations
Treat the child for wheezing ● Feeding recommendations for HIV infected
Oral antibiotic mother
Co-trimoxazole ● Counsel About Feeding Problems
Pain relief for HIV
Iron for anemia Special Feeding Recommendations:
Co-artemether for malaria
Paracetamol ● Feeding advice for child with persistent
diarrhea Poor appetite/ mouth sores
2. Teach the mother to treat local infections at ● Feeding advice for HIV infection
home ● Increase fluid during illness
● Advise mother when to return
Dry the Ear by wicking ● Advise mother when to return immediately
Treat for Mouth Ulcers and Thrush Soothe throat, ● Counsel the mother about her own health
relieve cough with safe remedy

3. Give Preventive Treatments in Clinic SICK YOUNG INFANT AGE 1WEEK UP TO

2MONTHS
Mebendazole/albendazole ___________________________________________
Vitamin A

4. Give Emergency Treatment in Clinic ONLY ASSESS, CLASSIFY AND TREAT THE SICK
YOUNG INFANT
Oxygen for sever pneumonia
Treat for stridor 1. Assess, Classify and Identify Treatment
Nebulized
INtramuscular Antibiotic Check for Possible Bacterial Infection
Diazepam for convulsions
Prevent low blood sugar Then ask:
Treat low blood sugar Does the young infant have diarrhea?
Then Check for Feeding Problem or Low Weight
Then check feeding in non breastfed babies
Then Check for Special Risk Factors
Then Check the Young Infant’s Immunization Status
Assess Other Problems
Assess the mother’s health
2. Treat the young infant and counsel the
mother
Practices that reinforce these principles:
> Ensuring that patients receive the care they need
> Respecting the right of patients to consent to or
deny
consent for treatment.
> Preventing incompetent staff from caring for
patients
> Following acceptable standards of practice

Oral antibiotic BENEFICENCE

Intramuscular Antibiotics
To treat for Diarrhea, see TREAT CHILD THE ● To do good to others
CHILD Chart Immunize every sick young infant ● Acting in a manner that promotes the welfare
Treat Local Infections at Home of the client
Correct Positioning and Attachment for ● To override patients’ decisions & invoke
Breastfeeding professional authority to take actions that
Common breastfeeding problems nurses view as in patients’ best interest is
Correct preparation of artificial milk viewed as PATERNALISM & interferes
How to feed a baby with a cup with the freedom & rights of patients.
Home Care for Young Infant

3. Give follow-up care for the sick young NON-MALEFICENCE

infant
● requires an intention to avoid needless harm
Local Bacterial Infection or injury that can arise through acts of
Thrush commission or omission
Feeding Problem ● In common language, it can be considered
Low Weight “negligence” if you impose a careless or
unreasonable risk of harm upon another
ETHICO -LEGAL CONSIDERATIONS
ISSUES IN THE CARE OF SICK MOTHER
AND CHILD JUSTICE
___________________________________________
● To be fair, to treat people equally and give
ETHICAL PRINCIPLES patients the service they need.

● ethos means those belief that guide life Practicing ethical decision making
(NURSING ETHICS) Purpose of the code

- Serves as an ethical framework for a nurses

practice

- Provides a nurse with direction in respect to

their ethical relationships, nursing
responsibilities, appropriate behaviours in
making day to day choices in their practices
LEGAL ISSUES
Principles of Ethics
● The legal foundation for the practice of
- Autonomy nursing provides safeguards for patients and
- Beneficence sets standards by which nurses can be
- Nonmaleficence evaluated.
- Justice
● Nurses need to understand how the law
applies specifically to them. When nurses do
AUTONOMY not meet the standards expected, they may be
held legally accountable.
● T
o respect patients’ freedoms , preferences, & ETHICAL CONSIDERATIONS OF
rights PRACTICE
 ● Some of the difficult decisions in health care
settings are those that involve children and
their families
The following are just a few of the major potential
conflicts:
- Conception issues especially those related to
in vitro fertilization, embryo transfer,
ownership of frozen oocytes or sperm,
cloning , stem cell research, and surrogate
mothers
- Abortion, particularly partial-birth abortions
- Fetal rights versus rights of the mother
- Use of fetal tissue for research
- Resuscitation (for how long should it be
continued?)
- The number of procedures or degree of pain
that a child should be asked to endure to
achieve a degree of better health
- The balance between modern technology and
quality of life
Nurses can help clients who are facing difficult
decisions by providing factual information and
supportive listening and by helping the family clarify
their values.
The Pregnant Woman’s Bill of Rights and the United
Nations Declaration of Rights of the CHild provide
guidelines for determining the rights of clients in
regard to healthcare
ASSISTED REPRODUCTIVE TECHNIQUES /
TECHNOLOGY
___________________________________________
Assisted Reproductive Technology (ART)
● used to treat infertility
● includes fertility treatments that handle both a
woman's egg and a man's sperm.
● It works by removing eggs from a woman's
body. The eggs are then mixed with sperm to
make embryos. The embryos are then put
back in the woman's body.
● In vitro fertilization (IVF) is the most
common and effective type of ART.
● ART procedures sometimes use donor eggs,
donor sperm, or previously frozen embryos. It
may also involve a surrogate or gestational
carrier.
● A surrogate / substitute is a woman who
becomes pregnant with sperm from the male
partner of the couple.
● A gestational carrier becomes pregnant with
an egg from the female partner and the sperm
from the male partner.
COMPLICATIONS:
● High rates of multiple delivery, preterm
delivery,
● low birth-weight delivery experienced.
RISK FACTORS:
● Miscarriage
● Multiple pregnancies
● Low birth weight
ART includes :
1. in vitro fertilization- embryo transfer (IVF-
ET)
2. gamete intrafallopian transfer (GIFT)
3. zygote intrafallopian transfer (ZIFT)
4. frozen embryo transfer (FET)
Types of ASSISTED REPRODUCTIVE
TECHNOLOGY
- IVF (In-Vitro Fertilization)
- IUI (Intrauterine Insemination)
- Intrafallopian Transfer
- ICSI (Intracytoplasmic Sperm injection)
IN VITRO FERTILIZATION
A.) eggs are removed from mature follicles within
an ovary.
B.) An egg is fertilized by injecting a single sperm
into the egg or mixing the egg with sperm in a
petri dish.
C.) The fertilized egg (embryo) is transferred into
the uterus .
How in vitro fertilization (IVF) works - Nassim Assefi
and Brian A. Levine - YouTube
INTRAUTERINE INSEMINATION (IUI)
GAMETE INTRAFALLOPIAN TRANSFER
- Eggs and sperm are collected as with IVF, but
then injected directly into the woman’s
fallopian tubes so fertilization occurs inside
the body
- Used when male has low sperm count or
sperm with poor motility or if a couple has
moral objections to IVF
INTRACYTOPLASMIC SPERM INJECTION
(ICS)
Ethical Issues In Reproductive Technology
___________________________________________
Conception Issues
___________________________________________
- Infertility can have devastating effects on the
emotional well-being of a couple who yearns
for children.
- As a result, many couples spend time and
money to conceive or adopt a child
- When medical procedures (such as fertility
medications, hysteron salpingostomy and
artificial insemination) fail and adoption is nit
an option, infertile couples may turn to in
vitro fertilization (IVF) or surrogate
motherhood.
What about the leftovers?
- About 15 to 20 embryos may result from a
ingle fertilization effort, but only 3 to 5 of
them are implanted in the woman’s uterus.
- Some individuals question whether it is
ethical to discard the leftover embryos,
destroy them, or use them for scientific study.
SURROGATE MOTHERHOOD
- a woman who gives birth after carrying the
fertilized ovum of another woman or more
commonly, after being artificially inseminated
with sperm from the biological father, In the
latter case, the biological father then legally
adopts the infant.
Offering hope
- Surrogate motherhood offers hope for infertile
couples in which the woman is the infertile
partner. It is also an option for a woman
whose age or health makes pregnancy risky.
A surrogate birth poses no greater risk to the
fetus (or surrogate mother) than any average
birth.
Whose rights are rights?
- Potential conflicts concerning the rights of the
surrogate mother, the infertile couple, the
fetus and society.
- The basic dispute involves who has the
strongest claim to the child. Doe the
surrogate mother have rights by virtue of her
biological connection? Does the surrogate
contract guarantee the infertile couple the
right to the child? Courts of law usually rule
in favor of the infertile couple.
Support Systems
- In a surrogate mother situation , the nurse’s
role is to support her patient. If the patient is
the surrogate mother, collaboration with a
social worker or a psychologist may be
necessary
Protection of Women from Domestic Violence Act
, 2005
___________________________________________
FORMS OF DOMESTIC VIOLENCE
● Verbal Abuse
● Physical Abuse
● Emotional or Psychological Abuse
● Economic Abuse
● Sexual Abuse
● Isolation
The Protection of Women from Domestic Violence
Act, 2005 (indiankanoon.org)
Roles & Functions of the nurse in the varied
settings in the Delivery of care to At -
risk/high/sick mother and Child
___________________________________________
● The primary role of a nurse is to advocate
and care for individuals and support them
through health and illness.
Various other responsibilities of a nurse that form
a part of the role of a nurse includes:
● Record medical history and symptoms
● Collaborate with teams to plan for patient care
● Advocate for the health and wellbeing of
patients
● Monitor patient health and record signs
● Administer medications and treatments
● Operate medical equipment
● Perform diagnostic tests
● Educate patients about management of
illnesses
● Provide support and advice to patients
Patient care
● a caregiver for patients and helps to manage
physical needs, prevent illness, and treat
health conditions
 ● follows the progress of the patient and acts
accordingly with the patient’s best interests in
mind.
● The care provided by a nurse extends beyond
the administration of medications and other
therapies. They are responsible for the holistic
care of patients, which encompasses the
psychosocial, developmental, cultural, and
spiritual needs of the individual.
Patient Advocacy
● advocate for the best interests of the patient
and to maintain the patient;s dignity
throughout treatment and care
● may include making suggestions in the
treatment plan of patients, in collaboration
with other health professionals.
Planning of care
● Directly involved in the decision-making
process for the treatment of patients.
● Think critically when assessing patient signs
and identifying potential problems so that
they can make the appropriate
recommendations and actions.
● Communicate information regarding patient
health effectively
● Collaborate with other members of the
medical team to promote the best patient
health outcomes.
Patient Education and Support
● Ensures that patients are able to understand
their health, illnesses, medications, and
treatments to the best of their ability.
● Take the time to explain to the patient and
their family or caregiver what to do and what
to expect when they leave the hospital or
medical clinic.
● Make sure that the patient feels supported and
knows where to seek additional information
MATERNAL-NEONATAL NURSING ROLES
& FUNCTIONS)
___________________________________________
Nurses involved in maternal-neonatal nursing assume
many roles. These may include:
- Care provider
- Educator
- Advocate
- Counselor
The functions involved for each of these roles
depend on the nurse’s level of education. Nurses
involved in maternal neonatal nursing may be:
- Registered Nurses
- Certified Nurse MIdwives (CNMs)
- Nurse Practitioners (NPs) or Clinical Nurse
Specialists (CNSs)
Registered nurse
- plays a vital role in providing direct patient
care, meeting the educational needs of the
patient and her family, and functioning as an
advocate and counselor.
Certified Nurse-Midwife (CNM)
- has achieved advanced education at a master’s
level or has obtained CNM certification
- A CNM works independently and is able to
care for a low-risk obstetric patient
throughout her pregnancy
- A CNM also licensed to deliver a neonate.
Nurse Practitioners
- performs in an expanded advanced practice
role.
- obtains histories, performs physical
examinations, and manages care (in
consultation with a doctor) throughout the
pregnancy and the postpartum period.
- may practice as a women’s health, family,
neonatal, or pediatric NP
Nurse Practitioners:
1. Women’s health nurse practitioner
2. Family nurse practitioner
3. Neonatal nurse practitioner
4. Pediatric nurse practitioner
___________________________________________
1. Women’s health nurse practitioner
- Educate women about their bodies and
offering information on preventive health
care.
- Cares for women with sexually transmitted
diseases and counsels them about
reproductive issues and contraceptive choices.
- helps women remain well so they can
experience a healthy pregnancy and maintain
good health throughout life.
2. Family Nurse practitioner (FNP)
- performs health physicals, prepares pregnancy
histories, orders and performs diagnostic and
obstetric examinations.
 - plans care for the family throughout
pregnancy and after birth
- provide prenatal care in an uncomplicated
pregnancy
- cares for the entire family, focusing on health
promotion, wellness and optimal functioning.

3. Neonatal Nurse Practitioner (NNP)

- highly skilled in the care of neonates and can

work in practice settings with various care
levels, from well-baby term nurseries to high-
level intensive care and preterm nurseries.
- can also work in neonatal intensive care units
(NICUs) or neonatal follow-up clinics.
- responsibilities include: normal neonate
assessment and physical examination as well
as high-risk follow-up and discharge planning

4. Pediatric Nurse Practitioner (PNP)

- provides well-baby care and maternal

counseling, performs physical assessments
and obtains detailed patient histories.
- serves as a primary health care provider
- can order diagnostic tests and prescribe
appropriate drugs for therapy, although
prescribing privileges depend on individual
state regulations.
- if the PNP determines that a child has a major
illness, such as heart disease, she may
collaborate with a pediatrician or other
specialists.
Clinical Nurse Specialist (CNS)
Evidence-Based Practice
● conscientious, explicit, and judicious use of
current best evidence to make decisions about
the care of patients (Falk, Wongsa, Dang, et
a., 2012).
● Evidence can be a combination of research,
clinical expertise, and patient preferences or
values.

- focuses on health promotion , patient Nursing Research

teaching, direct nursing care, and research
activities
- serves as a role model and teacher of quality
nursing care.
- may also serve as a consultant to registered
nurses working in the maternal neonatal field.
A special specialist
A Clinical Nurse Specialist (CNS) may be trained:
● the systematic investigation of problems that
have implications for nursing practice usually
carried out by nurses.
● plays an important role in evidence-based
practice as bodies of professional
knowledge only grow and expand to the
extent people in that profession are able to
carry out research (Christian, 2012).

- to provide care in NICUs

- as a childbirth educator
- as a lactation consultant

INTERPROFESSIONAL CARE MAPS

__________________________________________
Interprofessional Care (IPC)

- is the “provision of comprehensive health

services to patients by multiple caregivers
who work collaboratively to deliver quality
care within and across settings”
PROTECTION OF WOMEN AGAINST
SEXUAL HARASSMENT

OBJECTIVES:

• Define sexual harassment

• Identify the forms of sexual harassment
• Present the existing legal and regulatory measures
that are
necessary in order to protect and prevent women
against
sexual harassment at home or in the workplace.
• Present the nursing process overview: Nursing Care
of A
Family in Crisis (Maltreatment or intimate partner
violence)

SEXUAL
HARASSMENT

INTRODUCTION:

Over the past 30 years, the incidence of sexual

harassment in different industries has held steady, yet Republic Act 7877: Anti-Sexual Harassment Act of
now aside from being domestic more women are in 1995
the workforce and in other fields such as in academe
(as faculty or as a student) and so more women are AN ACT DECLARING SEXUAL HARASSMENT
experiencing sexual harassment as they work and UNLAWFUL IN THE
learn. The reports of sexual harassment that have EMPLOYMENT, EDUCATION OR TRAINING
dominated news headlines have illustrated just how ENVIRONMENT, AND FOR
pervasive this discriminatory behavior is in our OTHER PURPOSES.
society. Women who have remained silent for years
are now coming forward and sharing their SEXUAL HARASSMENT
experiences with sexual harassment that include lewd is committed by an employer, employee, manager,
or denigrating comments, hostile or demeaning jokes, supervisor, agent of
professional sabotage, repeated unwelcome sexual the employer, teacher, instructor, professor, coach,
advances, groping, demands for sexual favors, and trainor, or any
other offensive and discriminatory actions or other person who, having authority, influence or
language. moral ascendancy over
another in a work or training or education
STATISTICAL DATA environment, demands,
• A 2016 study conducted by the Social Weather requests or otherwise requires any sexual favor from
Stations found that women are most vulnerable to the other,
sexual harassment. regardless of whether the demand, request or
requirement for
• In Quezon City, Metro Manila’s biggest city with a submission is accepted by the object of said Act
population of over 3 million, 3 in 5 women were
sexually harassed at least once in their lifetime, Republic Act 9710 (Magna Carta Act for Women)
according to the report. In barangays Payatas and
Bagong Silangan, 88% of respondents ages 18 to 24 SEXUAL HARASSMENT
experienced street harassment at least once. “Violence Against Women”
➢Refers to any act of gender-based violence that
• Across all ages, 12 to 55 and above, wolf whistling results in ,or is likely to
and catcalling are the most experienced cases result in, physical , sexual , or psychological harm or
suffering to women,
• In the Philippines, 58% of incidents of sexual including threats of such acts, coercion , or arbitrary
harassment happen on the streets, major roads, and deprivation of
eskinitas (alleys). Physical forms of sexual liberty, whether occurring in public or in private life.
harassment occur mostly in public transport
WHAT ARE THE FORMS OF SEXUAL
HARASSMENT?
1. Physical
a. Malicious touching
b. Overt sexual advances
c. Gestures with lewd insinuation
2. Verbal, such as but not limited to, requests or
demands for sexual favors, and lurid remarks
3. Use of objects, pictures or graphics, letters or
written notes with sexual underpinnings
4. Other forms analogous to the foregoing.
PROTECTION OF WOMEN AGAINST
SEXUAL HARASSMENT
RA 62 92 (Anti-Violence Against Women &
Children)
• PROVIDE PROTECTIVE MEASURES FOR
VICTIMS, PRESCRIBING PENALTIES
THEREFORE, AND FOR OTHER PURPOSES.
RA 62 92 (Anti-VAWC) Protection Orders
A protection order is an order issued under this act
for the
purpose of preventing further acts of violence against
a woman or
her child. The relief granted under a protection order
serve the
purpose of:
Safeguarding the victim from further harm,
minimizing any disruption in the victim's daily
life, and facilitating the opportunity and ability
of the victim to independently regain control
over her life
RA 62 92 (Anti-VAWC) Sec. 8. Protection Orders.
The protection orders that may be issued under
this Act are the :
• Barangay Protection Order (BPO),
• Temporary Protection Order (TPO) ; and
• Permanent Protection Order (PPO).
RA 9262 Sec. 35. Rights of Victims.
In addition to their rights under existing laws, victims
of violence against women and their children shall
have the following rights:
(a) to be treated with respect and dignity
(b) to avail of legal assistance from the PAO of the
Department of Justice (DOJ) or any public legal
assistance office;
(c) To be entitled to support services form the
DSWD and LGUs’
(d) To be entitled to all legal remedies and support as
provided for under the Family Code; and
(e) To be informed of their rights and the services
available to them including their right to apply for a
protection order.
RA 9262 Sec. 40. Mandatory Programs and
Services for Victims.
The DSWD, and LGU's shall provide
the victims temporary shelters,
provide counseling, psycho-social
services and /or, recovery,
rehabilitation programs and
livelihood assistance.
• The DOH shall provide medical assistance to
victims
RA 9262 Sec. 41. Counseling and Treatment of
Offenders.
The DSWD shall provide rehabilitative counseling
and treatment to perpetrators towards learning
constructive ways of coping with anger and
emotional outbursts and reforming their ways. When
necessary, the offender shall be ordered by the Court
to submit to psychiatric treatment or confinement.
PROTECTION OF WOMEN AGAINST
SEXUAL HARASSMENT IN THE
WORKPLACE
Republic Act 7877 (Anti-Sexual Harassment Act
of 1995) SECTION 2. Declaration of Policy.
• The State shall value the dignity of every
individual, enhance the development of its
human resources, guarantee full respect for
human rights, and uphold the dignity of workers,
employees, applicants for employment, students
or those undergoing training, instruction or
education. Towards this end, all forms of sexual
harassment in the employment, education or
training environment are hereby declared
unlawful.
• RA 7877 SECTION 4.
Duty of the Employer or Head of
Office in a Work-related, Education or
Training Environment.
to prevent or deter the commission of
acts of sexual harassment and to
provide the procedures for the
resolution, settlement or prosecution of
acts of sexual harassment
Towards this end, the employer or head of office
shall:
• Promulgate appropriate rules and
regulations in consultation with and jointly
approved by the employees or students or
trainees, through their duly designated
representatives, prescribing the procedure
for the investigation of sexual harassment
cases and the administrative
sanctions therefor.
(a) shall include, among others , guidelines on proper
decorum in the workplace and educational or training
institutions.
(b) Create a committee on decorum and investigation
of cases on sexual harassment.
The committee shall conduct meetings, as the case
may be, with officers and employees, teachers,
instructors, professors, coaches, trainors, and
students or trainees to increase understanding and
prevent incidents of sexual harassment. It shall also
conduct the investigation of alleged cases
constituting sexual harassment.
• RA 9710 (Magna Carta Act for Women) Section
9 . Protection for Violence
The state shall ensure that all women shall be
protected from all forms of violence as provided for
in existing laws.
Agencies of government shall give priority to the
defense and protection of women against gender
based offenses and help women attain justice and
healing
The negative consequences of harassment can be
long-lasting and
severe. Those who experience sexual harassment in
any work
environment can suffer chronic health problems,
post-traumatic
stress, depression, substance abuse, employment
difficulties, and
relationship problems.
Nurse can respond to the victim of maltreatment or
sexual
harassment in a holistic manner, fulfilling a number
of
nontraditional roles, can promote the victim's smooth
navigation
of systems involved with her care. In so doing, the
nurse provides
continuity of care and facilitates the victim's recovery
from the
trauma of sexual assault by simplifying the process of
treatment.
NURSING PROCESS OVERVIEW
NURSING CARE OF A FAMILY IN CRISIS
ASSESSMENT
• Get as full a picture as possible.
• If maltreatment or violence in any form is
suspected, it is essential to get as full a picture as
possible. Our aim is to provide a clearer picture of the
phenomenon.
• We seek to better understand the roots and the
dynamics that drive it, in order to design the best
strategies to better prevent, respond to, and
ultimately, end this crisis. Remember, however, you
are not investigating the concern—you are doing an
initial screening to assess the need for referral and
reporting. Your agency’s patient protective services
department will do the actual investigation
NURSING DIAGNOSIS
Nursing diagnoses associated with maltreatment or
family violence should address both the physical and
the emotional results of the concern.
EXAMPLES:
• Risk for injury related to previous intimate partner
violence
• Risk for other-directed violence related to admitted
poor self-control.
• Disturbed self-esteem related to stalking and sexual
maltreatment.
OUTCOME IDENTIFICATION AND
PLANNING
Planning must center first on Ensuring the
safety of the maltreated family member and
minimizing the effects of trauma.
Second comes reporting the discovery to
authorities
Long-term planning includes:
➢helping a maltreated family member find safe
refuge and reestablishing self-esteem through self-
help or advocacy program.
➢Teaching empowerment, or the ability to take
charge of one’s life, is
particularly important for older children and women
in families where there is
maltreatment or violence.
➢the person who maltreated a child or woman needs
a program of therapy to
help prevent future offenses.
IMPLEMENTATION

• The most important intervention related

to family child maltreatment or intimate
partner violence is PREVENTION.
• Nurses can do much in all settings to be
particularly observant for families who
seem to be at risk for
maltreatment, harassment or violence .

EVALUATION

Expected outcomes should focus on specific

examples of improved family interaction, such as:

• The woman / parent states she has the Crisis Center

telephone number on her cell phone and will call for
help if she feels under threat for example, by her
partner
• The victim states she can still think of herself with
high self-esteem despite maltreatment or sexual
harassment.